NHS Funding Bill (Money Bill)

Lord Bethell Excerpts

3rd reading & 2nd reading & Committee negatived & 2nd reading (Hansard) & 2nd reading (Hansard): House of Lords & 3rd reading (Hansard) & 3rd reading (Hansard): House of Lords & Committee negatived (Hansard) & Committee negatived (Hansard): House of Lords
Wednesday 26th February 2020 Lords Chamber

Moved by

[Lord Bethell]

That the Bill be now read a second time.

[Lord Bethell (Con)]

My Lords, the NHS is the top priority of the British people and this Government. The NHS itself has a long-term plan to transform services in this country and to ensure that it continues to deliver world-class care for everyone while transforming itself into a sustainable service fit to face the challenges of the 21st century.

To deliver this plan, the NHS has told us how much funding it needs, and this Government are providing it—£33.9 billion extra a year by 2024. Through this Bill, we will provide the NHS with the financial certainty of a fully costed financial settlement over the next four years. Let me be clear about those numbers. This Bill will guarantee that the NHS budget will rise from £121 billion in 2019-20 to £148 billion in 2023-24.

This is the first time any Government have placed such a commitment to public services in legislation. By putting this commitment into law, the Bill removes any political uncertainty around the level of funding for the NHS. In doing so, it gives the NHS the stability it needs to plan for how to deliver the long-term plan over the next four years. This multiyear funding settlement means the NHS is no longer confined to planning on an inefficient annual cycle in which long-term interests can become obscured by short-term uncertainties about future funding.

Instead, this Bill means that the NHS can make investments now, confident that it will have the money it said it needs in future. This is better not just for patients, who will continue to get a world-class service fit for the 21st century, or for the workforce, who can focus on what they do best—delivering clinical excellence—but for taxpayers. It is not just me saying it; this is what the NHS is saying. Sir Simon Stevens said:

“we can now face the next five years with renewed certainty. This … settlement provides the funding we need to shape a long-term plan for key improvements in cancer, mental health and other critical services.”

By bringing forward this legislation, the Government are giving an ironclad guarantee to protect this NHS funding. It creates a double-lock commitment that places a legal duty on both the Secretary of State and the Treasury to uphold this minimum level of NHS revenue funding over the next four years. This point is very important: the legislation explicitly states that the Bill establishes a floor, not a ceiling, for how much we spend on our most vital and valued public service.

I will give noble Lords some examples of what this money will be spent on. The financial stability will give the NHS the space to invest in innovative technology and harness digital revolutions, to move services into the community so that people are treated in the right place at the right time, and to work together to design modern, integrated health services.

During the engagement with noble Lords, and in the other place, there was, quite rightly, significant interest in particular budget items. The area of most concern was undoubtedly mental health funding, which came up time and again. Within this financial settlement, spending on mental health will rise by an additional £2.3 billion by 2023-24, meaning it will increase faster than spending on physical health, which represents a significant step in moving towards proper parity of esteem. This historic level of investment in mental health will ensure that the Government can drive forward one of the most ambitious mental health reform programmes anywhere in Europe.

This funding will improve access to evidence-based and meaningful care for 370,000 additional adults by 2023-24. This will include, for example, adults with eating disorders, people with complex mental health difficulties who are diagnosed with personality disorders, and people with mental health rehabilitation needs.

This funding will deliver our commitment that 345,000 additional children and young people will be able to access mental health services and school-based mental health support teams by 2023-24. This will mean that by 2023-24 there will be a comprehensive offer for 0 to 25 year-olds that reaches across mental health services for children and young people and adults. Access standards for children and young people’s eating disorder services will be maintained, and there will be 24/7 mental health crisis care provision for children and young people in general hospitals and the community in every area of the country. We are not there yet, but this Government recognise that our mental health and our physical health must be seen on an equal footing. They are working hard to ensure that mental health is treated as seriously as physical health.

Let me give some other ideas of what else the funding in this Bill will deliver. It will help to create 50 million more GP appointments each year so that we can reduce the time people have to wait to see a GP. It will pay for new cancer screening programmes and faster diagnosis so that we can save the lives of 55,000 more people with cancer by 2030. It will pay for the prevention, detection and treatment of cardiovascular disease so that we can prevent 150,000 strokes and heart attacks by 2030.

This funding will help us to create more services in the community, closer to home, with pharmacies playing a much bigger role. It will allow the NHS to invest in innovative technology such as genomics and artificial intelligence, to create more precise, more personalised and more effective treatments. It will also allow the NHS to upgrade outdated technology to save time for staff and save the lives of patients. Above all, the record funding in the Bill will allow everyone in the NHS to work together to make long-term decisions about how the health system should be organised and delivered—not tied to what we have done in the past, necessarily, but driven by a clear view of what the NHS must do in the future.

Let me say a few words about funding outside the scope of the Bill. This £33.9 billion commitment is for NHS England’s revenue spending only. It is important to remember that, in addition to this funding, we have made a number of commitments that are outside the scope of the Bill, including on training and capital. On training, we made a clear commitment in our manifesto to deliver 50,000 more nurses. The latest figures show that the NHS now has a record number of registered nurses, midwives, nursing associates and nurses in training. But the truth is that we need more. We need not only the right number of nurses, but for those nurses to have the right skills, as nursing increasingly becomes a high-skilled and highly technical role.

So, from this September, we will give every student nurse a free, non-repayable training grant worth at least £5,000 each year to recruit more people into nursing. We are also expanding the routes into nursing with more nursing associates and apprentices, making it easier to become a fully registered nurse. We are also prioritising the care of our nursing staff to encourage more of them to stay in the NHS for longer. This new training package to get more nurses into the NHS is in addition to the funding contained in this Bill. We have purposefully not included training in the Bill, as the Government are working with NHS England and HEE to identify and develop a number of programmes to deliver doctors and the 50,000 new nurses. It would be premature to legislate for the cost before we have completed that work.

The NHS also needs more money for capital investment. Better NHS infrastructure is a major priority for the Government. Modern buildings with cutting-edge facilities and equipment are essential to delivering the NHS transformation we want to see over the next decade—40 new hospitals across the country, £2.7 billion for the first six hospitals alone, £850 million for 20 hospital upgrades and £450 million for new scanners and the latest AI technology. This is just to get on with those infrastructure schemes that have already been given the green light; there will be more. More capital funding will be allocated as plans are developed and costed. We do not want to include it in this Bill before the plans have been fully worked out. There will therefore be additional funding for areas that are not covered by this Bill, including public health and social care; they will be dealt with at future fiscal events.

This is unlikely to be last word on the NHS that this House will have this year. We are considering the NHS’s legislative asks around the long-term plan and will respond in due course. We will, of course, be discussing the NHS regularly in debates and Questions.

However, for now, we have this short and straightforward Bill. It can be summed up in a single word: certainty. It offers certainty to the NHS, to its 1.4 million hard-working staff and to the country—that the NHS will have the level of funding it said it needs over the next four years to deliver the long-term plan.

We have an ambitious long-term plan that will allow us not only to meet the needs of today but to rise to the challenges of tomorrow. The key to that is delivering the investment that the NHS has said that it needs to deliver the plan. That is why I am proud to commend the Bill to the House, and I beg to move.

--- Later in debate ---

[Lord Bethell]

My Lords, I join those who have paid tribute to the work of my noble friend Lady Blackwood, my predecessor at the Dispatch Box, who made an invaluable contribution to the Department of Health and Social Care and is very sorely missed. I also thank the noble Baroness, Lady Thornton, for offering to join my campaign team. It is an offer that I am very happy to accept.

I was warned by the Chief Whip not to say that this was a vintage House of Lords debate and the House of Lords at its best, because it is hackneyed—but it is true. This has been a terrific debate, very highly informed and very challenging. There have been an enormous number of challenges in this debate—far too many for me to get through all of them—but I will try my best. Forgive me if I rattle through things a little.

I reassure the House that the NHS is the top priority of the British people, as a number of noble Lords have rightly pointed out, and of this Government. I know that there may be cynicism about the long-term plan that is being discussed today and about the Bill. The numbers that have been put forward in the Bill came from the NHS itself. The Bill enshrines those numbers in law. It is not a gimmick, and it is not Swiss cheese, as one noble Lord put it.

[Lord Warner]

I think most of us thought that these numbers came from NHS England, not the wider NHS. Can the Minister clarify that?

[Lord Bethell]

I am happy to accept that clarification. The noble Lord is exactly right: the numbers are from NHS England and they apply in that way.

To go back to Swiss cheese, the Bill is an ironclad guarantee to protect NHS funding. We are giving the NHS the certainty it needs to invest now for the long term. I thank the noble Lord, Lord Hunt, who put his finger on it. He spoke about the culture of short-termism and rightly mentioned—as did other noble Lords—the excellent report of the noble Lord, Lord Patel, on long-term sustainability. The natural human instinct to mitigate and to hedge when finances and money are uncertain has been remarked on in this debate. It is an entirely human instinct. The Government want to remove that uncertainty and to send a really clear signal to the system. We want to remove any sense of political risk about finance, so that decision-makers in the health system can make the best possible plans without looking over their shoulders to the finance director. They can instead be brave and make the best decisions possible and, in that way, implement the long-term plan in the most efficient way possible.

Where I have a difference of opinion with the noble Lord, Lord Hunt, is in his scepticism that reducing demand for hospital care is not possible. This Government believe that prevention is better than cure. That is why we are placing huge emphasis on community services, primary care and supporting people to live in the community, which reduces the number of people looking for acute care. We are investing in GPs and in urgent care centres to ensure that people are treated in the right place and at the right time.

I will talk first about the Bill in its essence. A number of Peers, including the noble Lord, Lord Hunt, have remarked that it is not enough money. I remind noble Lords that the plan comes from NHS England and that the Bill does not limit the amount of funding that we put into the NHS. Instead, it sets out a budget that must be at least what we have committed to. I reassure the noble Baroness, Lady Brinton, that this is not a cap. That is laid out clearly in Clause 1, which states:

“In making an allotment to the health service in England for each financial year specified in the table, the Secretary of State must allot an amount that is at least the amount specified in relation to that financial year.”


I will now tackle a few points of detail. The noble Baroness, Lady Thornton, asked about transfers from capital to revenue. We have said that such transfers were a short-term measure and are being phased out. Furthermore, the Treasury operates strict conditions on transferring between capital and revenue budgets. This is not a blanket ban. Sometimes technical adjustments between capital and revenue are needed for operational reasons, but these are a temporary measure.

The noble Lords, Lord Hunt and Lord Warner, asked about trust debt. We totally recognise that the stock of debt has grown and in recent years has become a significant financial challenge. We are working with NHS England and NHS Improvement to agree a framework of bringing provider debt down to an affordable level. We look to establish a new financing framework for 2020-21 that complements the NHS long-term plan.

The noble Baroness, Lady Finlay, was 100% right to raise the challenge of health inequality. We were all chastened by the Marmot review, which told uncomfortable truths. We completely accept the right to a long life. This Government are not ducking the challenge of health inequality. In fact, when we talk about levelling up, what could be a more vivid and valued form of levelling up than health equality? That is why we have put so much emphasis on laying down concrete commitments to these financial numbers and laying out, to the best of our ability, a long-term plan for the NHS.

The noble Lord, Lord Warner, asked a marathon six questions, which I will not be able to answer in their entirety. I will just tackle the question of cash not being index-linked and numbered. The NHS budget, like many other departmental settlements, is always set out in cash terms. This is essentially to deliver certainty. Experience has taught us that every time inflation goes up or down, budgets need to be reopened and confusion reigns. Furthermore, we as a House should remember that we are proposing a floor, not a ceiling; this is the kind of clear reassurance that has been asked for by the system.

I reassure the noble Baroness, Lady Brinton, that additional spending on the NHS in England absolutely leads to an increase in funding for the devolved Administrations through the Barnett formula—£7 billion for the Scottish Government from 2019-20 to 2023-24; £4 billion for the Welsh Government; and £2.3 billion for the Northern Ireland Executive. We will undertake a spending review later this year and will publish multiyear Barnett-based block grants for the devolved Administrations shortly afterwards.

Many noble Lords asked about the capital budget and quite reasonably asked why the Bill is about only revenue, not capital. The Bill is very much about protecting the record revenue spending for NHS England. However, we all know and totally acknowledge the requirement for capital investment. The Government have already made significant commitments: 40 new hospitals, with £2.7 billion for the first six; a further £2 billion capital spending, including £850 million for the first 20 hospital upgrades; and so on. I reassure the noble Lord, Lord Warner, and others, that further decisions about NHS capital will be made at a fiscal event in the very near future.

I note the comments of the noble Baroness, Lady Tyler, about the mental health estate and the use of wards. I reassure the House, and the noble Baroness in particular, that her arguments have been heard loud and clear. The Government recognise that the mental health estate is not satisfactory and are looking at ways to modernise these out-of-date buildings and arrangements.

The noble Lord, Lord Young, made a plea for GP surgeries. This resonates with me personally. The patient experience of arriving at a GP surgery is essential. Time and again, from my own experience, from what I know of human nature and from what I hear from patients, it is an unhappy one. In particular, the role of the receptionist at the GP surgery is unfortunate. I feel enormously for front-line professionals who have to deal with triage and the awkward conversations that take place. Something must be done to rethink the way we present ourselves to patients and that initial interface through the receptionist: a patient-first modernisation will be important.

[Lord Bradley]

Going back to the Minister’s comment about further capital announcements at an event in the very near future, will that allow the department to release the cash for the seventh hospital, North Manchester General?

[Lord Bethell]

The noble Lord asks a very good question. The answer is not in my mega briefing pack, but I will be very glad to get back to him if I find an answer.

The noble Lords, Lord Hunt and Lord Warner, asked, quite rightly, about maintenance, which is brought up during every hospital visit I make. We recognise the challenge that maintenance presents to the existing estate and the Government have recognised the need for further capital investment in the NHS by announcing, over the summer of 2019, a £1.8 billion increase in NHS capital spending, including £850 million for 20 more hospital upgrades. We know that more capital funding will be needed and this will be dealt with in the near future.

The noble Lord, Lord Bradley, asked about capital for North Manchester General Hospital and the prospects for a green light for the project. As part of our health infrastructure plan, 21 new-build projects across 34 hospitals are receiving £100 million seed funding to help plan their schemes and move on to the next stage. I am delighted that Manchester NHS will benefit from £4.6 million seed funding to help plan and redevelop North Manchester General Hospital.

I move from the Bill to the central thrust of the debate, which was not about the Bill itself, but about what was not in it. I start with mental health, because Peer after Peer addressed this subject. I reassure the House that spending on mental health in the NHS long-term plan is an absolutely massive priority for the Government. This historic level of investment—£2.3 billion by 2023-24—will ensure that this Government can drive forward one of the most ambitious mental health reform programmes anywhere in Europe. It will ensure that 380,000 more people per year will have access to psychological therapies; that 370,000 adults and older adults with severe mental illness can access better support; and that 345,000 children and young people will be able to access services.

I cannot say exactly how many of the nurses that we will recruit will be mental health nurses. That data is not available, but I can say that we are transforming community-based mental health support so that more people can be treated closer to home. We are ensuring that the NHS is delivering the commitment to increasing investment in mental health provision. As a result, we have required all clinical commissioning groups to meet the mental health investment standard. The noble Baroness, Lady Hollins, had some detailed and significant questions about how the mental health investment standard was being applied. Rather than try to give a half answer now, I suggest that we meet to discuss her data in detail. I should be glad to understand more about her concerns.

[Baroness Hollins]

I am grateful to the noble Lord for his response. He mentioned increased access to mental health services for many more people but, in my experience, people with learning disabilities and autism are often left out of those services and seen as requiring something different, whereas they need to be included in all services. Can he confirm and reassure me that that is the case in, for example, psychological therapies?

[Lord Bethell]

The noble Baroness makes an important point and her work in this area is well known. It would be, however, slightly outside the remit of the Bill to go into that in great detail. I do not have the answer she is looking for but should be glad to meet her to discuss this important matter. I share her concerns and my interests in the area are entirely aligned with hers.

My noble friend Lady Penn put us all on the rack regarding the mental health White Paper. I would very much like to give her the absolute date and concrete publication arrangements for it but that is slightly beyond me. However, I reassure her that it will be within the next few months; spring is the hoped-for arrival time.

[Baroness Penn]

Can the Minister define when spring ends and summer begins?

[Lord Bethell]

My noble friend asks a question of such philosophical Whitehall subtlety that it is way beyond my pay grade to provide a clear, etymological answer to that. However, I reassure her that the matter is an enormous priority, and when I go back to the department I will lean on it hard to deliver this important publication.

The commentaries of my noble friend Lady Penn and the noble Baroness, Lady Tyler, on the visibility of spending on children’s mental health was important. The Government are 100% aligned on this. I noted the Minister of State from another place standing at the Bar, nodding with agreement while those words were being said. I know that a meeting has been agreed on this matter and a date is in the diary, I believe for next week, and I very much look forward to the outcome. I reassure the House that this question of visibility and publication is taken ex3tremely seriously.

The noble Baroness, Lady Tyler, asked about the mental health investment standard. CCGs are required to increase investment in mental health, as discussed earlier. All CCGs are on track to meet that standard, as the noble Baroness, Lady Hollins, rightly pointed out in 2019-20. I suggested in my previous speech that it would be premature to legislate for specific aspects in the Bill and capital will be considered in other fiscal events.

The noble Lord, Lord Bradley, spoke movingly about children’s mental health. I reassure the House that, in addition to increased mental health funding, we are implementing a progressive programme of transformational change for children and young people’s mental health services. This will include incentivising every school or college to identify and train a senior lead for mental health, creating new school and college-based mental health support teams, and piloting a four-week waiting time for children and young people’s specialised services.

The noble Lord, Lord Hunt, the noble Baroness, Lady Finlay, and others brought up the sensitive subject of adult social care. Fixing that long-term issue is one of the great challenges that this Government have taken to their shoulders. The reassurance I can give noble Lords is a political one. There are many complex questions to address, but our pledge as a Government has been clear: everybody will have safety and security, and nobody will be forced to sell their home to pay for care. Delivering on this promise will require an enormous amount of stakeholder engagement and political bridge-building, and we are embarking on that important process.

The noble Baroness, Lady Finlay, was quite right to say that social care workers are wrongly described as low skilled. I entirely agree with her sentiments; they are low paid but highly valued.

I am running out of time and have a few more points to make. I will jump to the conclusion and say that the Government take this Bill very seriously. The execution of the money involved in the Bill is also taken very seriously. There have been a number of exciting, important ideas about how that money should be spent from the noble Lords, Lord Willis and Lord Kakkar, among others.

We made our commitment in the manifesto and the Queen’s Speech to enshrine record NHS funding in law. We are delivering on that commitment and putting the NHS on a secure and stable footing for the future. The NHS belongs to us all, and this Government are backing that idea. I commend this Bill to the House.

[Lord Warner]

Before the Minister sits down, I have a question. I have been digesting his answer to me on inflation-proofing. Is he saying one way or the other whether these figures will be inflation-proofed annually, with the passage of time? Two-thirds of NHS costs are pay, and there will presumably be some pay increases. What is the Government’s position on inflation-proofing these figures?

[Lord Bethell]

It is the convention in the Treasury to express spending commitments in cash terms. That is the convention of government and how this Bill is expressed. It is not the commitment of government to uprate these figures necessarily according to inflation. They are adjusted for all the potential inflation that may happen. That said, if unexpected events happen or pressures are great, there is the opening and the capacity to increase spending if necessary.

Bill read a second time. Committee negatived. Standing Order 46 having been dispensed with, the Bill was read a third time, and passed.