NHS Long Term Plan

Lord Hunt of Kings Heath Excerpts

Thursday 31st January 2019 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

To move that this House takes note of the NHS Long Term Plan, published on 7 January, and the case for a fully funded, comprehensive and integrated health and care system which implements parity of esteem, preventative health and standards set out in the NHS Constitution.

[Lord Hunt of Kings Heath (Lab)]

My Lords, in opening this debate I declare my interests, particularly those relating to health, as listed in the register. The NHS gives extraordinary care to people in the United Kingdom. It enjoys huge popularity. Yet it is struggling. Austerity has taken its toll. We have seen a deterioration in services and the key access targets have not been met for many a month. Add in increased rationing of treatments, cuts to public health funding, inadequate mental health services and disinvestment in social care and it is hardly surprising that the NHS faces unprecedented pressure. This is what makes the NHS plan so important and why it is important we debate it today to try to turn this around.

I can say at once that much in the plan is welcome: the expansion of primary and community care; the drive for integrated care; the emphasis on clinical services for young people; and the identification of clinical services for cancer and cardiovascular disease, for example, where outcomes in this country lag behind many comparable countries. Welcome too is the acknowledgement of the role of carers, which appears a number of times in the plan. Particularly ambitious is the aim to transform services, using technology to provide many more online interventions and reduce patient visits to out-patient clinics by up to a third. The plan also hints at further centralisation of hospital services for major trauma, stroke and other critical illnesses, again to improve patient outcomes.

So the plan’s overall thrust is welcome as far as I am concerned, but my worry is that the Government have not learned from previous efforts to transform and integrate services. For a start, the plan is almost entirely focused on the National Health Service. It is a great pity that it was published in advance of the Green Paper on adult social care. It also shows scant recognition of the crucial role of local government, particularly in the current crisis in social care, yet the intended integration of health and care simply cannot happen without local authorities being full partners and some kind of long-term funding settlement for social care.

Similar challenges await the NHS, it seems. The plan promises increased investment in primary and community care, but where will it come from when acute hospital services are at full stretch and demand for services will inevitably grow? Although the plan is a sensible statement of intent, the question is: where is the beef to make it happen?

I start with funding. It is no surprise that the NHS is under funding pressure. A growing proportion of the population is aged 65 or over. We already have 2.9 million people with long-term multiple conditions. This is bound to grow over the next 10 to 20 years. It is always hoped that new technology will reduce costs, but the experience of health so far is that it tends to increase costs. If we add that to the current deficits among providers, the demographic challenge and the additional commitments given in the plan, there is a big bill to pay.

The report of the Lords Select Committee chaired by the noble Lord, Lord Patel, who cannot be here today, recommended that funding for the NHS should increase at least in line with GDP. We know that the consensus among health policy analysists is that we need 4% real-terms growth per year to meet these kinds of challenges. This is what the NHS received in patches, but on average, between 1948 and 2010. Since then it has flatlined at about 1% real-terms growth. Even the injection of an average of 3.4% over the next five years will not make this up.

According to the plan, the intention is for the NHS to return to financial balance. Productivity will increase, and the growth in the demand for care will be reduced through better integration and prevention. Overall, the plan presents this as a cohesive response to the funding crisis. All I would say is that that is a courageous offer from the NHS.

Alongside funding, the other big challenge is the workforce. We already have fewer doctors and nurses than any comparable country. This is likely to worsen in the near to medium term. The GMC—I declare an interest as a board member—points out that one in five doctors aged 45 to 54 are considering leaving the profession in the next three years. Even more worryingly, nearly a quarter of doctors in training and just over a fifth of trainees have informed the GMC that they feel burned out because of their working conditions and pressures. We know that other professions face similar challenges. We know too that we have a big problem with the largely low-paid social care workforce.

A big question to put the Minister is why the workforce implementation plan, which is some months away, was not published alongside the 10-year plan. What confidence can we have that the forthcoming spending review will provide the funding that, in the context of Brexit, is bound to be required for a huge increase in the number of training places? Also, why on earth are we having an NHS workforce plan? Why can we not have a health and social care workforce plan? The document preaches integration, but the Government have a wholly disintegrated approach, with no joint plans for money, the vision or the workforce. I say to the Minister: if the Government are serious about integration, for goodness’ sake start integrating your own efforts.

I will briefly touch on technology. I should again remind the House of my membership of the advisory board of Sweatco. The Secretary of State is putting a lot of effort into technology and the use of artificial intelligence. I support and welcome that. However, the report produced this week by the Academy of Medical Royal Colleges on some of the ethics involved in artificial intelligence is well worth reading. It makes the point that if technology is thought to help reduce demand on the health service, the Government might get a shock. As the academy points out, many of the technology approaches might actually encourage people to make greater use of health care, rather than being a sensible demand measure. I do not think the Secretary of State has quite got the hang of that yet, but he will need to if we really are to make the most of technology. The plan is lacking in detail on how performance and standards will be maintained, or how the impact of technology on patients, the workforce and cost-effectiveness will be assessed. We need to see that detail.

I refer noble Lords to my trusteeship of the Royal College of Ophthalmologists in saying that one example of something that works is the National Ophthalmology Database. It is a clear example of a large-scale audit that has improved the quality and safety of cataract surgery, reduced unwarranted variation and is making savings. Yet at the same time as we are being promised this great investment in technology, that database and others are in danger of being pulled because the department and NHS England are not making available the money to fund them in the future. I hope that the Minister might agree to meet me to discuss this, because it is one thing to say that we are going to have a great technology expansion, and quite another when some of the basic building blocks are being reduced or taken away.

On public health, which is perhaps the most disappointing aspect of the 10-year plan, the Government had an amazing report from the Chief Medical Officer just before Christmas in which she spelt out the problems of health inequalities and had a tough message for the Government. She said, “You’ve got to take this seriously”, and that hard fiscal measures to deal with obesity and some other public health issues are really the only way to make an impression. The 10-year plan ignores this altogether. My interpretation of it is that it is all down to individuals, and only individuals, to improve their own health. It is very disappointing that the Government have chosen to ignore the words of wisdom from their own Chief Medical Officer.

I want to touch on targets. As noble Lords will know, the standards for the NHS are set out in the NHS constitution but they are not being met. The plan is silent on this. The only thing that we know, from an announcement this week, is that the four-hour A&E target will be changed and relaxed. I know that the argument from Simon Stevens is that the target will be prioritised for the most serious illnesses. I understand that and accept the reasons for it. The problem is that for conditions that are felt to be a lesser priority, the four-hour target will no longer apply. I really worry that we will go back to the bad old days of people waiting for hours and hours in our A&E departments.

Whatever the views on targets, I have no doubt that that four-hour target helped to smarten up the NHS. It got rid of a lot of the fears the public had about long waits. The president of the Royal College of Emergency Medicine has warned that scrapping the four-hour target will have a near-catastrophic impact on patient safety in many emergency departments. This decision appears now to have been made but I hope that the Government will ask NHS England to look again at it.

I come to social care, on which the plan has nothing to say of any importance whatever. The plan actually looks as if it was written by NHS managers, and to produce a 10-year plan without having local government as your full partner to it is quite remarkable and very disappointing indeed. We are still waiting for the Green Paper. We have no idea what will happen to long-term funding for social care. How on earth can the plan be delivered unless social care is a full partner to the health service, and unless local government is brought right inside the building to share the decisions on the future? The one thing I would say to the Government is: for goodness’ sake, where in the report is the social care plan that will complement what is clearly the desirable aim of the 10-year plan itself?

I very much welcome this debate and am delighted that so many noble Lords are taking part in it. I think the Government will find that the plan’s aims receive a lot of support from throughout the House and that there is no argument with what the Government seek to do. But without long-term sustainable funding and a workforce plan that links into the requirements of the future, and without the full involvement of local government in social care, they will not be able to pull it off and that would be a great pity.

I turn to the Chief Medical Officer for my final words. In her extraordinary annual report, she spoke of how healthcare is often seen as a cost to the state but she was very wise in refuting that. As she said:

“The NHS and public health services are not a burden on our finances—they help to build our future”,


with,

“the good health of our nation … the bedrock of our happiness and prosperity”.

Amen to that, and I beg to move.

--- Later in debate ---

[Lord Hunt of Kings Heath]

My Lords, I have a minute to wind up. It has been an excellent debate containing five key messages. First, integration of health and social care will not happen unless the Government in Whitehall integrate their strategy on policy, finance and workforce.

Secondly, this House definitely supports the priorities in the NHS 10-year plan but it must not be at the expense of core services such as oral health or eye care. I hope the noble Baroness will meet with me and the noble Lord, Lord Low, to discuss the issues he raised about ophthalmology services.

Thirdly, the Government need to be brave on public health. It is clear from speeches made today in this House that huge support will be given to tough fiscal measures.

Fourthly, this is an English plan but its challenges relate also to Scotland, Wales and Northern Ireland. I hope that the noble Lord, Lord Rogan, will be heard, because the Northern Ireland health service is going through a tough time.

Finally, carers will be asked to do even more in the future, and they must have recognition and support.

This is a good plan but the agenda is tough. I hope the Government will listen to what has been said today. I beg to move.

Motion agreed.