NHS: Performance and Innovation

Lord Parekh Excerpts

Thursday 15th June 2023 Lords Chamber

[Lord Parekh (Lab)]

My Lords, I thank the noble Lord, Lord Scriven, for introducing this debate.

The NHS turns 75 in July this year. Right from the time it was born, it has been based on a simple principle: it is funded by tax and free at the point of delivery. Over the years, it has become an integral part of the British way of life and has even come to be called a national religion. I share this degree of confidence in the system. However, at the same time, as anyone who has turned 75—as I have—can say, things do begin to go wrong and memory begins to play tricks. I want to use this opportunity to look at the NHS over the last 75 years and say something about the way in which institutionalised memories have begun to fail, how things have begun to go wrong, and why, unless we do something drastic, we might end up regretting its demise. I will itemise five or six major criticisms of the NHS so that the Minister can reply to each of them separately.

The first striking thing about the NHS is that it is hospital centred. Half of all the GP appointments and 70% of the in-patient bed days are taken up by those with long-term conditions such as diabetes and others. Those people are best treated by GPs and nurses, yet only 8% of the NHS budget goes to general practice and community care. If one looks at the allocation of resources, far more resources go to hospitals than to GPs or community care, and one fails to see the point of that.

The second criticism I have of the NHS is that it is not only hospital centred but sickness centred. It is not the National Health Service but the national sickness service. It is supposed to cater to sick people. We are, for example, the third-fattest country in Europe, and an obese person costs twice as much to treat as one who is not obese, yet very little is done to encourage the positive health of the people of this country. We should be concentrating on encouraging people to maintain good health and to exercise and eat well—all sorts of things—not just treating illnesses that result from the failure to do this.

My third point is on the use of medical technology. It is very striking, for example, that ours must be one of very few countries where X-ray machines and CT scans have, at least until recently, not been used on a Sunday, or even Saturday, or public holidays. When I was in the States, it was quite common to get an appointment on a Saturday or Sunday, when those machines were in use.

My other point is about the distribution of money. I have already talked about the distribution of money between GPs—primary care as opposed to hospitals—but there is also the way it is done among the medical profession itself. I have been critical of the merit promotion system, and I have asked Ministers to explain to me the logic of it. In no other profession do you get the merit promotion system. If I get a Nobel prize in literature tomorrow, my salary will not automatically go up, nor will I get an extra increment. Why should doctors be able to get merit-based promotions: merit based on what? Merit is simply a part of what they are supposed to achieve anyway. I am told that merit promotion is not a question of just a few hundred pounds: the budget comes to quite a lot. The question is whether that money could not be used for other purposes.

There is also the danger, as is quite often pointed out, of overmedicalisation. There is sometimes what is called disease-mongering, a phrase that was first used in 1992. Imagine that a disease is invented because certain symptoms are not easily explained. The pharmaceutical industry has a vested interest in inventing diseases and getting people worried about them. Repeat prescriptions keep up the supply of medicines even when they are not used, and there is what is called defensive medicine, whereby doctors keep doing something because they are supposed to be doing something rather than doing nothing. Professor David Haslam has pointed out many of these things in his new book, Side Effects.

I have a couple of other points. I have often wondered about the poor co-ordination between GPs and specialists in hospital. There is a hierarchy between them which I had not noticed, and a hierarchy that means that hospital specialists carry a greater degree of authority than the GP. I have faced cases which puzzled me, when a hospital specialist would recommend a particular medicine, my GP would follow his advice and I would say, “Look, doctor, I don’t think this is right, because this has been given to me once in the past and it had an adverse effect”, but the doctor would say, “I can’t disregard what the specialist has said: he is my superior”. The result was that I had to pay the price for taking a drug which I should not have taken. There are cases where the hospital specialist’s authority is supposed to be unchallenged.

I have often wondered why, in order to go to a hospital specialist, I need to go through the GP route—why I cannot go directly. When the hospital specialist sends in a report, it comes to me via my GP. It takes days to arrive, when a copy could be sent to me directly. Again, from experience, there have been recent cases when I saw a specialist and I should have had the report, but I am still waiting for it because it will take days and days to travel to me.

My last, important point is that there is too much distance between hospital and the local community. The hospital is generally not in direct, regular contact with the local community. It is a separate place where you are sent by your doctor, or you go yourself to accident and emergency. There is no regular interaction between hospital staff and ordinary members of the community, there are no common social events which bring them together, there is no sense of identification by the local community with the hospital, and the result is quite obvious. I have asked for some statistics. It is very striking, when people make their will, how much of their money is directed to the local hospital. The answer is: very little. Why is it that hospitals do not come into the category of those to whom you would leave your legacy? You could leave your legacy to the school or the university, but rarely to the hospital because, unlike schools and universities, hospitals are not seen as an integral part of the community. There must be some way in which hospitals can become an integral part, taking an active interest in promoting the culture of good health within the community.

Broadly, my suggestions are meant simply to accelerate the regeneration of the NHS, because I do not think we can wait too long before the current situation creates a crisis.