The Long-term Sustainability of the NHS and Adult Social Care

Lord Rennard Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Rennard (LD)]

My Lords, I draw the attention of the House to my entry in the Register of Lords’ Interests.

Some years ago, when I was advising my noble friend Lord Ashdown on what to say during elections, I asked him to avoid using the phrase “rationing” when it came to talking about the NHS because the phrase is perceived very negatively. But in reality, trying to meet ever-growing demands with resources that are not growing proportionately will always mean having to ration those resources in some way.

The noble Lord, Lord Patel, and his committee are to be congratulated on their report. It does much to address the issue of NHS sustainability—much more than the Government seem willing to admit is necessary, at least publicly. The problem results from both significant demographic changes and a reluctance in the past to ask people to pay higher levels of taxation to fund the consequences of people living far longer, needing pensions for far longer, and needing much more healthcare intervention, particularly to deal with long-term conditions.

Forty years ago, a man who had worked and paid taxes for 50 years retired at 65 and lived, on average, for just two years in retirement. The cost of his pension and his healthcare was therefore not very great. Today, a man is expected to live for 20 years in retirement. His state pension, therefore, has to be paid for 10 times as long as was the case 40 years ago. Women may live for longer, but both women and men on average will now expect to have 12 years of good health in retirement but eight years when more active health and care intervention will be required, some of it very expensive.

We have had great economic growth over the last 40 years, and this has financed far greater levels of taxpayer support for the NHS than might ever have been expected during most of the last 70 years. Even so, the increasing level of taxpayer funding for the NHS is not keeping pace with the growing demands on it, or with the demands for social care. So we need people to pay more for their health and social care, and to recognise that the most efficient way of doing so is via general taxation to pay for a national health service and to integrate this properly with social care.

The noble Lord, Lord Layard, referred a few moments ago to a MORI opinion poll. I draw the House’s attention to the recent British Social Attitudes survey, which showed that most voters now back tax rises to fund the NHS if it needs more money—and, as the noble Lord, Lord Prior, indicated, it most certainly does. Options for paying more taxes found support in that survey from 61% of people. It showed that the alternatives—for example, charging for non-medical costs such as hospital food, or paying £10 to visit a GP—received just 21% support. The latter approaches are, I think, quite unacceptable.

The highest level of support in the survey was for people to pay more through a separate tax that would go directly to the NHS. A 1p increase in the basic rate of income tax, for example, would produce an additional £6 billion per year. However, it seems to me that a much more radical restructuring of the income tax and national insurance system is required to fund what is needed. I wish the Select Committee report had been less equivocal about hypothecating taxes for the NHS, because I believe that that is the only way forward by which people will agree to pay more taxation.

However, in my view the report was right to say that the long-term sustainability of the NHS requires more than an increase in taxpayer funding. For example, we need to do much more to reduce the demands on the NHS caused by factors such as the escalating rates of obesity and diabetes, and problems with alcohol misuse, and we still need to reduce further the prevalence of smoking tobacco.

In trying to tackle all these issues, we have to overcome the powerful lobbying interests of the food and drinks industry, as we have largely done with the tobacco industry’s activities in this country. We need also to promote healthier lifestyles. At this point, I should declare my interest in having benefited from a GP referral programme that successfully encouraged me to take more physical exercise. The result of that may not be immediately self-evident—but your Lordships should have seen me 10 or 20 years ago.

We also need to make much more effective use of technology to improve the functioning of the NHS, which has been far too slow in replacing paper and fax-based correspondence with electronic communication. Much greater use must also be made of assistive technology, whether funded publicly or privately or through the increased use of personal health budgets. Providing specialist equipment to children that reduces the likelihood of surgery in later life, adapting people’s homes, whether with grab rails, stairlifts or specially adapted kitchens, and ensuring that people have the most appropriate assistive technology to enable them to live their life to the fullest and most independent degree possible should become a much greater priority in the decades ahead.

That is all absolutely essential if we are to curb successfully the escalating demands on the NHS and, at the same time, enable more people with disabilities or long-term conditions to enjoy more gainful employment and contribute positively to society and to the economy.

Prescription Drugs: Dependence

Lord Rennard Excerpts

Monday 19th March 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Earl highlights a very important issue, and I reassure him that the review will look not only at the nature and causes of dependence on the drugs in scope, which include antidepressants, but at the correct and most evidence-based treatments for withdrawal.

[Lord Rennard (LD)]

Will the review by Public Health England be able to look specifically at alternatives to prescribing drugs, such as acupuncture, which is shown to be very effective in the relief of pain and reducing symptoms of anxiety, and perhaps also mindfulness, which has been shown to improve the mental health of very many people?

[Lord O'Shaughnessy]

I can attest to the benefits of both those courses of treatment. The review will look at prevention of dependency in the first place and in doing so will look at alternative courses of treatment. Of course, in the end there is a balance to be struck between the clinical needs of the patient and the right course of treatment. It is about making sure that clinicians are as informed as possible.

Emergency Hospital Admissions

Lord Rennard Excerpts

Wednesday 7th March 2018 Lords Chamber

[Lord O’Shaughnessy]

I agree with the noble Lord about funding. The Government have now made £9.4 billion of extra funding available to local authorities over three years, including in the most recent local government funding settlement. The noble Lord makes a good point about bed capacity: it had shown a downward trend for a long time before stabilising in recent years. I point to two successes this winter. The first is the improvement in delayed transfers of care—we have really started to get some traction on that. The second is about £60 million, I believe, of funding that went into providing extra bed capacity over winter. Occupancy levels are too high. The NHS is getting better at managing it more efficiently, but we certainly need to do better.

[Lord Rennard (LD)]

My Lords, does the Minister accept that part of the problem with emergency hospital admissions is the difficulty people have in accessing their GPs? Some of this is perhaps because of the high levels of stress among GPs, but there is also recent evidence suggesting that it is because of the £1 million pension cap imposed on GPs, which means many more of them are retiring before the age of 60. Surely, in the interests of the NHS, this particular cap should be looked at again.

[Lord O’Shaughnessy]

Although the number of early GP retirements has been rising, the number of total GP retirements has been falling, which is encouraging. It is also important to point out that, while the pension cap obviously applies to everybody, it has not had the impact that the noble Lord described on dentists or consultants, so there is something more to it. It is to do with how GP services are structured and providing support for that partnership model. That is what we are trying to do at the moment.

Alcohol: Minimum Unit Pricing

Lord Rennard Excerpts

Wednesday 28th February 2018 Lords Chamber

Asked by

[Lord Rennard]

To ask Her Majesty’s Government what assessment they have made of the cost benefits to the National Health Service and police of introducing minimum unit pricing for alcohol in England.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, data from the Sheffield University alcohol policy model in 2015 estimated that, in 10 years, minimum unit pricing could on an annual basis reduce alcohol-related deaths by 356, alcohol-related hospital admissions by 28,515, and crime by 34,931 crimes. Minimum unit pricing remains under review and the Government will consider the evidence of its impact once it is available.

[Lord Rennard (LD)]

My Lords, figures issued today by the Institute of Alcohol Studies suggest that, for each hour worked, it is possible to buy three times as much supermarket beer as was the case 30 years ago. Given the statistics which the Minister cited from the University of Sheffield, is it not urgent that we act to prevent the sale of perhaps four cans of beer in a supermarket for as little as £1?

[Lord O’Shaughnessy]

As I said, the Government are looking at this issue and, following the Supreme Court judgment, the Scottish Government can move ahead with their plans. The issue is not about the lack of evidence on whether reducing drinking has health benefits, but about making sure that any new system is implemented in a way that is fair on those who drink sensibly, particularly those on low incomes. The approach we have taken up to now is to use the tax system judiciously, including high duty levels for drinks such as white cider. As we move ahead and look at the evidence, we have to consider not just the health benefits but the economic costs that could be imposed on perfectly sensible drinkers.

Smoking: Vaping

Lord Rennard Excerpts

Tuesday 19th December 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is right; we are looking at the guidelines at the moment, with Ofcom and the Advertising Standards Authority. There are limits on what we can do on vaping under the current regulations, but we will have the opportunity to look again at this issue as we leave the European Union, and reconsider our domestic legislation.

[Lord Rennard (LD)]

My Lords, vaping has proved an effective way for many people to give up smoking tobacco—but there are, of course, no inherent health benefits in taking up vaping if one is not already addicted to nicotine. Does the Minister agree that we should seek regulations that allow the promotion of vaping solely as an alternative to smoking tobacco, and not something that people not already addicted to nicotine should be encouraged to take up? Can he tell us when Public Health England will publish its report on e-cigarettes, which was due in 2017?

[Lord O'Shaughnessy]

I think that the noble Lord is making the point that we need a balanced approach. We want to emphasise the relative health benefits, but we must also recognise that harmful effects can come from nicotine in itself. Obviously, we want to get to a position in which people are not smoking and not taking nicotine at all, and the relative benefits of the different ways people can go about that are taken into account. I think that the UK has a sensible approach. I am afraid that I do not have the date when the Public Health England report will be published, but I will write to the noble Lord with that information.

Nurses and Midwives: Numbers

Lord Rennard Excerpts

Monday 4th December 2017 Lords Chamber

[Lord O'Shaughnessy]

I agree with my noble friend’s point on communication. I shall certainly look at whether we can do that better as an NHS. It is why I do not miss an opportunity from the Dispatch Box to say how much those nurses are valued and how much we want them to stay. That is what the Government are committed to doing. I mentioned the increase in the number of training places which my noble friend has pointed out. New UCAS data out today show that the picture is slightly better even than when we talked about it last week. Although the total is slightly down on last year, it is the second-highest number of nurses recruited in the history of nursing being a degree profession.

[Lord Rennard (LD)]

My Lords, is this not a problem particularly given that 35,000 nurses and midwives left the profession last year? Does the Minister agree with the Royal College of Nursing that the problem is made worse by the loss of student bursaries, deterring more mature students from applying to train as nurses and denying the profession the benefit of their valuable life experience?

[Lord O'Shaughnessy]

Retention is critical. A number of nurses have gone through return-to-practice programmes to make sure they can come back into the profession. I recognise that today’s UCAS data show that while the number of applications has risen among the under-21s, it has fallen among the over-21s. It is important to point out that financial support is available for those people, in terms of both help with childcare and extra financial support. Now, for the first time, we are providing funding for second degrees if they are in nursing.

NHS: Winter Staffing Levels

Lord Rennard Excerpts

Thursday 26th October 2017 Lords Chamber

[Lord O’Shaughnessy]

I am grateful to the noble Baroness for raising this. We have discussed a number of times the impact of the test on recruitment from countries other than the UK. It is entirely sensible for the NMC to look at this. On nurse training, I hope she will have been reassured by the announcement from my right honourable friend the Secretary of State for Health at the Conservative Party conference that we will deliver a 25% increase in nurse training places from 2018-19 onwards.

[Lord Rennard (LD)]

My Lords, is not part of the problem for the NHS, and for hospitals in particular, during the winter that so many people have difficulty in accessing their GP? The number of GPs has fallen by 3% over the last two years. Is it not, therefore, counterproductive that the Government have been cutting funding for community pharmacies when many more people should be seeing their pharmacist and not seeking to see their GP or even turning up at A&E units?

Mental Health Services: Children and Adolescents

Lord Rennard Excerpts

Monday 17th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the right reverend Prelate for raising this issue. I have mentioned mental health training and single point of contact. There are also curriculum changes. There will certainly be a number of policies within the Green Paper that will address the points she has raised.

[Lord Rennard (LD)]

The Government in Scotland are considering providing mental health counsellors in every secondary school. Does the Minister accept that all schools should have dedicated members of staff able to do more than just provide mental health first aid, and that there should be a trained mental health and well-being lead in every school, college and university?

[Lord O'Shaughnessy]

That is what we are moving towards with the mental health first aid training for teachers in all schools. The noble Lord will recognise that schools come in all different shapes and sizes and that it is easier to do that initially in secondary schools, which are bigger than, for example, rural primary schools which might only have a staff of 10. It is critical to make sure that there is at least one member of staff who is highly trained in spotting and dealing with the initial signs of mental health problems and signposting them to the relevant authority—local health authority or whatever it is—for further care.

National Stroke Strategy

Lord Rennard Excerpts

Wednesday 5th July 2017 Lords Chamber

[Lord O’Shaughnessy]

Well, in order not to fall out with Scottish noble Lords, I shall not comment on that. Under successive Governments there have been improvements in stroke outcomes, which have come about through the centralisation and specialisation of care. That is not always popular because of what it does with reorganisations, but it is definitely paying dividends in England.

[Lord Rennard (LD)]

My Lords, there is very strong evidence that the number of strokes could be reduced nationally if there was better detection and appropriate treatment of atrial fibrillation. Will the Minister commit to a proper national screening programme to detect this condition and ensure that there is appropriate follow-up treatment for those diagnosed as suffering from atrial fibrillation?

[Lord O’Shaughnessy]

The noble Lord is quite right to highlight that issue. There is increased screening for atrial fibrillation as part of the community-based efforts to prevent the incidence of stroke, and that has been one of the factors that have reduced the incidence of stroke over the past few years.

Queen’s Speech

Lord Rennard Excerpts

Thursday 29th June 2017 Lords Chamber

[Lord Rennard (LD)]

My Lords, in the recent general election we heard quite a lot about the cost of trying to sustain our health and social care systems, but too little about action to make people healthier. The gracious Speech did not provide much hope that the new Government recognise that this is an important and continuing priority. I will focus my remarks on tobacco control. I speak as a former trustee of Action on Smoking and Health, and I am currently a vice-chair of the All-Party Group on Smoking and Health.

Those of us most concerned about this issue have recently had two things to celebrate. The first is the decline in smoking prevalence, which is shown by new data to be just 15.5% of adults in England—the lowest level on record. This is a huge achievement and the effort to bring it about will save many lives over the coming years. Particularly encouraging is the fact that the greatest decline in smoking rates has been among young adults aged 18 to 24. The reduction in smoking rates is testament to the success of the comprehensive approach adopted by previous Governments.

Secondly, in England, we are about to celebrate the 10th anniversary of smoke-free legislation, with Scotland having bravely led the way some two years earlier. This legislation has had a tremendous impact on public health, including significant declines in heart attacks and strokes, and hospital admissions for asthma attacks in children. The passage of the legislation required the efforts of many people to combat the fierce resistance and fundamental dishonesty of the tobacco industry. Since that time, a cross-party approach to tackling tobacco has continued to do much, for example in passing legislation to prohibit smoking in cars with children and putting cigarettes in drab-coloured, plain packaging.

Every step forward has been resisted, but tough tobacco legislation is no longer seen as something for which the tobacco industry can win significant support to block or delay for very long. A public survey for Action on Smoking and Health showed that 76% of respondents supported government action to limit smoking or wanted more to be done. Against that backdrop, the UK has widely been acknowledged as a world leader in tobacco control, and in 2015 received the prestigious American Cancer Society’s tri-annual award for exemplary leadership by a government department, as well as the World Health Organization’s World No Tobacco Day medal last year. The Government then committed £15 million to support implementation of the World Health Organization’s international tobacco treaty, the Framework Convention on Tobacco Control, in poorer countries between now and 2021.

That is a record to be proud of, but we cannot be complacent about the issue of tobacco control. Despite our successes over the last decade, smoking remains a public health epidemic. Every day, hundreds of children start smoking, and tobacco still kills around 80,000 people in this country every year. Smoking is responsible for half the difference in life expectancy between rich people and poor people—a difference of nine years—and that is a burning injustice. The smoking rate among people with a mental health condition is 40% and smoking is the leading modifiable risk factor for stillbirth and sudden infant death. Yet 18 months after the expiry of the tobacco control plan for England, no new plan has been put in its place. That is in contravention of our obligations as a party to the international tobacco treaty, which requires us to have a comprehensive strategy in place.

The obligations are based on good evidence that it is through such strategies that countries can be most effective in driving down smoking prevalence. We have been very effective in the last decade, with a comprehensive approach to tackling tobacco. If we are to be effective in the next decade, the Government urgently need to publish their next plan, with ambitious new targets to reduce health inequalities and lead us towards a smoke-free future.

In answer to a Question from me on 23 February, and further questions from across the House, the Minister made some very encouraging remarks about tobacco control. He said that a new tobacco control plan would be published shortly and that it was in an advanced state of preparation. In an earlier debate in the other place in December 2015, the former Health Minister, Jane Ellison, committed the Government to publishing a new strategy in summer 2016. It is now summer 2017. A year and around 80,000 more deaths from smoking-related illnesses later, we have waited long enough.

Earlier this week, the Government reiterated the commitment made before the election to publishing a new plan “shortly”, so I hope that today the Minister can go further and confirm a date for publication of a new tobacco control plan before the House rises for the Summer Recess.