NHS: Targets

Lord Hunt of Kings Heath Excerpts

Thursday 6th February 2020 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House takes note of the National Health Service’s performance in relation to its priority area targets; and the impact of adult social care pressures on patients of the National Health Service, and their safety.

[Lord Hunt of Kings Heath (Lab)]

My Lords, I welcome this opportunity to debate the current performance of the National Health Service. I declare my membership of the GMC board, my trusteeship of the Royal College of Ophthalmologists and my presidency of GS1, the organisation responsible for the “scan for safety” programme. I am very pleased that my noble friend Lady Wilcox will be making her maiden speech in this debate.

I have instituted this debate because I am increasingly worried about the performance of our National Health Service. Despite the heroic efforts of many staff, every key indicator is being missed. Last November saw the worst four-hour wait performance in A&E since figures were first collected in 2010. Two-week waits for GP appointments rose by 13% last year. The target of a maximum wait of 18 weeks for hospital treatment has not been met since 2016. The cancer target of 62 days between urgent referral and first treatment was last met in 2013-14.

I fully accept that these targets are not the only way to judge the NHS, but they reflect overall performance. At the same time, we have seen an increase in the rationing of medicines, and failings in ambulance services and services for people with learning disabilities or mental health issues. The CQC’s review of the Mental Health Act today refers to a number of very worrying problems in that area.

Given this, it is a huge tribute to NHS staff that so much care remains of a very high quality. I absolutely acknowledge that. However, the calamitous drop in performance over the past decade is clearly having an impact on patient safety and leading to those longer waits.

I was very struck just before Christmas by the Norfolk and Norwich University Hospitals NHS Foundation Trust advising staff to make “the least unsafe decision” following a huge rise in admissions. Over the new year, the Royal Cornwall Hospitals NHS Trust told its staff to reduce severe overcrowding by discharging patients, despite the obvious risks involved. These are not isolated incidents. What has caused this? Many factors and pressures are at play. The alignment of austerity with workforce shortages, inadequacies of adult social care and a complete failure to factor in the growing older population mean it is little surprise that the NHS is reeling.

If we look at funding, the lowest five-year period of funding growth was between 2010 and 2014, and the past five years have seen little improvement. It is no wonder that the NHS is cash-strapped, in deficit and finding it very hard to invest the resources necessary to prevent hospital admissions. We can see similar trends in the workforce. In March, the Health Foundation highlighted a shortage of more than 100,000 full-time equivalent staff, including more than 40,000 nurses. The GP workforce has continued to stagnate, despite government promises to increase the numbers, and the GMC’s 2019 workforce survey showed that one-third of doctors have refused requests to take on additional workloads and one-fifth have reduced their hours. It is part of a vicious cycle in the workforce. Fewer doctors and more patients means that doctors are overworked. They get ill from stress and exhaustion. They decide to cut their hours or just leave the profession, and the remaining workforce feels under even greater pressure.

All of this is happening when social care is in meltdown. In 2018, the House of Lords Economic Affairs Select Committee reported that 1.4 million older people in England had an unmet care need. We know that the number of older people and working-age adults requiring such care is increasing rapidly, yet public funding declined in real terms by 13% between 2001 and 2015. We see a second vicious cycle. The level of unmet need in the system increases, the pressure on unpaid carers grows stronger, the supply of care providers diminishes, the strain on the care workforce continues and the stability of the adult social care market worsens.

What is the Government’s response? It seems to be twofold. The attitude of the Secretary of State appears to be to get rid of any target on which the NHS is not delivering, but I remind the Minister that the Royal College of Emergency Medicine has said of A&E that there is

“nothing to indicate that a viable replacement for the four-hour target exists”.

I strongly encourage the Government to think again before they agree to change that target.

The second line of the Government’s defence is essentially to argue that they are dealing with an unprecedented increase in demand. I am the first to acknowledge that the drivers of change are intensifying and that the NHS is clearly caring for a patient population with more long-term conditions, more comorbidities and increasingly complex needs, but this is not a new problem. The Labour Government of 1997 faced the same demographic challenge, but turned it around through investment in 300,000 more staff, 100 new hospitals and new services such as NHS Direct and walk-in centres. Waiting times came down as dramatically as public satisfaction went up. It can be done.

The Government have their own long-term plan with a new five-year settlement of around 3.4% per annum. However, as the right reverend Prelate the Bishop of London said in the debate on the Queen’s Speech, the additional funding is not a bonanza; it will serve only to stabilise NHS services, and the right reverend Prelate knows what she is talking about when it comes to the NHS. Yesterday, the NAO warned that NHS trusts reported a combined deficit of £827 million and clinical commissioning groups reported a £150 million deficit in the financial year ending 31 March 2019. The NAO said that short-term fixes have made some parts of the NHS seriously financially unstable, with trusts in financial difficulty increasingly relying on short-terms loans from the Minister’s department.

As we look at the funding promised—we will have a Bill on it in your Lordships’ House soon—I refer noble Lords to a letter written by NHS leaders to the Times on Tuesday, which pointed out that this funding does not include areas crucial to the Government’s election promise to provide more hospitals, nurses and GP appointments. The additional funding does not cover investment in buildings and equipment, so there is very little relief for our crumbling infrastructure or money to fund new technology to improve care. We know that the NHS is facing a workforce crisis but the funding does not cover education and training budgets to help with recruitment and retention. Nor does it offer any relief for public health and social care services, which would, I hope, if properly invested in, keep more people healthy and independent.

Therefore, the question before us is how to turn this around. I am sure that noble Lords will come forward with many ideas in this debate but I would like to propose four key measures. First, we have to plan for the long term—not five but 20 or 30 years ahead. I want to come back to the House of Lords Select Committee report on the long-term sustainability of healthcare. It was published three years ago and chaired by the noble Lord, Lord Patel. The committee said that we have to get away from the short-term fixes that we currently see and have seen in the past. It suggested that we set up an office for health and care sustainability to look at the likely funding and workforce requirements for up to 20 years ahead. Like the Office for Budget Responsibility, which has now been well accepted as giving authoritative, independent advice to government, this body could give advice to government, Ministers and parliamentarians on the likely demands on health and social care over the next 20 years. I believe that would be the start of a much more fundamental way of ensuring that we have a high-quality healthcare service in the future.

Secondly, alongside those kinds of projections, of course we need the commensurate funding. The funding challenge is immense. No one in the health service believes, for instance, that the 3.4% being given will allow them to invest in services for the long-term five- year plan. The money is not there to invest in services to keep people out of hospital; we have a crumbling primary care service because of the pressure from patients coming through the door; and people who work in the health service regard the local plans—the STPs—as a flight of fancy. They have had to publish them and have had to agree the figures with the Government because, if they do not, they will get their heads chopped off. However, Ministers are living in a dream world if they think that these plans will be delivered. Therefore, we have to find a way of funding the health service seriously in the future, but at the moment I see no indication that the Government recognise the scale of the challenge they face.

Thirdly, on the workforce, we need better recruitment and retention, and we need to increase our training numbers, but much of the problem is due to what I am afraid I have come across many times—a bullying and blame culture. It is very off-putting for many staff in the health service. I know that Ministers are concerned about this but it starts with them, their attitude and the way they deal with the health service and the bodies responsible for it. They have to lead from the centre.

Fourthly, we have to find a solution to social care. The Government have promised to come forward with one but, as we know, the last 20 years have seen a failure of nerve and an absence of political consensus. Frankly, at the moment we seem no nearer to a solution. I must acknowledge that it is a wicked problem. However, can we really wash our hands of the pernicious situation in which many people receive no care at all and many face the loss of not just their homes but their savings as the price of their long-term care?

In this debate noble Lords will raise many other issues, including improving outcomes, developing a more robust approach to public health, targeting health inequalities, and prioritising mental health and learning disability services. However, at heart, I hope the debate will come back to the issue of performance. The targets were not plucked out of the air. They were chosen because they were a very good proxy for the overall quality and performance of the NHS as a whole. In 1997, we inherited something called the Patient’s Charter, which said that there should be a maximum waiting time of 18 months for hospital treatment. The Conservative Government at that point had come nowhere near meeting that target. We turned that around and delivered an 18-week maximum wait. We hit other targets as well. I fear that it will not be too long before we go back to those bad old days if we carry on as we are at the moment. I ask the Government to think seriously about the kind of health service that they want for the public in the future. Based on current trends, I am afraid the situation is deteriorating. I beg to move.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I first thank the Minister for her comprehensive response, and I thank all noble Lords who have taken part in what has been a wide-ranging and excellent debate. I congratulate my noble friend Lady Wilcox on what was, on any count, a brilliant maiden speech. I hope that she will speak many times in your Lordships’ House over the coming months.

In such a wide-ranging debate, one cannot do justice to what has been said, but I would identify three core themes. First, on social care, we are united in wanting to see a solution. The Minister is reassuring about the proposals that will come from the Government at some point in the year. I say to her that it is very important that these proposals deal with the now as much as they do with the future; it is now that so much pressure is being felt. I say to the noble Baroness, Lady Brinton, that if she is really looking for a quick solution, she just has to go back: you legislated for Dilnot. Raise the means test cap; implement Dilnot; and put more money into adult social care—that at least would give you a fundamental way to go forward. Your Government legislated for it; this is the remarkable thing about capping the cost of social care for individuals. It is quite remarkable that we are here, still desperately hoping that we will get a solution for the future, when we had it.

Secondly, I echo all noble Lords who have spoken so highly about the work of staff and so many great things happening in the health service. There is no doubt about that. The noble Lord, Lord Bates, referred to the US Commonwealth Fund designation of the NHS as the number one healthcare service in the world. He was right to do so. As he will know, the reason for this is that we came out very highly on cost-effectiveness and access to services. He will also know that we came bottom, with the US, on health outcomes. My concern about the issue of targets is that our continuing failure to meet them will lead to worsening health outcomes in the future.

This brings me to my final point. The Minister referred to the pressures that we are under. These are not going to go away, whether demographic pressures, growing health inequality or the fantastic opportunities of new medicine and treatments, which cost additional money. This is the way that health will go over the next period; it is not until the 2060s that the population demographic will start to change again. At the moment, the health service is reeling under huge pressure. It is simply not sustainable to think that we can go on like this over the next 10, 20 or 30 years. We have to level with the public that, if they want the NHS—and I think they do—they will one way or another have to pay for it.

We cannot run away from the kind of debate that the noble and gallant Lord, Lord Stirrup, said that we ought to have. I go back to what the House of Lords Select Committee on Long-term Sustainability of the NHS said three years ago: that we must face up to the long term to have any hope at all of getting through this and landing the NHS in the excellent shape in which we want it to be. I thank noble Lords for the opportunity to debate this.

Motion agreed.