NHS: Better Care Fund

Lord Turnberg Excerpts

Thursday 3rd July 2014 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, there is no doubt that care in the community is grossly underfunded. There are too many elderly people living alone and in need of care that they are being denied. We know that social services are now only able to provide care for urgent cases and then often only a quite inadequate 10-minute visit to help those people get dressed, bathed or fed. We know, too, that GP services are extremely stretched in many parts of the country. I do not think the BMA was simply crying wolf in its recent pronouncements when it said that it is having great difficulty coping with its growing workload. On top of that I hear it is having problems recruiting in general practice, especially in the north.

Now we hear from the Local Government Association that its budgets will have been cut by 15.5% by next year and that it is looking at a black hole of a £5.8 billion deficit by then. It is against this background that we see this inexorable rise in demand for both acute and longer-term care. On the one hand, the increase in numbers of those aged over 80 is heartening and is a tribute, at least in part, to modern medicine, but equally it is troubling that we have to cope with them accumulating multiple illnesses and disabilities. The prospect of dealing with more than 1 million people with dementia by 2030 is not exactly comforting either.

It is irrefutable that social care services need more funding and the Government’s response has been to rob Peter to pay Paul by taking this £3.5 billion out of the NHS and handing it across. Social services certainly need it and the rationale for doing so might seem reasonable on the face of it. After all, the budget for the NHS is so much bigger at more than £100 billion a year and, of course, we know that our hospitals are full of patients who would be much better off at home if care could be provided there. Some 30% of beds are said to be blocked in this way. So let us shift money across. However, that ignores the extreme financial stress that already exists in the NHS, where talk of a looming financial cliff edge in 2015 is commonplace. The impact of the Nicholson challenge with £20 billion savings already made, largely by short-term measures such as wage restraints and redundancies, and predictions of even more stringent savings of some £30 billion by 2020, is sending shivers down the spine of many a trust chief executive when 40% of them are already said to be running a deficit.

I hope the noble Earl will forgive me for introducing a note of aggression in my talk. He knows my normal benign nature does not allow for much aggression but I feel quite strongly about this. There are those who say that we should close some beds or whole hospitals and money will be freed up. That may be true—money will be saved, but at what cost to patient care? We have already heard of the stresses placed on hospitals by rising demands for acute care—that is acute care, not the care of longer-term patients within hospitals. It is the rising tide of acute emergency cases that is taking its toll now on hospital services that is so difficult. These demands are being made now, in the summer, when we have approaching 88% bed occupancy rates. Incidentally, we have the lowest number of beds per head of population in Europe and the shortest length of stay, so we are already pretty efficient.

Of course we should do more to improve efficiency. We should continue the process of focusing specialised services in fewer major centres; we should merge services between small, relatively inefficient hospitals; and of course we should be looking at better models of integrated care across the health and social care divide—that is essential. Today’s publication by the NHS Confederation and the Local Government Association is a step in that direction.

There could be more efficiencies, too, in the bureaucratic machinery that we have set up to run the service. I am struck by the fact that we removed two layers of administration, the SHAs and PCTs, and replaced them with four. We have NHS England with its large staff, the 40 outposts, 27 area teams and of course the 211 CCGs. That says nothing about the clinical senates, of which we hear so little, and the complex network of clinical reference groups. Instead of the promised bonfire of bureaucracy, we have had an explosion of bureaucrats. We could save money here with a closer look at all this superstructure but that is not going to happen any time soon.

Meanwhile, the cash-strapped NHS is being taxed again by the better care fund. To expect to be able to run an acceptable level of integrated care between hospital and community by shifting limited resources from one to the other may be expecting just too much. Yet we are a wealthy country: the fourth wealthiest in the world, according to the ONS, and with more billionaires than anywhere else. In spite of that, we have cut the proportion of GDP that we spend on this from around 8.2% in 2009 to about 7% now, and we are predicted to cut that proportion to about 6% by the end of the decade. I can well understand the Treasury wanting our services to be more efficient, but I cannot see what justification there can be to cut the share of the national cake for the care of our population to just 6%, which is so clearly well behind other OECD countries. The contrast between reports of a country said to be doing so well economically with those that show that at the same time it is starving our vital services is, I find, just too much.

I have a number of questions for the Minister. How is it intended that the money from the NHS will be used for care in the community? Is it to be ring-fenced? Will there be true integration between the NHS trusts and social services in the way that it is spent? Have the Government any plans to encourage recruitment into general practice, particularly in the north, and for A&E consultant posts, two key services at the interface between community and hospital?

Have they given any thought to their predictions for the future funding of health and social care beyond 2015? I know that the Minister will say that future spending plans will have to wait for the next spending review but I fear that the crunch will come rather sooner than that, and probably far sooner than the election. The department must be making contingency plans now about how the service will cope over the winter; I would be surprised if it was not. I wonder if the Minister would be willing to share some of that with us. I look forward to his response.