Health

Lord Hunt of Kings Heath Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, as we have debated public health so much, I must remind the House of my presidency of the Royal Society for Public Health.

I pay tribute to the noble Lord, Lord Crisp. He was a very distinguished chief executive in the NHS and Permanent Secretary, and more recently he has led some incredibly important work on global health issues. I thought he made a very profound speech this afternoon.

I, too, congratulate our maiden speakers, the noble Baroness, Lady Redfern, and the noble Lords, Lord Foster and Lord Smith. They were excellent maiden speeches and we very much look forward to hearing them, I hope, in the not too distant future.

We have had some amazing contributions from speakers: my noble friend Lady Jay on cross-government working; the noble Baroness, Lady Campbell, on independent living; the noble Lord, Lord Best, on housing. I find it quite remarkable that so many health and well-being boards do not have the housing sector represented, given that they are meant to be driving forward public health in their locality. We heard from the noble Baroness, Lady Masham, on the really worrying issue of sexual health programmes and policies, which risk being decimated because of the transfer of responsibility to local government.

The noble Lord, Lord Alton, spoke about the very different health and social care scene that we face now compared with 1948, yet we are still trying to work with a 1948 model. In fact, a lot of the barriers to the integration that noble Lords want to see are built into the very architecture—the targets that separate government departments set. I take the point made by the noble Baroness, Lady Walmsley, about vanguards, but until we get Whitehall to change its own architecture, it will always be driving forward the type of change that she identified with a hand behind its back.

The noble Lord, Lord Foster, talked about personal responsibilities, and the right reverend Prelate the Bishop of Bristol talked about isolation, which a number of noble Lords referred to. The noble Baroness, Lady Lane-Fox, talked about the NHS and technology. I agree with her—finally, having dabbled in this and spent a few billion pounds on the issue as well, we are on the edge of a major change in healthcare, and there are positive signs now coming through.

The noble Lord, Lord Smith, talked about human contact and the role of clubs, which I fully accept. The noble Baroness, Lady Neuberger, spoke about children and isolation, and the noble Lord, Lord Rea, spoke about the role of government in regulation and taxation, dealing with poverty in particular. The noble Earl, Lord Listowel, talked about loneliness and mentioned housing security in particular.

I thought that the noble Lord, Lord Mawson, was very interesting. He described health as an outdated silo and wondered how you translate excellence using the example of Bromley-by-Bow. I take his point. You cannot just ordain this: you have to grow it locally.

Clearly, in essence all speakers support the general point made by the noble Lord, Lord Crisp, which is that we need a paradigm shift in the way that we think about health and the role of the National Health Service. However, I am very wary of the five-year forward plan on the basis that suddenly, if we build these new models, we can actually expect to see a shift of resources from the NHS in order to fund them. I do not believe that.

If we look at the international comparisons, we spend so little on health and social care in this country. The recent OECD report showed that, of the OECD countries, we are 19th in terms of health expenditure per capita. In terms of doctors, we are 24th, nurses 19th, and hospital beds 26th, yet we know that the population will rise hugely. It has risen by 10 million in the past 10 years and it will rise hugely in the next 10 years. We have to be very careful not to think that suddenly we can turn off the tap of NHS provision by adopting this approach. All we can do is to slow down the growth.

I am very wary of people who think that the NHS can lose acute capacity. The idea that we could actually reduce the number of beds in the health service is ill-thought-out and ill-considered. It just does not accord with the reality of the pressure on the system. When I look at the five-year forward plan and the models, I can see that they are very good models, but the reason why no one believes we can reach the efficiency savings of £22 billion is that it is built on the fantasy of being able to transfer money from NHS acute care.

The other point made by the noble Lord, Lord Crisp, was about the huge range of inequalities in this country. The noble Baroness, Lady Walmsley, referred to the Commonwealth Fund, which gave us a great rating except in health outcomes. The OECD report does not give us such a good rating. Where it agrees with the Commonwealth Fund is about our appalling health status. Again, if we look at the OECD statistics for life expectancy at birth for men, we are 14th and for women we are 24th. It is the same when you look at life expectancy at 65. In terms of smoking among adults, we are 20th; we are 19th on alcohol consumption; and on obesity, where levels are appalling, we are 27th.^.There are 26 countries with a better record on obesity that this country.

We could also have mentioned mental health—again there is a huge worry about the scale of mental health issues. I have seen recent research suggesting that common mental disorders are twice as frequent in carers who care for more than 20 hours a week than in the general population. We know, simply from looking at population statistics, that the number of carers will have to grow hugely in the next few years.

The challenge is immense. I have to say to the noble Lord, Lord Prior, that the great thing in the five-year forward plan was the reference in a managerial document to the importance of health. That is the first time I have seen it so explicitly expressed. Yet, we see the public health budget being cut. It is so hard to fathom how a Government could do that. I hope that the noble Lord, Lord Prior, will address that in his response.

On the issue of Whitehall working, I agree with my noble friend Lady Jay. We used to have public service agreement targets which tied in different government departments into a common goal. I know that we can overdo targets, and I suspect we did, but there is no doubt that if different departments can be tied into a target that is enforced either by the Treasury, the Cabinet Office, or often by Downing Street, something does get done. This Government do not really do that.

We can see that in relation to the Department for Education. The Department for Education seems to be totally isolated from anything else in public policy in Whitehall. We debated a Bill on education recently. It is bizarre that, in respect of the Cities and Local Government Devolution Bill, which is all about the devolution of powers from Whitehall to the combined authorities, the Department for Education seems to know nothing about it and wants to have nothing to do with it. If we take the issue of obesity and the points raised by noble Lords on the lack of activity in PE, again the Department for Education is oblivious to this and its outcomes.

The DCMS is another example of a government department that does not understand Whitehall working at all. I have read its recent sports strategy. It is true that the Department of Health has a half-page in it, but why on earth is DCMS not doing, along with the Department of Health, a sports and health strategy?

In conclusion, this has been a great debate, but I would say to the noble Lord, Lord Prior, that the Government can do much; they cannot do everything. They can give leadership, and in this regard that is what this debate is asking for.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, I shall try to do this without hesitation, repetition or deviation, but I fear I shall fail on all three counts.

First, I echo what all noble Lords have said and thank the noble Lord, Lord Crisp, for introducing this debate, which has been fascinating. He brings to it a lifetime of experience in healthcare, both in the NHS in the UK and, of course, globally. He mentioned two quotes in his speech. The first was:

“Modern societies actively market unhealthy life styles”.

In a sense, that lies at the heart of much of what he said.

He also referred to the African saying: health is made at home, hospitals are for repairs. That is something we should take to heart. He has always said that we have much to learn from other countries, and perhaps we can learn a great deal from that particular saying.

I want to pick up some of the important issues raised by noble Lords in this debate. The noble Baroness, Lady Jay, talked about localism, about which she has some reservations. I suspect that that is an issue we will come to many times over the next few years. While I do not regard her as “a centralised dinosaur”, as she put it, the thrust of much of government policy over the course of this Parliament will be very much towards accountable localism.

The noble Baroness, Lady Williams, started her speech by almost praying for a whole-party approach to healthcare. It is probably unlikely, but it would be nice. She talked about prevention and education. I think that the curriculum for those aged up to 14 now has more time for nutrition and healthy eating, but she and other noble Lords mentioned the lack of time for PE. She also talked about mental health, domestic violence and equality of treatment for those suffering from mental health issues, something we all support in this House.

The noble Baroness, Lady Campbell, spoke movingly about what she called the empowerment model of putting patients—service users, or clients—much more in charge. We should not be so hamstrung by the medical model that has dominated healthcare for so long.

I congratulate my noble friend Lady Redfern on her wonderful maiden speech. She talked about nutrition—perhaps not surprisingly, as she said that she comes from a place where beetroot and celery are much talked about. She also talked about rehabilitation and reablement. Acute hospitals need to do a lot in the field of rehabilitation and reablement so that we can get much earlier discharge of care.

The noble Lord, Lord Best, reminded us that housing and health used to be part of the same department. I do not know how many years ago that was, but it is an interesting observation. He reminded us that home can become a trap, a prison—indeed, a fridge if the temperature is not right. Those were very important observations.

The noble Baroness, Lady Masham, talked very powerfully about the Paralympics and the power of sport. However, she also reminded us that there is no room for complacency about infectious disease and the treatment of people with drug and alcohol problems, and, of course, about the importance of hospital food.

I congratulate the noble Lord, Lord Foster, on his maiden speech. Like many of us, he was once a young rising star, but sadly those days are behind most of us. What he had to say about personal responsibility is very important. We can look to the state and to government institutions, but we need to take responsibility for ourselves as well, wherever possible.

The noble Lord, Lord Alton, made some very interesting comments about variation across the system. It is patchy. We talk about a National Health Service, but it is very different depending on where you live. It was interesting to hear him say that 660 million antidepressants have been prescribed where the underlying problem is loneliness, and that medicine is not a remedy for that. The right reverend Prelate the Bishop of Bristol quoted John Donne:

“No man is an island”.

We are all “part of the main”. I fear that the bell might be tolling for myself this evening, but he again made a very strong point. Social isolation and loneliness were common themes from many of your Lordships.

The noble Baroness, Lady Lane-Fox, knows a great deal about the internet. When she said that the organising principle of our age is the internet, she made a profound point. I have absolutely no doubt that the power of the mobile phone and of the various apps being developed will reshape healthcare. It will shift power away from medical professionals towards individual users. I believe that there is now an app that can monitor your life signs from a drop of blood taken once a month. That is hugely powerful. She warned us of the risk that so much of this technology is concentrated in a small number of highly successful technology firms based in California. We need to be well aware of that.

My noble friend Lord Smith talked about the importance of clubs, participation and social interaction. He reminded me of Burke’s “little platoons”, which are such an important part of society. He also reminded us that in 1666, the average life expectancy was 35, so we have come a long way since then.

The noble Baroness, Lady Neuberger, talked about loneliness and how hugging a young baby or child actually helps develop their brain. It is not just about the very young, but the old as well. Lonely people suffer both physically and mentally. We all love human interaction and know that it is not just the elderly who suffer from isolation; many parts of society suffer from loneliness. I fear that computers have not done us proud when it comes to interacting as individuals with others.

The noble Lord, Lord Rea, talked about the importance of primary prevention. He quoted from Sir Michael Marmot’s book on health inequalities, which of, course, is very powerful. I will write to him, if I may, on Sure Start centres after this debate. The noble Earl, Lord Listowel, talked before to me about loneliness and isolation, in particular the importance of relationships for looked-after children, adolescents and those in their early years. I am not familiar with the Bromley-by-Bow model raised by the noble Lord, Lord Mawson, but I would like to learn about it. I was fascinated by his strictures about replication: you cannot just pick up a model in Bromley and dump it in Birmingham, or probably in any other part of London. There are aspects, however, that can be translated. He said it is always better to start small, rather than trying to start big. In the NHS, we perhaps get ahead of ourselves sometimes.

I turn to the comments made by the noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt. This has been an important debate that reaches across a wide part of government. It raises issues that are not just pertinent to this country, but global. At their base, they reflect the fact that our population is increasingly elderly and people are suffering from many chronic long-term conditions. Lifestyles are causing a growing disease burden, particularly from obesity but also from alcohol and smoking. People’s expectations are changing all the time, and, of course, the cost of new surgical and pharmaceutical developments is huge. I suspect that genomic development and genomics will only add to those costs.

At the moment, however you measure how we fund these things—whether it is 16% of national wealth in America or more like 8.5% in this country or 11% in Germany—healthcare is consuming a vast amount of our GNP. Whatever health system you are in, there is an issue of sustainability. I believe that a strong economy is fundamental to any strategy that any of our parties would wish to have. We must have a strong economy, but that is not just so that we can afford better healthcare: it is actually more profound than that. It is because we have a strong economy that we will have high levels of employment. Work is a critical part of addressing some of the concerns of my noble friend Lord Crisp. If people have decent employment, they will tend to have higher levels of physical and mental health.

Education is also fundamental. It was Sir Michael Marmot, I think—or somebody else—who said that you could pretty much predict people’s future lifestyles from the age of 11. If their educational attainment is well below average at the age of 11, the outlook for the rest of their lives is not good. We also need to consider that the transition from adolescence into adulthood is also a critically important time. So I welcome the last Government’s and this Government’s increased commitment to apprenticeships.

The life expectancy of people living in Kensington and Chelsea was referred to earlier in the debate. I think I am right in saying that the life expectancy of people living in Salford is something like 25 years less than that of people living in Kensington. That cannot be explained just by reference to healthcare. Healthcare is demonstrably a very small explanatory component of such a difference in life expectancy. The differences are much more profound than just those associated with the NHS. When we talk about the health of the nation, it is tempting to focus just on the NHS, but it is only a very small part of it.

I wish to expand on devolution a little more because the driving force for devolution, particularly in Manchester but increasingly in the Black Country and other parts of the country, is to try to get greater economic regeneration. I believe that that, together with devolving more power to local authorities, will help to build a healthier society. I do not want to make a party-political point on this at all but I congratulate the principles underlying the work that Iain Duncan Smith has done in developing the universal benefit to try to make it easier for people to move from welfare into work. It is my fundamental belief that work is a crucial part of building a healthier society.

I wish to give noble Lords two quotes. Having said that the NHS is not a big part of this, I want to dwell briefly on it. The first quote is from the NHS Plan 2000. Perhaps the noble Lord, Lord Hunt, was a member of the Government in 2000. The NHS Plan states:

“The NHS is a 1940s system operating in a 21st century world”.

I believe that that comment, made in 2000, was profound. Now here we are in 2015 and the NHS Five Year Forward View states that,

“there is broad consensus on what that future needs to be. … It is a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment. One that no longer sees expertise locked into often out-dated buildings, with services fragmented, patients having to visit multiple professionals for multiple appointments, endlessly repeating their details because they use separate paper records. One organised to support people with multiple health conditions, not just single diseases”.

So we all know what the issue is and yet getting change in the NHS has proved extremely difficult. I take issue with the noble Lord, Lord Hunt: I think that we have to push these new models of care and treat more people outside hospital settings, not because it is lower cost but because it is better care.

[Lord Hunt of Kings Heath]

I am not arguing against the models; all I am saying is that I think there is a simplistic view that, if you develop the models, you can reduce the pressure on your acute care capacity. I, and I think many commentators, are doubtful about that, given that our acute care capacity is so much less than that of most comparable countries. That is the point I was making.

[Lord Prior of Brampton]

I understand that fully. To be clear, at the heart of the Five Year Forward View are both the new care models—the vanguards referred to by the noble Baroness, Lady Walmsley—and a change in productivity. I wish to dwell on productivity for a minute because the NHS is a lean system. I do not argue against that at all. It is a very high-value system. I was at a meeting with people from the Mayo clinic very recently and they said that they felt the NHS was the highest value healthcare system in the world. That does not mean that it is perfect. However, although we are always highly critical of it, by world standards it is a very good system.

We are going to address productivity through using much greater transparency—using the work of the noble Lord, Lord Carter—as well as trying to get a much higher degree of clinical engagement so that we get real traction. In the past we have had a top-down approach to try to drive through productivity improvements. This time we hope to have a much more bottom-up approach, with a much higher degree of clinical engagement.

The noble Lord, Lord Crisp, divided this issue into three, and the third aspect was the most important. The message is that it can be done. For example, the number of teenage pregnancies has been reduced by half. The number of people who die in fires has been reduced by half. Smoking prevalence has come down from 40% to 18%. Health-acquired infections such as MRSA and C. diff have come down very significantly. We can do it, if people work together.

Some of your Lordships may have read the McKinsey Global Institute report into obesity. It is a very good report. Obesity is a global problem: 2.1 billion people in the world are overweight—30% of the global population. It is going to rise to 50% by 2030. It costs billions of pounds and wrecks millions of lives. The McKinsey analysis makes three good points. First, there is no single intervention—no silver bullet. It is not just passing a sugar tax or a new regulation. In its view, when it comes to tackling obesity there are 74 separate interventions that must be done: housing, education, personal responsibility—it is a combination of all these things. Secondly, no part of society can do it on its own. It cannot just be top-down from government. It cannot just be bottom-up from individuals or the community. It has to be top-down, bottom-up and in between. Thirdly, you can never have all the evidence. If we wait until we have all the evidence about every single intervention, we will end up doing nothing. That is quite a good illustration of what the noble Lord, Lord Crisp, is aiming at. If we are going to have an effective strategy for obesity, which we will be revealing early in the new year, it has to be multifaceted. There is no silver bullet.

Treating illness is the tip of the iceberg that we all focus on but the much greater part of the iceberg is below the water. Improving and reducing health inequalities will require an effort that goes way beyond the NHS. Of course, the NHS has a big part to play but there is a much bigger and wider role for society as a whole. I thank the noble Lord, Lord Crisp, for raising this issue. It has been a fascinating debate and I look forward to pursuing discussions with him and others outside the Chamber.