NHS: Long-term Sustainability

Lord Patel Excerpts

Thursday 18th April 2024 Lords Chamber

Moved by

[Lord Patel]

That this House takes note of the long-term sustainability of the NHS to be able to deliver comprehensive, timely and affordable health and social care for all, including options for systems of care and funding.

[Lord Patel (CB)]

I see noble Lords leaving. The debate will not be that bad. It has certainly emptied the House.

I am grateful to the noble Lords who are taking part in the debate. I look forward to their speeches, particularly the maiden speech of the noble Baroness, Lady Ramsey of Wall Heath; I wish her well. Several noble Lords—the noble Lords, Lord Stevens of Birmingham and Lord Darzi, the noble Baronesses, Lady Harding and Lady Watkins, and the noble and gallant Lord, Lord Stirrup—would have joined us, but other commitments do not allow them to do so.

I declare my interests. I am a fellow of several medical royal colleges and faculties. Importantly, I worked for 39 years in the NHS in its glory days. My comments will be based on comparing the current state of our healthcare system with 26 other systems that I have looked at. They all have some problems but, compared with more developed systems of universal care in Europe and the Far East, ours is severely strained.

On 26 April 2018, 6 years ago, we debated this exact Motion. There were 50 speakers and the debate lasted nearly seven hours, interrupted by a Statement on artificial intelligence, which mentioned how AI will transform healthcare. Today’s debate may well mirror that debate in 2018. What has happened since then? We have daily media reports of the demise of the NHS as we know it, and lots of suggestions for how to improve things. Public satisfaction with the NHS is at its lowest point; waiting lists are at their highest level; waits at A&E are long and harming patents; and there are huge inequalities in health and poor outcomes—I could go on.

After several reorganisations and reforms, including a seismic one in 2012, the NHS has not found the equilibrium that it needs. But the NHS is still capable of delivering superb primary, community and hospital care. Thousands of hard-working, resourceful and committed front-line professionals are prepared to go the extra mile, despite feeling undervalued. They need to be better supported and valued before they too give up. It is access to care that has become a major problem.

The current state of NHS is not because of some inevitable built-in decay; it is a system failure. It is the result of decades of political short-termism, a lack of long-term planning and an underinvestment in capital infrastructure and technology. The system lacks capacity, with fewer beds and equipment such as CT, MRI and PET scanners, and with a huge workforce shortage compared with other countries. We now have a workforce plan stretching to 2035, with no longer-term funding. We need it to work. I congratulate the Minister for getting 50,000 nurses in place, as the Government hoped to.

A lack of planning means that disease is diagnosed at a later stage, leading to poor outcomes. Modelling suggests that, by 2040, one in five people will be living with a major illness, which is upwards of 9 million people. Nearly 3 million people of working age will not be in work due to ill health. Not investing in health means greater pressure on the budgets of other departments. Anxiety, depression and chronic pain will be the main causes of ill health, which has implications for primary and community care.

Unfortunately, there is no silver bullet to reduce the growth in people living with major illness in the short to medium term. Diseases that affect millions, such as diabetes, cardiovascular disease, stroke, some cancers and chronic lung disease, are all amenable to either prevention or early detection. The focus needs to change to prevention and health, not just healthcare. We need to move from: “I am ill; I need to get better” to “I don’t want to be unwell”. Countries that have recognised this are seeing the benefits of higher life expectancy, people living more years in good health and being more economically productive. The system needs to change to make primary and community care a central part of our care system.

The current funding of primary care is at 8.4% of the total NHS budget of £192 billion, which is the lowest in eight years, and it employs only 154,000 of the total 1.3 million workforce. This proportion will need a significant increase to at least 20% or more if we are to see improved access to primary care. The traditional system of a single portal of access to healthcare also needs to change. To enable patients to have greater choice of access, community care will need to be staffed by a multidisciplinary team of professionals, including general practitioners.

An explosion in data, generated by patients and the health system, will drive healthcare through screening services’ early detection of markers of disease, such as blood pressure monitoring and hypercholesterolemia, to mention but two. Population and risk-based genomic screening, liquid biopsies, individual health data monitoring and so on will lead to early risk identification and detection of disease. Healthcare will be digitally driven, technologically enabled, personalised and patient-centred. Patients will be involved in planning and managing their own health. The best health systems in the world have strong community care, with a focus on helping people stay well.

From birth to death, health, healthcare and long-term care in old age is a continuum. If any part of it is not functioning, it affects the rest. The lack of a properly funded and organised social care system is having a huge effect on the NHS. We have had 28 years of kicking the can down the road. After seven policy papers, six consultations and four independent reviews, we have a social care system that is means-tested, needs-assessed and underfunded.

There is a lack of a workforce plan for a service that needs 1.5 million staff, with 2 million people still needing care—one-third of whom get no support. With a rise of 20% in working-age adults needing social care, this needs urgent attention. Capacity is getting worse, and public satisfaction with social care is as low as 13%.

Various options have been considered, including free personal care, the Dilnot cap and universal care. The best performing comprehensive system of social care is provided in countries with a long-term care insurance, or which is tax funded, based on the principle of social solidarity. People above a certain salary range pay throughout their lives. Without a solution to the funding of social care, the NHS cannot survive.

I now turn to the key issue of funding the NHS. Funding of the NHS has always been a rollercoaster, despite its link to the performance of the NHS. The planned budget for 2024-25 is £192 billion, an increase in real terms of 0.6% from the 2023-24 settlement but a reduction from 2022-23. According to NHS England, it will provide a spending increase of 0.25%. Over the parliamentary term 2019-20 to 2024-25 the increase has been 3% per year, but from 2010 to 2019 it was 1.4% on average.

Following the famous “expensive breakfast” in 2000—when Prime Minister Tony Blair announced on breakfast television an uncosted commitment that he would bring NHS spending up to the EU average—and the Wanless report, there was a multiyear increase in funding leading to better NHS performance. Waiting lists came down dramatically and health inequalities began to improve.

If the EU average had been maintained in the years that followed, the budget would now be £40 billion higher per year. Lack of capital funding—an average of £2.5 billion per year from 2010 to 2019—has led to poor infrastructure and a lack of equipment; it has not increased. Rising costs have led to calls for funding reform. Social insurance, some element of self-pay and hypothecation have all been suggested. Each has its own problem. Analysis suggests that a single-payer system is most effective in costs and complexity. The public seem to prefer a tax-funded system. What is important is that there is properly costed long-term funding that tracks GDP growth. Also important to note is that while measures of prevention and healthy living may make people live longer in good health, they will not cut costs. If cutting costs is a priority, a different model of care will be needed—but people may not live longer.

In conclusion, a sustainable future for both NHS and social care is possible, and with it a healthier population that leads to increased life expectancy and decreased health inequalities. It needs a long-term funding commitment, including in capital funding, and strong primary and community care with a focus on prevention and health. It needs to be digitally driven, connected and tech enabled, and to have a clear plan with timelines for its introduction. An overcentralised, bureaucratic system will not address the fundamentals of effective healthcare. This may well be the last opportunity for the NHS as we know it and as we want. If not, the public may well seek an alternative that could lead only to a two-tier system of care.

My question, in this election year, is to the Minister and the noble Baroness on the Opposition Front Bench: what plans does each party have to make the NHS sustainable in the long term? What support will the Liberal Democrat Front Bench give to make amends for the part it played in the reforms of the coalition years? I beg to move.

--- Later in debate ---

[Lord Patel (CB)]

My Lords, the new rules do not allow me to speak at length, so I am constrained. I truly am constrained, because I would have loved to dissect some of the speeches made by some of my friends. I wish that the hospital, wherever it was, had treated the noble Baroness, Lady Murphy, better, because her speech might have been different. When I put in a bid for this debate, I did not imagine that I would get the talent pool we got today, or the brilliant speeches that have been made. Top of the list, of course, is the maiden speech by the noble Baroness, Lady Ramsey of Wall Heath; we look forward to hearing her over and over again.

I had intended that this would not dissolve into a political debate, and I am glad that it did not. I am glad that my challenge to all three Benches paid off. By the way, I say to the noble Lord, Lord Allan, that it was this House that won the vote to put mental health at equal esteem; it was not the other House, although the Minister, Norman Lamb, did help. It was an amendment by the noble Baroness, Lady Hollins, that won, although I had to call it because the noble Baroness was not here at the time.

I thank all noble Lords again; I am grateful that they all joined in this debate. It contained lots of ideas, but the key thing that came out was the need to make community and primary care stronger. The second thing was the solution to social care: it is funding, whichever way we go. The other thing was data. By the way, as the noble Lord, Lord Allan, was speaking, I asked ChatGPT: “How can data help healthcare?” It produced immediately a 700-word, six-point response; I might send it to the noble Lord.

Motion agreed.