All Baroness Tyler of Enfield contributions to the NHS Funding Act 2020

Wed 26th February 2020
NHS Funding Bill (Money Bill)
Lords Chamber

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2nd reading (Hansard): House of Lords
3rd reading (Hansard)
3rd reading (Hansard): House of Lords
Committee negatived (Hansard)
Committee negatived (Hansard): House of Lords
2nd reading
Committee negatived
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NHS Funding Bill (Money Bill) Debate

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Baroness Tyler of Enfield

Main Page: Baroness Tyler of Enfield (Liberal Democrat - Life peer)

NHS Funding Bill (Money Bill)

(3rd reading)
Baroness Tyler of Enfield Excerpts
Wednesday 26th February 2020

(1 year, 7 months ago)

Lords Chamber

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Lord Hunt of Kings Heath Portrait Lord Hunt of Kings Heath (Lab)
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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.

Baroness Tyler of Enfield Portrait Baroness Tyler of Enfield (LD)
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My Lords, I am pleased to contribute to this Second Reading debate, and—as it is my first opportunity to do so—I welcome the Minister to his new role. I look forward to working with him.

This Bill sets out the current long-term funding settlement for the NHS, as set out in the Long Term Plan published last year. While I welcome the fact that the Government have provided a long-term funding settlement to provide some of the certainty we have heard about, the key question is not whether legislation is needed—frankly, it is not necessary for the Government to commit themselves in primary legislation to something that is already well within their powers—but whether the funding allocation for NHS England increasing to £148.5 billion by 2024 is sufficient to meet a decade of NHS underfunding, to respond to an ageing population and to meet the plan’s commitments to raise standards in healthcare.

As alluded to by the noble Lord, Lord Hunt, and like many external commentators, I note that the King’s Fund, Nuffield Trust and Health Foundation have all said that an increase of at least 4% is required to modernise the NHS and improve standards. In big picture terms, the overriding concern about this Bill is that it does not apply to the whole healthcare budget. As has already been said, NHS England does not operate in isolation, and to improve the health of the population, it is essential that new funding is accompanied by equivalent and sustainable investment in public health, social care and capital funding. Failure to invest now will simply increase the strain on the NHS and store up problems for the future.

I will focus the rest of my remarks on mental health funding, which the Minister focused on in his introductory speech. It was a positive step forward that the long-term plan placed a considerably stronger focus on mental health services, with a commitment that funding for mental health services would grow at a faster rate than the overall NHS budget, increasing by at least £2.3 billion per year by 2024. That is an important figure, which I will come back to. For far too long, people with mental health problems have had to put up with second class services, with too many people struggling to access treatment and support. Decades of underfunding and neglect mean that services are too often delivered in sub-standard and sometimes dangerous facilities and buildings, and there are significant shortages in the mental health workforce.

With that as the overall context, I of course welcome the commitment that funding for mental health services will grow faster than the overall NHS budget and that funding for children’s services will increase faster than total mental health spending per se. However, we must not underestimate the challenge of ensuring that money earmarked for mental health services reaches the front line. This is the crux of the matter that I want to talk about. Although the additional funding for mental health is ring-fenced in the long-term plan, it is unclear how this will work in practice. We need much greater clarity from the Government about how they plan to guarantee that this money is spent on front-line mental health services. Frankly, it is impossible to gauge this from the data currently available. I will say a few more words about this.

During the Commons stages of the Bill, a cross-party group of MPs supported amendments to require the Secretary of State to report to Parliament every year on whether the money received by mental health services was taking us closer to achieving parity of esteem. These amendments were not accepted by the Government—sadly, from my perspective—and, as this is a money Bill, we are of course unable to table any amendments here.

I was particularly enthusiastic about the amendment tabled by my honourable friend Munira Wilson MP, which would have required the Secretary of State to lay before Parliament an annual report on spending on child and adolescent mental health services. In my view, this would have done a lot to strengthen much-needed transparency and accountability in this area. However, to try to remain positive, I noted in Hansard that the Minister replying, Edward Argar, expressed some sympathy with the sentiment behind the amendment and agreed to meet Munira Wilson and other colleagues to discuss further what could be done to improve the reporting on children’s mental health services. I look forward to hearing the outcome of that meeting and hope that the Minister in this House will make a commitment that he will report back to noble Lords on what happens in those discussions.

I want to explain briefly why I think that the CAMHS expenditure is so important. When you analyse it at a national level, it all looks pretty okay; it looks like it is going in the right direction. But this masks continued and really worrying inconsistencies in reporting by CCGs, which prevent parliamentarians and researchers being confident in the figures published at local level. For example, 34 CCGs reported spending less on services for children and young people combined, including on eating disorders services, in 2018-19 compared to the previous years, with nine of those areas having reported spending cuts of at least 27%. This is hardly in line with the public commitment to spend more in this area. I also find it baffling that CCGs which are reporting spending cuts in the dashboard are simultaneously getting a tick to say that they have met the mental health investment standard. I am really perplexed by how this is happening and, if the Minister can shed any light on this, I shall be really grateful.

Something that I have been calling for for some time now is a separate children and young people’s mental health investment standard with a dashboard, so that we can get a more detailed breakdown on the way money is being spent on services for children’s mental health, ranging from preventive to crisis care. In the same way that the mental health dashboard reports on whether each CCG has met the mental health investment standard, it should also report separately on whether each CCG has increased the proportion it is spending on children and young people’s mental health. In addition, if any CCG fails to increase the amount it spends, I really feel that it should provide a public explanation of the reason. Speaking personally, I would also like to see sanctions applied to CCGs which do not provide a satisfactory explanation.

There are a couple of other areas which I would like to cover briefly. One is the workforce. Mental health has one of the most serious workforce shortages in any part of the NHS, and securing and retaining the right workforce is probably the biggest barrier to delivering the Government’s commitments to improve mental health care. We know at the moment that, to meet the promises already made for mental health and to reduce vacancies and cover requirements, we need about 4,500 additional consultant psychiatrists for 2029.

Where are these people going to come from? The recent census by the Royal College of Psychiatrists showed that the rate of unfilled NHS consultant psychiatrist posts had doubled in the last six years and that one in 10 posts is vacant. Despite the shortage of doctors, our medical schools operate under a strict admissions cap, often turning away highly qualified and ambitious students. We need to double the number of medical school places by 2029 to train enough consultants to fill the roles already promised. I would like to see places allocated in particular to schools that have a plan in place to encourage students to choose psychiatry.

Substantial investment in expanding the workforce is urgently required and I eagerly await the publication of the NHS People Plan, which, I hope, will set out how the Government plan to address these shortages. It is vital that the Government use the opportunity of the forthcoming Budget to commit to additional investment to support the recruitment and training of mental health staff.

Finally, on capital funding—this has already been alluded to—the review of the Mental Health Act found that mental health facilities where patients are admitted are often the most out of date in the NHS estate. At times, they have more in common with prisons than hospitals. There are badly designed, dilapidated buildings with poor facilities, which all contribute to a sense of containment and make it difficult for patients to be effectively engaged in therapeutic activities. I was particularly taken with what the review said about how inappropriate it was that we still use dormitory provision in mental health wards for people who have been sectioned under the Mental Health Act. It just does not seem right at all.

The Minister alluded to the fact that the Government have taken some steps to address capital funding issues, including announcing plans to build 40 new hospitals through the health infrastructure plan. However, so far, mental health has been almost totally overlooked in these discussions, despite the review’s findings. Therefore, I again call on the Government to use the 2020 Budget to set out a major, multiyear capital investment programme to modernise the mental health estate and bring it into the 21st century.

To recap, the Government must do more to ensure that the additional funding in the Bill leads to sustained investment in mental health in every local area in England, to address the shortages in the workforce and to commit to much-needed capital investment.

Baroness Finlay of Llandaff Portrait Baroness Finlay of Llandaff (CB)
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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”

and that

“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.