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

Baroness Tyler of Enfield Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, in its excellent report, the Select Committee chaired by the noble Lord, Lord Patel, makes it plain that very significant investment in the NHS and social care is needed to ensure its long-term sustainability and avoid further damage both to the quality of and the access to care. Indeed, it is no exaggeration to say that the current system is near breaking point. We cannot carry on patching a gaping wound with a sticking plaster.

The recent Nuffield Trust report said that public satisfaction with the NHS is falling. The main reasons cited included staff shortages, long waiting times, lack of funding and government reforms. Primary care is particularly underfunded and overstretched, placing far more pressures further downstream on hospitals. A recent Daily Mail survey found that one in seven patients had to wait longer than a fortnight for an appointment with their GP. In a report earlier this year, the King’s Fund describes public health as dying from a thousand cuts. All the evidence shows that, to mitigate further costs, we must greatly ramp up our public health efforts to prevent disease. That was well addressed in the Select Committee report—but where is the response?

As the Select Committee report plainly stated, the issue of the workforce,

“represents the biggest internal threat to the sustainability of the NHS”,

and I want to focus most of my remarks there. As we heard in our recent debate in this Chamber on Brexit and the NHS, there are roughly 40,000 vacancies in nursing. Yesterday, the Guardian reported three times more departures from nursing than before Brexit. I was struck by a piece on Monday’s “Today” programme about GPs leaving because of the immense stress and pressure that they were under, which left patients in Plymouth regularly waiting two to three weeks for an appointment and one patient calling 93 times to be connected with her doctor. Britain has fewer GPs per person than other wealthy countries and, like nurses, they are leaving faster than they are coming. Those shortages increase the strains further down the system in the more expensive bits of the health service. A trip to the GP costs less than one-third of a visit to A&E. But nowhere is the situation more acute than in the mental health sector. Psychiatry is experiencing some of the highest vacancy rates—between 15% and 20%, with mental health nursing at 15%. In the current climate, it is salutary to note that some 40% of mental health staff come from overseas.

So what is being done about this? Health Education England’s recent draft workforce strategy provided, frankly, precious few solutions. There is a distinct lack of detail, with no modelling for the future NHS workforce beyond 2020-21. A better plan must surely look beyond the culture of short-termism to staffing solutions that can meet long-term demand, address supply issues, promote innovative and technological change and consider—this is really critical—new roles for health professionals and new ways of working for doctors and nurses. This should include applying best practice from overseas and looking at radical reconfiguration of services.

In addition, we must ensure that the workforce operates within far more efficient systems that allow people to get on with their jobs and to spend the time they need with patients rather than dealing with regulation and bureaucracy. Some of our current systems are very unproductive compared with other countries, which other speakers in this debate have touched on. It is clear that the NHS has yet to get to grips with these critical and worsening workforce issues and the current—opaque, I feel—division of responsibility between NHS England and Health Education England is not helping. Can the Minister, when he concludes, say who is ultimately responsible for the long-term planning on these key issues, such as workforce planning and productivity?

Turning specifically to mental health, what should be read into the fact that the key recommendation relating to mental health regarding parity of esteem was totally ignored in the Government’s response? To say it is not encouraging is something of an understatement. What does it say about the Government’s commitment to integrated care? The mental health investment standard is the statutory requirement to increase mental health investment in line with other services. However, recent data from the Royal College of Psychiatrists shows that more than one in 10 CCGs are failing to meet this standard. Can the Minister also say what action the Government intend to take in this area?

It sometimes feels as if we are engulfed in a veritable blizzard of new initiatives of the alphabet soup variety—we have STPs, ACOs and vanguards; I looked on the NHS website and there are a raft of others. I did not really understand what they even stood for and, frankly, it was impossible to understand how one related to another. We know the sustainability and transformation partnerships were set up to integrate health and social care across wide geographical areas, which is absolutely key to sustainability. But STPs have been told in no uncertain terms that they must prioritise cutting debt over everything else.

Achieving long-term sustainability will also need a far greater emphasis on integrated care. If I had more time—which I do not—I would give an excellent example in my own area, at the Whittington Hospital and the Highgate Hospital, of mental health and physical health having a really excellent physical health liaison service and working well together. From these small seeds longer-term change can grow, but it needs real political will and leadership.

On the big picture for future funding, I have been very interested to hear politicians of all stripes and other expert commentators talking about various ideas, including the Liberal Democrats’ long-term funding solution for the NHS and social care, which is a progressive hypothecated tax. Cross-party consensus is important and I hope that a cross-party commission will be set up. I am very rarely disappointed in the noble Lord, Lord Hunt, but I was disappointed at the beginning of this debate when he said that he did not think that was a good way forward. I think it is. We await further details from the Prime Minister on the long-term funding settlement but, frankly, we cannot wait much longer. Unlike previous cash injections that have gone into the black holes of hospital trust debt, any new funding must go to radical reform and, particularly, more resources for primary, community and mental health care.

To conclude, the time is right for a national conversation on all this; it is long overdue, which is something that I think the noble Lord, Lord Turnberg, said. The time is right for it now. The general public have responded quite positively to ideas such as an earmarked tax, as long as it is tied to deliverable promises of real improvements in the health and social care that they receive and they know what they will be getting for their money. This is where we really need to focus moving forward.