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

Baroness Finlay of Llandaff Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, this important report is a 70th birthday gift to the NHS—a gift crafted and delivered expertly by my noble friend Lord Patel and his committee. Perhaps the Government’s response reads a little more like a hesitant thank you letter.

We must not forget that the NHS came into being following the Beveridge report and, as Aneurin Bevan entitled his book, it came In Place of Fear. To quote Bevan:

“The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health”.


We must not lose sight of that as we see an NHS in which fields of private endeavour have certainly developed improvements—but some aspects of commercialism, such as PFIs, have left the NHS deprived of its own funding. The recommendations on funding in this report now appear to have been taken up as government thinking, which is a fantastic compliment to the committee.

I would like to briefly address the issue of the workforce across several sectors and touch on opportunities for integration. As the noble Lord, Lord Willis, said, we depend on our workforce. A series of pressures, including Brexit, have compounded the strain felt everywhere. For doctors, particularly those in training, the events following the tragic death of six year-old Jack Adcock have shaken medicine to the core, because in many places the current system does not feel sustainable, with staff working at or beyond the limits of their capacity. This seismic effect has resulted in a loss of confidence in the system and has been felt in primary care. We need a workforce trained for today and for the future. The increased number of medical students is welcome but will probably not be anywhere near enough. We have been far too dependent for too long on importing staff at all levels for health and social care. In our changing world, we know there are predictions of shortfalls at every level.

For patients themselves, accurate diagnosis is essential. Reaching a diagnosis requires not only listening to the patients but picking up all the cues from around them and those who matter to them, as well as their environment. But diagnostic services underpin accurate diagnosis. Let me illustrate this with pathology. Pathologists are at the heart of cancer screening, diagnosis, monitoring and treatment. They diagnose tumours and determine the type of cancer, its grade and responsiveness. Blood cancers are treated by pathologists specialising in haematology. There has been a 4.5% growth in demand for pathology year on year, and longer survival thanks to treatment advances.

The tests to inform treatments are increasingly complex and, as has already been mentioned, screening will put a further demand on pathology—histopathology in particular. However, staffing levels have not risen in line with demand. Ten per cent of posts lie vacant and there is a predicted 25% workforce shortage by 2021 for both pathologists and reporting scientists, even allowing for information technology improvements. The Cancer Workforce Plan predicts that there will not be enough histopathologists in the NHS to deliver its ambitions.

Bevan had hoped that prevention would decrease the pressures of illness. We know perfectly well that it is not either/or but both. Prevention plus early diagnosis and rapid intervention are the challenges for the future. If we are to meet the challenges addressed in the report for better care in the community and freeing up hospital beds, the social care sector itself needs to address its recruitment and retention. Carers need to be registered, with a clear prospect of career progression. The Care Quality Commission has reported that a quarter of care homes require improvement. That cannot be ignored.

The pressure to move patients out of hospital beds into the community is so great that transformation and improvement at a local level is becoming a lower priority, yet it cannot happen without integrated systems. My noble friend Lady Murphy has already addressed this. More money alone will not solve the problem. People who go home early often do surprisingly well, yet our discharge services can be risk averse. People tell us what they need—but they need to be listened to.

Continuity of care is often provided by the social care workforce, who see someone day in and day out. They see the changes and the deterioration. But the problem of lack of integration means that, so often, people are bounced into emergency departments because that is where the lights are on 24/7 and the entrance door is there to other bits of healthcare. Emergency departments have seen an increase of almost 1.5 million attendances since 2010-11, equating to the workload of 10 medium-sized departments. Those pressures are still rising. They have been squeezed beyond the point at which the pips squeak. They know that safety is increasingly compromised. They are dealing with the sickest people, often in sudden crisis, across all disciplines, moving from one resuscitation to another—always calm, compassionate and competent, irrespective of the pressures and the severe distress they manage and the abuse sometimes hurled at them. How can you start a shift knowing that there are no ITU beds and that the hospital is full? The struggle is day in, day out. Some departments are putting in support such as positive reporting, mindfulness and the little things that recognise everybody’s importance. That cup of tea is terribly important.

In my last few moments I shall address a missed opportunity. I declare my interest as vice-president of Hospice UK. Better integration of hospices and the NHS can certainly free beds and result in an up to 40% decrease in the use of hospital beds, with significant savings of more than £1,000 per patient. It can improve quality of life. Yet this is a missed opportunity. We still rely on the voluntary sector to look after the most vulnerable at their most vulnerable time. The silos have to go. This important report needs action and its recommendations must be taken forward, underpinned by a radical commitment to a National Health Service. The NHS reaches three score years and ten this year, but it is not near the end of its life. This can be the beginning of a new era, developing from Tredegar and Bevan’s dream.