National Health Service

Lord Turnberg Excerpts

Thursday 8th January 2015 Lords Chamber

Moved by

[Lord Turnberg]

That this House takes note of the future of the National Health Service.

[Lord Turnberg (Lab)]

My Lords, it is a privilege to be able to open this debate on the future of the NHS. It comes at a time when we are gearing up for the election and when it seems entirely possible that the NHS will be of some interest to the electorate. I will try to set the scene with a broad brush and leave it to other noble Lords to focus on various specific aspects.

We are going through a time when the media are full of one NHS disaster after another; with reports of cancelled operations, GPs and A&E departments being overwhelmed and waiting lists rising. We have not been short of media analysis in the past few days. That this is not simply the usual media hype is pretty obvious. We have had a number of careful reports from the Nuffield Trust and the King’s Fund, for example, that make sobering reading, with titles such as Into the Red? The State of the NHS Finances and Is General Practice in Crisis? suggesting that all is not well and that we cannot continue as we are.

The Government have woken up rather belatedly, with a sudden rash of activities. We have had NHS England’s Five Year Forward View, full of interesting aspirations; the Dalton review, with some ideas about how to go about achieving some of them; a number of crisis funding rescue efforts; and the Prime Minister reportedly sending in his pre-election “hit squad” to try to sort things out. However, it is pretty clear that quick fixes are not the answer and that the nature of the difficulties we face requires much longer-term solutions. It is good to hear that my own party is making some realistic proposals that might make a difference.

The causes of the problems are pretty widely understood. A service designed largely around acute hospital care has ignored for too long the needs of people with multiple long-term illnesses, especially those of the growing band of elderly patients whose needs are much better met in the community than in hospitals. This demand is certainly rising. The number of over 80 year-olds is set to double over the next few years and, for example, the number of people on more than three different pills for their multiple illnesses is growing by the day. I dare say that there will hardly be a Member of your Lordships’ House who is not on at least two pills keeping them in the fine trim that we see today, and I fear that I am no exception.

However, it is not only the growing proportion of the elderly and the worrying rise in the number of people with dementia that is causing difficulties; it is also the pressing demand placed on acute services. We can do so much more for patients than we ever could, and the population increasingly expect that they will be given the most effective treatments available. Many of those treatments are now very expensive. Complex scanners and investigations, coupled with the development of designer drugs produced specifically in response to an understanding of the genetic make-up of smaller and smaller subsets of patients, pose severe problems for a service working within rigid financial constraints.

It is in that financial squeeze where the nub of the problem lies. The fact is that the rate of inflation in health service costs is running way ahead of general inflation rates and certainly ahead of the growth in GDP. So every year the gap between demand and the funds available is widening, and this is what is responsible for the idea so often trotted out that the NHS is a “black hole” into which money just disappears. I do not believe that for a moment, and I will explain why shortly.

You might think that a Government would try to keep pace, if not with inflation then at least with the rise in GDP, small though that might be. In fact, the slice of the national cake devoted to health has gone down from about 8.5% when Labour left office in 2010 to 7% now—that is a fall of 17% in our share of the nation’s wealth. Even worse, predictions by the King’s Fund point to a further fall to 6% of GDP by 2021, on the current Government’s projections. That, I suppose, is all part of their plan to reduce overall public expenditure to pre-1940s levels, despite their protestations about a desire to protect the NHS.

It might be asked why these problems seem to have become much more acute in the past few years. After all, we have not all suddenly become older and sicker. The fact is that when Labour left office five years ago we had managed to get rid of waiting lists, patients were seen on the same day by their GP and patient satisfaction levels were high. It is no coincidence that we had appointed some 130,000 more front-line staff to cope with demand. So what has happened that left us with our current difficulties? Certainly, the distractions of the Lansley reforms did not help, with all the redundancies and re-employment of senior managers and the loss of continuity in leadership that followed. As Maynard Keynes said:

“It is not sufficient that the state of affairs which we seek to promote should be better than the state of affairs which preceded it; it must be sufficiently better to make up for the evils of the transition”.

I fear that we are still suffering from the evils of transition.

Then we have had the Nicholson challenge and the so-called efficiency savings of no less than £20 billion over the past five years. Of course anyone working in the service knows that it is always possible to improve efficiency, but now it is clear that the pips are being made to squeak too loudly as we run out of such short-term measures as wage freezes and the like. The inevitable result is that we are failing to keep up. GPs are overwhelmed, waiting times in A&E departments are rising, waiting lists are growing, social service departments are failing to cope and many such departments are now able to deal only with those in most serious need.

So what is to be done? I shall focus on four specific areas: disease prevention by public health measures; bringing hospital and community services much closer together; focusing on some specific aspects of care where we are clearly failing, namely A&E services, general practice and mental illness; and stimulating much more research and innovation where the potential dividends in health and well-being, as well as economically, are considerable. Of course none of these sounds entirely novel, but the fact is that we have failed miserably to achieve them so far. I want to examine why that is the case and what we should do now to ensure that we do not fail again.

First, with regard to prevention with the aim of reducing demand, no one can argue with the need to try to prevent the many illnesses caused by smoking, drinking too much alcohol and eating too much food. That is why I believe that the Government must get on with the plain packaging legislation, for example. We also know that the most effective measure to reduce alcohol consumption is to increase the duty on alcohol. It is pretty clear that whenever the price of alcohol goes above the rise in the general cost of living, the incidence of death from liver disease goes down—and, let’s face it, the increased revenue generated could make a useful contribution to the Exchequer and the NHS. I will leave it to other noble Lords to go into why the Government are reluctant to use this most effective measure, but the problem here is not that these are not vitally important things to be doing—they clearly are—it is the expectation that we will see financial savings from doing them in any reasonable timespan. Any impact on costs will inevitably take time.

Secondly, I turn to the need to see much greater co-operation and collaboration—what we used to call “integration”—between community-based and hospital services. The report from Sir David Dalton provides some very helpful ideas about how this might be achieved. He, of course, has managed to show how it is possible to integrate services extremely successfully in Salford and his report describes a number of other potential models for collaboration that fit in with different local circumstances. Clearly, the removal of the barriers between hospital and community is highly desirable and the idea of pooling health and social care budgets could be a very supportive measure. However, we have to be sure that current competition laws do not get in the way, and even more importantly, we have to be clear that the funds are available to facilitate this transition. It would be naive to believe that it could be done within existing budgets, even though in the longer term that sort of joined-up service will be more efficient, and of course it will suit patients’ needs much better. But in the short to medium term, it will need transitional funding.

The idea behind the Government’s better care fund was to try to bolster community services at the expense of the NHS, which itself is pretty cash-strapped. Robbing Peter to pay Paul is never going to be popular with Peter, and we now have the lowest number of beds per head of population than anywhere in the western world. If we are to see this vitally important change in the way services are delivered, we have to accept that fresh money will have to be found from somewhere.

Thirdly, I turn to three of the biggest challenges facing the NHS at the moment: problems in general practice, gaps in mental health services, and the troubles in A&E departments. The problems in general practice have been well rehearsed. I had a letter from a young general practitioner the other day in which she encapsulated the difficulties she faced. She said she was increasingly exhausted as her workload just seemed to grow and grow. She pointed to the shortages of practice nurses and care workers, the difficulty in recruiting to those posts, the fact that many of her colleagues were retiring early and that general practice was becoming a very unpopular option for young medical graduates. It seems likely that that is the reason why it has proved difficult for the Government to encourage medical schools to get 50% of their graduates into general practice. It is striking, too, that she said that she had to spend up to 50% of her time in administration. What a waste of her valuable time, which could be much better spent in dealing with her patients.

So there is much to do there. We need to recruit and train more support staff, especially practice and district nurses, who are in such short supply; we should bring together bigger groupings of general practices into multipractices or the like so that there are economies of scale; we need to recruit and train more GPs by making the job much more attractive; and we definitely need to reduce the horrendous bureaucratic burden under which they labour. I am afraid that once again your Lordships will have noticed that none of that can be done without some additional funding.

On accident and emergency departments, which have been in the news so much of late, there is this somewhat optimistic view that once we have stopped people smoking, drinking and eating too much and once primary and community care is up to scratch, the pressures on A&E departments will disappear. But that, of course, is some considerable way off and it denies the evidence from everywhere else in the civilised world that there is a universal rise in A&E visits. So, once again, moving the deckchairs here will not solve the problem and it seems inevitable that more funds will be needed to recruit and fill posts, both medical and paramedical, in these desperate departments. We are clearly wasting far too much money on expensive locums when that money should be directed to permanent posts.

Mental illness, despite much rhetoric about parity of esteem between physical and mental illness, remains a Cinderella service. I suspect that other noble Lords will expand on this, but there can be little doubt that more resources are needed there, too.

Finally, I will say a few words about research and innovation in the NHS. The UK has been pretty successful in supporting medical research through both public funds and the research charities—and here I should express my interest as scientific adviser to the Association of Medical Research Charities. Some good things are happening here: for example, with the National Institute for Health Research, under the direction of Dame Sally Davies with the strong support of the noble Earl; the Health Research Authority is streamlining ethical approval; and the MHRA is providing quicker routes for licensing new medicines. However, there are many problems, too, because while we may be good at research, we are too often sluggish in taking up innovations. There are concerns that future funding for NIHR and its invaluable academic health science networks and centres remains uncertain, and there are also worries about the willingness of CCGs to support the Charity Research Support Fund. We are also failing to encourage and support those entering a clinical research career while their conditions of service are being neglected.

A tortuous funding approval process also gets in the way. It may come as some surprise to learn that to get the approval of NHS England for a new medicine to treat a rare disease there are no fewer than eight committees through which it has to go. It has been said that if you want to avoid making a decision, set up a committee. If you want never to make a decision, set up eight committees. That is a case where NHS England needs to look at its own efficiency, and if it is just an example of its committee structures, it has some way to go.

In the pressure for ever more efficiencies, we must avoid being so short-sighted as to leave research and innovation to wither away. The dividends we will lose are just too great. I believe we know what should be done—there is a growing consensus on that. However, it is increasingly clear that without an input of more resources we will not be able to rescue the NHS from this downward spiral. Even Simon Stevens, the chief executive of NHS England, has said as much. The next Government will have to face up to this issue and square with the public about how they intend to protect an NHS and a social service system that is so precious to them and to focus on the sources of the increased funds that are needed. I look forward to the speeches of other noble Lords and to the Minister’s response.

[Baroness Jolly (LD)]

I remind the House that time is very tight, so I ask noble Lords to keep their remarks to six minutes. When the clock shows six, your time is up.

--- Later in debate ---

[Lord Turnberg]

My Lords, I thank all noble Lords for their wide-ranging and well informed contributions. I have learnt a lot. I clearly cannot comment on every noble Lord’s contribution, but I particularly wanted to say how pleased I was to hear from the noble Baroness, Lady Wilkins, who is back in her place and in fine voice.

Clearly, we were never going to solve all the problems of the NHS today, but I believe that this debate has been a useful contribution as we ease our way into the next election. The next Government will have to level with the public, who are very supportive of the NHS, and grapple with the issue of how we might cope with the conundrum of paying for a service that becomes more complex as every day goes by.

Of course we should become more efficient, but I am reminded that Aneurin Bevan, when the NHS began, thought that as we cured and prevented more diseases the service would get cheaper. However, every year it seems to have got more expensive, and as we cure one disease, another disease pops up. It is an unfortunate fact that the mortality rate among humans is almost 100%—exactly 100%. On that happy note, once again I thank all noble Lords for their contributions and look forward to the next Government’s actions as a result.

Motion agreed.