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

Lord Willis of Knaresborough Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Willis of Knaresborough (LD)]

My Lords, I begin by congratulating the noble Lord, Lord Patel, on his excellent introduction to this debate, his expert chairmanship of the inquiry, and his patience with committee members who sometimes resemble a herd of cats trying to be assembled into some order. Through his persistence in eventually getting a response from the Government, he has shown tremendous tenacity over the past 12 months. I am rather sorry that the spokesman from the Labour Benches immediately rejected the core thread of the report, which is: without consensus, we will go nowhere. Simply talking about the problems we have today, without being able to look ahead to 10 or 15 years, which is exactly what the report does, does a disservice to this House and the whole of the NHS and adult social care.

I am sorry that there was such a non-committal response from the Government, although it is gratifying that a number of the recommendations have already found their way into new policy initiatives. A department for health and social care is welcome, and we should celebrate it. The acceptance of a long-term funding settlement for health and social care is welcome and we should work on it. A return to a Dilnot-esque funding formula for adult social care again is back on the table, and a draft health and social care workforce survey is again extremely welcome. The latter is particularly welcome following an admission by the Secretary of State that,

“workforce planning is an area where we have failed, and successive governments have failed”.

However the strength of this report, with its wealth of oral and written evidence, is its recognition that the health service and adult social care is a very complex organisation. If we are to develop a 21st century system, we need long-term bold political decisions. Frankly, simply raking over the coals of past mistakes will not get us there.

We added “adult social care” to the title of our report as we swiftly recognised the folly of treating NHS and adult social care as separate organisms within a future healthcare ecosystem. Despite the compelling case for substantially more resources to secure long-term sustainability, we did not become preoccupied with quantifying the amount needed. We emphasised that resource must follow function and that a far more pressing priority for sustainability was service transformation. That point was forcefully brought home when we examined the development of the STP programme, where transformation has been largely abandoned on the altar of sustainability simply to achieve budgetary targets.

Service transformation maintained by long-term funding stability must be the holy grail for all of us, but that will not happen if transformation has to meet early and often unrealistic financial targets. This is particularly true of workforce transformation, where often double funding is required as systems overlap and develop. HEE’s recently published draft health and care workforce survey for England goes up to 2027 and commences with quote from the noble Lord, Lord Crisp, from an article in the Lancet in 2010, when he said:

“Health is all about people … the core space of every health care system is occupied by the unique encounter between one set of people who need services and another who have been entrusted to deliver them”.


That has not been the case. All too often, those who deliver services, the workforce, are treated as a commodity rather than as a precious resource. The fact that this is the first time in 25 years that the health service in England has consulted on a comprehensive workforce survey is as damning an indictment of past policy as it is ambitious about the future.

The consultation is in direct response to recommendations 6, 8, 9 and 12 of our report and, in particular, the challenge to Health Education England to take a far bolder lead in co-ordinating workforce planning with other key partners. While I declare an interest as a consultant to HEE, I applaud HEE and its colleagues in NHS England, NHSI, Public Health England, the Care Quality Commission, NICE and the Department of Health and Social Care on coming together for this initiative—the first time that has happened since 2012 and, again, it should be celebrated.

However, transforming the workforce will not be possible without challenging what Gavin Larner, director of workforce at the DoH, said are,

“strong culturally conservative parts of our healthcare system, where the different professional tribes see particular ways of delivering services”.

The committee recognised this challenge, despite the number of past presidents of royal colleges there, and recommendations 11 and 12 are directed at clinical hierarchies. The committee challenged the current length of medical training, the overreliance on traditional disciplines and early career specialisation, the difficulty in moving between disciplines, and the difficulty of the appellation of prior learning, even when postgraduate qualifications at doctoral level were reached in several appropriate subjects.

We challenged why, when 70% of patient episodes are dealt with in primary care, there is such an imbalance of postgraduate specialism in community-based practice. But we also applauded the initiative by HEE, supported by the NMC, to introduce nurse associate roles, recruiting and training some 5,000 additional colleagues this year, 50% of whom want to train as registered nurses. So we are growing our own nurses rather than depending on recruiting from abroad, adding to the skills mix on wards and in the community. Transformation means that many new roles will be introduced in traditional areas from surgery to midwifery, as well as nascent roles yet to emerge. The emphasis of royal colleges and other professional leadership groups as well as government and regulators should be on assessing their benefits to patients, not on fighting a rearguard action to protect past structures.

The future sustainability of the NHS and adult social care is not about more of the same but about developing a workforce that is flexible, ambitious and confident. As the report states, that will require continuous investment in healthcare’s most valuable resource, its people.