NHS: Long-term Sustainability

Lord Carter of Coles Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Carter of Coles (Lab)]

My Lords, it is a delight to follow the noble Baroness, Lady Boycott. She certainly has a different view on things. I congratulate my noble friend Lady Ramsay of Wall Heath; she gave a tremendous maiden speech and brings great experience to this House, for which I am sure we will be very grateful. I was particularly struck by her comment on reorganisation, which I will return to later. We have had too much of that and a little less performance. I draw attention to my interests in the register. The noble Lord, Lord Patel, made a tremendous, and very knowing, opening speech. It was very clever how he went across the whole spectrum of things. I am perhaps a little less Olympian and will focus on one or two more narrow things.

Modern, high-performing healthcare systems are characterised by high quality, high productivity, and critical, consistent and predictable funding. That then leads to high patient satisfaction. This is being achieved in other parts of the world. For patients, it means access, rapid diagnostics, timely care and rapid discharge, preferably to home. How is that delivered? It is by providing the patient with a seamless journey along the continuum of care. Nowadays, that can be AI-enabled, but that needs an IT system that sits behind it to provide the single view of the patient. It is siloed, and it is very hard to deliver integrated care—I am sure that my noble friend Lady Pitkeathley knows this—unless you have a data system that gives you that access.

In other countries where such a system has been deployed, we have seen diversion away from hospitals—something many noble Lords have commented on. Between 20% and 40% of people simply do not need to go in; they need to be treated in other places. One encouraging thing—the National Health Service gets things right sometimes—is that the integrated care boards stand a chance of delivering this, but we have to focus and get on with it. It will take five years, but it needs to be done.

In the meantime, we must operate what we have a lot better. There are a number of things that are key to that: getting the primary care contract fixed; getting healthcare professionals facing up to patients much more on a substitution basis; and streamlining the primary care back offices. These are simple things—they are managerial, but critical.

Acute hospital productivity must rise, which the noble Lord talked about. Why did it take us so long—perhaps the Minister can say—to go back to payment by results? In a system that is desperate for activity, we went to block contracts, which is as close to lunacy as you can get. Can we go back to payment by results, and can we broaden it to encourage more providers, so that we get diversity of provision and also location? We need to move closer to the patient, and the only way to do so is to create certainty of payment through the tariff system. Those are the straightforward things that we can do.

I suggest doing two things. I have already talked about payment by results but, secondly, we must simply face up to the issue of delayed discharge. As happens in many other countries, we need the National Health Service to pay for the first 60 days post discharge. That would cut it all out and get people out of the hospitals. It is a very straightforward solution. It must be paid for at some point—but better that it is paid for and the arguments are moved out to somewhere else while people consider how to fund it. Long-term care funding and social care funding are, I think, matters for another day.

No healthcare organisation can truly be efficient and deliver at high quality if it has appalling staff morale. According to the last staff survey, only 44% of those employed in the NHS felt valued, which means that 56% did not. Some 25% felt bullied by their colleagues or managers. In most health systems, if that figure got to 5%, they would have the drains up. This is absolutely hopeless.

What all this comes down to is a management problem. We have had a lot of strategies; we have great strategies. Again, Ministers sort of knew what to do, so they commissioned the Messenger report. That report was absolutely tremendous, and had nine things we can do to fix things. Perhaps the Minister can tell us if those nine things will be implemented, because it is two years since the report was published. If we do not get the management right, nobody will put any more money in.

I am short on time, but I just share a little anecdote. If you have a group of NHS managers, and you ask them to name the 20 best-run hospitals in England, you get the usual: Northumbria, Chelsea and Westminster—despite the diet—Leeds and South Warwickshire. People can name eight easily; if they are lucky, they name 10. At best they name 15. There are 135 hospitals in this country. What does that tell us about the depth of management? The critical thing, therefore, if this is to work—I will shut up in a moment—is to get NHSE working properly. I am not sure that I will be as dramatic as the noble Lord, Lord Warner, but we must face up to the fact that we do not have a working management system. It is Soviet, and we are way past Soviet times. Let us hope that we can save the NHS and keep it free at the point of delivery.