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

Lord Hunt of Kings Heath Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I applaud the noble Lord, Lord Patel, and his committee for this excellent report. It is a huge wake-up call to all concerned about the state of the NHS and social care, which has been given added weight by this morning’s call by the noble Lords, Lord Darzi and Lord Prior, for substantial and long-term increases in funding.

The drivers of change—from demographic factors and changing disease patterns, to technological and medical advances and increasing healthcare costs—are intensifying at a relentless pace. The system, which was originally designed to treat short-term episodes of ill health, is now caring for a patient population with more long-term conditions, more co-morbidities and increasingly complex needs. With the share of the population aged 85 years and above set to increase from 2.4% now to 7.1% in 2066, this represents a formidable challenge for the NHS and social care. That is what makes funding so critical.

On average, spend on the NHS has risen by 3.7% in real terms since 1949-50. Yet at a time when pressures have never been so great, the Government and their coalition predecessor chose to cut adult social care and their spending on the NHS down to a miserable 0.2% per year average in real terms for the whole of the current decade. No wonder the NHS is reeling: targets have been abandoned; waiting times are growing; crude rationing is on the increase; doctors, nurses and other staff are demoralised; and there is huge unmet need in social care.

The Government’s response, to which the noble Lord, Lord Patel, referred, has been what I shall describe as underwhelming. What is remarkable is how many months it took the department to come up with its response. However, it has emerged that the Secretary of State is canvassing support for a long-term funding settlement, potentially embracing a ring-fenced hypothecated tax. This is something the Select Committee gave attention to. I particularly look forward to the comments from the noble Lord, Lord Layard, on this because he has done a lot of work in this area. I can see the attraction. It would enable the public to see a direct link between taxes paid and benefits received in the shape of the NHS.

National insurance is often favoured as the most straightforward way of doing that. English health expenditure in 2015-16, at £119 billion, is remarkably close to NI contributions for the same year, at £114 billion. However, to get to a baseline health and social care figure for England you would have to add another £15 billion for social care. You would then need to add in more to get the kind of settlement that the noble Lords, Lord Patel and Lord Prior, are arguing for, and that would cover only England because the devolved nations, in one way or another, would also have to be factored in. A rise of 1% in national insurance would raise about £5 billion, so to get a reasonable baseline figure national insurance would have to rise considerably. It would also be a huge figure for any Chancellor to effectively lose control of in all the schemes that are being proposed. I am not an expert on national insurance—

[Lord Forsyth of Drumlean (Con)]

Could the noble Lord indicate whether, when he talks about revenue from a rise in national insurance, he is talking about contributions from employees, or from employees and employers?

[Lord Hunt of Kings Heath]

It came from a paper from the Office for Budgetary Responsibility. I believe that it is to be a general rise of around 1% across the board, but I will check that out and place a copy of any letter that I send to the noble Lord in the Library.

The point is this: clearly considerations would need to be given if there were to be a rise in national insurance, such as to its impact on employees and employers. Would it be a tax on jobs? Would it be an increase in taxes on working people, when the main beneficiaries of the NHS are older people who do not pay national insurance? Although national insurance contributions are mostly progressive, they become much less so when you hit the upper earnings limit, where employee contributions decrease from 12% to 2% on incomes over £805 per week. I know some noble Lords believe passionately that this is the way forward, and it is an idea worth exploring, but we have to be realistic about some of the drawbacks.

[Baroness McIntosh of Pickering (Con)]

If 1% were added to national insurance contributions, what would the cost be to the health service, being the largest employer in the land?

[Lord Hunt of Kings Heath]

I do not know the answer to that but clearly it is another point that has to be factored in, as it would in the care sector more generally. We have already seen this: clearly, it is welcome that the living wage has been introduced, but it has had a knock-on impact when the funding for those services has not gone up at the same time.

I also caution about the desire to create a cross-party approach, as the noble Lord, Lord Patel, asked. Last month, Dr Sarah Wollaston, chair of the Health Select Committee, wrote to the Prime Minister asking for a parliamentary commission on health and care to be established to report on the long-term future funding of the NHS. Today, my noble friend Lord Darzi announced his independent review.

All this is welcome. The more we can debate the pressing need to fund health and social care properly, the more likely it is that the public will support a rise in taxes, which is what I believe this debate is essentially about. But the decision cannot be offshored. In the end, you need a Government with the political will to make the investment necessary, put in place a plan to fix staffing and properly support people to manage their own health care and conditions for the long term. Labour did it. We increased the amount of money going into the health service, reduced waiting times dramatically and invested in the infrastructure. It can be done, but it takes a Government with the political will to do it.

Alongside the issue of funding, we surely have to get on with redesigning the current regulatory and structural mess that the Government have got the NHS into. As the Select Committee report said:

“A culture of short termism seems to prevail in the NHS and … social care”,


with the department,

“unable or unwilling to think beyond the next few years”,

so there is no long-term funding plan and no national long-term strategy on workforce planning. The NHS is seemingly incapable of driving up productivity, using data effectively or adopting new technology quickly, as the Select Committee concluded.

The Health and Social Care Act 2012 has much to answer for. Its conflicting threads have led to fragmentation, friction and confusion. The Act is dominated by obeisance to a competitive market, with economic regulation to the fore. It established lighter touch oversight from the Government, with NHS England created as an arms-length organisation, subject only to an annual mandate, and GPs were supposedly put at the heart of decision-making through their dominance of clinical commissioning groups.

What has been the reality? Competition has proved a very expensive foible. It reached its ultimate folly with the competition authorities intervening in a sensible reconfiguration of service proposals at a cost of millions of pounds. Large parts of the competition regime have now been ditched but, as the Act has not been repealed, NHS bodies are endlessly at risk of legal challenge. As for light-touch oversight, the reality is that NHS England behaves in the way of all state bureaucracies: heavy-handed and highly interventionist. As for GPs being in control, so frustrated have CCG leaders become at their impotence and unwanted role as rationers of services that many have gone back to their surgeries or even retired.

Ministers preside over this with glorious ambiguity, consistently washing their hands of the shambles and performance failures that they and their colleagues created. The Secretary of State humiliatingly calls in the bosses of the so-called independent NHS Improvement, NHS England and CQC for a weekly berating and demand that ever more chief executives be sacked.

When the Sainsbury chief, Roy Griffiths, was asked to look into NHS management in 1983, he said that if Florence Nightingale were to come back to inspect NHS hospitals, she would find no one in charge. I wonder, if that great man were asked to come back to do a report, what he would say about the current arrangement. Actually, I think we have a pretty good idea. The noble Lord, Lord Rose, was asked by the Secretary of State in 2014 to recommend how leadership in NHS trusts could be transformed. By the time he finished, I think the Secretary of State regretted asking the question, because in his report he talked about the level and pace of change being unsustainably high, with the administrative, bureaucratic and regulatory burden fast becoming unstoppable. He talked about a lack of stability and a deep-rooted concern over the many and varied messages sent from the centre of government. Indeed, not surprisingly, the report died the death. We continue with a huge system that is under huge pressure, underfunded, under-resourced with people, and yet it is having to cope with one of the most complex, conflicting administrative systems ever seen.

One thing I particularly welcome in the report of the noble Lord, Lord Patel, is that he did not confine himself just to funding. He talked about the culture and some of the other issues that need to be tackled. The report is excellent, and we have an excellent debate ahead of us. I hope that the Government will listen. It is a great pleasure to follow the noble Lord, Lord Patel, who has shown such leadership in chairing the Select Committee and presenting his report so well this morning.