NHS Funding Bill (Money Bill) DebateFull Debate: Read Full Debate
Baroness Tyler of EnfieldMain Page: Baroness Tyler of Enfield (Liberal Democrat - Life peer)
My Lords, I am grateful to the Minister and welcome the opportunity to take part in this Second Reading debate. I declare my membership of the GMC, trusteeship of the Royal College of Ophthalmologists and presidency of GS1.
Extra funding for the NHS is always welcome. The Minister was confident that the Bill would give the NHS long-term certainty and all the money that it needs to implement the NHS plan—indeed, he said that it has been given all the money that it asked for. I just remind him that most people in the NHS understand and are clear that the amount of resources promised is nowhere near what is required. When he said that the NHS was satisfied that the money was sufficient he meant NHS England. I remind him that NHS England is a wholly owned quango accountable to him and his ministerial colleagues. The idea that it speaks for the NHS is taking quango-land fiction a little too far.
The Bill is certainly a departure—setting out the allocation to the NHS up to the 2023-24 financial year—but the suspicion is that it is little more than a political gimmick that is by no means sufficient for the needs of the NHS. There is no legal or government financial rule requirement for such legislation; it has never been done before. I am at a loss to understand why the Government have done it, because, as the Minister implied, it is quite clear that the Government will be forced during this four-year period to put more money in to shore up the deficits that will inevitably be run up by the NHS.
Our debate of two weeks ago on the performance of the NHS told its own story. Despite the heroic efforts of staff, 18.3% of people attending A&E in January spent more than four hours there from arrival to admission —the worst performance of any January since records began. The target on treatment within 18 weeks has not been met for at least four years. Other targets are missed consistently. We know that rationing is on the increase, and there are many other failings in ambulance services, mental health services and services for people with learning disabilities.
Clearly, many factors are at play in this, but when we align austerity with workforce shortages—the estimate is of a 100,000 FTE shortage at the moment—1.4 million people with an unmet social care need and a complete failure to factor in a growing elderly population, it is little wonder that the NHS is reeling under the pressure. The settlement of 3.4% growth per annum over a four-year period is certainly less than the 4% that most commentators have argued is needed—I actually think it needs more. I remind the Minister that the right reverend Prelate the Bishop of London—a former Chief Nursing Officer—said in our debate on the Queen’s Speech that the additional funding was not a bonanza and would serve only to stabilise NHS services and pay off deficits.
On deficits, NHS Providers trusts reported a combined deficit of £827 million and clinical commissioning groups a deficit of £150 million in the last financial year. The National Audit Office recently warned that trusts are becoming increasingly reliant on short-term measures, including one-off savings, to meet yearly financial targets. Clearly, many trusts in financial difficulty are increasingly relying on short-term loans from the Minister’s department, which, the NAO says in its recent report, are effectively being treated as income by these organisations, which have run up a level of unsustainable debt that reached £10.9 billion in March 2019. The NAO says that those trusts are very unlikely to meet any of that debt. Could the Minister say what is to happen to it?
The Bill is notable for what it does not include. The Minister acknowledged this. Little wonder that NHS leaders wrote to the Times at the beginning of this month, pointing out that the funding does not include areas crucial to the Government’s election promise of providing more nurses, hospitals and GP appointments. The NHS is facing a massive workforce crisis. The funding does not cover the education and training budget to help with recruitment and retention, nor does it offer any relief for public health and social care services that help keep people healthy and independent. The new migration policy announced this week, which excludes care workers as “lower-skilled”, simply adds more pressure to the social care system.
I have listened twice to the Home Office Minister’s response in your Lordships’ House. She blithely washes her hands of the problem, quoting the Migration Advisory Committee, which says that the care sector’s problem should be solved by the sector investing in making jobs in social care worth while. Have your Lordships ever heard such nonsense? How on earth, with the resources available, can the social care sector invest more in training and paying staff? At the end of this year, we will have an absolute crisis in the care sector unless, as I suspect, the Home Office is forced to reverse this ludicrous policy of excluding people coming to this country to help our care sector.
The Minister mentioned capital. The NHS was formed in 1948; 14% of its buildings are older than it is. He talked about the new hospitals. The backlog of maintenance is about £6.5 billion. The NAO produced a report that warned that the Government’s real story on capital is that in the past five years they have transferred £4.3 billion from capital to revenue to shore up the everyday finances of the NHS. The Minister is pinning his hopes on the NHS long-term plan to transform everything and make the NHS cope with the extra demand it faces. Excuse me for being a little cynical, but the NHS long-term plan is a reiteration of every plan that I have seen for the NHS in the last 30 years. It is based on the fiction that services produced outside hospitals will miraculously reduce the demand in those hospitals. Anyone who knows anything about the NHS knows that this is complete bunkum and that the Government have no chance whatever of getting anywhere near the targets that the plan produces. We will be carrying on the short-term funding crisis that we have seen over many years.
I am very glad to see the noble Lord, Lord Patel, in his place. One of the best reports on health in the last few years was that of his Select Committee on the Long-Term Sustainability of the NHS. It highlighted what he, and those working in the NHS and adult social care, described as a “culture of short-termism”, with the Minister’s department and front-line services absorbed by day-to-day struggles. Little has changed since then. I strongly support that committee’s recommendation on the establishment of an office for health and care sustainability to look at likely funding and workforce requirements up to 20 years ahead. Like the Office for Budget Responsibility, it would give authoritative advice to the public, Ministers and the NHS. Ministers would still set the budget, and answer to Parliament for it, but it would allow for a much longer-term workforce and financial plan for the NHS, taking account of the demographic pressures that we face over the next 30 years. Would it lead to more resources coming into health and social care? Nothing is certain, but it would set the context in which the country could come to a sensible decision about how much it will be prepared to pay for health and social care.
The Government’s decision to legislate with the Bill for the next four years is, on the face of it, to fund an unnecessary political gesture. Legislation clearly is not required and the Government will never be able to stick to these figures when the pressures come incessantly into the system. If, in time, it came to be a building block towards a long-term sustainable future, the Bill would be of no little significance. So far, there is precious little sign of that.
My Lords, I, too, congratulate the Minister on his new position and declare my interests as a past president of the BMA, a fellow of various medical royal colleges, and vice-president of Hospice UK and Marie Curie.
Yesterday, a letter went to the Prime Minister from the medical royal colleges and faculties and the Royal College of Midwives and the Royal College of Nursing, urging him to
“accept the recommendations of the report Health Equity in England: The Marmot Review 10 years on, and to go a little further.”
They announced that they
“are coming together to establish the Inequalities in Health Alliance”
“will be asking other organisations across the UK to join … particularly those representing social services and local authorities in all four nations.”
They went on to point out that
“The report published today by the Institute for Health Equity and commissioned by the Health Foundation, says life expectancy has stalled for the first time in at least 120 years. We are sure you know that there is a 15-20-year difference in healthy life expectancy between some of the new seats represented by the Conservatives, and others that your party has traditionally held. These disparities directly impact on NHS services, with emergency attendances doubling in the areas of lowest life expectancy.”
The letter goes on to say that it is essential that the
“government works with the devolved administrations”.
It points out that health is not in isolation and that
“earning a living wage is linked to healthy life expectancy”
“Poverty has the most impact on infant and child health”
and therefore that needs to be focused on too.
The co-signatories to that letter—a full page of them—make the point clearly that looking at health in isolation is not adequate. Although we all welcome the funding that will be coming forward and the fact that it will go to the devolved nations, the problem is that it will be made on a population rather than a needs basis. The funding needs to be according to needs-based consequentials. Taking Wales as an example—I declare an interest as somebody who lives and works there—we have a population that is iller, older and poorer. It matches the north-east of England and is now reaping the disbenefit of all that happened prior to devolution, with the problems of poverty, industrial closure, and so on.
Wales, like the north-east of England, has been heavily impacted by welfare cuts. It now has protected combined spending on health and social care that is 11% higher than in England, working out at £3,051 per head of population, and there is a policy to protect social care. I urge the Minister and the Government to abandon the phrase that social care workers are “low skilled”. They are not; they are low-paid. They are very highly skilled. It is the skilled social care worker who will avoid a hospital admission and sound the alarm before a problem arises; and when it comes to people with mental health problems, learning difficulties and so, I defy anyone in this House to claim that they will be any better than a skilled care worker at managing a crisis in the community. It is very difficult work. However, there is no protected spend in the Bill for population health and, as the Minister has said, there is nothing on public health, but change will occur only through public health initiatives.
In Wales, we are tackling alcohol-related harms by bringing in minimum unit pricing on 1 March. I declare my role as chair of the Commission on Alcohol Harm. Minimum unit pricing is already in place in Scotland. We also have the Well-being of Future Generations (Wales) Act 2015 and are trying to reverse our heritage of really poor health and lack of health gains in our population. However, in Wales, as in other less wealthy parts of the UK, we have until now been quite dependent on Objective 1 funding and the European Social Fund, particularly for the third sector. That money needs to be replaced. I urge the Government to recognise that not only is there a requirement for needs-based funding but they have a duty to replace the funding that has now been lost.
As I have said, across England the royal colleges are calling for social care to immediately receive better—and, indeed, sustainable—funding. This will alleviate the pressures caused by delays in transfers to care. There is no reason why people should be discharged late in the day. There is a fair amount of evidence that if people are discharged from hospital in the morning with a care package in place, the result is a lower number of readmissions and better long-term outcomes. Other than the fact that the system is completely gummed up and log-jammed, there is certainly no excuse for discharging people to their homes in the evening or during the night without adequate care being in place. There has to be integration between the sectors at every level, with efficiency built in, and that requires a new financial settlement for social care and finding a long-term sustainable solution to providing care and support for people in England. That will probably be one of the greatest challenges for England, Wales and Scotland in the future.
Years of underfunding in social care have meant that thousands of older people have failed to receive adequate funding for their care. Delays in transfers to care will continue, resulting in the accumulating backlog arriving in A&E. As the noble Lord, Lord Hunt of Kings Heath, has pointed out, the figures for A&E are worse than ever. That is through no fault of the A&E departments at all. In December, fewer than 80% of patients were admitted, transferred or discharged within four hours. This was a record-breaking monthly low and the 53rd consecutive month that the 95% target was not met. As well as 200,000 more people waiting more than four hours to be admitted this winter compared with the same point last winter, there were nearly 200,000 waiting more than four hours in trolley beds in corridors this winter, 56,000 more than this time last year. The number of trolley waits is almost six times more than last winter. These figures alone demonstrate the logjam that exists across the whole system.
Will the Minister, having announced that this is not a ceiling, confirm that the money to go for training and workforce, the money to go specifically to public health, and other funding will continue to be distributed as well to the devolved nations? As well as it being calculated on a population basis and the old Barnett formula, there should be a needs assessment, taking into account the sophisticated data that is now available from the Marmot review and similar reviews, so that the spending is actually targeted at the areas of greatest need.