NHS and Social Care Commission

Andrew Murrison Excerpts

Thursday 28th January 2016 Commons Chamber

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I rise to support the motion, and I hope in my contribution I will be able to explain why. I should first declare my interest as a licensed medical practitioner, albeit one who is in awe of my colleagues in the Chamber who regularly see patients, which is something I thoroughly commend. I think most of the people out there—apart from those who write for some of the more scurrilous parts of our national press—appreciate the fact that there are people in this place who are still engaged in medical practice of all sorts. It makes us relevant, it makes us current and it gives us some authority, as we have heard already today, when we talk about areas of expertise.

There are some omissions in the motion, however. I suspect that its magisterial generality is probably by design; nevertheless, it fails to mention public health directly, which is an important part of the piece. If we are to consider the entirety of health and social care in this country, we need to talk about public health, which I think, if I am honest, has been neglected by consecutive Governments, largely because nobody fully understands what public health is. There is not really an accepted definition of “public health”. It means many things to many people. Some of us still believe, I suppose, that it is a rather old-fashioned thing, to do with the pre-1974 vision of medical officers of health, who dealt exclusively with infectious diseases. It is much bigger than that. Public health pervades all elements of the public service and needs to be addressed head on if we are to deal with some of the pressures we face in the acute sector, as well as ensuring that we meet some of the imperatives that apply to health in this country, which, as my hon. Friend the Member for Bracknell (Dr Lee) has pointed out, should mean being focused pretty much exclusively on healthcare outcomes.

The right hon. Member for North Norfolk (Norman Lamb) mentioned outcomes almost in passing. Let me gently suggest that outcomes, mortality and healthcare experience throughout life are absolutely what we must be remorselessly focused on, and there the story is not a particularly good one, as the Commonwealth Fund made clear. Of course, the Commonwealth Fund report is quoted selectively by those who want to say that our system is the best there is, and that is fine: I trained in the NHS, I have worked in the NHS and I would be reliant on the NHS, so I defer to nobody in my admiration of the national health service and all that it stands for and does. However, it is naive to suppose that it is perfect in all respects, which is what I suspect really lies at the heart of this motion, as we look to the distant future.

The Commonwealth Fund says that outcomes in this country are not good, and I think our people deserve much better. I want outcomes in this country to be among the very best in Europe, not, frankly, in the lower quartile, as is too often the case with common forms of disease. We are betraying those who put us here if we demand anything less than that. The motion is relatively modest, because it tries to work out how we will square the gap towards the end of this decade. I think that, in the minds of those who wrote it, they are worried about the £30 billion—that will apply in five years’ time—but we are perhaps not looking forward to improve on where we are at the moment. There is too much talk, really, of marking time. The concern we have about the gap in funding makes us think that what we have now is good enough, but frankly it is not. We need to be much more ambitious, as we look ahead, about how we improve our health service right across the piece, including public health, to ensure that our health outcomes approximate the very best in Europe and not, in too many cases, the very worst.

The hon. Member for Leicester West (Liz Kendall) mentioned the Barker report, and she was right to do so. The Barker report was useful. The hon. Lady will not be surprised to hear that I did not necessarily agree with all its conclusions; nevertheless, Kate Barker produced some figures that were useful. She pointed out that spending on health in this country is less than in some of the countries with which we can reasonably be compared. She talks of Canada, France and the Netherlands, and suggests that by 2025 we will need to spend a great deal more of our national wealth on health and, by implication, social care, and I agree with that. She suggested 11% to 12%, which, given the demographics, is probably reasonably modest.

The dispute is about how we would deal with that, because £30 billion does not really come close, given what is happening. It does not come close even if we stand still, let alone seek to improve outcomes in the way I have suggested we must. The question then is how on earth we close the gap—whether we do it through general taxation, national insurance, some sort of hypothecated system or a mutual, as applies in France, for example, or whether we go for co-payment. I suspect there is pretty much a consensus in the House that we can discount some of the options fairly easily, but it is important that the commission that the right hon. Member for North Norfolk seeks to set up should examine all options, even if there is a general understanding that some of them will not be palatable, for a variety of reasons, be it fairness, efficiency or not being geared sufficiently well to the lodestar of outcomes. Nevertheless, we need to examine all options if we are to do this for the very long term, as I believe is the intention.

My hon. Friend the Member for Bracknell was right to focus on structure—something on which I believe there is a need for cross-party discussion and, I would hope, consensus. It is all very well talking about the NHS estate in general, but although what he described from his personal experience was terribly brave, I know from my personal experience that when that is translated into the specifics of our constituencies, for many Members it becomes extraordinarily difficult. It is the local that inspires many people in their love of the NHS. They would love to have their local hospital and local services that they identify with. When it comes to talking about the NHS estate, what we are really talking about is change.

Sometimes change is great locally, because it means a spanking new hospital, but too often it means at least a perception of loss, and people feel that acutely. One of the first things I did when I was elected here 15 years ago was to introduce a ten-minute rule Bill called the bed-block Bill. I find to my horror that, 15 years on, the issues remain. In essence, my Bill was designed to promote community hospitals—cottage hospitals. I had four in my constituency at that time and I felt that each was, for different reasons, under threat. I was a strong advocate for them, and the bed-block Bill, which was designed to promote them and unblock acute hospitals, was duly presented and, like all these things, duly drifted into the sand.

The issue remains relevant, but at the higher level we also need to talk about whether we are right-sized for acute or district general hospitals, and whether we should have these relatively small institutions across the country—far more than there would be in France, for example—offering, or attempting to offer, pretty much the same stuff. An example would be gastroenterology. The British Society of Gastroenterology has produced reports on this issue, pointing out that in many district general hospitals people are not guaranteed to have out-of-hours upper gastrointestinal endoscopy services available to them. I put it to the House that in the 21st century, not being sure that someone is going to be scoped if they have an acute upper GI bleed is simply not acceptable. That is bound to translate into poorer outcomes for a relatively common set of conditions.

It seems to me that the only way we can achieve better outcomes in that kind of situation is to think about whether we need to move towards regional and sub-regional specialist centres rather than continue with the pretence that we can mirror those services in each one of our district general hospitals. More commonly, people talk about stroke and heart attack—and the same applies. It is simply not the case that people will get the same treatment regardless of the hospital they go to.

This is professionally driven. It is the specialists themselves who are saying that we need increasingly to specialise. The day of the generalist is pretty well coming to a conclusion. In order to get that level of specialisation, we must have critical mass, and the only way of achieving that is by having a smaller number of what might be seen as “clinical cathedrals”—large centres offering highly specialist services, geared towards improving outcomes.

The downside is obviously where the cuts then come. Right-sizing the NHS estate inevitably means some will gain and some will lose in the process—in terms of the immediacy of services. Nobody wants to have to travel miles and miles to access services. We get complaints from our constituents about this all the time. There is a process of education for the public to go through. They need to make a choice. They have either immediacy of service just down the road to an institution that will give them sub-optimal care, or better outcomes of a sort that might reasonably be achieved in a regional or sub-regional centre. That is the choice.

Part of the work of the commission suggested by the right hon. Member for North Norfolk will encompass that work of education. That is one reason why, however, I think his 12-month timeframe is very ambitious. I would certainly not want to have a commission reporting in five or 10 years’ time, but the right hon. Gentleman will have to be more realistic about how long this will take if it is going to be an iterative process.

At a lower level, we need better step-up and step-down care. That is at the heart of our ability to unblock some of our acute centres. It is important to look at this issue again. The reason why community hospitals went ever so slightly out of favour relates to the costs of the services they provided, which occurred because the case mix was all wrong. Too often, this became a convenient way of relieving social pressures, admitting people ostensibly for medical reasons to a medical bed when those people primarily needed social care. It always comes back to social care, and if we put people requiring social care into what remains a medical bed, it will of course become impossibly expensive. That is why it did not add up. I am afraid that the onus is on the practitioners and the controllers of those places—general practitioners—to ensure that the case mix is correct. If we do that, community hospitals will become both effective and efficient.

[Mr Jim Cunningham (Coventry South) (Lab)]

One issue that has certainly come to light in Coventry when we are talking about bed-blocking—it is another factor associated with it—is that people cannot be released from hospital until they have a social worker arranged to look after them outside. Social workers are normally employed by the local authority, so if there is a shortage of social workers, the beds will be blocked again—at an additional cost. I think the commission should look at that.

[Dr Murrison]

The hon. Gentleman is absolutely right. It comes back to the issue of integrating health and social care. We have to say that some progress has been made in that respect.

At this point in my contribution, let me make it clear—despite the fact that this is intended as a non-partisan initiative—that I feel very strongly that without a strong economy, we will not make any progress at all. Improvement requires the sort of economy to which we aspire—not one such as has been sustained in Greece, Spain and Portugal. If we look at those three countries, whose healthcare systems were not comparable to ours before their respective crises, we should note what has happened subsequently, as their Governments have struggled to control their economic situation by making huge cuts. We need to be very aware that we have avoided that in this country. Without a strong economy, talking about improving public services across the board—and particularly in the huge area of healthcare—is, frankly, pretty pointless. There will not be the resources to sustain what we have at the moment, let alone the 12% increase suggested by Kate Barker in her report. That is fundamental.

I want to give credit to Ministers for sustaining the Stevens plan. We have heard some contributions today suggesting why that the plan might not turn out to be sufficient, but finding that sort of money at a time of austerity is a huge achievement, which should be acknowledged. I was proud to stand only a few months ago on a manifesto that supported the £8 billion spend. That allows us to have a service that is at least sustainable, notwithstanding my fears for the future and the inadequacy of our plans at this point in time, and should take us through to the end of the decade and beyond at a time when local government funding is being cut. That means that the pressure on social services, which was not anticipated by Simon Stevens, applies, while we face further pressures on the public health budget, too. Together, those pressures will mean having a deficit by the end of the decade that will need to be addressed. Beyond that, looking to 2025 and even further as Kate Barker has done, we need to determine how to find the extra funds that she feels are necessary, notwithstanding the dispute about where the funds might come from. I imagine that these issues will be examined by the commission proposed by the right hon. Member for North Norfolk when it is set up.

Let me finish with a few more small points about public health. Among my distinguished medical colleagues in this place, I believe I am the only one with a postgraduate qualification in public health and the only one who has done a job with a significant public health input. I have a bit of a soft spot for this discipline, and I hope I understand some of what it is about.

“Healthy Lives, Healthy People” has, in my view, been a success. It has set public health on the right track, handing back to local government a function that it arguably should never have lost, and setting up Public Health England, which I think has done a good job on the whole. I suspect that the Minister, who will answer the debate shortly, will have fallen off his stool when he read the King’s Fund report a little under a year ago, which essentially said the same thing—that public health appears to be on the right track in this country at the moment and that the changes introduced in the White Paper five years ago have largely been successful.

However, there is absolutely no room for complacency, as I am sure the Minister will agree, particularly when we have healthcare indices on areas such as our rate of teenage pregnancy. Although it has improved, it remains among the very worst in Europe. We do just slightly better than Bulgaria, Romania and Slovakia. Nobody here would be satisfied with that, I hope, and while we have public health indices as disastrous as that, there is no room for complacency.

One of my worries about what has happened over the past several months is that we appear to have changed from a model in which healthcare is pretty much exclusively funded through general taxation—that is to say, national insurance and income tax—to one that is partly funded by local taxation, with all that means when it comes to cuts in hard times. In my view, the sort of public health interventions that are having bits shaved off them at the moment are not discretionary, but essential parts of healthcare.

We can all come up with wonderful figures to show why we need to invest in healthcare. By and large, public health investment saves money in the long term, but the potential for public health intervention prevention services to have a real impact on people’s lives is truly enormous. Very little of it is going to happen overnight, so it will not show up on people’s metrics—certainly not within an electorally obliging timeframe—but they nevertheless remain.

If we are setting up a commission to look at how we do healthcare in the very long term, we most certainly need to focus on public health. We need to ensure that resources for public health are maintained and sustained. Those resources are not discretionary, but an essential part of what we should be doing for healthcare in this country—although I accept that when it comes to making economies, it will always be tempting to shave bits off public health services rather than cutting an acute service, which would be much more obvious to the public.

I support the motion, and I congratulate the right hon. Member for North Norfolk on tabling it. He is right to say that party politicians meddle with this national religion of ours, the national health service, at their peril. If we accept that we face huge challenges in the long term, beyond 2020, it is important that we not only engage in a national debate so that we can address some of the difficult issues that we have discussed this afternoon—the estates, for example, and how we pay for healthcare—but try to gain that usually impossible goal of securing some level of cross-party consensus.

--- Later in debate ---

[Jeremy Lefroy (Stafford) (Con)]

It is an honour to follow the right hon. Member for Don Valley (Caroline Flint), my hon. Friend the Member for Lewes (Maria Caulfield), the right hon. Member for Sheffield, Hallam (Mr Clegg) and other Members who have spoken. Excellent points have been made in every single contribution to the debate. One reason why I support the motion is that in my first contribution during this Parliament I said:

“Let us use the five years of this Parliament to set up a cross-party commission to look at health and social care for the next 20 to 30 years.”—[Official Report, 2 June 2015; Vol. 596, c. 524.]

I believed that then and I believe it now.

A substantial reason why I believe that comes from my experience representing Stafford since 2010 and my involvement in the community in the years before that. In the previous Parliament, there was a tremendous coming together of people from all parties in Stafford so that we could protect our health services and respond to the serious problems that we faced. We made proposals to the Government, as well as arguing with them and opposing some of their ideas, but we wanted to support our area’s health services. It was a privilege to be part of a process in which people from all the main political parties and none were putting aside their differences and working together. I know that a similar thing happened in other constituencies, but I was especially grateful that that happened in Stafford, given what we had been through.

Another reason why I strongly support a commission—or a commitment, or a way of bringing us together—is that there are incredibly important issues to decide. My hon. Friends the Members for South West Wiltshire (Dr Murrison) and for Bracknell (Dr Lee) made important points about the issue of specialism and generalism. There is a danger of going too far down the specialist route and thinking that everything must be in a specialty. According to the Royal College of Physicians, this country has something like 62 specialties, yet some of the royal colleges want to go even further. Indeed, I understand that there is a desire further to split up cardiology into interventional and non-interventional cardiology, although I hope that that is not the case.

By contrast, the RCP pointed out that in Norway there were just over 20 specialties—it is a more generalised system. Whereas I agree that specialties need to be concentrated in the way that my hon. Friends have suggested, we must not cast out general medicine. We must not cast out those who would like to work in a more general way in a more localised setting. For many people that can be a more satisfying route, seeing the broad range of health, rather than one increasingly narrow part of healthcare.

[Dr Murrison]

Does my hon. Friend agree that one solution might be to develop further the GPs with specialist interest model, which was started some years ago but, if we are honest, has never really found its place in our NHS?

[Jeremy Lefroy]

That is an excellent point. I declare an interest, being married to a GP. Many GPs are already doing that—many have specialist interests. Perhaps there could be a specialism of generalism, if that is not a contradiction in terms—the idea that it is possible for someone to say, “I want to practise my medical career in a smaller place where I do a wider variety of tasks, but I have the knowledge to recognise the limits of my competence and when to refer onwards.”

I welcome the motion and the commission, although I will suggest some boundaries to it. The points that have been made about not going over old ground and not making the commission’s remit so broad that it is of no earthly use are valid. The Barker report has done some tremendous work in that respect and I will come on to that. There are other reviews going on, which I am sure have not escaped Members’ notice. The maternity review under Baroness Cumberlege, to which I have made a submission, is extremely important.

Here again, we see the contrast. On the one hand, we want the best possible care for mothers, pregnant women and their children when they are born; on the other hand, women want to be as close to home as possible. In some cases, and with midwife-led units, which we have just got in Stafford to replace our consultant-led unit, that can work for a limited number of women, but probably only about 30% of women will be able to go into such units; 70% will have to go further afield. We need to think about whether that is the right model. In the UK the largest unit, I believe, is in Liverpool, with more than 8,000 births a year. In Germany the largest is the Humboldt in Berlin, with about 4,500 births a year. Is there something to learn from that model, from the French model, from the Dutch model? I am hoping that Baroness Cumberlege’s report will show us that and give us a clear path for maternity and newborn care in the NHS.

I welcome the Government’s commitment to fund the five-year plan. That was not an easy step to take, but it was extremely important. As far as I can see, funding has been increased even since the election, but as others have said, it is a very challenging plan. Nobody has ever managed to achieve £20 billion or £22 billion of savings and we are already seeing some potential problems with that. I was lobbied yesterday by community pharmacists, who are seeing potential cuts in the sums allocated, which may result in the closure of pharmacies in the future. Of course, reform is needed, but the Government need to look carefully at that area.

I welcome, too, the additional money for child and adolescent mental health services. I chaired a roundtable of mental health providers in my constituency a couple of weeks ago. The additional money, the first part of which is just coming through, was welcomed and should plug some of the gaps in that service, although there remains an awful lot to do, as the right hon. Member for Sheffield, Hallam so eloquently pointed out.

I shall focus on two areas—integration and financing. At present the two main acute hospitals serving my constituents, the Royal Stoke and the County hospital in Stafford, are full. As other Members have pointed out, this is at a time when we have not had a major flu epidemic or abnormal winter pressures. We have something like 170 beds at the Royal Stoke with patients who should really be out of hospital but cannot leave, and in the County hospital we have around 30 beds. Of course, that means it becomes more difficult for their A&E departments to meet their targets.

I must say that the people in those departments are doing a great job. I urge Members to watch the little online video recorded in the Royal Stoke by The Guardian and see just how hard they are working in a hospital that this time last year was going through a very difficult time. It shows exactly what we are talking about, with people working long shifts and putting patients first, as they are in the County hospital and, indeed, in hospitals up and down the country.

We clearly have a problem in getting people out of hospital. As Members have said, that was raised 10 years ago, but we have still not fixed it. That is a real reason for integration. It is something the commission needs to look at, not to reinvent the wheel, but to look at where things are working and say, “Let’s get this right across the country.”

I think that the supported housing review, which was discussed in yesterday’s Opposition day debate, is critical. If a lot of the funding for supported housing goes as a result of changes to housing benefit, we will see a greater problem, with more pressure on A&E departments and in-patient services.

I very much endorse what Members have said about community matrons and district nurses, who perform a vital role. Only this week my wife was talking about the work of the district nurses in Stoke-on-Trent and how valuable and appreciated it is. However, not many of them are available at any one time, particularly over the weekend, which means a lot of juggling to see when they can go out to see her patients. Members have talked a lot about integration, and they have far greater knowledge than I have. I will just make the point that the commission needs to look at best practice.

I want to spend some time focusing on financing. It is absolutely right that the commission should examine all the options, but I have to say that, having looked at this quite carefully over a number of years, I do not think that we have too many options. I tend to agree with the Barker commission on that. Its report states that there should be a ring-fenced budget for NHS and social care, and it rejects new NHS charges, at least on a broad scale, and private insurance options in favour of public funding.

I have come to that view because I do not think that there is any other way in which the volume of extra resources needed will be raised. At the moment—I stand to be corrected on this—we probably spend between 2% and 3% less of our GDP on health than France or Germany does, which could amount to an additional £35 billion to £45 billion a year that we need to raise and spend.

I have to say that the NHS is a very efficient system. Given that efficiency, just think what would be possible if we came up with that extra 2% to 3% of national income, as our neighbours in France and Germany do. I am not talking about the 18% that the US spends, which in my view is far too much. A huge amount is wasted in the US system, and it does not necessarily achieve the right outcomes, particularly for people who are uninsured—thankfully that is changing as a result of recent reforms—or in lower income groups.

That is where we will run into political problems, which is why it is so important to put it into a cross-party, non-party political commission. In our fiscal system we lump together many different things and call them public expenditure, but what is called public expenditure is, in fact, made up of very different categories of spending. There is spending on state functions, such as defence, policing and education, and then there is spending on individuals, of which the biggest categories are pensions, welfare and, of course, the national health service, yet we are coming to a situation in which we talk about it all as if it is tax. So often in politics tax is bad, yet a lot of this spending is good; the two things do not make sense. In countries such as Germany, the latter forms of expenditure—the more personal ones—are often provided more through income-based social insurance. In the UK we started with that system more than 100 years ago, with national insurance, but over the past 50 years we have allowed national insurance to become less relevant, except in relation to eligibility for the state pension and certain benefits.

--- Later in debate ---

[Heidi Alexander (Lewisham East) (Lab)]

It is a pleasure to follow the hon. Member for Central Ayrshire (Dr Whitford), and I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing the debate today. I thank all the right hon. and hon. Members who have contributed to the debate. It has been an important and well-informed one.

Many hon. Members have spoken about the seriousness of the financial challenge facing our health and care system. They are right to do so. Many hon. Members have also been right to say that we need a big, honest national debate about what excellent care services look like and how we might pay for them. I have been the shadow Secretary of State for Health now for just four months. In that time, it has become obvious to me that the NHS and care system is facing unprecedented challenges—huge hospital deficits, care home providers on the brink of failure, older people in hospital because they cannot get the support that they need at home, more critically ill people waiting longer than ever before for ambulances and large chunks of the workforce so demoralised that they want to up sticks and leave for the southern hemisphere.

For many people who use the NHS, this picture may sound unfamiliar. For the majority, the NHS still provides excellent care and it is important to recognise that and to thank the thousands of dedicated staff who ensure that that happens. But the system fails many others, and the risk is that it starts to fail more and more people as time goes on.

When I was asked to do this job, I knew that the NHS and care system was under pressure. I knew that demographic change and the march of technology, both in and of themselves good things, were placing demands on a system designed for a different century. As a constituency MP, I have visited isolated older people, many feeling like prisoners in their own home, surviving with the help of a meagre care package or the support of family and friends if they are lucky. As a local authority councillor, I saw the soaring demand for adult social care, and the woefully inadequate budget to deal with it. Demand is growing because our population is ageing but also because advances in medicine enable babies who previously might not have survived to live not only into childhood but into adulthood.

On a personal level, I knew that in my own family, my grandmother had spent the last few years of her life in and out of hospital on an almost weekly basis, driven as much by crises of loneliness as by a deterioration of her chronic obstructive pulmonary disease. I knew that my other nan was forced to sell her home to pay for her care when she developed vascular dementia, meaning that all but £23,000 of her £140,000 estate disappeared. All these things I knew before I became the shadow Secretary of State, but it was only when I visited hospital after hospital up and down the country in the past few months that my eyes were really been opened.

The image of frail, elderly people, perched alone on beds in emergency admissions units or in rehabilitation wards is the abiding picture that stays with me following my first four months in this job. It made me feel uncomfortable. As a childless 40-year-old woman, I asked myself whether that would be me in 50 years. Was it the best place to be? Was it the best we as a country could do? The image may have been uncomfortable, but the numbers say it all. One in four hospital beds are occupied by people with dementia. Half of all people admitted to hospital are aged over 65. More than 300,000 people aged over 90 arrive at A&E by ambulance every year.

When we get older—and it will come to all of us, hopefully—hospital will sometimes be necessary, but it should not become the norm. I know that we have to address this problem. The system needs to be redesigned so that it gets the right sort of support to people at the right time and in the right place to prevent problems from escalating.

We have to be honest, however, about the fact that this involves a price tag. While savings can still be made and there will be ways to make the system more efficient and less wasteful, there are simple underlying pressures that cannot be wished away. With every day that goes by, more older people are living with increasingly complex and often multiple conditions. Some say that family members need to step up and care for elderly relatives, but others say that that is unrealistic. New drugs and treatments also become available every day, yet at not insignificant cost. It might be tempting to brush these uncomfortable truths under the carpet, but we cannot, and we would fail generations to come if we were to do so.

That brings me on to the proposal that we are debating: the establishment of an independent, non-partisan commission to determine what a long-term financial settlement for the NHS and social care system might look like. I understand the superficial attraction of the proposal. I have been stopped on the street and in the gym by people I have never met who say, “Why can’t the politics be put to one side when it comes to the NHS?” I understand that sentiment, as politicians are not always the most popular bunch and we are too often seen to be advancing our own parties’ interests rather than those of the public. However, the way in which we fund elderly care is the most deeply political question that our country faces in the next decade, and it is political because it is about who pays and who benefits.

While the NHS is a universal, taxpayer-funded system that is free at the point of use, social care provision is a mixed bag. Those with money pay for care themselves, while those without rely on councils to provide what support they can. There has been a “make do and mend” approach to social care in recent times, but our changing population means that that is no longer an option.

I spoke earlier about my nan, a woman of limited means who experienced catastrophic care costs because she developed dementia. My family is not a rich family, but we are not a poor family either—we are like many families up and down the country. When I was growing up, my dad decided to take us on a two-week holiday to Spain each year instead of paying into a pension. He has never bought a brand-new car in his life, but he never let his children go without either. The costs of care faced by my nan and my family fell randomly. Is it right that a woman of limited means who dies of dementia at the age of 85 passes nothing meaningful on to her family when a wealthy man who dies of a heart attack at the age of 60 does? What about those who plan their financial futures having invested in expensive tax advice to avoid the costs of care? These are deeply political questions.

If the NHS and care system are to be adequately funded in the future, the truth is that a political party needs to be elected to government having stood on a manifesto that sets out honestly and clearly how we pay for elderly care, and how we fairly and transparently manage the rising costs of new treatments, drugs and technology. No matter how well researched, intentioned or reasoned an independent commission’s recommendations may be, someone at some point will have to take a tough decision.

Given the cross-party work that has been done in this area in the past, I think that I can be forgiven for being cautious. Let us take the discussions that took place between by my predecessor, my right hon. Friend the Member for Leigh (Andy Burnham), and the then Conservative and Liberal Democrat Opposition prior to the 2010 election. Just weeks before the election, the Conservatives pulled the plug on those talks, and accusations of “death taxes” were suddenly being hurled around. So much for a grown-up debate to answer the difficult questions. Take also the attempt at cross-party agreement in the previous Parliament which led to some of the Dilnot proposals on capping the costs of care. Those proposals were in the Conservative party’s manifesto, but were swiftly kicked into the long grass just weeks after the election.

I am not sure that attempts to take the politics out of inherently political decisions have worked. Even in the case of something straightforward—a new runway, for example—an independent commission has not exactly led to consensus on how to proceed. It has just led to more delay. As the well-respected Nuffield Trust has said, “Experience shows that independent commissions into difficult issues can have little impact if their recommendations do not line up with political, local or financial circumstances.”

How we pay for elderly care is one of the most difficult decisions facing our generation. It will require political leadership. A political party needs to own the solutions and be determined to make the case for them. I am not ashamed to say that I want the Labour party to lead that debate. I want us to build on some of the excellent work that has already been done in this area, in particular the work of Kate Barker and the King’s Fund. I want the Labour party to spend time talking to people up and down the country about the kind of health and care service they want to see, and to have a frank and honest discussion about what some of the different options to pay for that service might be.

I must be honest, though, and say that I think it was a profoundly political decision in the previous Parliament to cut the amount of money available to councils to pay for adult social care. I say gently to the right hon. Member for North Norfolk that he stood at the Government Dispatch Box and defended the cuts that his Government were making to social care. He dismissed many of warnings that my hon. Friend the Member for Leicester West (Liz Kendall) was making when she was the shadow Care Minister about delayed discharges, cuts to home care, and reductions in other vital services, such as meals on wheels and home adaptions. It is neither realistic nor right to pretend that we do not have fundamental differences on this issue. Any attempt at finding consensus must begin with an acknowledgement of the damage done to social care over the past five years.

[Dr Murrison]

I am grateful to the hon. Lady for giving way, particularly as I was not in at the very beginning of her remarks. It is most gracious of her. I have been listening carefully and she is making a powerful case. Then she came over all partisan. Does she not accept that fundamental to spending on healthcare, as with the rest of our public services, is a sound economy? Does she accept that this Government have had to make some extremely difficult choices in order to get that economy back on track?

[Heidi Alexander]

I accept that difficult choices have had to be made, but some of those choices have impacted enormously on some of the most vulnerable people in our society. The hon. Gentleman was not in the Chamber for the beginning of my speech, when I recognised the seriousness of the problem and the need for urgent action to tackle it. I want to find a solution that works and delivers the change that is needed.

The public are crying out for honesty in this debate. They understand the pressures created by rising demand and new technologies, and they want to be treated like adults. To suggest that this can be all neatly sewn up by an independent commission with the politics taken out of it sounds attractive, but I worry that it will not deliver. For the millions of people who depend on our NHS and social care system, I agree with the right hon. Member for North Norfolk that we cannot afford to have another Parliament where we fail to grasp the nettle. I know his proposal is well intentioned, but I fear that it is not the answer.

--- Later in debate ---

[Alistair Burt]

Well, the platform was clearly stunningly successful. I am not embarrassed by being reminded of the Labour party’s NHS platform at the last election, because it did not succeed. For one reason or another, the public did not believe the stories run about us and the NHS, and they did not believe in Labour’s competence to handle the NHS. As we know, the amount of private sector involvement in the NHS is extremely small, and I am not sure that I accept the hon. Lady’s description of how it has all turned out. This is an example of how careful we must all be in dealing with such issues. We must not pretend to our publics that we are something we are not and that our opponents are something that they are not.

My hon. Friend the Member for Stafford (Jeremy Lefroy)—he has great experience, given the work he has done with the NHS—spoke about best practice. He wanted the commission, but again added more pressure in the things it would be doing and considering. I would make the point that such a commission happens at a point in time. I know that it would be designed to look ahead, but it would inevitably consider the circumstances pertaining at the time. We need a process for discussing the NHS and its funding—where the money is coming from and how it is spent. We need to make the process work, rather than thinking that one push into the grass will do the job. Again, I am not sure that the weight will be borne in that way.

[Dr Murrison]

Earlier in his remarks my right hon. Friend talked about having a discussion within the confines of the Palace of Westminster. He appears to be moving in that direction again. Does he agree that there is a need for a more iterative process with the public at large? A commission of the sort that the right hon. Member for North Norfolk has proposed might go some way towards that.

[Alistair Burt]

I think that engagement with all involved is essential. When I am away from Westminster, engaging with patients, the public and staff is fundamental to the visits that I make to the services for which I have responsibility.

There is nothing to stop any of the work that the right hon. Member for North Norfolk is suggesting from starting. It is essential that everybody is fully involved. I do not think that the Government or the Opposition will make any of their decisions on the NHS or its expenditure by excluding anyone.

The hon. Member for Walsall South (Valerie Vaz), in a turbo-charged contribution, also spoke of the importance of getting integration right. She reminded us that Dick Crossman started it all off. I am sure that we have all had election manifestos that have spoken of an integrated transport system and integrating health and social care. Now we just have to make sure it happens. She made the point that no amount of talk or number of recommendations relieves someone of the burden of doing it. At the end of the day, it is doing it that counts. That is the role of the Government, while being appropriately challenged by all others.

I am delighted that my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) spoke of the importance of the workforce, particularly the workforce in social care, who have a very difficult time of it. They have great skills and need to be on a career pathway where they can acquire more. They also need to be valued. Again, my hon. Friend believed that the current mechanisms were better than others for dealing with these difficult problems.

To conclude, I will give my sense of the debate. I found it slightly hard to distinguish what the foundations of the debate were—whether it was about the quantum of funding or how the funding was gathered into the health budget in the first place. The commission is expected to cover a breadth of issues, but I am not certain that it can bear the weight. Decisions need to be made, no matter how the information comes forward.

We do not need a commission to deliver the process or to take the heat out of the debate. We have to be careful about how we speak about these subjects. By and large, what happens upstairs gives the public a good sense of how we deal with witnesses who come in from outside, members of the public and each other. We can do much more of that without the need for a commission. We must remember to handle things carefully.

I am not sure that structural change could be handled through a commission. That is very much a local decision. This is not all about funding; it is about how the funding is used. We have to ensure that we do not get into the trap of measuring everything by what we put in, rather than by output. One of the most telling points was when the right hon. Member for North Norfolk said that in the Commonwealth Fund analysis that gave the NHS such a good rating, the one thing it dropped down on was outcomes—treating people and whether people stayed alive. To most people, that is probably the most important outcome of all. We have to make sure that, for all the other good things that we are doing, such as the work the Secretary of State is doing on transparency and all the efforts we are making to give people more information, we recognise the importance of that.