NHS Funding Bill (Money Bill)

Lord Bradley 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

[Lord Bradley (Lab)]

My Lords, I begin by declaring my health interests as given in the register. I would like to contribute to this Second Reading debate by discussing NHS funding and by raising, in particular, the crucial issue of mental health and other complex needs funding, which the Minister and other noble Lords have recognised.

During the debate on the Queen’s Speech, I suggested that, as well as enshrining

“in law the National Health Service’s multiyear funding settlement”,

it would

“also be appropriate to enshrine in law the commitment to achieve parity of esteem and equality of access between mental health and physical health expenditure over the same funding period, rather than merely retaining it as an aspiration in the NHS mandate”.—[Official Report, 9/1/20; col. 384.]

Clearly, this suggestion found no favour with the Government, but it is worth making the case again today for significant additional investment in mental health and related needs.

Let us consider some of the reasons why this is so important—for example, children and adolescent mental health services, or CAMHS. Currently, on average, children and young people visit their GP three times before they get a referral for a specialist assessment, and then have to wait more than six months for treatment to start. Children are reaching crisis point before getting the support they need, and the number of children attending accident and emergency departments because of their mental health, in a situation of crisis, is increasing year on year. Similarly, suicidal children as young as 12 are having to wait more than two weeks for beds in mental health units to start their treatment, despite the risk to their own lives.

As Justin Madders MP, our health spokesperson in the other place, identified in the Commons debate on this Bill, three out of four children with mental health conditions do not get the support they need. Over 130,000 referrals to specialist services are turned down because, as demand increases, thresholds for access to care rise. Appallingly, 400,000 children and young people with mental health conditions are not receiving any professional help at all. We know that mental health conditions in adults often begin in childhood, so the failure to adequately invest in CAMHS will end up costing the NHS far more in the long run.

We know that mental health represents about 23% of the total disease burden on the NHS, but a mere 11% of the NHS budget is spent on mental health; and only 15% of that 11% is spent on child and adolescent services. It is clearly welcome that the NHS long-term plan made a specific commitment to add a further £2.3 billion to the mental health budget by 2023-24, but as the Institute for Public Policy Research has pointed out, to achieve parity of esteem for mental health services, funding for those services needs to grow by 5.5% on average over the next decade. The NHS planned to spend £12.2 billion on mental health funding in 2019, but the IPPR estimates that this needs to reach £16.1 billion in 2023-24 and £23.9 billion in 2030-31. So, what is the Minister’s view on this apparent huge shortfall in investment in the mental health budget?

Of course, not all mental health and related services are funded by the NHS. As the Centre for Mental Health has noted, significant elements of mental health support for people of all ages come from outside the NHS, predominantly through local government. The largest part of this derives from adult social care, but there are important contributions from public health—for example, drug and alcohol services, suicide prevention and smoking cessation programmes. While it is accepted that NHS funding is projected to rise over the next five years, social care has only one year’s funding agreed to date, and public health services are yet to receive information on next year’s public health grant. This will clearly exacerbate the severe problems in a wide range of support services for people with many complex needs. Do the Government recognise the fragility of this situation and will they announce a robust funding settlement for social care in the Budget in two weeks’ time?

This fragility is further evidenced by the state of the workforce, as we have heard. There were a staggering 8,000 mental health nursing vacancies in England in the third quarter of 2018-19, with vacancies continuing to rise. One in 10 consultant psychiatric posts is vacant, as we have heard, rising to a dreadful one in six in child and adolescent mental health services, according to the Royal College of Psychiatrists. These figures underline the huge challenge to recruit the nurses to meet the massive needs and demands of the service. I welcome the decision to offer maintenance grants to people in nurse training from September. This will help to attract applicants, but universities such as Salford, where I am pro-chancellor, and NHS employers will still struggle to recruit, train and, crucially, retain the large numbers of additional mental health staff required over the next five years, especially, as we have heard, after the end of the transition period following exit from the European Union. The Prime Minister has committed to recruiting 50,000 more nurses across the NHS, so can the Minister confirm today how many of those will be specifically for mental health and related services?

I have two further points. The first is about speech and language therapy. From my work with the development and rollout of liaison and diversion services, and given that core services now cover 100% of the country, I recognise the value of speech and language therapists. I certainly hope that, with the additional NHS investment, they will form a key part of the further enhancement of liaison and diversion services. More generally, as the Royal College of Speech and Language Therapists has made clear, it is hoped that, alongside reform proposals in the NHS long-term plan, this Bill will help to ensure the provision of adequate services for people with communication difficulties and swallowing needs. As it points out, there are many such people in the United Kingdom. In fact, 20% of the adult population experience communication difficulties at some point in their lives, and more than 10% of children and young people have long-term communication needs.

In areas of social disadvantage, around 50% of children start school with delayed language and other identified communication needs. People with a range of conditions will also have swallowing needs. These include people who have had a stroke and those who live with various cancers or neurological conditions, such as dementia, Parkinson’s disease, multiple sclerosis and motor neurone disease, as well as those with learning disabilities and mental health problems. It is clear that speech and language therapists play a crucial role in supporting these people, their families, friends and carers, and the other professionals who work alongside them. It is therefore essential that the appropriate level of speech and language therapy be commissioned out of the extra funding in this Bill, so that those people’s needs are identified and met.

Finally, on capital funding, as we have heard, this Bill enshrines in law only revenue funding, but huge amounts of capital are required to address such major problems as maintenance and repair backlogs in the NHS estate and replacement of out-of-date equipment. The Government have committed to 40 new hospitals but amazingly, only six of these have been given the green light to proceed. One of the remaining 34 schemes —which I understand is “oven ready”—is North Manchester General Hospital, now part of the Manchester NHS hospital trust, in whose area I live. This hospital rebuild is desperately needed to meet the huge healthcare needs of the population of that area. When the Minister responds, will he tell me exactly when this hospital development will finally be given the green light to proceed as the seventh of the Government’s 40 committed schemes? Will he also give me the assurance I seek that the investment identified in this Bill will genuinely lead to parity of esteem and equality of access for some of the most vulnerable people in the country, who are suffering mental health conditions or have other serious complex needs?

--- Later in debate ---

[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.