NHS: Long-term Sustainability

Baroness Cavendish of Little Venice Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Cavendish of Little Venice (CB)]

My Lords, I pay tribute to the noble Lord, Lord Patel, his tireless work for the NHS and, as the noble Lord, Lord Carter, called it, his Olympian view across the system that he shared earlier. I too will focus on only one or two things. I am very glad that the Messenger report has been mentioned, and I echo the noble Lord’s question to the Minister, because it is two years since it was written. Gordon Messenger, as someone who served in the Army, really does know how to run a system.

I will talk briefly about two things beyond hospitals that other people have already talked about: prevention and social care. On prevention, to echo some of what the noble Baroness, Lady Boycott, said, my simple question to the Government is this: when will they fully implement the 2015 obesity strategy, written under the Cameron Government, which included, for example, broadcasting bans on unhealthy food? I would have thought that that would be a very simple question to answer. It has now been quite a long time since that report was written.

On social care, I was intrigued by something that the noble Lord, Lord Patel, said, which I had not expected him to say: he spoke warmly about long-term care insurance. I thought I would take my cue from that and talk a little about it. In the past few years, we have seen many interesting proposals for better funding of personal care. We have seen the cap, led by Andrew Dilnot, which is due to come into force in 2025 but on which I note that there is spectacularly little activity. I think that there is an opportunity now, post-Covid, with a public who are much more aware of the value of social care than they were before Covid. This has become a politically salient issue in a way that it was not before, because so many people have seen what care workers really do and how many of them stepped up to the plate. We saw people moving into the homes of older and disabled people, leaving their own families and putting themselves at risk. That made a big impact in a way that it had not before. The truth is that you do not understand what social care is unless you or a relative are in receipt of it. The vast majority of people in this country still do not really know what it is, but the polls show that people are increasingly aware that it is complex, patchy and deeply unfair. People are increasingly prepared to say that, yes, we need more money but we also need a new look at the system.

As others have said, the single-payer system for the NHS is the right and only answer. I do not think that that should be reopened, as the noble Lord, Lord Patel, said. However, there is an opportunity to look for a different model for social care. On the long-term care insurance point that the noble Lord made, Germany and Japan, two countries that I have studied in depth, spent several years having a deep conversation with their voters about a long-term care insurance system—it is slightly different in each place—in which everybody pays something in and everybody is able, if they need it, to take something out. That is a simple, transparent and sustainable approach that we do not have at the moment. What we see at the moment are battles over continuing healthcare, where the primary health need is not defined, and 40% of care home residents paying all their own fees and cross-subsidising other people with less money. I could go on, but we are all aware of the depth of unfairness in the current system. I simply ask whether the Government have any plans to look at other possibilities beyond the simple cap on care.

One of the problems—and I think one of the reasons why Andrew Dilnot, a great man, is so frustrated, and why successive Governments have not implemented the policy—is that it is very hard politically to describe to people a cap that is not a cap; it does not cap the bed and board costs. Imagine being a politician on the doorsteps trying to sell people what is ostensibly a cap on what they need to spend but it is not. It is very hard to deliver that. The other issue is that while it would obviously help people facing truly catastrophic costs, it would help only quite a relatively small number of people. Therefore, there is an opportunity to have a much bigger and wider conversation. However, I am afraid that that would mean going to the heart of an issue that is dear to many voters in this country, which is the question of their primary asset: would they be prepared, and should they be made, to sell their home to pay for care?

I note that Boris Johnson changed his language on this over time. He discovered—as everybody who looks at the issue does—that you cannot get a sustainable funding system while making no claim whatever on the homes of people who, yes, have saved to buy that home but, yes, may have also been lucky that their home value has increased. Will the Government consider, or do they have any plans to consider, looking at that alternative to the Dilnot cap?