Health and Social Care in England

Lord Crisp Excerpts

Thursday 11th July 2013 Lords Chamber

[Lord Crisp]

My Lords, I, too, congratulate my noble friend on securing this debate and on his excellent speech. In fact, there have been many excellent speeches and, as a result, I have completely rewritten what I was going to say. I declare an interest as a former chief executive of the NHS and I have many non-commercial health interests, mainly abroad.

The core issue here is that we have an NHS designed and created in the previous century that is trying to deal with the problems of this century. We have an NHS that is focused on illness not prevention, that separates GPs and primary care, that is designed to treat episodic illnesses—heart attacks, infections and cancers that are not chronic diseases—and we need a different sort of health service. We need a massive change in the way that it is delivered, using technology, using staff differently and changing the infrastructure. I agree with the noble Lord, Lord Filkin, that that is a major change, and that it is the fundamental change that needs to be done, but we can make a start on it. It is important that we have a clear vision of what we want our health and social care system to look like in the future. This debate is not just about funding. Using the wrong model to deal with today’s problems is a recipe for inefficiency. We are not alone. Every developed country has the same issue. If we look across the Channel at, for example, France and Germany—which, incidentally, spend 20% and 25% more than we do—according to the United States Commonwealth Fund, they are less efficient in how they do it than we are. So this is a common problem. It is a big problem but we can make a start on it.

There are no simple solutions but let me mention two possible ones. First, the most interesting study on waste in health systems comes from the United States. It is estimated that 30% to 40% of expenditure in the health system in the United States is waste. The biggest reason for that is not overtreatment and the sort of things you would expect in America; it is a failure to co-ordinate care. It is somebody with multiple problems having to go to one doctor for this problem and to another doctor for that one. It is a failure to co-ordinate that and having repeated inputs into the system. It is also not getting the treatment right first time. Those are the biggest impacts on waste. I suggest to the Department of Health that it might wish to use the same methodology to look at waste within the United Kingdom because I think we will see a lot of similarities.

Paradoxically, we need to focus on quality in order to manage costs. As people working in industry will know, this is the way to do it. The Japanese guru, Kano, talks about three levels of quality. The first level of quality is doing it right first time—actually doing what is needed to deal with the problem, making sure that if you are in hospital that the X-ray or whatever is needed is done in time so that you do not have to spend the rest of the following week there as well. The second level of quality is doing the same thing but with cheaper inputs. The obvious question in the NHS is: to what extent can things that are done today by doctors and people working expensively be done by other people within the system? And the third level of quality is adding something. It is only that third level of quality that adds cost; the first two save cost. We see it across industry and in the best examples in the UK. Many people in the NHS know this and there are many isolated examples. This could be the really big push that I believe is needed to tackle many of these issues.

The second area, which I have touched on, is staffing. Reducing the drug budget by 10% saves 1% of the NHS budget; reducing staffing by 10% saves 6% or 7% of the NHS budget. We need to be much bolder and braver in thinking about who does what within the NHS, particularly when we are aware that new technology allows things to be done. We know how we can do that well. There is plenty of evidence of task-shifting or substitution, using people who are less trained and skilled but properly supervised to do things, not least from the All-Party Group on Global Health which I chair and which published a report looking at this worldwide and demonstrating how this could be done.

So those are two areas where I believe there is a great deal more that we should be doing. Before we get too radical about trying to change the financing system, we should be focusing on changing the NHS. In conclusion, this debate needs to be about the NHS and the social care system we need. There are no simple answers but there are many promising leads. Political, NHS and social care leaders need to do much more to lead and to win the arguments about the future with a sceptical public. There is at the moment, I believe, no clearly articulated vision from either Front Bench. We need one if the NHS and social care are going to continue to serve the UK population effectively in the 21st century.