Department of Health and Social Care

Geoffrey Clifton-Brown Excerpts

Wednesday 5th March 2025 Commons Chamber

[Sir Geoffrey Clifton-Brown (North Cotswolds) (Con)]

Thank you, Madam Deputy Speaker, for granting us the opportunity to debate this supplementary estimate, which provides an opportunity for all Members of this House to look at the Public Accounts Committee’s report on health and discuss how the money might be spent on different priorities.

As the Chair of the Public Accounts Committee, I am honoured to introduce the first estimates debate on the supplementary estimate of the Department of Health and Social Care. I made this application jointly with the hon. Member for Oxford West and Abingdon (Layla Moran), the Chair of the Health and Social Care Committee, and my right hon. Friend the Member for Salisbury (John Glen).

As Members of this House will know, the Public Accounts Committee is one of the oldest Committees of this House. It exists to protect taxpayers’ money and ensure that their pound is being used effectively. It goes back, I think, to about 1867. Unlike other Committees, we do not take evidence from Ministers; instead, we take evidence directly from permanent secretaries and the most senior civil servants and public sector officials. The National Audit Office provides us with audited accounts and value for money reports, and we produce reports of our own with recommendations to Government to which they must formally respond as part of the Treasury minute.

At this point, I pay tribute to Amanda Pritchard, who has recently announced that she will be stepping down as chief executive of NHS England this summer. She oversaw the NHS at a time when it was under so much pressure post pandemic, and I wish her well in her future endeavours. I also congratulate Chris Wormald on his promotion to Cabinet Secretary. These vacancies at the head of NHS England and the Cabinet Office provide an opportunity for completely fresh thinking within the NHS.

[Layla Moran (Oxford West and Abingdon) (LD)]

I echo the hon. Gentleman’s thanks to Amanda Pritchard for her time at the head of NHS England. While I also welcome the appointment of Dr Penny Dash as its new chair, the hon. Gentleman is right to say this is a really important moment in the future of the national health service.

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[Sir Geoffrey Clifton-Brown]

I thank the Chair of the Health and Social Care Committee for her endorsements of the worthy work that all these individuals have put into the health service.

The Department of Health and Social Care is one of the highest spending Departments in the UK, with a total departmental expenditure limit standing at a huge £210.1 billion. I am not sure anybody believes that the NHS is working at optimal productivity. NHS England is the largest quango with the highest budget in Whitehall; however, when allocating funds, it is also one of the few Departments that is making life and death decisions that affect the lives of literally millions of patients and their families. I think it does, therefore, deserve the highest level of scrutiny, which is part of what we are doing today.

Before even getting on to the figures, the NAO confirmed that the level of productivity in the NHS has dropped by around 23% since the pandemic. I simply say that unless that is sorted, any reform that the Government announce will be sucked into the black hole of the NHS without commensurate value for money or results.

[Leigh Ingham (Stafford) (Lab)]

rose—

[Sir Geoffrey Clifton-Brown]

I do not want to give way to too many people; otherwise, you will reprimand me for taking too long, Madam Deputy Speaker. However, I am, of course, happy to give way to the hon. Lady.

[Leigh Ingham]

On that point specifically, I was at my local hospital—County hospital, in Stafford—a couple of weeks ago, where I noticed that staff were still using paper to make notes on patients. One of the biggest barriers to the NHS being more efficient is the inability to have effective digital systems. Does the hon. Gentleman agree that the investment that has been announced in the move from analogue to digital in the NHS is long overdue?

[Sir Geoffrey Clifton-Brown]

I agree entirely with the hon. Lady. She has obviously been reading my speech— I will cover the announcement later in my speech, at which point she will hear exactly what it says.

As I say, the NAO has confirmed that productivity levels have dropped by 23%. I welcome the Government’s commitment to a 10-year plan for the NHS. We have also repeatedly warned that, with an ageing and increasingly sick population, the NHS will struggle to cope with the ever-increasing multiple complex demands of our population.

I wish to split this speech into three sections: how productivity could be improved in the NHS; funding; and, as the hon. Member for Stafford alluded to, technical advancements and a shift into community care.

The Department of Health and Social Care’s day-to-day spending—RDEL—is set to increase by £10.9 billion—from £187.9 billion to the main estimate as produced today of £198.5 billion. The capital spending is, however, set to decrease by around £1 billion, from £12.5 billion to £11.5 billion—a decrease of 8%. That is worrying as it shows that more and more funds are being redirected from long-term investment—for example, in the new hospitals to which the previous Government had committed themselves. I welcome the new Treasury guidelines that have stopped the practice of the past few years of redirecting up to £1 billion from capital spending to day-to-day spending. That should help to make more money available.

The NHS estate, as we all know from our constituencies, is in desperate need of investment, and our capital investment programme is running behind schedule. The problems with reinforced autoclaved aerated concrete have only added to the necessity of upgrading our hospitals, and I hope the Minister will listen to this plea.

The latest NAO report on the DHSC annual report and accounts shows that local systems, such as integrated care boards and NHS providers, reported a year-end overspend of £1.4 billion. This has nearly doubled from £621 million in 2022-23. This was despite an extra £4.5 billion of additional funding during 2023-24, which was to support pay deals for non-medical staff, mitigate any impacts from industrial action and provide money to address the costs of new pay arrangements for doctors and dentists.

What I do not think is acceptable is the glacial pace of agreeing priorities and approving final budgets for the local systems. In November, our Committee was shocked to hear that, in the past two years, those local systems—ICBs and others—had not had their financial plans approved by the Department until June and May respectively. That is up to three months after the start of the financial year. How can our poor local systems plan efficiently when these final allocations and guidance are so late? If the Department’s own accounts were finalised much sooner, our local systems would be able to have the money allocated in a more timely way, making wastage and inefficient spending less likely.

I welcome the Secretary of State’s prognosis that the NHS is far too big and complicated. There should be a shift towards allowing NHS trusts more control of their own budgets, as clarified in the 2025-26 priorities and operational planning guidance published in January. Moving more funds directly to NHS trusts, ICBs and local systems will improve accountability and give them a level of flexibility about how their funds should be better spent, rather than just focusing on targets and directives. For example, if they were to run a surplus because they had run their operation so well, they could reinvest the money in desperately needed capital projects rather than returning it to Whitehall. That must also go hand in hand with a need to improve productivity. Between 1996 and 2019, the NHS averaged a measly 0.6% a year increase in productivity.

Since the pandemic, productivity has now fallen by 23%. In March 2024, the Conservative Government announced that the NHS would receive £3.4 billion of capital investment for digital improvements between 2025-26 and 2027-28, which begins to address the point that the hon. Member for Stafford mentioned. As part of that investment, NHS England committed to achieving ambitious average productivity improvements of 2% per year through to 2029-30. However, those digital improvements, presaged by that additional £3.4 billion, have not yet been fully actioned.

[Chris Vince (Harlow) (Lab/Co-op)]

I thank the hon. Gentleman for his speech and, importantly, for his scrutiny of the NHS. He reflected on the fact that productivity has worsened since the pandemic. Does he not think that is to do with the mental health of staff? To support our NHS professionals to be as productive as possible, should we not be considering looking after their health, including their mental health?

[Sir Geoffrey Clifton-Brown]

The hon. Gentleman is exactly right. The NHS employs an enormous number of staff—more than 1 million people, I think—and their conditions of work are really important if we are to retain them. That does mean that their mental health needs close attention, especially when they have problems. If the NHS cannot help with mental health issues, who can? The hon. Gentleman has hit on a really important point.

One reason that productivity is not improving more is that there are 19% more staff in the NHS, but they are seeing only 14% more patients. At our hearing, NHS officials stated that this was due to more complex and acute health needs, meaning longer stays in hospital. I also understand that it was due to staff sickness, absences and the then ongoing workforce industrial action that affected most patients last year, making targets more difficult to meet. I do not know about other hon. Members, but I am still getting emails from constituents whose appointments and operations were cancelled at the last minute due to that industrial action and who are still waiting for their procedures to be rearranged.

Along with staff, technology plays a big role in improving efficiency and productivity. The 2025-26 priorities and operational planning guidance stated that the NHS organisation

“will need to reduce their cost base by at least 1% and achieve 4% improvement in productivity.”

I understand that these figures are hard to pin down due to the NHS still negotiating with bodies such as the ONS on the definition of productivity and how it can be measured. I say to the Minister that, even if the numbers are disputed, we have still not seen a plan for how these productivity gains can be achieved, and the Committee believes that NHS England has produced unrealistic estimates. We need to have a realistic estimate from the Department of what productivity gains can be achieved over the next few years.

Without significant productivity gains, the NHS will not substantially reform waiting times and achieve the best value for the large amount of money that we spend on it. On average, there is a 4% real terms increase in our spending each year, when the economy is growing by only 1%, which is unsustainable in the long term. If we go back to 2013, the Health Secretary had set the NHS a challenge of going paperless by 2018. Clearly, as we all know, that has not happened, because the NHS is still using fax machines. In a digital age of AI, that lack of modernisation produces a risk to both patients and employees in the NHS. Investing in better technology would help with the Government’s ambition to shift more care into the community.

Community healthcare can take many forms, from GP surgeries and community hospitals to pharmacies, dentists and social care. I fear that when we talk about the NHS budget, we predominantly focus on hospital care, rather than the care that most of our constituents need every day. Indeed, Lord Darzi’s report, which was commissioned by the Government last year, said that

“the NHS budget is not being spent where it should be—too great a share is being spent in hospitals, too little in the community, and productivity is too low”

This is where I would like to pay tribute to our GPs and all their staff across the country, especially in the North Cotswolds. Our GP surgeries are usually the first point of contact with our NHS, from antenatal services to blood tests and vaccinations. They also offer a number of services that could be termed preventive care.

As a Committee, we questioned NHS officials on their prioritisation of preventing ill health rather than treating it, thus avoiding much more expensive hospital interventions in the future and a much better patient experience. Their reply was that they had little additional headroom to grow preventive services, yet the public health grant used by local authorities to commission preventive measures, such as health visitors and drug and alcohol services, is expected to fall in value next year by £193 million, despite the Government’s commitment to maintaining it in real terms. I cannot stress enough how I believe that we should be paying much more attention to prevention rather than cure; it is just so important.

NHS England said that, rather than moving funds, there should be a focus on the role of GPs and how they can advise their patients. However, according to the Royal College of General Practitioners, although more than 90% of patients’ direct experience of the NHS is through primary care and GP practices, less than 10% of the total budget is currently spent on primary care. I say gently to the Minister that we are getting our priorities wrong there.

As a Committee, we have recommended that the Government clearly define what counts as health prevention spending within the next six months and track that spending annually. ICBs should be given more flexibility in how they spend their money, which might include redirecting services to more community settings that are closer to patients. It might also include redirecting funds to help manage discharges from hospital. According to the House of Commons Library, the latest data shows that last year an average of 12,340 patients a day remained in hospital despite being clinically fit to be discharged. Even though there is a slight decrease of 1.2% from last year, more can be done to ensure that patients who are well enough can leave hospital for the community and be closer to their families. That will require better working between social care and hospitals.

[Andrew George (St Ives) (LD)]

The hon. Member is making a powerful case for reform and review. This morning, the Health and Social Care Committee was looking at the very issue of delayed discharge of medically fit patients. Does he not accept that we need more integration? If only a quarter of those delayed discharges are down to a lack of social care packages, that means many patients cannot be discharged because they have a primary healthcare condition that needs to be taken care of, so we need integration and not just social care reform.

[Sir Geoffrey Clifton-Brown]

The hon. Member makes an extremely powerful point. I am coming to the conclusion of my speech, which is on precisely that point.

The social care system is not working in this country. It is a political football that keeps being passed from one Government to another. I understand that the Government have committed to another review of adult social care and that we should not expect results until at least 2028; for many of our elderly patients, that will be too late. The funding of social care is rising exponentially. There needs to be more focused and joined-up thinking from the DHSC, NHS England and local authorities on how they can support those who need help to be discharged from hospital in a timely manner and live in their own homes for a longer period than they might otherwise be able to do. It should not be a postcode lottery, as exists now.

With more joined-up thinking between different parts of the NHS, the patient experience could be better. However, without substantial increases in productivity, increased spending on preventive care and public health, and a better functioning social care system, our NHS will never be able to operate at the optimal level with world-leading standards.

[Several hon. Members rose—]

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[Mr Clive Betts (Sheffield South East) (Lab)]

It is a pleasure to follow the Chair of the Public Accounts Committee, the hon. Member for North Cotswolds (Sir Geoffrey Clifton-Brown). Although we sit on opposite sides in the Chamber, we now spend most of our time in this place on the same side of the table in the Committee. I congratulate him on his appointment and the work he is doing as Chair.

The clear remit from the Secretary of State is to move to prevention, community care and digital services; that is how it is laid down. When we had the officials from the Department and NHS England before the Committee, we said that we thought they were complacent about the NHS’s finances. I thought that there was no sense of purpose or long-term strategy to deliver on the Secretary of State’s objectives; that was the worrying thing.

Let us look at the immediate problems. We have a service where trusts and others can run up deficits and seemingly there is no consequence. Unlike local government, which has to balance the books or go to the Government for approval to capitalise losses, that does not happen in the NHS. We have the problem in South Yorkshire that Doncaster hospital runs at a loss every year—I am not blaming the hospital, because it has an old building that needs massive refurbishment, or probably complete rebuilding, and it has not had the resources—and those losses go into the wider ICB system and put pressure on other hospitals and trusts not to distribute any surplus they might make to community services in Sheffield but to fund others’ losses. That is no way to incentivise a proper financial arrangement.

The hon. Member was absolutely right on moving towards community services, which is about not just getting people out of hospital but stopping them going into hospital in the first place. That certainly could be done. GPs hold 90% of appointments and get 10% of the funding. That is clearly wrong; we have got to switch that.

On social care, about eight years ago the Health and Social Care Committee and the Housing, Communities and Local Government Committee produced a joint report to which 22 Members of Parliament signed up, but we are still here talking about the funding. Louise Casey is a great appointment as she has a great “get up and go” attitude, but I am sure she could be asked to get up and go a bit before 2028, because that is a long time to wait for any response.

We should be looking a lot more at moving services out of hospitals. There is a proposal around—and I say “around” because the NHS does not tend to act quickly—a diagnostic centre at Crystal Peaks in my constituency. The south-east of Sheffield is a long way from the two teaching hospitals, so to put services such as MRI scans, ultrasound scans, X-rays and CT scans there and to have GPs working with consultants who come to see patients in their clinics in the community would save money and provide a better patient service. But that seems to get locked up in discussions about NHS financing and commissioning, and who gets paid what to see who and when. We have got to unravel that and recognise that services can be made to improve significantly.

On digitalisation, the example of fax machines is of course legendary, but the other week I had to change a hospital appointment a couple of times—the service was really helpful in changing it—and I got not merely three emails and three texts but three letters with a first-class stamp on them, all for one appointment. That is a complete waste of money. I have talked to the hospital in Sheffield, which is bringing in new IT systems to cover the whole of the hospital operation, but that does not link into the GP systems. It is just nonsense that in this day and age we have that sort of unjoined-up thinking.

I will raise a couple of other issues. The consultant who has been treating me for the last seven years—successfully at this stage—for my myeloma has got an idea. People have so much chemotherapy to go through—probably at least six different sessions, twice a week—and for those sessions they have to go into the day ward. That is all right for some people—my timetable was helpfully rearranged to suit me coming down here and going back—but for many that is not possible, particularly if they have to go to a specialist unit that is many miles away. He has developed an idea for home chemotherapy, which works and is good.

[Sir Geoffrey Clifton-Brown]

I am sorry to intervene on my deputy, who does an excellent job on the Public Accounts Committee. In the last Parliament, before he joined the Committee, we went to Denmark, where they do precisely what he is talking about: give chemotherapy treatment to people in their homes where they have a history of not reacting to it.

[Mr Betts]

Absolutely. Obviously, it is done with a clinician’s approval and with the patient’s agreement. The idea has been around for two years now, but again it is lost in the labyrinth of NHS discussions, boards and committees. Come on—let us do it now. It is a good idea, which is actually cheaper and benefits the patient. Why cannot these ideas be got up and moving much more quickly?

I absolutely agree with the comments made by the Chair of the Public Accounts Committee on public health. It is like an afterthought. The grant for public health comes out at least two, three or four months after the main grants for the NHS and local Government—it is like the money down the back of the sofa that the Treasury finds at the last minute—and over the years it has been cut significantly in real terms. Public health in Sheffield does an absolutely great job, working with NHS Sheffield Place. It has done some really good work in deprived communities to increase and improve community care in the north of Sheffield. That is the sort of initiative we ought to pursue, and we should give the ICB the wherewithal to support and engage with that.

Finally, we ought to build equality of treatment into our aspirations. In Sheffield, from one end of the city to another, life expectancy changes by 10 years. That is simply not acceptable. However, for child vaccinations, GPs get paid by the number of vaccinations they do, so those GPs with the easy patients to reach—probably those in the wealthier areas—get a lot more money for doing vaccinations than those struggling to engage with deprived communities. That sort of initiative from the NHS is wrong and we need to correct it.

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[Sir Geoffrey Clifton-Brown]

I shall be brief. I thank the Minister for her very comprehensive reply, and I congratulate her on her new role. I also congratulate everybody who spoke in this debate; there were some excellent speeches. Can I ask the Minister to thank her officials for appearing before my Committee? It is very much appreciated. I also thank the members of the PAC, a very hard-working Committee that produces two major reports a week, and in particular my deputy, the hon. Member for Sheffield South East (Mr Betts).

To sum up, as I said in my speech, productivity is the key to long-term reform of the NHS. Increasing funds at 4% per year in real terms when the economy is growing at only 1% in the long term is unsustainable, so something has to be reformed in the health service. As I did in my speech, I ask the Minister to consider producing a productivity plan, so that, without all the arguments with the Office for National Statistics and everybody else, we can see the DHSC’s best estimate for productivity gains over the next five to 10 years, and can start to see how such goals will be met. In such a productivity plan, modern digital technology will be really important. The Minister skated over one word that I am really concerned about, which is “cyber”. We had a wake-up call with WannaCry two or three years ago. The NHS has some very important personal data, so it is vital that we move towards modern machines that can withstand cyber-attacks better than some of the analogue equipment in the NHS.

It has been a great debate, and I am sure that the Minister will have plenty to think about.

Question deferred (Standing Order No. 54).