NHS: Long-term Sustainability

Lord Warner Excerpts

Thursday 18th April 2024 Lords Chamber

[Lord Warner (CB)]

My Lords, I congratulate the noble Baroness, Lady Ramsey, on her excellent initial contribution to our debates. Unlike the noble Lord, Lord Patel, my experience is that too many interests are still worshipping at a 75 year-old NHS shrine that only 25% of the population is satisfied with. The NHS is trapped in an over-centralised management and service delivery model that cannot improve efficiency fast enough to cope with the tighter funding it faces.

As others have said, too many services are delivered to what I would describe as overcrowded, expensive and overprotected acute hospitals. We have neglected investment in primary care, community health services, social care and public health. We should ignore pleas to pour more money into this dysfunctional 75 year-old and focus on fundamental reform, led by people capable of delivering change at pace. My sketch of a five to 10-year operational plan to do this has five main strands.

First, we need fundamental change of a failing top management at the Department of Health and Social Care and its replacement with a new health and care management board, chaired by the Health Secretary, a CEO with high-level management experience outside the NHS, supported by a chief people officer for all workforce issues, and a chief finance and efficiency officer. I will not go into more detail, but I think this would lead to the abolition of NHS England—which would get quite a few cheers in the NHS, I suspect— and some other health quangos, which would get a further lot of cheers.

Secondly, we should consider emulating Singapore, which has similar health outcomes to the UK while spending less than 5% of its GDP on health. This low figure is accomplished because it delivers so many services outside acute hospitals, using up-to-date technology. It is very difficult to get into an acute hospital in Singapore. To achieve this change, we need to restrict the proportion of NHS funding going to acute hospitals over a five to 10-year period and invest much more in community-based services. We would need a clinically led national team, perhaps using the Academy of Medical Royal Colleges, to concentrate more specialist services in fewer sites, but with an enhanced capital investment programme for selected hospitals. Those hospitals with fewer services should become local community hospitals, and this should be the end of the district general hospital, a 1960s model. To make these changes stick, they should be underpinned by secondary legislation.

Thirdly, in consultation with the Royal College of Surgeons, all elective surgery should be undertaken in its own units, either provided by the NHS or contracted for with the private sector at NHS prices, which we managed to achieve in the noughties. Again, that would be a capped five-year budget which would not be used for other purposes.

Fourthly, we should be devolving responsibility for the management of all GP contracts, primary care, community health, social care and public health to new regional bodies, with elected mayors heading up as many bodies as possible, using devolution deals such as that done in Manchester. There should be a protected budget for this sector, growing faster than acute hospital budgets, with any real-terms cuts reported to the Public Accounts Committee.

Fifthly, a statutory proportion of the NHS budget should be devoted to public health, administered under the guidance of a new independent office of public health, set up on the lines of the Office for Budget Responsibility. It would be able to take the kind of difficult decisions on public health that the experience of recent years suggests elected politicians find very difficult. I would call this the “tough love approach”, and it is the direction of travel the NHS needs to consider taking. If the Front Benches want to find out more, they can go to the Social Market Foundation website and read my pamphlet on the NHS at 75.

Dementia

Lord Warner Excerpts

Thursday 18th January 2024 Grand Committee

[Lord Warner (CB)]

My Lords, I share the views of the noble Baroness, Lady Browning, on parity of esteem, but my contribution will concentrate on the problems caused by a failing NHS and a failing adult social care system. It is very difficult to achieve parity of esteem between the two services if both are failing and both are trying to shift costs to someone else.

I declare my interest as a member of the three-person Dilnot commission on social care funding. Our 2011 report had cross-party support and was accepted in principle by the coalition Government. For less than £2 billion, we demonstrated that it would be possible to cap at £50,000 individuals’ lifetime liability to pay for adult social care. This would have made a real difference to people with dementia. Despite legislation to implement our proposals, successive Chancellors from George Osborne onwards have deferred implementation. Jeremy Hunt has now achieved what his predecessors achieved by deferring the introduction of any form of cap until at least October 2025.

This is only part of a very sorry social care saga. Successive Governments since 2010 have allowed the funding of adult social care to decline relative to the funding of the NHS, increased service demands and the true cost of care for our ageing population. This approach has reduced NHS capacity, with more elderly patients admitted to, and staying in, hospital for longer because of the absence of social care. Governments have relied on council tax increases and occasional government handouts, rather than thinking through the funding of the social care system—even though one Prime Minister said that he would fix social care within a year; guess who. Whatever glowing account the Minister may give of the Government’s track record on social care funding, the really accurate assessment of that funding is set out in the King’s Fund contribution to the Library evidence for this debate.

Asking the NHS to do more for dementia patients in its current state is totally unrealistic. I am afraid that it is a failing institution in many parts of the country: it has not met its main access targets since before Covid, it has a backlog of about 7 million patients awaiting treatment and it is as short of staff as the adult social care system. It is totally impossible to think about making huge changes to improve services for dementia if we cannot repair the basic structures of the NHS and the adult social care system.

--- Later in debate ---

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

I add my thanks to my noble friend Lady Browning not only for bringing this debate but for her commitment generally in this area. I also thank all noble Lords for their contributions. These sorts of debates are always a pleasure, and one thing I have learned in the almost 18 months that I have been involved in the Lords is that it does not matter what the subject is; you always find expertise and learn about colleagues’ experience, such as that of the noble Baronesses, Lady Greenfield and Lady Murphy. I always find having the power of that knowledge around the table a real asset for the Lords and a real contribution to these types of debates.

My noble friend Lady Browning quite rightly said in her introduction that the statistics are gobsmacking, if I can use that word. I note the fact about one in 11 of those over 65. The one that really resonated with me—noble Lords have heard me mention it many times—is the fact that 25% of our beds are occupied by people with dementia. There is a real feeling that not only is that not the right place for them but it is not a good use of money. I therefore totally agree with that sentiment.

We see virtual wards and hospices at home as part of the answer to this. I have seen some good technological advances: at the light end of the scale, for want of a better word, we could look at people’s electricity usage, for example, and start to learn their patterns. For a lot of people, there is a surge at 8 am when they put on the kettle, so if that surge suddenly is not there, that is an early warning that perhaps there should be a call because something is wrong. There are also motion detectors around the house to start to understand their patterns. To my mind there is a spectrum of those sorts of virtual wards from the very heavy intervention ones to just trying to make sure that people are generally fine and going about in their normal way or, if they are not, it can be an early warning.

I will come on to staffing, but a key part of that in the home is dom carers. It is a point that the noble Lord, Lord Allan, made well. We have made a lot of progress in what we are trying to do with career progression, but I want to be assured that we have really got this area right.

My noble friend Lady Browning mentioned the fundamental need for a care plan in all that. In preparing for this, my noble friend Lord Evans said that that was what he needed in his recent situation with his mother. That is what ICSs should be starting to do now. I take the point made by the noble Lord, Lord Allan, that there is probably no better example of trying to learn how they are working than using this as a case study. My general experience of ICSs—of course it is early days, even now I think we are only 18 months or so in—is that, as ever with these things, there are some very good examples and probably some which need to do a bit more work. I am quite happy to take that away to try to find some test cases that we can try to learn from. The NHS has set out best practice guidance that it expects all ICSs to follow. My understanding, which I will check on, is that part of that is having a dementia lead, which my noble friend Lady Browning mentioned.

As the noble Baronesses, Lady Ritchie and Lady Donaghy, and other noble Lords mentioned, diagnosis is key. The target is two-thirds. We are getting quite close to that, but we have been behind, so there has been an investment of £17 million to catch up. I accept the point about whether two-thirds is enough and whether we would accept that in other areas and let one-third go undiagnosed, but step one is making sure that we hit that two-thirds.

The noble Baroness, Lady Ritchie, asked what sort of resource we are putting behind this. CDCs already have the equipment, in terms of scanners, and the ability to do that, but I accept the point made by the noble Baroness, Lady Murphy, that it is probably more about the people. It is less the equipment than making sure that people are trained to do that. I will come on to staffing later, but I take that basic point.

What is the point of diagnosis? First, it is to make sure that people get the right care. Secondly, it is so that we can start to deploy some of these new treatments. Again, it is great to have the expertise of the noble Baroness, Lady Greenfield. In answer to the question from the noble Baroness, Lady Ritchie, we are expecting NICE approval of the drugs to slow dementia down in early summer, and we expect to then roll that out during the summer period. However, we all know that they are only on the nursery slopes, and that is why there is a commitment to research of £160 million per year.

To fuel the moon shot, I am really excited about the power of the data that we own. I was recently on a fact-finding mission to Boston and they were talking about a major $250 million investment that a private venture group had made into the 9 million hospital records in Mayo Clinic. They were saying, “You don’t realise what you have in the UK. You have 50 million records in England, and you have primary care as well”. The whole problem around dementia is that we do not know what we are trying to tackle, in terms of the early causes. The reason we were so good at tackling Covid was that we knew exactly what we were going after. Right now, in things such as dementia and Alzheimer’s disease, it is still a case of shots in the dark.

However, regarding the 50 million records we have, if we look at people who have dementia today, wind back 15 years and ask what they were visiting their GP about then, and throw that all at AI, we can get some of those early-warning indicators. I know some of the anecdotal ones. For instance, as mentioned, urinary tract infections are often an early indicator of dementia because people do not understand that they are there. Throwing all that at AI and making sure that that data exists is a real way to fuel the moon shot so that we know where we should be putting our research efforts to try to find treatments.

On the funding of social care, as I said, the £8.1 billion investment over two years is a major investment. I learned a lot from my noble friend Lady Berridge. I did not realise that being committed under the Mental Health Act is a main way to get there. On the question from the noble Baroness, Lady Wheeler, about CHC transparency, I do not know the answer off the top of my head, but I will come back on that because it is a good point. As ever, I will try to come back and cover it more fully in writing.

The reform plans that we have announced are about making sure that we have the proper staffing to do this. As I mentioned in answer to the earlier Question today, we are starting to turn a corner, although it is early days. On career progression and training, I believe that what we announced last week is a key part of making this a real profession that people will want to stay and progress in. I agree with the point made by the noble Lord, Lord Allan, that paid progression has to come along with those qualifications; otherwise, you will not get people wanting to enter it.

I understand, as a few noble Lords have mentioned, including the noble Baronesses, Lady Wheeler and Lady Pitkeathley, that the role of the carer is vital and often overlooked. As noble Lords know, I have had personal experience of that as a carer. Quite honestly, all I can say is that we are making some early steps in trying to get some of the funding, but I freely accept, from personal experience, that there is a lot more that could be done in that space.

I have tried to give a flavour—before my throat totally gives way—of what we are trying to do in this area. As ever, I will respond fully in writing, but I hope there is an understanding from the Government’s side, as echoed by all noble Lords, that this is something we do take seriously.

[Lord Warner (CB)]

I am sorry to test the Minister’s vocal cords, but he mentioned that there was good practice guidance issued to ICSs. My experience as a Minister is that the department is extremely good at sending out guidance but extremely bad at checking whether anyone ever follows it. What arrangements has the department got to see if that good practice guidance is put into operation?

[Lord Markham (Con)]

The noble Lord makes a very good point, and it is one I have some personal experience of as well. The hope, when setting up 42 ICSs, was that this would be the right size for them to pool resources and take a holistic view, and that 42—while still a lot— would be a manageable number. As Ministers, we have divided those up into seven each that we can get to know, and live and breathe and understand; we also have dashboards that we can use to monitor progress in these areas. That is the way we plan to do that. I freely admit, again, that it is early days; I accept the noble Lord’s point that you can give out guidance until you are blue in the face—and they will receive a lot—but it is the follow-up that really matters.

I thank the noble Baroness again for the debate. I hope there is a feeling that we understand and that we are trying to give the parity of esteem that this deserves, and I look forward to following up more thoroughly in writing.

Cancer Referral Targets

Lord Warner Excerpts

Monday 5th June 2023 Lords Chamber

[Lord Markham (Con)]

The noble Lord is correct. I have a friend who is in that situation. We all understand the stress of waiting and what it can cause. I will come back to the noble Lord on the research into the impact on mental health. I absolutely accept that a lot more needs to be done, but one of the main things is the target of diagnosis within 28 days, which we are now hitting 75% of the time. That gives people peace of mind quickly, particularly as 94% of those people end up being negative—only 6% are positive. Peace of mind is crucial here.

[Lord Warner (CB)]

My Lords, is the Minister aware that in 2017 this House, under the distinguished leadership of the noble Lord, Lord Patel, produced a report which said that the sustainability of the NHS was in doubt unless there was a workforce plan? Would he like to remind his friend the Chancellor, who was the Health Secretary at the time, of that report?

NHS GP Surgeries: Purchase by US Companies

Lord Warner Excerpts

Monday 5th June 2023 Lords Chamber

Asked by

[Lord Warner]

To ask His Majesty’s Government, in the three years up to 31 March, how many GP surgeries providing NHS services have been purchased by private companies of which one of the controlling shareholders was a United States company; and whether they intend to take action with regard to such purchases.

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

This information is not held centrally because local commissioners arrange appropriate services for their populations by contracting with providers. Commissioners do not normally request details of corporate structure. Our focus is on high-quality services and patient experiences, regardless of practice ownership. All GP contract holders and providers of NHS core primary medical services are subject to the same requirements, regulations and standards. We expect commissioners and regulators to take action if services are not meeting the reasonable needs of patients.

[Lord Warner (CB)]

My Lords, I am a little surprised by that particular Answer. I would have thought that, given the problems of shortages of GPs in the NHS, there might be a little more interest in the Department for Health and Social Care in finding out about this. Is the Minister aware of the scale of acquisition of GP practices that has been achieved with very little public transparency? Let me give him the example of Operose Health, which is a UK subsidiary of Centene Corporation, a major US health insurer, which now owns nearly 70 GP practices serving nearly 600,000 patients. I would have thought that the centre might want to take a little more interest in this, because what is very clear is that the APMS system is an offering that many corporate individuals can exploit to get a hold of very large numbers of GP practices—and, just for afters, Centene is in deep trouble in the United States.

Branded Health Service Medicines (Costs) (Amendment) Regulations 2023

Lord Warner Excerpts

Thursday 25th May 2023 Lords Chamber

[Lord Warner (CB)]

My Lords, I support the regret Motion moved so ably by the noble Lord, Lord Hunt of Kings Heath. I agree with quite a lot of what the noble Lord, Lord Lansley, has said, but I am not going to be as wide-ranging as him. The Minister may be relieved to know that.

I speak from the perspective of having been a Pharmaceuticals Minister who negotiated a 7% reduction in the price of branded medicines, under the old PPRS, without damaging the UK’s life sciences industry and with the agreement of the Treasury. So it is possible to do these things and make such schemes work if, across government—we will come back to that—there is a willingness to engage properly with the industry. What we see here is that failure across government to deal with the industry.

Unfortunately, the regulations before us will, as has been said, significantly damage the UK life sciences sector. That was confirmed for me by the briefing received from the ABPI and some of the pharmaceutical companies that have also set out their views in relation to these regulations.

The regulations increase the repayments by pharmaceutical companies in the statutory price scheme to bring them into line with the already high levels in the voluntary price scheme, so we have a scheme which is catching up to an already unsatisfactory scheme. That is a wonderful achievement for government departments to have delivered. Government departments seem to have simply ignored the warnings they have been given about what will happen if they press on with the regulations as they stand. Instead, they have produced what I would regard as an unconvincing and wordy impact assessment, which has already been commented on. It totally downplays the warnings from the industry. The industry made its position very clear in the ABPI briefing for this debate. It points out that the proposed rebate of 27.5% of companies’ revenues

“is a rapid escalation from historical and international norms. Prior to this the average payment rate across the last four years was 10.6% and in 2022 the rate was 14.3%”.

That is almost a doubling of what the rate was a year or so ago.

When one looks at comparator countries, as has been mentioned, the UK rate is an extreme outlier within western Europe. Some countries do not even have comparable schemes, but in those that do, the rates are 12% in Germany and 7.5% in Spain and Ireland. The only comparable clawbacks to the UK’s are in Romania and Greece, two countries that, if I may say so, are hardly in the Premier League in terms of the life sciences. The ABPI brief goes on to state that

“the UK is already seeing worrying signs of decline in the UK life sciences industry including in R&D investment, access to clinical trials and medicines launches with companies making long-term decisions on the future of their UK footprint.”

The new proposed rate will accelerate this investment and jeopardise the availability of new medicines, which will lead to poorer NHS performance and patient outcomes. The ABPI contrasts the UK’s approach with incentives to new life sciences investments in France and Ireland, where Pfizer has recently announced big investments in both countries. AstraZeneca has followed suit in Ireland. The ABPI briefing is also supported by the briefing from AbbVie, a top-five, US-headquartered global biopharmaceutical company. It points out that the NHS already lags behind other countries in the take-up of new medicines. Branded medicines expenditure is reducing in the NHS, while the NHS budget is increasing. That is no mean achievement. I never got to that stage when I was the Pharmaceuticals Minister.

UK patient access to industry clinical trials is declining rapidly, and the average annual loss in the UK’s share of R&D spending is declining by about 3% a year. The briefing from Roche, another major company, is in a similar vein to that from AbbVie. This is not just the industry complaining about these regulations; these concerns are shared by patient groups. Gene People, which supports people with genetic conditions, has set out in its evidence the impact of these regulations for patients and on their access to the drugs that they will require over time.

I am genuinely puzzled by why the Department of Health and Social Care has simply ignored the evidence provided by the industry and patient groups on the damage that these regulations will do to UK life sciences and UK plc. The ABPI commissioned research which found that continued high payment rates in both the statutory and voluntary schemes would cost the UK £50 billion in GDP and £17.9 billion in tax revenue because of lost R&D investment of £5.7 billion by 2028. These are considerable losses to the UK economy. There is not a mention of them in the impact assessment. The ABPI company survey also suggests that repayment rates of around 24% across both the voluntary and statutory schemes

“would result in job losses in over 9 out of 10 companies”.

The savings to the NHS budget from these rebate schemes is modest compared to the economic damage that they do.

Despite all this evidence, Ministers from the Department of Health and Social Care are ploughing on with these regulations, seemingly unaware that the industry’s timescales for making R&D investment decisions are much closer than they realise. In the next year or so, these decisions will be taken in relation to 2030 onwards. Somewhat bizarrely, 2030 is the date the Prime Minister is talking about for cementing the UK’s place as a science and technology superpower.

It crossed my mind as I prepared for this debate whether the Prime Minister and No. 10 are aware of the contradictions between the Department of Health and Social Care and the Prime Minister’s aspirations for the UK economy. It is also strange that on the very day that we are debating this regret Motion on these regulations, the Chancellor is sitting with the industry at the Life Sciences Council, discussing the life sciences sector in this country. It seems an interesting coincidence.

I should like clarification from the Minister on one point and to ask him a question. The point of clarification is whether, as the usual convention requires, he is speaking fully on behalf of the Government in responding to the Motion tabled by the noble Lord, Lord Hunt. My question relates to the new discussions on the voluntary scheme, which are taking place or have begun. Can the Minister confirm that these discussions are indeed taking place? If so, what is the point of pursuing these regulations if, in these new discussions, there is the possibility of a more positive approach to rebates under both schemes, given the more sensible proposals put on the table by the ABPI—the Minister may be able to confirm this—which suggest that we should be talking about single-figure rebates if we want this country’s life sciences industry to be successful?

[Lord Allan of Hallam (LD)]

My Lords, I am very grateful to the noble Lord, Lord Hunt, for his Motion, and for giving us an opportunity to debate a series of questions raised by the statutory instrument about the life sciences sector more broadly.

I do not think that it is enough for us simply to say, “Look, Britain is great”, and expect that to act as a magnet for international pharmaceutical companies to invest in it. We certainly have a very strong sector and excellent skills, but the market is not sentimental: it reacts to financial signals. The noble Lord, Lord Lansley, was quite right to put us in the position of those people sitting in boardrooms, where soft signals such as the Prime Minister holding a summit are fine but the determinations will be based on hard numbers in spreadsheets. That is the way businesses work.

The concern that we should have in considering the statutory instrument is whether this settlement will be absorbed as simply the cost of doing business in the UK or whether it will change behaviour of businesses in a negative way. On all sides of the House, I think we hope that it will not do the latter. The ideal outcome is that businesses continue to invest in spite of taking a hit, but the risk that that will not be the case is genuine and deserves the debate that we are having today.

We have already seen some companies move from the voluntary to the statutory scheme. It would be helpful if the Minister could indicate how many. I understand that the rates are similar, but it is a pretty strong signal when a company says in that board discussion that it is important for them to say, “We are not taking this lying down. We are upset. Therefore, we will pay what we have to pay, but only if you make us do it. We are not willing to do it on a voluntary basis.” As I said, the numbers may look similar, but the signal seems pretty clear to me. I hope the Minister can indicate the scale of the trend and his views on whether we should be concerned that that is happening.

It is interesting to note from the Explanatory Notes to the legislation that the consultation responses were nearly uniformly negative. I was going to say that they were uniformly negative, but they were not: only 30 out of 33 were. I was fascinated by this comment in paragraph 10.3, which referred to having more responses than in previous years. It said:

“It is likely this rise in the number of responses reflects a stronger level of interest in the consultation from industry in advance of negotiations for a new voluntary scheme to succeed VPAS, which expires at the end of 2023.”


I suggest that the increased number of consultations reflects something else: it is a cry for help and a protest against the fact that the rate is now over 20% and seems to be rising inexorably. Businesses are not responding in greater numbers just because of something happening in the process but because of the substance. When the noble Lord, Lord Warner, made his 7% reduction some years ago, I suspect he would not have had the same number of responses, because the reduction was not at the levels we are seeing now. The fact that we are at over 20%, and that there seems no prospect that that will reduce, means that businesses want to engage.

Here is the question for the Government: what signal do they want to send to these major companies that produce medicines that our population depends on? Is it that the trend is going to improve over time, so that they are encouraged to invest in test facilities and research in the UK—that they can expect to have more free cash flow, as it were, from the sales that they are making in the UK, to invest back into the UK? Or will the trend stay the same, at a level that they have told us they already find unacceptable, or even worsen? As the Covid backlog is, hopefully, dealt with more expeditiously, there will be more dispensing of branded drugs, and there is a scenario in which things continue to get worse. If companies feel that they have less to invest, those signals will be negative.

--- Later in debate ---

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

I thank noble Lords for the debate, and I particularly thank the noble Lord, Lord Hunt, for bringing forward this important subject. It was clear from the contributions of noble Lords that we all want the same thing here, and this is a discussion about how best to achieve it. We all want the UK to be a

“science and technology superpower by 2030”,

as quoted by the Prime Minister. We all want a thriving life science sector, we want access to the best medicines for the NHS and we all want to ensure that the NHS is achieving value, in terms of money for the front line—I think we are united on those things. I also commend the fact that this debate was very much a discussion, so I will respond in that vein, rather than reading out a speech. I will try to discuss this from the Government’s point of view. I apologise if that means that I might not come across as quite as polished, but I would rather respond directly to the points raised.

We would all accept that we are striking a delicate balance here: between having value for the NHS—through, for example, the funding of £2.5 billion this year—and having value and making savings for frontline services, which we all want to see. While we are focusing on those, we also want to make sure that we do not go too far and damage what is, and what we want to be, a thriving sector.

The noble Lord, Lord Hunt, asked whether the Government are being complacent about this. The words of the Prime Minister, saying that he wants a negotiated outcome with the ABPI, are probably the strongest sentiment in terms of wanting a sensible, negotiated outcome. At this point, I say to the noble Lord, Lord Warner, that I am responding on behalf of the Government.

As the noble Lord, Lord Warner, pointed out, just today, the Chancellor is having a round table with the life sciences industry. That, too, is very much about getting a solution that works all the way round. Having said that, please remember that some of the comments I am making in this debate are about a balance. We are all aware that we are entering into a negotiation and obviously, in any negotiation, sides make points—sometimes at the negotiating table and sometimes publicly. Please take my comments in that vein; we want to make sure that a balance is brought to the debate.

[Lord Warner (CB)]

I am sorry to interrupt the Minister’s flow. He said that we are having the fruitful discussions that the Prime Minister wants with the industry and that they are starting to progress. However, the industry itself is starting with a figure in the single figures, nowhere near 27%. I am curious as to why we are having this discussion about progressing these regulations, as they seem to be going in totally the opposite direction from the aspirations the Prime Minister has.

[Lord Markham (Con)]

The mechanics behind this debate—I was planning to say that my noble friend Lord Lansley made this point—are about the alignment of the voluntary and statutory schemes. I think that we would all agree that it is sensible that the two are roughly aligned. We can argue over how high or low that figure should be, but we would agree, I think, that it is quite sensible that the two are aligned. If you had large disparities between the two, you would disadvantage, for instance, the members who have joined the VPAS system.

[Lord Warner (CB)]

I am sorry to interrupt the Minister again. We are talking about signals given to the outside world, in these discussions that are now taking place about the voluntary scheme. As the noble Lord, Lord Lansley, asked, rather elegantly, why do we have two schemes in the first place? There is something very odd about levelling up to a voluntary scheme’s level with a big increase and, at the same time, sitting down with the industry and saying how much we love it and that we want a new, agreed programme, when the industry is talking about figures which are nowhere near the figures in these two schemes. It seems almost politically inept.

[Lord Markham (Con)]

As I said, this is about the scheme and the pricing for this year. The negotiations happening now are about future years, while, technically, this debate is about making sure that the alignment is there for this year and its pricing. Given that the discount has been decided on for this year for the voluntary scheme, having alignment will ensure fairness, so that members in the voluntary scheme are not suddenly disadvantaged against the statutory scheme—which would happen if we were not putting in a similar price. It does not in any way predicate what a negotiated outcome might be for future years.

In terms of a future negotiation, if there was a VPAS-type scheme—again, everything is on the table—you would have the argument about alignment. Most people would accept, as my noble friend Lord Lansley was saying, that having an alignment between the two is a sensible mechanism. The real debate today is about what level that discount should be. Regarding the balance—and I am not making any value judgment about what the right level is—when this was first forecast in 2018, a forecast was put out about what the discount would be over a five-year period, and in year 5 it showed a discount in 2023 of 31.1%. Those were the projections made, at that time—in 2018—the ABPI welcomed the scheme as an innovative one. In fact, today, the discount is less than that, at 26.5%. This was all known and projected as part of the scheme at the time. That is not to say that, in these negotiations, it should not be reset or that we should not make sure that there is a sensible conversation, but I am trying to do this while making sure that there is a balance in the negotiation.

Health and Care Bill

Lord Warner Excerpts

Lords Hansard - Part 1 & Report stage
Monday 7th March 2022 Lords Chamber

[Lord Warner (CB)]

My Lords, I rise to speak to Amendments 141, 143 and 144A—to all of which I have added my name. In the unavoidable absence of the noble Lord, Lord Lansley, through Covid, I shall be moving Amendment 144A with his agreement. I also declare my interest as one of the three members of the Dilnot commission and, unsurprisingly, I shall be supporting the findings of the commission’s report in speaking to these amendments.

The coalition Government passed the Care Act 2014 to enable the Dilnot cap to be implemented but, since then, there has been no action to do this until now, with Clause 155 of this Bill. Unfortunately, that clause has major unfairnesses and shortcomings, as has been pointed out by all three speakers—the noble Baronesses, Lady Wheeler, Lady Brinton and Lady Campbell—so I am not going to repeat what they have said. This is a deficient clause, and no reasonable person would see it as a fair and reasonable implementation of the Dilnot proposals on the cap. As far as I am concerned, Clause 155 is an unsatisfactory attempt at implementing that commission’s report and should be deleted from the Bill.

I turn to Amendment 144A in the name of the noble Lord, Lord Lansley. The purpose of this amendment is very simple: to require the Government to bring Sections 15 and 16 of the Care Act 2014 into force by April 2023. That is the time when one might expect the Government to bring the cap into force if Clause 155 remained in the Bill, so I do not think we are doing anything very adventurous by putting that date in the amendment. However, the removal of Clause 155 without any replacement would create uncertainty as to whether Sections 15 and 16 of the Care Act would be activated. If, as I and the noble Lord, Lord Lansley, hope, Clause 155 is deleted, Amendment 144A would ensure that the cap was brought into force by April 2023, but also on the basis that the cap was calculated to include the costs of all eligible needs met by the responsible local authority. In short, Amendment 144A would ensure a date for the Dilnot report on fairer care funding to finally start being implemented.

I acknowledge that if the noble Lord, Lord Lansley, were here to move this amendment, he might be more trusting than I am and willing to accept assurances from the Minister that Sections 15 and 16 would be activated by April 2023. I am afraid that someone who wrote and contributed to a report over a decade ago—which has been subject to prevarication ever since then—is rather less trusting, and I think it is absolutely essential, if we want to implement the Dilnot recommendations, that we should not offer that comfort of assurances to the Minister.

I turn briefly to Amendment 143, spoken to so well by the noble Baroness, Lady Campbell, in the absence of the noble Baroness, Lady Bull—another Covid casualty. The Government have made—if I may put it this way—a total hash of the Dilnot recommendations on page 24 of our report. These made it absolutely clear that anyone born with an eligible care need—or who developed an eligible care need before the age of 40—should have a zero cap. We set out the evidence and the arguments for this recommendation extremely clearly. The Government have chosen to ignore our clarity and have muddled up—for charging purposes—the income and capital circumstances of two very different groups of people: older adults and disabled working-age adults. As the noble Baroness, Lady Campbell, has shown, this is very unfair to working-age disabled people. I suggest to the Minister that the Government need to remember the title of our report was Fairer Care Funding—that is what it said on the tin, and that is what we expected to be implemented. The extra cost of sticking to our recommendations on working-age disabled people is—at the most—about the cost of 10,000 people by about 2030. That, if I may put it crudely, would be about the cost of a few rather dodgy PPE contracts.

These three amendments—141, 143 and 144A—work together well as a package. They remove dubious government amendments; they restore the Dilnot proposals for younger disabled people at a modest cost; and they start the implementation of the Dilnot cap in April 2023 on the basis that we recommended.

[Lord Lipsey (Lab)]

My Lords, it gives me great pleasure to follow the noble Lord who sat on the Dilnot committee. I think it was a first-class report, which, at the time, I was prepared to endorse as the least bad solution to the social care problem. But I have changed my mind since then. Why? Because the facts have changed. I set out some of those facts when I spoke in Committee, and they include the large rise in house prices that makes many people much more able to pay for care for themselves at the moment. The facts have changed again in the last couple of weeks because of this disgusting war that has broken out in Ukraine. As a consequence, we are going to have to spend more on defence, as the Germans have already recognised. Therefore, public budgets are going to have to be squeezed in other areas. I regret those squeezes, but it is President Putin’s fault, not ours.

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[Lord Kamall (Con)]

I thank all noble Lords who have spoken in this debate and I am sorry I was unable to engage as much on this issue as I was on others. I will speak first to government Amendments 128 to 140 and 187. We believe that these amendments are crucial to make the adult social care charging reforms work as intended. If they do not stand as part of the Bill, it will lead to unfairness between those whose needs are met by a local authority and those who self-fund their care. The intention of these amendments is to correct this.

Without these amendments, some costs which individuals have incurred will not meter towards the cap when they should do so. Currently, individuals eligible for funded support who have not had a timely needs assessment may incur costs in getting their needs met in the interim. This applies whatever system of charging we come up with. The costs incurred during periods of delay currently do not count towards the cap, and my amendments fix this. We came across this issue when we were looking back at previous Bills and unintended consequences.

I have also tabled an amendment to clarify the circumstances in which an independent personal budget must be provided by a local authority and what information those documents must include. We want these to be forward-looking documents, personal to the care user. To support this and to simplify the metering process, we are also removing the link between these documents and what meters.

Finally, as set out in the recent impact assessment, our charging reform implementation plan includes a small number of trailblazer local authorities that will implement charging reform earlier than others. I have tabled Amendment 187 to allow these trailblazer local authorities to begin implementing the reforms before others. For these reasons, I ask that noble Lords support my amendments.

On the other amendments, a number of noble Lords have asked questions and I will try to answer them. We believe that the £86,000 level set for the cap balances people’s personal responsibility for planning for their later years with a need to put in place a system to ensure that nobody faces unpredictable costs. Removing Clause 155 or simply omitting Clause 155(2) would have the effect of removing the ability to meter towards the cap by individual contribution only. Instead, progress towards the cap would be based on both individual and local authority contributions to care costs. This policy is unfair. However, it is also considered unaffordable.

Removing these clauses would increase the cost of the overall reforms by about £900 million per year, if you keep all other parameters the same—although. of course, other noble Lords have asked for other amendments, so those parameters would not necessarily be the same. This would require raising the cap, reducing means-tested support or expecting people to make contributions towards their daily living costs that are unaffordable from most people’s income. None of these is preferable to the approach that the Government are proposing to take.

We argue that the Government’s reform package is affordable and deliverable. We have indeed seen many reports over the years, and I understand that the noble Lord, Lord Warner, was on the Dilnot commission, but we have to ask ourselves why these were not implemented. Although we may see many merits in a number of a different systems, and we all have our own biases or views on what the system should—

[Lord Warner (CB)]

May I give the Minister the answer to why they were not implemented? Successive Conservative Chancellors declined to implement them.

[Lord Kamall (Con)]

The noble Lord may say that, but I have been advised that they were considered unaffordable.

On Amendment 142, I thank the noble Lord, Lord Lipsey, for his engagement with me on his very interesting idea. I agree with him; I regret the fact that the private sector has not come forward sufficiently to offer products. I agree that that could have solved a number of problems, but I should clarify that the taper rate is not linked to income, as suggested. It is what people are considered to be able to afford to pay towards the costs of their care, based on their capital.

The amendment would make the means-testing regime significantly more generous than in the Government’s proposal, and I can see why that is attractive. However, once again, to answer the questions from many noble Lords, that would be considered to make charging reform unaffordable. We would be unable to afford to invest in wider improvements in the social care system that we are all keen to see. The Government’s plans balance providing protection and predictability when it comes to care costs with how much additional burden should be placed on the taxpayer. We believe that our reform is responsible, deliverable and affordable. I repeat that although it may not be optimal, our proposal is better than the existing system, where there is no cap.

Amendment 143 suggests a zero cap, which would equate to free personal care for those identified as having eligible care needs before the age of 40. We considered this issue carefully and, as acknowledged by the noble Baroness, Lady Campbell of Surbiton, we looked at this system and engaged with her, but, as she rightly said, the issue was the cliff edge. One may disagree about the cliff edge, and there are other cliff edges, but we felt that one of this magnitude was unfair. We also believe that younger adults will benefit from the announced charging reforms. From April 2022, the social care allowances will be uprated in line with inflation to allow everyone to keep more of their income.

The noble Baroness, Lady Campbell, asked about data on the under-65s. We need to improve the data that we hold on under-65s who are drawing on care and support so that we better understand their needs and how reforms impact them. The Minister for Care and the Minister for Disabled People this week met a large number of organisations representing working-age disabled adults to discuss this and other issues. This group will continue to meet as our reform programme progresses. I hope that that offers some reassurance to the noble Baroness.

Amendment 144A would require the full rollout of the government reforms to be commenced before 1 April 2023. One of the reasons we looked at October is that we recognise that implementing reforms of this magnitude —noble Lords will have heard me say previously that we have grasped the nettle—requires a significant lead-in time to enable local authorities to prepare. We have invested £3.6 billion in preparation for these reforms, and we cannot do it overnight. In addition, we want to have the flexibility to work with some of those trailblazer authorities to make sure that we really get the best of the discovery process to ensure that it works and that we can spot any unintended consequences.

We do not believe that there is sufficient time for local authorities to prepare for full national rollout by April 2023. It is vital that we take the time to work with the sector and local authorities on the process of implementation if we are going to get this right. To enable a successful rollout, we want to see how the trailblazers will work before we go for the full national rollout by 2023. Trialling and engagement with the sector would have to happen anyway, whether Clause 155 stood or not. As I have said, if Clause 155 does not stand, we would not be able to afford to implement charging reform.

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Moved by

[Lord Warner]

144A: After Clause 155, insert the following new Clause—
“Commencement of sections 15 and 16 of the Care Act 2014
The Secretary of State must make regulations under section 127(1) of the Care Act 2014 (commencement) to ensure that all provisions under sections 15 and 16 of that Act have come into force before 1 April 2023.”

[Lord Warner (CB)]

I wish to test the opinion of the House.

Health and Care Bill

Lord Warner Excerpts

Lords Hansard - Part 1 & Report stage
Thursday 3rd March 2022 Lords Chamber

Finally, whether or not these amendments are pressed, I hope that the Minister will reconsider whether the Goldacre review should be published before the final version of the new NHS data strategy, Data Saves Lives. I welcome the fact that the Goldacre review is going to deal with information governance, but it is important that we should see that before the final version of Data Saves Lives.

[Lord Warner (CB)]

My Lords, I rise even more briefly to support Amendment 116. It is worth reminding the Minister and the House that the Government Statistical Service is independent. It was made so by the Blair Government so that Ministers could not withhold, distort or delay the publication of uncomfortable statistics. Rebukes on dodgy statistics secure public reprimands of Ministers and departments.

The logic of this position is that you do not put the collection or publication of health statistics in the hands of an operational arm’s-length body, particularly because there could be a conflict of interest. That point has already been made. These functions should be left in the hands of an independent non-operational body, which is what the amendment in the name of the noble Lord, Lord Hunt, does. Can the Minister explain why the Government are making this change? My instinct is to be mightily suspicious.

[Baroness Walmsley (LD)]

My Lords, I simply rise to say that I agree with all noble Lords who have spoken and look forward to the Minister’s reply.

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[Lord Lansley (Con)]

My Lords, I will intervene. I was not intending to speak but I was prompted by a recollection arising from the reference to anaesthetists by the noble Baroness, Lady Finlay. I recall that the Centre for Workforce Intelligence produced in February 2015 a report on the future supply and demand of anaesthetists and the intensive care medicine workforce. I have just checked the report, and it projects for 2033 that the number of full-time equivalent staff required will be 11,800, and supply will be 8,000. Therefore, in February 2015, we knew of this set of projections produced by the CWI. It said, among other things, that there should be

“a further review in the next two to three years.”

However, the CWI was abolished in 2016 and its functions were restored, I think, to the Department of Health.

The noble Lord, Lord Stevens, did not refer to this directly, but we must bear in mind the general presumption that there has never been workforce planning, although in certain respects, there has. The report on anaesthetists is only one of a whole string of reports—I could list them, but I do not need to—produced by the Centre for Workforce Intelligence before it was abolished. Their main purpose was to say to Health Education England, “This is the level of education and training commissioning you should be undertaking in the years ahead”. As the noble Lord said in Committee, it did produce a set of proposals; it is just that they were not acted upon.

I just say this: legislation may be the right way to proceed now, but let us not lose sight of what is actually required, which is for Health Education England not to have its budget cut, as happened in 2016, but to have its budget increased and for that budget to be turned into an education and training commissioning programme that delivers the numbers of trained professionals in this country that we project we will need. It is no good saying, “Oh, we’ve never had planning; we passed a piece of legislation.” I am sorry, it could be a case of legislate and forget unless the money is provided and the commissioning happens. There have been organisations whose job it was to do it—Health Education England, the Centre for Workforce Intelligence—but they were not supported, and in one case, abolished.

[Lord Warner (CB)]

My Lords, I support Amendment 111 in the name of the noble Lord, Lord Hunt, to which I have added my name, and Amendment 80 in the name of the noble Baroness, Lady Cumberlege. On Amendment 111, I want to emphasise two points. First, GPs are and have always been the gatekeepers to the NHS. Without GPs, there is less primary care and less access to the NHS. Over 90% of patients access the NHS through their GPs and primary care. If you are unlucky enough to live in an area with a serious shortage of GPs, your access to NHS services is highly likely to be diminished and your health put at greater risk.

My second point is that it follows that a shortage of GPs is also likely to contribute to health inequalities, a topic much discussed during the passage of the Bill. In addition, this is likely to mean that you live in a place which the Government say they want to level up. So, if the Minister accepts the amendment of the noble Lord, Lord Hunt, he will be helping to deliver two government objectives: reducing health inequalities and levelling up. What’s not to like? Who knows—he might even get a promotion out of it.

I turn briefly to Amendment 80, which I support and will vote for if the noble Baroness pushes it to a vote. I want, however, to emphasise two points that follow on a great deal from what the noble Lord, Lord Lansley, said. For too long the NHS has relied on buttressing its inadequate system for training home-grown staff by recruiting from abroad. Brexit and tighter immigration policies have significantly reduced this supply line. It will take long-term planning and consistency of purpose over many years to rectify the health and care workforce supply problems.

My second and last related point on workforce is that the track record of the Department of Health on long-term planning is appalling. It is not just me saying that; it was made absolutely clear in the report by this House’s Select Committee on the Long-term Sustainability of the NHS and Adult Social Care, so ably chaired by the noble Lord, Lord Patel, who unfortunately, as we all know, is laid low by Covid. Those who support Amendment 80 should hear the arguments in the debate on Amendment 112, which would support its implementation. The noble and learned Lord, Lord Mackay, thought that something more elaborate than Amendment 80 was required. That may be the case, particularly for social care, but Amendments 80 and 112 complement each other. They are not rivals or alternatives; they put in place a structure thoroughly independent of government and which requires the Government then to pay attention to what has been independently provided.

[Baroness Fraser of Craigmaddie (Con)]

My Lords, it is clear that there remain huge and serious concerns across the House and beyond regarding how the Bill addresses the chronic staff shortages in our health and care services. I say health and care services, because as we know, the staff shortages affecting the delivery of services are not just within the NHS but felt across the board, in health, care and public health services. While this is a current and urgent issue, future workforce planning will be the single most important factor in limiting our ability to deliver the ambitions we all have for the future of health and social care and importantly, the ambitions of the Bill.

Like many other noble Lords, I have the greatest respect for my noble friend Lady Cumberlege, and if she feels that the current duties the Bill places on the Secretary of State in Clause 35 to report at least every five years are inadequate, then I urge the Government to take note. As my noble friend said when she introduced her amendment, she is not alone: at least another 100 organisations are calling for this aspect of the Bill to be strengthened. I ask the Minister today, therefore: if the Government are not planning to accept the amendment, how do they plan to address the challenges of future workforce? How will they assess the future needs of health, social care and public health services? Previous work has not quantified the workforce numbers needed and we cannot wait for another review.

I have a couple of observations on the amendment itself, which I commend in that it does require the Secretary of State to report on this wider health, social care and public health workforce, unlike the current Clause 35, which refers only to the health service. However, I sound a note of caution, because if we simply assess vacancy rates, or get into the mindset of needing to replace like for like, role and service development, which will be essential to support future health and care services as they evolve, risk being stifled, as my noble friend Lady Harding referred to.

Those who hold much of the data on health and care professionals are not only the royal colleges, as the noble Baroness, Lady Finlay, mentioned, but also the regulators. I note that proposed new subsection (4) of the amendment does not mention health and care regulators, which I think should be consulted, in the spirit of my noble friend’s explanatory statement.

Finally, when describing the system in place for assessing and meeting workforce needs, as training and regulation are UK-wide, I hope there will be a spirit of co-operation between NHS England and the devolved nations to ensure that we are training the right people for the right roles across the UK NHS: this needs to be in any future workforce assessment as well. I also cannot understand why we do not accept that the royal colleges in Glasgow and Edinburgh can help us recruit. That seems completely bananas—that is the technical term. Will the Government accept that we cannot put workforce planning yet again into the “too difficult” box? We need to do more and go further, as my noble friend Lady Cumberlege urges. I accept there are no silver bullets, but the regular publication of independently verified projections of future demand and supply of workforce could, over time, create a sustainable model for improvement that would have a positive impact on both patient care and staff experience.

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[Lord Kamall (Con)]

My Lords, I am grateful to noble Lords for bringing the discussion of workforce planning before the House today. Perhaps before I go further, all noble Lords will want to join me in wishing the noble Lord, Lord Patel, a speedy recovery. He definitely would have spoken in this debate if he had been able to join us. I should also say that I was particularly impressed by the double act of the noble Lords, Lord Hunt and Lord Stevens. Perhaps they will be known in future as the Morecambe and Wise of the House of Lords.

We all agree that the workforce is at the heart of our NHS and social care. It is right to ensure that we have the workforce that we need for the future to keep delivering world-class, safe and effective healthcare. Some noble Lords may not like to hear this, but I remind them that we have a record number of nurses. We continue to look at different ways of recruitment, and in response to Oral Questions I have referred to the way that we are looking at different pathways into nursing for British people. It is also a fact that we have always recruited people from overseas. Indeed, our public services were saved, post-war, by people from the Commonwealth coming to work in public services. I remind noble Lords that now we have left the EU we will no longer give priority to mostly white Europeans over mostly non-white non-Europeans. We will focus on ensuring that we have equality across the world.

I will not repeat what I have said about other issues, but if you are to have workforce growth, which we all want, it must be accompanied by effective, long-term workforce planning. That is why the department has commissioned Health Education England to work with partners to develop a robust, long-term strategic framework for the health and regulated social care workforce for the next 15 years. This includes regulated professionals working in adult social care, such as nurses and occupational therapists, for the first time.

[Lord Warner (CB)]

I am sorry to interrupt the Minister but when I listened to that last statement about Health Education England, I wondered whether he had seen the article in the Economist of 5 February, which shows that the guaranteed forward funding of Health Education England extended to less than a month ahead.

[Lord Kamall (Con)]

I am grateful to the noble Lord because that was a point I was hoping to come to when I lost my line. The budget will be agreed by the start of the new financial year and, as in all previous years, following the outcome of the 2021 spending review, spending plans for individual budgets in 2022-23 to 2024-25 inclusive will be subjected to a detailed financial planning exercise, and it will be finalised in time. We have also commissioned NHS England to develop that long-term workforce strategy and the key conclusions from this work will be set out.

Clause 35 will increase the transparency and accountability of the workforce planning process. Noble Lords referred to Her Majesty’s Treasury. The department is working closely with the Treasury to deliver a bigger and better NHS and social care workforce. The spending review 2021 provides a further £23 billion for the NHS for April 2022 to March 2025 and gives a three-year settlement. It will keep building a bigger and better-trained workforce.

Noble Lords also referred to agency staff. The flexible staffing policy aims to provide sufficient temporary staff to the NHS to meet fluctuations in demand. In 2015 the Secretary of State announced the introduction of several measures to reduce the agency spend, including price caps, procurement frameworks and expenditure ceilings. These have contributed to the NHS reducing spending on agency staff by one-third, but we recognise that there is more work to be done. We also recognise that the health and social care workforces are often spoken about separately, and the department is working to integrate the two workforces, as outlined in the integration White Paper. Noble Lords will recall that, in addition, we have started a voluntary register for care staff, which we hope to move to being mandatory in due course, following a consultation to better understand the landscape of the workforce, and to look at different qualifications and make it a better career.

We know that work on long-term workforce planning at a national level will need to be replicated at a local level. Subject to the passage of the Bill, ICBs should be the vehicle to support that. To guide that work, in August 2021 NHS England published draft guidance for ICBs explaining their central role, ensuring that the health and care system has the necessary workforce to meet the needs of the populations it serves. A copy of this guidance has been laid in the House Library. In addition, the amendments on ICBs’ forward plans and annual reports will require ICBs to report on how they exercise their duty to promote education and training for the current and future workforce.

Amendment 82 refers to safe staffing. The Government are committed to ensuring that we deliver safe patient care and that there are safe staffing levels across the NHS. Safe staffing should remain the responsibility of local clinical and other leaders, supported by guidance and regulated by the Care Quality Commission. The ultimate outcome of good-quality healthcare is influenced by a far greater range of issues than how many of each staff group are on a shift, even though that is clearly important, and it is why the Government are committed to continuing to grow the workforce.

I now turn to the amendment addressing GP distribution. We fully support the intention, particularly as part of our agenda to level up and recover from the pandemic. However, the pandemic’s impact on the workforce is not yet fully understood and the system is moving to meet the impact in new ways. As a result, a review of GP distribution is likely to be premature but, as noble Lords will recall, we have opened new medical schools in areas where there has been a lack of workforce, in the knowledge that many people stay in the areas where they were trained. That is part of our plan to make sure that there is more equitable distribution. We will also use the targeted enhanced recruitment scheme to incentivise trained doctors to work in hard-to-recruit areas.

Health and Care Bill

Lord Warner Excerpts

Lords Hansard - Part 2 & Report stage
Thursday 3rd March 2022 Lords Chamber

Briefly, Amendments 98B and 98C are intended to ensure that the unions are among the consultees on the likely impact of payment schemes. I am grateful to the noble Baroness, Lady Brinton, for her support for that proposal. The Minister sees no place for unions in setting the terms and conditions of external providers, so it is even more vital that trade union consultation is made an explicit requirement of the pricing process. This is particularly so given that the providers themselves are to be consulted on the prices they are to be offered—in stark contrast to the workers, under the current draft. I hope the Minister will agree to modify these provisions accordingly.

[Lord Warner (CB)]

My Lords, my Amendment 100 requires NHS England to

“conduct a public survey of whether patients have been offered choices about where they obtain treatment and must report to the Secretary of State what action they will take as a result of the survey.”

I am grateful for the support of the noble Lords, Lord Hunt and Lord Lansley, and the noble Baronesses, Lady Cumberlege and Lady Brinton.

Currently, there is no regular survey of whether patients are aware of their right to choose or of how many have exercised it. The last NHS England official survey of whether patients were aware of their choices was in 2015, when just 47% of those questioned said they were aware.

Waiting times vary enormously by geography. Knowing about the right to choose could mean a significant cut in the waiting time for treatment. For example, waiting times for orthopaedic care vary from 89 weeks in Bedfordshire Hospitals NHS Foundation Trust to 25 weeks in the relatively nearby Milton Keynes trust. Recent polling by the Royal College of Surgeons showed that 73% of patients questioned would willingly travel to a surgical hub which was not their local hospital if they could be treated more quickly.

There is no system for monitoring whether patient choice is working. Amendment 100 fills this gap and restores the situation to where it was before 2015. I hope the Minister will accept this simple amendment in the interests of patients.

[Baroness Jones of Moulsecoomb (GP)]

My Lords, I am implacably opposed to privatisation of the NHS—not for ideological reasons, although the Green Party is strongly opposed as well. I think it is inefficient. Privatisation has not worked. It has failed to deliver on promises to increase quality, decrease cost and help patients. Rather than save money through reduced bureaucracy, the main cost savings of privatisation seem to be in cutting the terms and conditions—chiefly the pay and pensions—of staff. If private companies can compete for public services, let them compete on a level playing field, rather than simply capturing staff and paying them less.

I am pleased that the noble Lord, Lord Lansley, explained his Amendment 98 because I had understood it completely the other way around—that he was protecting private services. I was going to have a word with him afterwards about it, but there is now no need.

As the noble Lord, Lord Hendy, just said, most people in Britain do not want a privatised NHS. They want a public service because that is what will give them the best results.

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Tabled by

[Lord Warner]

100: Clause 69, page 63, line 21, at end insert—
“6H Survey relating to patient choiceNHS England must annually conduct a public survey of whether patients have been offered choices about where they obtain treatment and must report to the Secretary of State what action they will take as a result of the survey.”

[Lord Warner (CB)]

I am grateful to the Minister for his reassurances on the issue of patient choice. I suggest that the arrangements that he outlined in his response to my amendment are not well known, even to those such as the Independent Healthcare Providers Network, so I wonder whether he might look at the arrangements for publicising that information. In the meantime, I shall not move my amendment.

Amendment 100 not moved.

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Moved by

[Lord Warner )]

112: After Clause 80, insert the following new Clause—
“PART 1AHEALTH AND CARE SUSTAINABILITYOffice for Health and Care Sustainability
(1) There is to be a body corporate, independent of the Government, called the Office for Health and Care Sustainability (“the Office”) to safeguard the long-term sustainability of an integrated health and adult social care system for England. (2) The Office must be established within six months of the passing of this Act and must publish a report of its initial findings relating to its main functions within a year of its establishment.(3) The role of the Office is to continually assess the outlook for the health and care system over the coming five, 10 and 15 years.(4) The Office has no function in operational or service delivery aspects of the health and care system.(5) The Office must—(a) monitor and publish data relating to demographic trends, disease profiles and the likely pace of change relating to future service demands,(b) assess the workforce and skills mix required to respond to those changes and publish regular reports on those matters, and(c) consider the stability of health and adult social care funding relative to changing demographic and disease trends, including the alignment between health and adult social care funding, and publish regular reports.(6) The functions of the Office are to be exercised on behalf of the Crown as if it was a public department.(7) The Office is to consist of—(a) an executive chair appointed by the Secretary of State with the consent of the Public Accounts and Health Select Committees of the House of Commons,(b) two other members appointed by the Secretary of State with the consent of the Public Accounts and Health Select Committees of the House of Commons, and(c) two other members nominated by the Office and appointed by the Secretary of State.(8) The initial appointments under subsection (7) are for a term of five years and no more than two terms may be served.(9) The remuneration of the executive chair is to be agreed by the Secretary of State but may not be less than that paid to the Permanent Secretary of the Department of Health and Social Care; and all other salaries and gratuities for members may be agreed by the Office with the consent of the Secretary of State for Health and Social Care.(10) The Office may employ staff on terms and remuneration consistent with that of the civil service.(11) The Office may—(a) establish such committees and sub-committees as it deems necessary,(b) determine its own procedures and those of its committees and sub-committees, and(c) do anything calculated to facilitate, or conducive or incidental to, the carrying out of any of its functions.(12) The annual budget of the Office is to be provided by the Secretary of State after consultation with the Public Accounts Committee of the House of Commons.(13) The Office must keep proper accounts and records in relation to its accounts, and must prepare and publish each year an audited statement of accounts.(14) The Office must prepare an initial report on its work within one year of its establishment, and thereafter annually, and may at any time publish a report on its functions when it considers that this assists safeguarding the long-term sustainability of an integrated health and adult social care system in England.(15) The Secretary of State must lay any report prepared by the Office before both Houses of Parliament.”Member’s explanatory statement
This amendment implements recommendations 33 and 34 of the 2017 report by the House of Lords Select Committee on the Long-term Sustainability of the NHS and Adult Social Care. It draws on the legislation setting up the Office for Budget Responsibility.

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[Lord Warner (CB)]

My Lords, Amendment 112 is my name and the names of the noble Lords, Lord Hunt, Lord Scriven and Lord Kakkar. I am grateful for their support. This amendment goes much wider in terms of independence from the Secretary of State than Amendment 80, moved so convincingly by the noble Baroness, Lady Cumberlege, earlier today.

Amendment 112 establishes a new body to help to secure the long-term sustainability of our health and care system. That body is an independent office for health and care sustainability as recommended by this House’s Select Committee on the Long-term Sustainability of the NHS and adult social care. This new body is based on the model of the Office for Budget Responsibility. That body is widely accepted as having worked well over a number of years. My amendment draws heavily on the 2011 legislation setting up the OBR.

The new office of health and care sustainability has three main functions which are set out clearly in the amendment, so in the interests of time I will not repeat them. The new body would look five to 10 to 15 years ahead and publish regular reports which would be laid before both Houses of Parliament. It would produce an initial baseline report within a year of its establishment. Like the OBR, the new body would have an executive chair and five members. The chair and two members would be appointed by the Health Secretary but—and this is a very big but—with the consent of the House of Commons’ Public Accounts Committee and Health and Social Care Committee. The remaining two members would be chosen by the office itself. Like the OBR, the new body would not have a membership controlled by Ministers.

The new office of health and care sustainability would be much more independent of the Secretary of State than is provided for in Amendment 80. It would have a much wider remit in terms of improving the balance between the NHS and social care, on both staffing and funding. The greater long-term independence seems essential given that the Department of Health—now the Department of Health and Social Care—has a political and official track record which was revealed to the Lords Select Committee as pretty unsatisfactory.

The Department of Health has been failing to plan for the future for a very long time. The evidence given by its Permanent Secretary totally failed to convince the Select Committee that it took long-term planning seriously. That Permanent Secretary is still in place. I do not like personal attacks, but in evidence to the Select Committee this person actually said that he did not see long-term planning as part of his job description. So we have a situation where the long-term planning of the NHS and social care is simply not on the agenda of the government department responsible for it.

With this track record and the Covid recovery programme that the Department of Health and Social Care now faces, it seems to me a triumph of optimism over reality to rely on that department and its harassed political head to undertake long-term planning. I say that despite the House passing Amendment 80. We are looking for a situation in which there is more independence of the Secretary of State and, indeed, more independence in the collection of information, the sifting of that information, and the analysis that that information shows—and that covers funding as well as workforce issues.

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[Baroness Penn (Con)]

My Lords, I thank noble Lords for bringing this debate before the House today. As mentioned in the debate in Committee, the specific functions described in Amendment 112 are crucial functions that the Government are committed to ensuring are discharged. This commitment is underlined by the fact that there are already bodies and mechanisms in place to fulfil these functions. These are core components of the Government’s commitment to evidence-based health provision. This commitment has been made clear in many of the Bill’s provisions, in our wider programme of public health reform and in the proposals set out in the Government’s plan for health and care.

The amendment makes recommendations on both appraisal and scrutiny of funding and of social and demographic trends. With regard to the monitoring of trends, the department already publishes data relating to disease profiles, which incorporates demographic trends where relevant. This is supported by independent academic modelling from the Care Policy Evaluation Centre, CPEC, to produce projections of the long-term demand on adult social care services. As for funding, noble Lords will also be aware that successive Governments have used the well-established spending review process to set public service budgets. This takes into account the needs of service users, but crucially also considers the fiscal context and how healthcare expenditure balances with the range of priorities across government.

As noble Lords have noted, aligned to those spending decisions, the Office for Budget Responsibility already scrutinises the Government’s fiscal approach and our management of fiscal risks. For example, in October 2021 the OBR provided an independent analysis of the Government’s reform to the funding of adult social care in England and has announced that it will provide more analysis of the long-term implications in its next fiscal sustainability report. There is also, as noble Lords will know, a wide range of highly influential non-governmental bodies dedicated to the kinds of functions proposed for this new body—the King’s Fund, the Health Foundation and the Nuffield Trust to name just three. All of these contribute richly to the public debate on financial sustainability and on the size and composition of the workforce, as well as other related issues, and to the ability of this House to scrutinise government decisions on spending and policy.

The Government therefore do not think that the creation of a further body would add value. At this crucial time for the health and care system, we must proceed with the reforms we have outlined. For these reasons I hope that the noble Lord, Lord Warner, will feel able to withdraw his amendment.

[Lord Warner (CB)]

My Lords, no chance. I wish to test the opinion of the House.

Health and Care Bill

Lord Warner Excerpts

Lords Hansard - Part 1 & Report stage
Tuesday 1st March 2022 Lords Chamber

[Lord Warner (CB)]

My Lords, very briefly, I support Amendments 171 and 178 in this group, spoken to so ably by the noble Baroness, Lady McIntosh, and the noble Lord, Lord Hunt. I do so as a former pharmaceuticals Minister and a former NICE Minister. The rather boring thing about all this is that the postcode lottery issue was alive and well when I stopped being a Minister, 15 years ago. It has continued to flourish throughout that time. The noble Lord, Lord Hunt, does not exaggerate in any way how the NHS is quite creative at finding ways around implementing speedily some of the drugs and medicines recommended by NICE.

For a long time, part of the problem has been—Amendment 178 starts to make a move in the direction that I think has been lacking—that we simply do not monitor enough what has happened to NICE recommendations and the take-up of new medicines. It is not really built into the regulatory system. If we are serious about inequalities—I have listened to many of the debates on inequalities today and previously—and levelling up, access to new medicines is pretty important. I have a terrible suspicion that, if we looked around very carefully, we would find that the same parts of the country, year in and year out, are not taking up the medicines as speedily as others. The reason I say this is that we know from the regulator’s evidence that the financial and clinical underperformers are, much of the time, the same places, year after year. I suspect that these are many of the places we need to look at if we want to tackle the postcode lottery of NICE recommendations.

[Lord Lansley (Con)]

My Lords, I join the debate briefly to add my thanks to the Government for the amendments on research that they have brought forward in this group. It is extremely helpful, as the noble Lord, Lord Kakkar, said, to entrench the concept of a research culture inside the NHS. In our various ways and guises, we have all encountered some of the difficulties of diffusing innovation and the take-up of new medicines in the NHS.

The point was made very well by the noble Lord, Lord Hunt of Kings Heath, but he did not say why the NHS does not adopt new medicines as rapidly as some other European systems have. I do not think we have more conservative clinicians than other countries, but we do not have a third-party payments system. We do not have a system whereby the patient can ask “What about this?”—these days, increasingly, they do—and the clinician can say yes, and pass the bill to somebody else. Instead, our system centrally determines the extent to which new medicines will be available. We have a particular requirement in the National Health Service for a system which looks for areas where there is value in innovation, disseminates it, takes it up and makes it available to patients.

I make two other points. One is to say thank you, as I am not sure I will get another opportunity to do so. We had substantive discussions about rare diseases; the noble Lord, Lord Sharkey, in particular spoke very well and fully about the needs involved, and the Government published their England Rare Diseases Action Plan yesterday. On orphan drugs, that will give significant additional impetus to the availability of treatments for those with rare diseases. I very much welcome that.

Secondly, Amendment 178 in particular is interesting. I do not necessarily advocate that we adopt it, but it asks the Government do something that they generally have not done and ought to do, which is to come back to the issue of access to medicines and treatments—and, I would add, to medical devices—and ask how well we are doing at the process of bringing that into effect and how well our Accelerated Access Collaborative, which is supposed to look at all these things and make them work together, is making that happen.

The beauty of Amendment 178, on which I will add just a little, is that we ought to have a very clear timetable for how we move the system forward. I hope the Government will adopt this. In January 2024, we will have the next voluntary pharmaceutical pricing and access scheme. The industry will be looking, rightly, to arrive at a position where all the initiatives mentioned give patients access to medicines in this country as soon as in any other healthcare system. On that basis, the industry will be prepared to understand that not just the NHS but the Government will look to get some pretty cost-effective prices out of it.

Now I do not happen to think that it is NICE’s job to make that relationship happen. I happen to think that NHS England is increasingly equipped to be a central player in this process. It should sit alongside NICE when it carries out health technology assessments in what is effectively a trialogue with the industry and say, “Well, how can we ensure that the patient has access to this medicine, and at what price? Can NICE act as the referee to establish whether the price and the incremental benefit are reconciled to be cost effective for the NHS?”

We should build that into the system over the next 18 months so that, when we start the new scheme in January 2024, the system is understood to work. It should not depend on large-scale transfers of money, with overpriced new branded medicines on the one hand being recycled back to the NHS to go into the innovative medicines fund on the other. This tracking of money around the system is not the best way to make it happen. We should aim for the industry to be paid what the health technology assessments and the NHS budget requirements mean is a fair price for the medicines it is providing—and that is what the industry should expect.

Everybody should be working to arrive at a position where, when a medicine obtains authorisation—in other words, when it is deemed safe, clinically effective and of good quality—and a clinician recommends it for a patient, the patient should have access to that medicine through the NHS. That is what we are aiming for. It has not always been true, but it ought to be in the future. We need a system that people, including clinicians in the NHS, understand and that supports their ability to prescribe medicines in that way.

Health and Care Bill

Lord Warner Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Lord Young of Cookham (Con)]

My Lords, it is a pleasure to follow my new room-mate, the noble Baroness, Lady Hollins, and I agree with every word that she has just said. I also agree with the other speeches that we have heard in favour of the various amendments. I pay particular tribute to the noble Baroness, Lady Pitkeathley, for her tireless campaign over 40 years on behalf of carers.

I have added my name to Amendment 219 but I will focus on my Amendment 269, which focuses on young carers. I am grateful to the three noble Baronesses who have added their names. Might I be allowed a word on one line in Clause 80, whose future I thought we were debating in this group but which has now been incorporated into the Bill? The line is:

“The Community Care (Delayed Discharges etc) Act 2003 is repealed”.


Noble Lords with long memories may remember that Bill. At the time, I said it was the worst I had seen in 30 years. Instead of doing what this Bill seeks to do —to bring together health and social care to facilitate closer co-operation—it established an antagonistic relationship between the NHS on the one hand and social services on the other by enabling one part of the public sector unilaterally to fine another part. It was a friendless piece of legislation, heavily criticised in your Lordships’ House, as the noble Lord, Lord Hunt of Kings Heath, who had the misfortune to pilot it through, will doubtless confirm.

At the end, my noble friend Lord Howe said, nearly 20 years ago:

“On a more philosophical level, we need to ask ourselves whether this system of financially driven imperatives is what we want to see pervading the fabric of our public services wherever the NHS and social services interact. I am clear that it should not”.—[Official Report, 17/2/03; col. 929.]


How appropriate that, 20 years later, my noble friend helps to put the final nail in the coffin of that Bill. However, it had one redeeming feature: the obligation to assess prior to discharging a patient from hospital. However, as drafted, as other noble Lords have said, the proposals could have the unintended consequence of weakening protections for children who look after adult relatives.

My amendment is about young carers and is shaped by my experience when in another place of working with Andover Young Carers. Children barely in their teens were combining education with caring for disabled parents. The organisation was based in a small bungalow on a local authority estate, and it did heroic work, forging closer links with schools and children’s services. Some of the children spent more than 30 hours each week looking after parents and elderly relatives—almost the equivalent of a full-time job—as well as often having caring responsibilities for younger siblings. They cooked, did the housework, shopped, collected prescriptions, leaving little or no time to enjoy their childhood. The noble Lord, Lord Howarth of Newport, spoke movingly about the work of young carers in Kingston.

According to research from 2018, as the noble Baroness, Lady Wheeler, told us, there are more than 800,000 young carers in the UK. Recent figures show that 180,000 children in England who care for an ill or disabled relative are missing out on support, simply because they are not known to their local authority. Hence the need for this amendment which ensures that young carers are identified before adults are sent home from hospital to be looked after by them. If contact with adult carers is necessary, as we have heard, it is doubly necessary for young carers.

This is because we have clear evidence from Barnardo’s—I am grateful for its briefing—which shows that adults are being discharged from hospital into the care of children, without first making sure that these children are aware of their new responsibilities and that they have the support necessary to enable them to discharge them. I fear this is set to only get worse, placing more caring responsibilities on small shoulders, unless the Bill as currently drafted is amended.

The Care Act 2014 gave a young carer under the age of 18 the right to a needs assessment and placed a duty on local authorities to take reasonable steps to identify young carers in their area who may need support. Yet, in its report Still Hidden, Still Ignored, Barnardo’s found that young carers were still slipping through the net. Its finding is reinforced by the latest CQC survey, which found that 21% of people did not have their family or home situation taken into account when staff prepared them for discharge, a point referred to in the excellent paper which many noble Lords received today from Dr Moore at the University of Manchester.

This amendment places an obligation on the NHS to ascertain whether a patient will be cared for primarily by a young carer and, if so, to contact the local authority concerned for an assessment and the necessary support. This will not delay discharge but would ensure that hospital staff ask if a child under 18 will be the primary carer. If the answer is yes, the hospital should contact the relevant local authority which will ensure that a needs assessment is carried out.

I know the Government have made positive steps to ensure that the needs of young carers are recognised in the guidance which will accompany this Bill, and for that I am grateful. However, without a clear duty on hospitals to establish whether a patient is being discharged into the care of a child, the current situation is likely to continue. Guidance is worthy, but sadly not definitive. Therefore, the pathway for young carers to get the local authority assessment they are entitled to needs to be strengthened and here the health service is the key missing link. I speak to this amendment today because young people who care carry huge responsibilities and we must, as a society, do more to ensure they can live the flourishing lives they deserve.

[Lord Warner (CB)]

My Lords, I strongly support all the amendments in this group. The noble Lord, Lord Young, has been so persuasive and I endorse what he said about young carers. As someone who has been involved with carers for almost as long as the noble Baroness, Lady Pitkeathley—I now regard her as my general in these matters—I want to focus on Amendment 221, to which I have added my name.

It is worth remembering that this Bill is being considered in the context of adult social care funding having been starved, in my view, by three successive Governments. Even when huge sums of money are being raised for health and care through a national insurance levy, social care has to wait its turn. A bit like Oliver Twist, it is at the end of the queue—hopefully there will be some money left in the coffers after the NHS has removed a substantial part of it. That context is very important.

In that context, I find it surprising that somebody somewhere in the Department of Health and Social Care thinks it is a good idea, as the noble Baroness, Lady Pitkeathley, said, to weaken the protections for carers. It is worth bearing in mind that one in five carers now waits over six months for an assessment. In a survey from last November, only 24% of carers had received a carers’ assessment or reassessment in the past year. This is the context in which officialdom and Ministers have thought it a good idea to weaken the protections provided in the 2003 Act. There may have been some weaknesses in that Act, but this was not one of them, as it provided for the NHS to undertake these assessments before people were withdrawn. The noble Lord, Lord Hunt of Kings Heath, is not in his place, but he was the person who took that Bill through and achieved support for that protection for carers.

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We also know that know that local authorities are already under existing duties to assess and meet carers’ needs for support. We are concerned that duplicating these duties by placing them on the NHS in addition to local authorities might not offer a clear benefit to carers, and this should be done at the ICB level. The draft hospital discharge guidance that I mentioned is clear that people should be discharged on to the right pathway, not only on the discharge to assess model but whatever is the most appropriate model.

[Lord Warner (CB)]

I am sorry to interrupt the Minister’s flow. I have been listening very carefully to this. What I do not understand is what happens if there is not enough resource in the local authority. Local authorities have had pretty poor treatment over the last decade compared with the NHS. If there is not enough resource to either do an assessment or meet the needs of that assessment, does it then fall to the NHS to plug the gap if it wants to get the person out of hospital? We would like a little more clarity on that particular aspect.

[Lord Kamall (Con)]

I thank the noble Lord for his question. The goal is to make sure that the NHS and local authorities work better together. The noble Lord talks about resources. One of the reasons for the levy—whatever one thinks of it—is to help plug that gap and to make sure that there is more money going into social care as well.

Turning to the points made about the term “carer”, we believe that the term is used to capture the whole spectrum of carers, including children and adults who care, unpaid, for a friend or family member. By not imposing a statutory definition, we avoid inadvertently excluding groups, and ensure that ICBs and NHS England promote the involvement of all types of carers and representatives.

Turning to the last amendment in this group, existing legislation already requires local authorities to carry out an assessment of need for all young carers upon request or on the appearance of need. This assessment must consider whether it is appropriate or excessive for the young carer to provide care, in the light of the young carer’s needs and wishes. Indeed, as some noble Lords have said, sometimes what happens is that the hospital may decide it is appropriate but those who are supposed to be doing the caring at home do not feel they have the ability.

We hope that under this, as part of the discharge planning, the current discharge guidance can set out any considerations that should be given to young people in the household who have caring responsibilities. We want to strengthen current processes in respect of young carers too. We are also working with the Department for Education to ensure that protections for young carers are reflected in the new guidance, including setting out where young carers should have a needs assessment arranged before a patient for whom they provide care is discharged, or as soon as possible afterwards.

Given the comments from noble Lords, especially the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Warner—sorry, I should say, General Pitkeathley and Major Warner—clearly there are still some concerns over how this will work. It would be worthwhile having some more conversations on this issue to better understand how we see integrated care working, where there may well be gaps in our understanding and whether we can help to close the gaps between the two sides.