Brexit: Import of Radioisotopes

Lord Warner Excerpts

Thursday 7th March 2019 Lords Chamber

[Lord Tebbit (Con)]

My Lords—

[Lord Warner (CB)]

My Lords—

[The Lord Privy Seal (Baroness Evans of Bowes Park) (Con)]

It is the turn of the Cross Benches.

[Lord Warner]

My Lords, to what extent does the Minister consider that patients will be put at much greater risk in a no-deal scenario if a large number of oncologists up and down the country take the view that they cannot rely on the supply of medical isotopes and therefore start a programme of delaying access to an assessment and treatment by them? Does she consider that the Government cannot give these assurances because they do not know what the behaviour will be of individual clinicians who require the isotopes to treat their patients?

[Baroness Blackwood of North Oxford]

One of the reasons why we worked so closely with the Royal College of Radiologists to provide the guidance, as well as working closely with NHS England to communicate to the NHS, is to ensure that reassurance has been sent out through the system with regard to the arrangements which have been made for medical supplies so that those concerns can be allayed and to ensure that clinical pathways are not disrupted. For that reason we do not expect any patient harm to arise from this, and changes to clinical pathways and practice are expected to be minor and short lived.

European Qualifications (Health and Social Care Professions) (Amendment etc.) (EU Exit) Regulations 2018

Lord Warner Excerpts

Thursday 7th March 2019 Lords Chamber

[Lord Deben]

I have got it right this time. That is what they say. In every individual case, negligibility may well be the truth, but what is negligible in one case, when added up with a lot of other “negligible” costs, ends up being rather expensive. I am amazed at the number of things you can do with negligible cost. We are filled with these SIs—with all the things that we can do for nothing. I ran businesses, and I have to say that I do not know anything you can do in business which does not cost you something. I would love the Government to explain to me how they are managing to move whole areas of control and regulation over to British regulators without any cost. I would be able to apply that to my businesses and it would be extremely valuable, because all I know is that the moment you change or move anything, it costs money.

I want to know not only how much it costs but whether we have the resources for it. It is also said that we have these organisations that are perfectly capable of doing all this, as if this is an easy thing to do, when in fact it is not only difficult, but if we get it wrong, we are endangering people’s lives. Clearly, we have not worked out what the cost of doing this is; I just do not understand whether we have the human resources and the trained resources to do it. After all, we have shown so far that we cannot run the National Health Service without large numbers of people coming in from outside. I would like to understand whether we can regulate all this without some additional resources, and if so, we ought to know exactly what resources we will need and how much they will cost.

I am sorry that I have to say this to the Minister with such vigour, but it needs to be said; otherwise, this House looks pretty damn stupid. We look as if we are sitting around, having a gentle argument about what is the programme for catastrophe. This is what we are talking about: how a nation decides how to put itself into a very much less favourable position than it is in at the moment. Sometimes people say, “Ah, but Britain will manage—look what it did during the war!” But we did not ask for the war; we did not say that we wanted it. It happened, and we said that we had to fight it. Here we are asking for it, and are seriously sitting around planning for it. We are asked to do that with a degree of politeness and charm, and courtesy and care, when we ought to be very angry indeed that any Government should even suggest that we need SIs like this.

[Lord Warner (CB)]

My Lords, it is a positive delight to follow the noble Lord, Lord Deben, as I have done on a number of occasions in the past few months in debates on other SIs which have been considered in Grand Committee. The one thing I would say about the noble Lord is that he has been masterly in the consistent way in which he has expressed himself. I do not altogether share his high assessment of previous Conservative Governments on costings, but we will let that one pass.

--- Later in debate ---

[Baroness Blackwood of North Oxford]

I thank your Lordships for what I think we can call a robust debate. I will start by discussing the designation criteria, which were at the core of the questions from the noble Baronesses, Lady Thornton, Lady Jolly and Lady Hayman, and the noble Lord, Lord Hunt, and are central to this SI. It is important to set out the differences between the current system and what future recognition might look like under the SI. Obviously, we understand that this would happen only in a no-deal scenario, which the Government very much wish to avoid.

To clarify, the current system is based on automatic recognition of EEA and Swiss qualifications, as listed in Annexe 5, with eligibility based primarily on an applicant’s nationality rather than where the qualification was gained. In future recognition, eligibility would be based solely on whether the individual holds a relevant EEA or Swiss qualification. UK regulators would therefore be able to apply for designation of an individual EEA/Swiss qualification as well. That is where the concept of flexibility comes from, which so upset my noble friend Lord Deben. Some aspects of the directive would no longer apply to the UK, so some of the ways in which the directive applied previously—such as on hours, which have previously been used to determine qualification—might no longer be appropriate in determining whether a qualification has been met.

This flexibility in setting standards should be welcomed. Indeed, we noted that Charlie Massey, the chief executive of the GMC, has previously raised concerns about the training of some individuals we had to accept under this automatic recognition process. For example, he raised concerns about family doctors in Italy before the Health and Social Care Select Committee. The General Dental Council has also raised concerns about the quality of some Romanian and Spanish dental qualifications. Under the new proposals, we would be able to raise such concerns through the designation process. They would go to the Privy Council because that is already the normal process through which UK regulators designate qualifications in the UK system. The process proposed under this SI is the standard UK process for establishing professional qualifications.

Moving on to how this would work, the instrument enhances the UK regulators’ powers to protect the public by designating as no longer acceptable EEA and Swiss professional qualifications that they are currently obliged to accept automatically. As I said, the grounds for designating a qualification will be determined by the UK regulator, which is best placed to make such decisions. The UK regulator will be able to seek designation of any individual professional qualification about which it has concerns. The most likely basis for such a designation will be that a qualification does not meet the standard of UK qualifications. We do not expect the approaches to designation to vary significantly between regulators as they have a shared objective of protecting, promoting and maintaining the health and safety of the public—and long experience of doing so. Therefore, the reasons for seeking designation and evidence supplied in support of designation are expected to be largely consistent. As I said, Privy Council consent must be given for a qualification to be designated. This standard system has been used previously.

The Government have been asked whether they will set out guidance on the criteria to be applied by regulators when seeking designation of a qualification. We do not intend to do so because we believe that the most likely basis for designation will be a qualification not meeting the standard of equivalent UK professional qualifications. We think that UK regulators, not the Government, are the authority on standards for healthcare professionals practising in the UK. They set the standards for UK health and care professional qualifications and are therefore best placed to understand if there is a case for designating a qualification. As I said, the Privy Council has a well-established role in overseeing the UK’s health and care professional regulators. For some regulators, including the GCC and GOsC, it approves UK qualifications and the appointment of council members. Its new role in approving applications for the designation of EEA qualifications is simply an extension of its existing role.

Costs and the impact assessment were referred to by a number of noble Lords but particularly exercised my noble friend Lord Deben. I am afraid that we have gone into the costs in some detail, despite the concerns he raised. He will know that UK regulators operate on a full-cost-recovery basis and set registration fees that meet the cost of processing applications. The cost to regulators of moving to the new system is considered negligible because it mirrors the current system, as far as possible, for at least two years—we intend to review that, once the regulations come into force. Should the regulator incur additional cost, it will be able to recoup it through fees. We estimate the total cost to regulators on the automatic system—including the NMC, the GMC, the GPhC and the GDC—to be £250,000 per year and an additional £60,000 for recruitment costs in the first year of these regulations coming into force. This could raise registration fees by an average of 27 pence per registrant per year for the regulators to recoup additional administration costs. We have costed the impact and believe the assessment to be reliable. That is why we have the GMC’s support; it believes that the impact assessment is reasonable and that it can cope with the impact.

I want to address concerns raised about temporary workers. I know that the noble Baroness, Lady Jolly, wanted to re-raise this even though I tried to address it in my opening speech, as the noble Baroness, Lady Thornton, acknowledged. As we said, we do not think that the removal of this group of registrations will cause concern as only 160 professionals are registered on a temporary and occasional basis. Professionals practising on such a basis, even in that small group, will not lose their registration on exit day; they will be able to practise until their registration expires, up to 18 months later. At that point, it will be open to them to seek full registration in the same way as any other holder of an EEA or Swiss qualification. It is important to note that the number of joiners from the EEA has remained steady at around 2,050 a year since 2016. In 2017-18, doctors joining the register from non-EEA and UK routes made up 32.4% of the total, while EEA applicants made up 16.2%. We are confident that the impact on that point will be manageable but we will keep a close eye on it and ensure that it is kept in check.

Moving on to the question about the IMI, raised by my noble friend Lord Deben and the noble Baroness, Lady Jolly, it is absolutely right that if the UK leaves the EU without a deal, we will no longer have access to EU systems, including the IMI system which gives us access to the exchange of information about healthcare professionals. The regulators are aware of this and they are preparing for it. It is important that this instrument will mean that they will not be required to put in place new procedures for the recognition of EEA qualifications and that any costs involved with the loss of the IMI system are unavoidable in the case of no deal. Such costs depend on a number of factors. While we would like to see continued access to the IMI system, it is worth bearing in mind that the registration of international health professionals takes place with non-EEA registrants without access to IMI. We have managed to ensure that that happens safely, effectively and efficiently. However, we will do our utmost to ensure that we consider other means to replace IMI that comply with the GDPR, such as standard contractual clauses. I hope that reassures noble Lords on that point.

Perhaps I may go on to answer the questions raised by the noble Lord, Lord Crisp, and the noble Baroness, Lady Jolly, on Spanish nurses and nurses from the Republic of Ireland. There is an issue on this point and I recognise the concerns that have been raised. There will be no change as a result of these regulations in the way Irish and Spanish qualifications are accepted, but at this point the Spanish regulator has said that it will not recognise the UK practice of Spanish nurses. This is a matter for the Spanish body, but we are continuing to discuss as a matter of urgency how EU regulators will recognise UK practice and qualifications, so that it does not matter which we are taking up.

As regards Ireland, the regulations ensure the continued recognition of Irish professional qualifications in Northern Ireland for at least two years after exit day and will allow professionals practising under temporary and occasional registration status to continue to do so until that registration expires. We are making sure that health and care practice across the island of Ireland is maintained smoothly and continuously. This has been a priority for the Government.

With those comments, I hope I have addressed the main concerns raised by noble Lords and given reassurance on those points. On that basis, I beg to move.

[Lord Warner]

My Lords, can the noble Baroness give me some answers to the points I raised about guidance being given in the event of no deal and exit on 29 March? First, how are the Government going to communicate that guidance to all the interested parties in the time available? Secondly, I asked about the status of these SIs in the event that the Article 50 period is extended beyond 29 March but there still being no deal. Does that mean that after that period, these SIs would come into effect when the period of exit is established post 29 March? Thirdly, what happens to these SIs if there is a deal? Does the present status carry on, with these SIs being put into limbo and therefore not introduced?

[Baroness Blackwood of North Oxford]

I apologise to the noble Lord for missing out on my answers to his questions; that was most remiss of me. These SIs come into force only if there is a no-deal exit. Should there be an extension of Article 50, they would not come into force until or if there is a no-deal exit, which is obviously most undesirable and something the Government are seeking to avoid.

On the communication of the effect or implementation of these SIs, they have been developed in close collaboration and consultation with the regulators that would be impacted. They are well informed about their operation, and given that the effect of the SIs is to continue with business as usual as far as possible, we hope that that is the de minimis effect. I shall write to the noble Lord in response to his final question, as I am afraid I have forgotten what it was.

Adult Social Care

Lord Warner Excerpts

Wednesday 11th July 2018 Lords Chamber

Asked by

[Lord Warner]

To ask Her Majesty’s Government when their Green Paper on the future funding of adult social care will be published; and whether the Green Paper will draw on the experience of other countries.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, as recently announced by the previous Secretary of State for Health and Social Care, the Government will publish a Green Paper in autumn 2018 setting out proposals for social care reform alongside the NHS plan. In developing the Green Paper, the Government are drawing on best practice of what works abroad to create a sustainable social care system.

[Lord Warner (CB)]

I thank the Minister for his Answer. Is he aware, however, that according to a report in May by the Health Foundation and the King’s Fund, adult social care funding needs to increase by between £5 billion and £8 billion by 2020-21? Can he reassure those service providers who are leaving the publicly funded adult social care system in droves that the Government’s financial cavalry will arrive by Christmas?

[Lord O’Shaughnessy]

The noble Lord is quite right that there is a need for more money in the social care system. That is why, in addition to the funding set out in the spending review, the Government have put £9.4 billion over three years into the system in the short term. The point he makes, which is right, is about the long-term sustainability of the settlement. I would point him to the seven principles underpinning the Green Paper, which my right honourable friend set out. One of those is a sustainable funding model—a model which, as we have said, cannot put pressure on the NHS. That means that we need to find the money to ensure that it can subsist.

The NHS

Lord Warner Excerpts

Thursday 5th July 2018 Lords Chamber

[Lord Warner (CB)]

My Lords, I, too, add my congratulations to the noble Lord, Lord Darzi, on his excellent speech and his constructive IPPR report. He and I have both had a go at reforming the NHS, and I think we can at least congratulate ourselves on not creating a mess on the scale of the Health and Social Care Act 2012, from which the NHS still suffers.

The NHS has been a key part of our welfare state and a great piece of communal risk pooling and social cohesion. It has survived some difficult years with its funding veering around from famine to feast and back again. It has become like David Attenborough and Judi Dench: a national treasure. However, the trouble with national treasures is that they can end up like Danny Boyle at the 2012 Olympics, engaging in a fantasy view of something that badly needs to change but gets frozen in the national psyche.

The NHS and its staff are tired in part because its business model and operations badly need a major overhaul. The NHS still operates the organisational silos created 70 years ago. It has not integrated its own services very well, let alone integrated with social care. It is still largely a sickness service rather than a health service. Public health, mental health and adult social care remain Cinderella services financially, while the acute hospitals remain the financial preoccupation of most elected politicians. The patient base of the NHS now lives much longer than in 1948, with a set of comorbidities that come largely from lifestyle choices, but the service delivery system has changed little, despite countless reorganisations. It certainly does not deliver consistent quality across the country.

The way services are delivered needs to change radically and swiftly. Simply giving giving the NHS shedloads of new money without a credible and enforceable long-term reform plan would be a waste of taxpayers’ money. The NHS England long-term plan promised for this autumn needs to provide for a radical shake-up of the way in which services are delivered outside hospital, the way in which staff are trained, treated and deployed, and the way in which technology and regulatory change are to be implemented. There needs to be a sweeping away of the 2012 governance and accountability arrangements. This plan must lock funding into reformed services outside hospitals and will need regular parliamentary scrutiny on its delivery. It must also be supported by a new, credible and sustainable funding system for adult social care, which remains in a parlous state both financially and through the growing collapse of the publicly funded social care provider market. Unless the Government show a greater sense of urgency about a new funding system for social care, they are setting up the NHS to fail.

Let us be clear. There is no Brexit dividend for the NHS. The OBR forecasts show the UK economy flattening out, flatlining at about 1.5% growth a year after Brexit. This will make it very difficult to sustain a 3.4% real-terms annual increase for the NHS over a long period. So the NHS had better get on and reform itself quickly while the financial sun shines briefly for a moment.

Long-term Plan for the NHS

Lord Warner Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord Warner (CB)]

My Lords, could the Minister say something about the economic literacy of this announcement? As I understand it, the Conservative chairman of the Health Select Committee, Dr Sarah Wollaston, has said that the Brexit dividend idea is “tosh”. If we write that one out of the script, can he say something about what economic assumptions the Government are making on the growth of GDP in each of the next five years?

[Lord O'Shaughnessy]

I know that the noble Lord no longer serves the Labour Party, but he might be interested to know that the Labour leader said in February that,

“we will use the funds returned from Brussels after Brexit to invest in our public services”.

Clearly, we are not alone in believing that, once we leave the European Union—and, as a party, we are committed to leaving the European Union—we will no longer be sending subscriptions to Brussels but using them for the NHS. For further detail on the funding settlement, the noble Lord will need to wait until the Budget, when the Chancellor will outline the plans.

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

Lord Warner Excerpts

Thursday 26th April 2018 Lords Chamber

[Lord Warner (CB)]

My Lords, finally we have a chance to debate a report that the Select Committee, of which I was a member, produced over a year ago under what I might call the benign and able chairmanship of my noble friend Lord Patel. The bland response from the Government could have been written, I would suggest, within a week or so of our report’s publication and hardly seems worth discussing—so I will not. Its complacency contrasts dramatically with my noble friend Lord Patel’s introduction and the leadership that he has shown. It is true that the Department of Health has become the Department of Health and Social Care, as the Select Committee recommended, but the hole in the funding of adult social care continues to grow, dragging more local authorities—many Conservative run—towards insolvency.

Our report raised many important issues, but I shall focus on just one: the key topic of funding. In today’s world, a tax-funded, pooled-risk healthcare system such as the NHS, which is free at the point of clinical need, requires a more generous and reliable funding system than we currently provide or seem to be contemplating. We need to stop our feast or famine approach to NHS funding and relying so heavily on local authority funding for social care. We should face up to capping individual liability for social care costs, retain its means-tested basis, but find a more reliable national system for funding long-term care from taxation or social insurance, as they do in Germany and Japan.

Facing up to these rather inconvenient truths will be tough for everybody—politicians and public alike. It is much more comfortable to believe that everything will be okay if we just get a bit more efficient, use more technology, integrate health and social care and employ more doctors and nurses. Of course, we may well need to do these things. The updated NHS England Five Year Forward View and related initiatives are important steps in the right direction. We need to reduce the huge variation in the cost and quality of care around the country. Narrowing this variation would save somewhere in the region of £3 billion to £5 billion a year, as the noble Lord, Lord Carter, has demonstrated. But all these changes take time for a hard-pressed NHS to absorb and all require investment, both capital and revenue.

Improving efficiency and patient outcomes are important, but they are not a financial panacea for the tsunami of rising demand. That demand probably has an annual cost of at least a 2.5% to 3% increase in real terms year after year. This is considerably more than the less than 1% annual increase that has been provided to the NHS since 2010 and the 25% cut in real terms in adult social care budgets over the same period.

So, what to do? As our report showed, the funding of health and care has zigzagged all over the place over the past 25 years—I commend the graph on this, which is set out in the report. It has been inconsistent between health and social care, despite these services dealing with the same levels of demand. Periods of generous increases are followed by periods of great scarcity, irrespective of service demand. Lots of short-term handouts are provided, when what is needed is much more consistent funding allocated for longer periods ahead, so that people can plan better and make better use of the resources that are available.

This approach would not of course crack the issues of the level and method of funding, which are essentially matters that come down to political choice. What is clear is that, if the NHS is to be mainly funded from taxation, Governments need to be a lot more creative about how we raise the money. I am a great fan of the 1960s American radical, Abbie Hoffman, who memorably said in 1968:

“Sacred cows make the best hamburgers”.


Why can we not ask the group who use the services most to pay more? They do not all need winter fuel allowances, free travel passes, free TV licences and suchlike. Why should older workers not pay national insurance? Why are there so many ways of avoiding paying inheritance tax? Why can we not collect more care costs from estates? Why can we not levy more tax on the sales revenues of the Amazons, Googles and Apples, and so on, rather than from their absurdly low declared profits? If it is politically easier to collect taxes for health and care by hypothecating the revenue for those purposes, as many have suggested, why can we not just overrule the Treasury’s objections?

I know that the cry will go up that this is all pie in the sky and politically impossible. That is possibly true. But let us consider the alternative to more radical taxation action. Winter pressures become all-year pressures. Access to care deteriorates further and faster. Premature death rates among both young and old rise. We slide further down the international league tables in terms of healthcare performance. The trajectory towards care and treatment mediocrity continues and gains greater momentum. More staff leave the NHS and young people stop going into the UK health professions because the pressures, work conditions and pay get increasingly worse. EU health professionals stop working in the UK post Brexit, and the so-called Brexit financial dividend proves a mirage.

These things are already happening and will get worse. Our elected politicians need to get out of their trenches and lead a grown-up conversation about realistic funding for the NHS and social care. If they want to outsource the job to a time-limited independent commission, they should at least give an advance, approved parliamentary guarantee that its recommendations will be acted upon within a single Parliament. They would be helped if they set up an independent office for health and care sustainability, answerable to Parliament, as the Select Committee recommended, to oversee change and keep people focused on the longer term.

NHS and Social Care: Winter Service Delivery

Lord Warner Excerpts

Thursday 25th January 2018 Lords Chamber

[Lord Warner (CB)]

My Lords, I too congratulate the noble Baroness, Lady Wheeler, on securing this debate and on her elegant demolition of the Government’s winter planning. I also welcome the conversion of the noble Lord, Lord Macpherson, to hypothecated tax—having left the Treasury—as well as his rather telling analysis.

Each night the BBC brings us the latest bulletin on what is happening in our hospital, GP and ambulance services up and down the land. Sick patients wait on trolleys and in cubby-holes for a doctor to see them; ambulances queue to discharge their patients and then cannot leave because they cannot get their trolley back; cancer patients wait longer and some probably die sooner; and surgery waits lengthen as more operations are cancelled. Welcome to Britain’s 21st century NHS, often said by Ministers to be the best in the world. What the Government have achieved, I suggest, is to make Hugh Pym a household name.

This winter’s crisis has highlighted how dysfunctional our health and care system has become and how difficult it is for staff to work in it. Committed doctors, nurses and a multitude of other staff are being driven to exhaustion and burn-out. Their good will and professional commitment are being taken for granted and will not last—they are rapidly evaporating. We are now well past the point where the promise of a Boris £5 billion bung in a glorious post-Brexit future will encourage the staff to stay. What people working in the NHS and social care want to see is a credible and funded plan for fixing a broken NHS business model, and rebuilding and aligning the social care system effectively with the NHS.

The Government remind me a bit of Blackadder waiting for Baldrick to come up with a cunning plan. Even when they were given a respectable route map by your Lordships’ Select Committee last April, they did not seem to know what do with it. Ten months later we still await a response. The 2011 Dilnot proposals for capping individual liability for care costs was legislated for and then abandoned. Social care reform has been kicked into the long grass following the election campaign fiasco. We now have yet another review, which almost certainly will delay any substantial reform until the early 2020s. Sadly, I think that this Government are so preoccupied with Brexit that they lack the bandwidth to get to grips with the complex and difficult problem of making our NHS and social care system fit for purpose for 21st century needs.

Yet the narrative on social care is appalling. There has been a 25% to 30% real-terms funding cut since 2010, and that is only starting to be reversed this year. The shortfall from these cumulative cuts will never be made up. The absence of further funding in the Autumn Budget and the local government finance settlement means that a further funding gap of £2.3 billion is now emerging. Those are not my calculations; that is according to the Conservative-led LGA.

Hundreds of thousands fewer people now get publicly funded social care than in 2010, and the numbers are continuing to rise. Furthermore, thousands of care beds have simply disappeared from view. In this situation, why should we be surprised that so many older people now turn up in A&E and hospital beds? The Government were warned repeatedly that this would happen, and now it has. It is inevitable that many local authorities simply will not be able to reach the Government’s totally unrealistic and “undeliverable”—not mine but the Conservative LGA’s word—expectations on delayed transfers of care from hospital. The Government seem reluctant to face up to what we have all known for some time—that a sustainable NHS requires a sustainable social care system.

If the Government want to avoid continuing NHS crises, they must start spending more money now on social care than they are currently planning to do. They must do this for the next three years or so while they work out a longer-term funding plan. That means probably allocating a further £5 billion to £6 billion over the next three financial years. In order to be a bit constructive, as a short-term expedient I suggest that the Minister and his colleagues start quickly to think about reducing hospital bed-blocking by funding more transfers of NHS patients to step-down care in nursing and residential care homes as part of NHS continuing care, instead of waiting for the unavailable care packages.

Finally, I want to say a few words about NHS sustainability, and this is where I share the views of the noble Lord, Lord Macpherson. No Government can have a sustainable NHS that meets the population’s needs without a plan for handling the unrelenting rising demand that has an unaffordable funding tab of a 4% increase a year. This Government have no such plan and, as far as I can see, nor do the Opposition. This Government have demonstrated that you cannot achieve NHS sustainability with funding increases of a little over l% in real terms a year for the best part of a decade and with no investment strategy for changing the wrong business model to meet demand. Unless we change faster the way that we deliver health and social care, we will be setting up the NHS and its staff to fail. We also have to ensure that when we give the NHS more money, sufficient of it is ring-fenced for investment and that it does not go towards propping up the present system.

NHS: Staff

Lord Warner Excerpts

Thursday 30th November 2017 Lords Chamber

[Lord Warner (CB)]

My Lords, the noble Lord, Lord Clark, deserves our thanks for providing this opportunity to discuss what I would call the bleak direction of travel that this Government are setting for our health and care system. I congratulate him on his robust and thoughtful analysis, which I share. It was also a privilege to hear my noble friend Lady Emerton. I, like others, will miss her wisdom in the future.

Next year the NHS will be 70. For much of its existence it has had an annual funding increase averaging about 3% to 4% in real terms. Since 2010 the annual increase has shrunk to less than 1.5%. During this decade the NHS has become rather like a pensioner finding it difficult to live in the style to which it was accustomed. It now faces an uncomfortable old age, partly because it failed to change its business model when it had the chance, but increasingly because of this Government’s obsession with both a reckless Brexit and a linked fiscal policy based on unrealistic national debt reduction.

First, I acknowledge that the NHS has contributed, to some extent, to its current problems. For too long it has been reluctant to change its hospital-centric business model when the changing demography and disease profile of its customers strongly suggested that it should. For too much of its history too many NHS leaders have distrusted local government and, for the most part, until recently, have failed to understand the NHS’s dependence on a reliably-funded adult social care sector. Even when there have been sensible plans for change, an adequate investment strategy has usually been lacking. Certainly, there has been a failure to provide a strategy for reshaping a workforce that needed to work differently and more innovatively, embracing new technology in all aspects of its work. If you add in an expensive and misguided Conservative-led reorganisation five years ago, it is not difficult to see how poorly placed the NHS and its staff are to deal with what comes next.

The state of our health and care system is evidenced in the report by this House’s Select Committee on the Long-Term Sustainability of the NHS, of which I was a member. The report was published in April and we still await any response from the Government, other than the Minister telling us that it is on his desk. The report also presents a powerful body of evidence on the damage done to the prospects of NHS sustainability by the persistent failure by Governments to fund adequately adult social care, even taking account of the £2 billion now being invested over three years. This sector is experiencing a serious reduction in the provision and quality of publicly funded adult social care, as the loss of 4,000 nursing home beds in a single year demonstrates. In turn, it is placing an increased and unnecessary burden on the NHS and its staff.

Brexit and the Government’s fiscal policy will now administer new shocks to an already battered NHS workforce. No doubt the Minister would prefer it if I did not mention Brexit but I am afraid I do not inhabit the “Mary Poppins” world of many Ministers on this subject. It is now important that the public understand that far from producing an additional £350 million a week for the NHS, Brexit will seriously damage the NHS. I can find no credible economist who believes that leaving the single market and the customs union—the Prime Minister’s declared aim—can do other than reduce our GDP, with any compensating new trade deals a very long way off in the future. Companies are already making their dispositions accordingly and many more are likely to do so early in 2018.

A few success stories in the life sciences sector do not alter the bigger picture—one in which the tax take goes down as the economy shrinks and there is less money for public services. We can already see the impact of Brexit on the public finances with the £3 billion Brexit contingency fund in the Budget, and more to come to pay a divorce bill somewhere north of £40 billion—unless the Minister has some better figures.

We have discussed on several occasions the impact of Brexit on the supply of EU staff to our NHS and social care system. The total failure of this Government to provide a cast-iron commitment to EU staff working here about their future in the UK has led to a worrying exit of valued staff from our health and care system. This outflow is likely to increase further and faster in 2018. Wise heads in the NHS are already trying to plug the gaps from other sources but this will be a big ask in the short term, and the cost of replacement is likely to be greater than retaining those staff who have been lost. Our long-term failure to become more self-sufficient in the staffing of our health and care system will be seriously exposed by Brexit. Staff account for two-thirds of the costs of running the NHS and we will have to pay more than now to recruit, train and retain staff. This will be a big financial pressure, which has not been reflected in the Chancellor’s Budget.

Finally, I turn briefly to fiscal policy. The Office for Budget Responsibility’s assessments accompanying the Budget show economic growth declining, poor national productivity and an inflation rate much higher than health and care spending. The Chancellor continues his predecessor’s obsession with reducing the national debt. Despite this—what I can call only—austerity fetishism, the Government have missed all their debt reduction targets, continuously damaging public services into the bargain.

This Budget falls a long way short of a credible response to the challenges that the health and care system faces for the rest of this Parliament—always assuming that the Government last that long. Most seriously, there was no relief for adult social care, which is now massively underfunded after a 25% cut in real terms since 2010. The promised Green Paper on social care will now not appear before next summer, having been promised for this autumn. Meanwhile, our elderly and disabled population can expect in many parts of the country to have reduced access to social care services, as more providers exit the publicly-funded part of that sector. This will put further pressure on the NHS.

Apart from £10 billion of capital in the Budget, mainly, I suspect, from NHS land sales, the Chancellor has provided an extremely modest revenue increase for the NHS. There is £350 million—again, £350 million but only for a whole year—in the current year. There will be another £1.6 billion in 2018-19 and a further £0.8 billion in 2019-20. This falls well short of covering the likely cost of inflation over the period. The black hole in the NHS budget at the end of this Parliament is expected to be at least £20 billion.

My understanding is that any pay increase for staff in this period will depend on a productivity deal. Having tried to negotiate productivity deals with the NHS unions in the past I can assure the House that this is a notoriously difficult thing, both to achieve and to satisfy the Treasury that you have done so. In practice, if some staff are to get more it is highly likely that others will get less, unless the Government put in much more money, which currently looks highly unlikely. We now have an NHS workforce who have had the best part of a decade with capped pay increases, often below inflation, and now face a period of great work pressure, with inflation of around 3% a year and no certainty over their pay. This seems a bit like being a boxer who thought he was in a 10-round bout but now finds his bout is one of 15 rounds.

In conclusion, the Government’s 70th birthday present to the NHS seems to be a few bandages for the wounds, continuing short rations and no investment in reform. To quote the Royal College of Physicians, the NHS will remain, “underfunded, underdoctored and overstretched”. The enthusiastic Brexiteers now need to reflect on the consequences of what they wished for.

Hospitals: West London

Lord Warner Excerpts

Wednesday 18th October 2017 Lords Chamber

[Lord Warner (CB)]

My Lords, it is good that the noble Lord, Lord Dubs, has given us a chance to traverse the well-trodden paths of the future of north-west London’s hospitals. I want to put his concerns into a wider context. First, let me declare my interest as an elderly resident of Barnes with a personal interest in these hospitals. But I have also dabbled in the issues of London’s hospitals both as a Health Minister and subsequently as the chair of a provider agency established by the former strategic health authority for London which attempted to reshape some of the provider services in London.

Let me start with that latter experience. Reforming London’s health services is rather like battling through the Somme mud. Occasionally after a well-thought-out battle plan you make an advance. This happened with the reform of London’s stroke services where the number of stroke centres was cut from 32 to eight which saved lives and money, and produced better recovery outcomes for patients. This change, however, was a whole-London system change driven by the London SHA which was rather cavalierly abolished by the Secretary of State in the coalition Government. More often, the forces of local public and professional conservatism have thwarted change, as has consistently happened with the various attempts of the noble Lord, Lord Darzi, since 2007 to reshape London’s health services to meet today’s needs rather than those of the 1960s.

All the worthwhile attempts to reform the effectiveness of London’s acute hospital services have required a level and consistency of capital investment which has usually not been forthcoming from any Government. That looks to be the case for the proposals put forward in the five London STP plans. They call for a capital investment plan of about £6 billion over four years. This is probably an underestimate, but in any case, is highly unlikely to be forthcoming, unless the Minister has a surprise up his sleeve. Moreover, it is difficult to see whether these five separate STP plans are consistent with the overall needs of London, especially in relation to the consolidation of specialist services. This is where the loss of the London SHA is very telling. Will the Minister enlighten us on who will knit the five STP plans together in the best interests of Londoners?

Let me now turn to the issue of revenue budgets. According to the STPs themselves, the aggregate London “do nothing” revenue funding gap will be £4.1 billion by the end of 2021. This is without any allowance for any likely, and I have to say sizeable, shortfall in adult social care funding. If London was fairly treated on the basis of its weighted capitation population in 2021, this gap would shrink by about a third. So, can the Minister explain why London is being treated so unfairly in its NHS allocations, given the character and nature of its population? All this assumes that the whole NHS estimated deficit in 2021 will be as low as the NHS has calculated on present assumptions, which is a mere £17 billion.

I say all this because, despite the well-intentioned work that has gone into the STPs, those for London may have no more relevance than the latest Harry Potter story. The truth is that there is no credible funded plan for reshaping London’s health services as a whole. The STPs seem likely to suffer the fate of the noble Lord, Lord Darzi. Instead, what we will actually experience is more likely to be a series of actions aimed at trying to balance the books and patching up the services as best they can. That kind of patch-up approach seems to me—let me assure the noble Lord, Lord Dubs—a much more likely outcome for Charing Cross Hospital which, in any case, under the STP plans, is not due to change before 2021. I would be a bit more relaxed about the NHS’s capacity to reshape Charing Cross Hospital that much before the middle of the next decade.

However, it is crucial that as the London STPs evolve—and they will evolve; they are not going to be set in stone as they stand—they need much greater clarity about the future location of specialist services, not just A&E departments. They should also develop a much better definition of the services to be provided in what is starting to be called a “local hospital”—a term almost designed to raise local anxieties, unless you explain much more clearly than has been done what it means.

The NHS in London also needs to explain better than it has so far why it may well need to reduce its secondary care footprint by selling higher value land and buildings to fund the new community facilities that London so badly needs—and, as the noble Lord, Lord Suri, said, to help to contribute to providing land for affordable housing. So we should not get too excited about demolishing some hospital buildings in London to provide alternative facilities for the NHS and other social goods such as affordable housing, where land is very scarce.

I have to say, in conclusion, that the STPs have made a valiant attempt at coming up with a plan, but that plan lacks coherence across the scale of the whole of London and they do not seem to have done that good a job of taking the public with them.

Health and Social Care

Lord Warner Excerpts

Thursday 12th October 2017 Lords Chamber

[Lord O'Shaughnessy]

I reassure my noble friend that he is quite right to point out the benefits that attend to a cap. The intention is to consult on both the floor and the cap.

[Lord Warner (CB)]

My Lords, I declare my interest as a member of the Dilnot commission but I will not actually go down that territory. Are the Minister and his department aware that over the last three or four years there has been a considerable surge out of publicly funded social care by all providers, particularly nursing homes? What risk assessment has his department made of the implications of that, particularly for the NHS?

[Lord O'Shaughnessy]

The CQC report, which I am sure the noble Lord has looked at, talks about agencies and indeed nursing home providers deregistering. It also talks about the ones that are registering. There is a fairly consistent turnover in the number of those, so it is about balance. There is a similar number of providers within the market—again, with slightly fewer residential nursing and slightly more domiciliary to reflect the kind of balances of care that we have discussed.