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

Lord Bradley Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Bradley (Lab)]

My Lords, I first declare my health and university interests in the register. Secondly, I want to clearly record what a pleasure it was to be a member of the committee; I pay tribute to the diligence with which the noble Lord, Lord Patel, led the committee throughout our deliberations. I want to touch on three aspects of our report: the funding of and investment in the NHS and social care, particularly in respect of mental health; workforce planning; and the function of regulators and current governance arrangements. As a quick aside, I want to give some good news to my noble friend Lord Carter of Coles: I was discharged from the University Hospital of South Manchester 55 hours after my hip replacement operation and I pay tribute to the staff for achieving that outcome, although I am still hobbling slightly.

On funding investment in mental health, let me first put my comments in context. In 2015-16, NHS England’s budget was around £116 billion. Of that, the mental health budget was just 13%, but it is known that one in four people suffer from mental health conditions. The NHS Five Year Forward View estimated that the cost to the economy of not tackling mental health is £100 billion a year—effectively the entire cost of the NHS budget. Furthermore, only 7% of the 13% is allocated to children and adolescent mental health services, and while the recent addition of a £1.4 billion investment in CAMHS is welcome, it represents, spread over four years, a mere £350 million a year for the whole of England. That is less than £2 million for each clinical commissioning group, which will set its own independent priorities.

The current funding is woefully inadequate for adults and children, and the ambition to achieve parity of esteem between physical and mental health clearly has a very long way to go. As our report concluded, this will be achieved only when properly addressed through a genuine, long-term strategy of financial investment to meet the needs of people suffering these conditions. The Five Year Forward View for Mental Health was published in 2016 and the Future in Mind report for children in 2015. Although both reports made good recommendations for service improvement, funding remains the key area of concern to make continued improvement and transformational change for genuine integration of services. An example of this is the funding in the Future in Mind report, which is due to last only until 2021, having been extended by one year. That is a mere three years away, but it is non-recurrent spending that is currently not intended to continue beyond that point. A long-term commitment to continuing to fund improvement to children’s mental health care beyond 2021, for at least another 10 years, is essential if any early progress on better services for children and adults is to be sustained.

My second point concerns workforce planning. As our report made clear, the absence of any comprehensive national long-term strategy represents the biggest internal threat to the sustainability of the NHS. Early indications show that the Government’s reforms to undergraduate nursing education in England are failing to increase the number of nursing students required. Overall, applications to nursing courses have fallen by 33% since March 2016. Furthermore, applications from mature students have been disproportionately affected by the funding reforms, dropping by 28%, but it is mature students who are more likely to choose the shortage areas of mental health and learning disabilities. In addition, crucially, some courses may simply become financially unviable for universities to run, with a disastrous knock-on effect for local workforce planning. This must stop. The Government must urgently review their reforms to nursing training and develop a long-term strategy for the whole workforce in the NHS and social care.

My third point relates to governance and regulation. The committee stressed that the Health and Social Care Act 2012 has created, as we have heard, a fragmented system that is frustrating efforts to achieve further integration and the service transformation aims of the Five Year Forward View, which are crucial for the long-term sustainability of the NHS and social care. Too often, the independence of commissioners, particularly CCGs, on the one hand and the independence of providers, particularly NHS acute trusts, on the other creates silo working and barriers to stability of governance in delivering long-term transformation. This is exacerbated by the failure to implement long-term financial certainty.

Laudable attempts are being made for effective partnership working through a whole-system approach. The devolution of health and social care in Greater Manchester, my home area, is a prime example of this. We have also heard of the laudable efforts in Salford, which have achieved remarkable integrated results. But I do not believe that the benefits of such an approach can properly be realised until such partnership working has the crucial legislative back-up that is required.

Further, as we commented in our report, the regulatory framework might also not be fit for purpose. We recommended the merger of NHS England and NHS Improvement, but it would be helpful if the Government looked closely at the clear contradictions often displayed by NHS Improvement and the quality regulator, the Care Quality Commission. Strict financial limits are imposed on the NHS providers by NHSI through rigid financial control totals, while the CQC rightly identifies the need to invest in services to ensure quality of care and patient safety. This causes huge difficulties in practice. How on earth can this be addressed if provider bodies cannot invest beyond their strict control totals?

I would welcome the Minister’s views on these points and an assurance that the Government are genuinely committed to their ambition to move to a long-term financial settlement for the NHS and social care, which our report shows is so desperately needed; that there is a relentless emphasis on general integration of mental and physical health; and that more resources will be moved upstream to underpin preventive and early intervention programmes to support the population’s health and well-being, rather than just its ill health.