NHS and Social Care Commission
Nick Clegg Excerpts(8 years, 10 months ago)
Commons ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Mr Nick Clegg (Sheffield, Hallam) (LD)
I join all those who have spoken so far in congratulating my right hon. Friend the Member for North Norfolk (Norman Lamb) on securing the debate. It concerns what is undoubtedly one of the biggest questions that we face as a country, as a Parliament, and as a political class: the question of how we can square the circle of an ageing population, and how we can put the NHS on to a sustainable financial footing.
My grandfather was editor of the British Medical Journal from the time when the NHS was founded until the mid-1960s, and I suspect that if he were around today, he would say that the challenges currently faced by the NHS would be entirely unrecognisable to his generation of medics.
It is right that my right hon. Friend is pushing us all to try to sketch out solutions on a cross-party basis. It could be said that he and I tested the virtues and pitfalls of cross-party working to destruction—some would say, unfairly perhaps, to self-destruction—in the last Government. Notwithstanding that experience, however, I think that issues such as pensions, long-term infrastructure investment, Europe, decarbonisation of our economy and, in this context, the sustainability of the NHS are not susceptible to single-Parliament, single-Government, single-party solutions. I therefore say, “All power to my right hon. Friend’s elbow”, and I hope that the Government will look kindly on his proposal.
I intend to dwell on an issue which I hope the commission will subject to real examination, namely the role of mental health in the NHS. We have come a very long way. I remember standing, eight years ago, a little way in front of where I am standing now, shortly after becoming leader of my party, and asking Gordon Brown a question about mental health during Prime Minister’s Question Time. I recall that I was heard in what was almost a slightly shocked silence, because at that time raising the subject of mental health was considered to be rather “novel” and brave. The extent to which the debate has advanced since then is fantastic.
There have been truly moving debates in the Chamber, when a number of our colleagues have spoken for the first time, very openly and movingly, about their own struggles with mental health conditions. Society and the media now talk more comfortably about mental health, and a barrage of celebrities have lent their considerable weight to that. The debate, the rhetoric, and the awareness of mental health as a major challenge that affects one in four of our fellow citizens have been transformed in recent years, which is a wonderful development. We have lifted the lid, lifted the taboo, and lifted the slight foot-shuffling embarrassment that used to overshadow the subject of mental health, which is a great step forward.
I am immensely proud of some of the things that our coalition Government managed to do in pushing the agenda forward and putting mental and physical health on the same legal footing. My right hon. Friend and I worked together closely on the introduction of NHS waiting time standards relating to mental health, which had existed in relation to physical health issues for a long time, and took many other important steps.
What worries me is the growing gap between the rhetoric about mental health and the reality of what is happening on the ground. There will always be a gap, because rhetoric is easier to deliver than change on the ground; there will always be a time lag between the moment when the debate and the policy prescriptions alter, and the moment when that change percolates down to the ground. However, I think that this gap is becoming dangerously wide. That is, of course, very bad for the many patients with mental health conditions who are not being properly treated, but I also think that if we do not address it soon and follow up the rhetoric with action, there will be real cynicism about what the political classes have meant during the journey that we have made over the past few years towards talking more comfortably and openly about mental health issues.
I know that many Members are already familiar with the scale of the problem, but I think it worth illustrating that scale with a couple of facts. Mental health makes up 23% of what is somewhat inelegantly described as the UK disease burden, but it accounts for only 11% of NHS spending, and the majority of people with mental health conditions still go untreated. On average, just 30%—less than a third—eventually gain access to treatment. If that applied to any physical health condition, it would be seen as a Dickensian state of affairs requiring urgent action. I hope that the cross-party commission will think carefully about the step change that is required in the organisation, because support and funding for mental health will be critical to its considerations.
Let me now invite the Minister to focus on three issues, in the short term and in the slightly longer term, because I think that there is currently a blockage that is preventing the rhetoric from being translated into the kind of action that most Members on both sides of the House want to see.
The first issue is that, last year, just before the last Budget of the coalition Government and the general election, I announced, on behalf of the Government, £1.25 billion in funds to transform what could be described as the Cinderella service within the Cinderella service, namely child and adolescent mental health services. It was the most ambitious blueprint ever set out by any Government to transform the service and, indeed, to fund it properly. As the Minister will know, that £1.25 billion equates to roughly a quarter of a billion pounds, or £250 million, to be invested in child and adolescent mental health services per year. Over the last financial year, however, the amount invested has been not £250 million but, I think, £143 million.
The Minister for Community and Social Care (Alistair Burt)
It was about £170 million.
Mr Clegg
I stand corrected. Anyway, it was not £250 million.
There may be perfectly explicable teething problems. The announcement was made in the spring of last year, and it will have been necessary for all the mental health trusts to shift gear. However, I hope that the Minister—or, if not him, the commission—will ensure that not only future mental health reforms but previous commitments are delivered and funded in full. The £250 million that has not been delivered over the last year needs to be made up for between now and the end of this Parliament.
My second point concerns the importance of prevention —in all areas of health, obviously, but perhaps especially in mental health. The need for better prevention measures was one of the key findings of the mental health taskforce’s public engagement exercise, yet there has been little if any mention of it in recent Government announcements. Mind, the mental health campaign and policy group, has established that local authorities spend just 1% of their public health budgets on the prevention of mental ill health. That is £40 million out of a total budget of £3.3 billion. Yet we all know—even if we are not clinical experts, we know as parents, and as human beings—that intervening early to improve child and adolescent mental health avoids so much illness, so much heartache, and, to be candid, so much cost to society thereafter. Half of those with lifetime mental health problems first experience symptoms by the age of 14, and 75% of children and young people who have a mental health problem do not get access to the treatment they need.
Waiting times are still far too long. Average waiting times for CAMHS is two months—and as yet there are no waiting time standards in children, adolescent and mental health services. I think we all know, and I certainly accept it, that as we try to revolutionise the approach to mental health, the waiting time standards that have already been announced need to be spread and extrapolated to other parts of the service. Members have talked about the need to reconcile and bring together social care and healthcare, and if we want to put the NHS on a financially sustainable footing, which is the purpose of the cross-party commission, we also need to understand that the lack of prevention and of early intervention on mental health problems is one of the biggest drivers for subsequent inflated costs on the NHS budget. It is therefore essential that the commission looks at this as well.
Thirdly—and arguably most importantly, and also perhaps most technocratically complex—is the issue about the formula or mechanism by which mental health is funded. The problem is that for as long as anyone can remember mental health trusts have been funded according to block grants, through a lump sum of money given to them by some varying formula, while other NHS trusts—acute trusts—are paid on a per patient, per outcome, per recovery basis. That of course is deeply unfair, because it means that any time any Secretary of State for Health, Chancellor or NHS boss needs to make savings, the easiest thing to do is quietly shave a little money off that block grant, as no one really notices it —it does not stick out like a sore thumb like other financial cuts do—and that is precisely what has been happening. That is one reason why—even in recent years, however much new and welcome emphasis there has been on the priority mental health should have in the NHS—the basic funding formula or mechanism constantly discriminates against mental health trusts.
Dr Philippa Whitford
If I understand the right hon. Gentleman correctly, he is suggesting a tariff system for mental health, rather than a block grant, but it has been obvious from evidence in the Health Committee that the tariff can also work against having more community care. I met a paediatrician who did outreach work and, having reduced admissions by 40%, the hospital pulled it because it was getting less money. So be careful what you wish for.
Mr Clegg
The issue here is about moving from a block or lump of money to an outcome-based formula. One can then decide from an infinite number of ways how to administer the outcome-based funding formula, but the principle that mental health trusts are rewarded and financed for the outcomes they produce, rather than having some random, and often arbitrary and unjust, lump of money, is the fundamental point.
What is happening at the moment is that mental health budgets are, whether we like it or not, at risk of being raided to pay for the unsustainable deficits in acute health. In 2014-15 London’s health commissioners spent 12% of health expenditure on mental health, and in 2015-16 that fell to 11%. In other words, there was a transfer of money from mental health to acute trusts. That is completely the wrong direction of travel.
In 2012, to address this problem, the then coalition Government announced that we would pilot a new approach to mental health funding via what were called care clusters. They work in the following way: adults receiving care are assigned to one of 21 mental health clusters based on their needs, and services are then tailored on the basis of the needs of the people in each cluster and the effectiveness of the interventions on offer. Each cluster is then given a local price, and commissioners work out payments to the mental health trust based on how many patients fall into each cluster.
It is fearfully complex yet there is evidence that transferring the funding of mental health trusts from a block grant system to this care-cluster, outcome-based system has already yielded results. Recent research by the Independent Mental Health Services Alliance has found that mental health trusts operating under block contracts had more delayed discharges and more emergency readmissions than trusts operating without a block contract. Geraldine Strathdee, national clinical director for mental health, has agreed. She says that block grants
“do not facilitate access to timely evidence based care such as those set out in the new mental health access standards”,
and Monitor itself has been very critical indeed of block contracts:
“Despite the introduction of the care clusters, most local agreements still rely on simple block contracts. We believe that block payments…do not work in the interests of commissioners, providers and, most importantly, patients.”
Frustratingly, notwithstanding the decision in principle to shift the whole system to an outcome-based, care-cluster system and away from the punitive effect of the block contracts, 35 out of 62 NHS trusts are still providing mental health services using those block contracts.
Forgive the technocratic detour, but the devil really is in the detail, particularly if we want to close the gap between the much more aggressive aspirational rhetoric that finally has occupied the public and the political debate around mental health and the pressing need to get on and push the system in a radically different direction, not only because it is the right thing to do to end the outrageous discrimination—and it is discrimination, although it might not have been felt or expressed like that—that has existed against patients with mental health issues who have suffered in silence, alone and untreated for generations, but also because if we do not do that and do not make some of these fundamental changes the spiralling costs then placed on to the shoulders of the NHS will merely continue. This is a vital element in meeting the cross-party commission’s mandate to arrive at a new Beveridge-style, cross-party consensus on how to place the NHS on a long-term and sustainable footing.
Caroline Flint
I hope that I have not given the impression that good work is not happening and good services do not exist. In my constituency not long ago, our district nurses were supporting treatment and care in the home for people who had problems with their legs and needed them bandaging. For a couple of months, those patients were incredibly nervous because they had heard that the nurses would no longer come to their home and they would have to go to the GP’s surgery for bandaging. Fortunately, it did not work out like that, but the stress about the future of their treatment caused those people a problem.
We can all talk about things that are working or not working in our constituencies. We can all point to good practice. It is a frustration of mine, not just in health, that best practice is not the driver for good practice everywhere. I do not know why we keep reinventing the wheel. We have to look at the bigger issues, and that is why I commend the right hon. Member for North Norfolk (Norman Lamb), my hon. Friend the Member for Leicester West (Liz Kendall) and the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) for securing the debate today.
We have an important role in this House. It is not only about holding this or any Government to account; it is about shining a light on the social problems that our country faces and offering solutions that are not just for one term of a Parliament. The motion helps to highlight an ongoing generational problem and proposes a path to find some sort of solution.
The UK is an ageing society. We are a society growing older. Looking around the Chamber today, I am tempted to say, “Put your hand in the air if you are under 50.” Five.
Caroline Flint
I think we are talking about a minority. We are here as politicians, but also as citizens with families and living in our communities as we discuss the policies and politics that will touch people’s lives. We are living longer, and that brings a lot of joy. We often talk about the things that are bad, but there is a lot of joy about living longer, too. It is not uncommon today to meet older people who are great-grandparents yet still active enough to look after their great-grandchildren.
The current generation of older citizens share some of the problems of previous generations. There is still poverty, and loneliness is ever more common, as those living longest outlive their lifetime companions, and as families no longer live in close-knit communities. But this generation are different from previous generations. They are less deferential—and rightly so. They expect more from life. They are not waiting for the grim reaper—they have lives to lead. Many will live 30 or more years in retirement. Not so long ago, that was half a lifetime. This generation rightly demand more. They are less likely to accept just what the state offers and lump it. If the options for their retirement, for their living arrangements, for their social care or other assistance are not to their liking, they will voice their protest. And they do so, as a generation who overwhelmingly own their own homes and want to remain independent, within four walls to call their own, for as long as possible.
Madam Deputy Speaker, this debate is timely because, less than a year on from the general election, none of the big, long-term problems facing the NHS, in particular the integration of social care and the fair funding of social care, is any closer to being resolved. We know that the NHS has always been an election issue, and we should not apologise for that. Nor should we expect that to change in the short term. We know that in the last election and the one before, the problem of funding social care, so that families do not always lose their homes to pay for long-term social care, has been an election issue. I recall in 2010 a Conservative billboard with a tombstone and the message, “Now Gordon wants £20,000 when you die. Don’t vote for Labour’s new death tax.”
I am not going to sound purer than the driven snow on this. Our party has also upped the ante on some of these issues. Yet today, one in 10 of the public can face bills of over £100,000 for social care. It makes a bill of £20,000 deferred seem a pretty attractive deal. But so nervous are Governments of this issue that this Administration have deferred the introduction of a cap on total costs from 2016 to 2020. And the cap is only on costs over £72,000. I do not want to spend time on the merits of the Government’s proposals. Suffice it to say that they are complex. They rely on local authority assessments. They create different thresholds and ceilings for contributions. Coming forward with proposals that are fair to all yet meet need, without unduly penalising those who saved for a lifetime, is not easy; it really is not, and the problems will not be solved by a five-year plan.
The challenge remains to put in place a social care funding system that is fair to people of different income levels, a system that can be embraced by all parties and, crucially, by successive Governments of different colours. For these reasons, I believe that the motion is so right today. We need an independent commission for those big long-term decisions. The same problem applies to some of the other challenges facing the NHS that colleagues have raised today. They include securing long-term funding for the NHS, particularly when successive Governments are rebalancing the Government’s income and expenditure to reduce and then eliminate the deficit and meeting the long-term challenge of demographic change, of the rising sophistication and costs of new medical technologies and of new pioneering treatments. At one and the same time, the potential for new and radical treatments is almost unlimited, but the budgets to meet them are not.
Added to that, as we look at how we devolve services in England, to which I am not opposed, we need to think about where the accountability lies, and whether there are the checks and balances to ensure that there is not only quality, but value for money. As a relatively new member of the Public Accounts Committee, I can already see that we do not have the accountability structures in place to ensure that those providing services regionally and locally are operating transparently.
When I was first elected in 1997, half the buildings used by the NHS predated its existence. Financial pressures had led to a huge backlog of investment in NHS buildings. Between 1997 and 2010, the Labour Government invested record amounts in new NHS buildings—from major hospitals to modern, multi-purpose health centres, walk-in centres and GP practices. One of the ministerial jobs that I was most proud to hold was public health Minister, because one aspect of providing better buildings in the community was moving services out of hospitals and closer to people. That was especially important in areas where health inequalities were evident, because it was a way of ensuring that the people there, who are often the most vulnerable and least assertive, could see in their community the services available to them.
If we are to plan for future investment, we need consensus, because while those buildings were welcomed, not least by NHS staff and patients, their private finance initiative funding has always remained contentious. Planning for sustained investment requires a consensus that gives future Governments—and, dare I say it, this Government —the courage to take big decisions. Only a truly independent commission with real expertise and weight will begin to unpick the real costs, options and pinch points facing the NHS, and deal with the hard choices about how we meet the future of health and social care.
Such a commission can also play a role in involving staff and the public. We need a grown-up discussion outside this place—we need one inside, too—about the challenges ahead. The public and NHS staff need to be involved, so that they can be helped not only to make decisions, but to understand the responsibilities that they might have in supporting a new NHS and social care service. Such a process would represent a worthwhile investment of public money if it could achieve a social contract between the parties and the British people to provide a new secure base for the future of health and social care.
This is about change. Today’s NHS bears no comparison with that created some 60 years ago. We need to face up to change and importantly, as part of that, to help people to cope with change, because that can be frightening. We want a better and stronger NHS, but let us also have a smarter NHS. I hope that Government and Opposition Front Benchers will respond positively to the proposal.
Alistair Burt
I will. We had this discussion in the Health Committee the other week. I will of course look very hard at the evidence, whether it comes from Greater Manchester and shows that somebody is working effectively and appointments are being filled, or from places where that is not currently the case. We have to wait and see in that regard.
The spending review showed our continued commitment to joining up health and care by confirming an ongoing commitment to the better care fund. Again, the integration process is extremely important. In terms of the general argument about what should be done, a clear commitment was made, based on an independent assessment of what was required. That required a Government who were prepared to make difficult decisions, and a strong economy, and we assumed that responsibility.
Let me deal with some of the remarks made by right hon. and hon. Members during this conversation—for it is, as the hon. Member for Central Ayrshire (Dr Whitford) said, a conversation, and a really good one. If more debates about health had the flavour of this afternoon’s discussion, the public might be happier. She said that her preferred method for dealing with things, as with most of us, is bringing people into the same room and having a conversation—but perhaps not this room. However, there are other rooms in this place in which to do that. Indeed, my hon. Friend the Member for Totnes (Dr Wollaston), the Chair of the Health Committee, does so regularly. This place can provide opportunities for the sorts of discussions that would be at the heart of any cross-party consideration of what we want to do. We should not neglect the fact that we can do that, and we have had a good conversation today.
I agree with the hon. Member for Lewisham East (Heidi Alexander) in that I am fundamentally shy of the idea that we can just put this on to others and with one bound we are free. I understand the sentiment that we somehow need to get, if not the politics, then the heat of the politics, out of it in order to allow for the conversation that we need to have. However, at the end of the day, that still requires a process. Like her, I believe that the process is that we discuss it, come to conclusions within our own party about what we can do, and offer it in a sensible way to the electorate. I entirely agree with those who say that there are times when we have all been guilty of the most ridiculous adverts. At the end of the last general election campaign, I was in a marginal constituency and had a piece of paper in my hand that was our last-minute leaflet. I knocked on doors and said, “Look, we have a choice—I can either hand you this leaflet, which is complete nonsense, or you can give me 20 seconds to explain why you should vote for David Cameron tomorrow and keep a Conservative Government.” They laughed and said, “Go on, then”, and I had my 20 seconds. We all know that we are sometimes guilty of producing material that in the cold light of day we would not wish to, and in relation to health we need to be extra-careful about that.
As the debate went on, I was concerned about whether the commission that the right hon. Member for North Norfolk and his colleagues is proposing can bear the weight of the many different things that we would like it to cover. My hon. Friend the Member for Totnes wanted it to report rapidly, but my right hon. Friend the Member for Sutton Coldfield (Mr Mitchell) intervened to say that it had to be for the longer term, so which is it to be? My hon. Friend also spoke about the problem of variation in the system, but that is not to do with resources. No commission could be so directive as to make sure that best practice is delivered everywhere. We have to do that in another way.
The hon. Member for Leicester West (Liz Kendall) in, as always, a very thoughtful and sensible speech, recognised the political problem in agreeing on this, and she was right to do so. It is very difficult for her, or any other Labour Member, to talk about the introduction of private medicine. If I did not stand here and say, with no deviation, that the Conservative party and the Government believe in a tax-funded health system free at the point of delivery, the roof would fall in. Therefore, there are constraints on what we can say politically, and we have to be thoughtful about how we deal with those responsibilities.
My hon. Friend the Member for Bracknell (Dr Lee) added more weight to the commission by talking about structure, and how we deal with these reviews of where hospital premises might be located. Again, there is this problem of politics. When approached by patients or doctors with a vested interest in keeping a physical bit of bricks and mortar and in saving “our” hospital, it would be a brave one of us who said, “Do you know what? That may not be the best thing.” That difficult problem was alluded to by my hon. Friend the Member for South West Wiltshire (Dr Murrison). No commission can get us over that sort of problem.
The hon. Member for Strangford (Jim Shannon) invited me to Northern Ireland to see some integration at work, and I would be keen to visit. My hon. Friend the Member for South West Wiltshire and a number of colleagues made the point about public health. Prevention is about not just the public health budget—significant resources are still going into public health—but what we are trying to do with the shift from secondary to primary care to ensure that people are seen earlier.
The hon. Member for Central Ayrshire talked about ensuring that we keep people well longer. She said that instead of seeing the national health service as an organisation that looks after just the ill, we should consider what it can do before that, which is very important.
The right hon. Member for Sheffield, Hallam (Mr Clegg) spoke principally about mental health. As a Health Minister, I know full well what the coalition Government as a whole did in relation to mental health. They picked up a trajectory that had been disappointingly low, but we are now well on track. I wish gently to correct something that has been creeping into the narrative, which is that it was all going fine until six months ago, but it has slightly come off the rails now. It has not. It was not all sorted during the coalition, and I reject the charge that it is now all about rhetoric and not delivery. We are delivering, and making sure that CCGs spend the increased money that they get on mental health, and we are tracking it for the first time.
That £1.25 billion for children and young people’s mental health, which was a very significant delivery by both the right hon. Gentleman and the coalition, has been increased to £1.4 billion, and it will all be spent in that area by 2020. We are dealing with the issue of mental health tariffs as well, and we want to have waiting and access times for children and young people’s mental health services.
I encourage the right hon. Gentleman to see, at least in this part of my portfolio, that what I seek to do is to build on what the right hon. Member for North Norfolk did in my role. I would rather that the right hon. Member for Sheffield, Hallam did not talk in that manner and think that it has all come to a halt, because it has not. We are having to repair one or two things, such as perinatal mental health, in which we have put significant resources. The conversation has been advanced enormously in exactly the right way by consensual discussion, and we will certainly carry that on.
Mr Clegg
The right hon. Gentleman is being a little over-sensitive. I bent over backwards to say that it is entirely understandable that there is always a lag of time between rhetoric and delivery. All I will say, in the most consensual, cross-party, non-finger-pointing way, is that there is a real delay now between the pilots that were started back in 2012 and the paucity of the number of mental health trusts that have placed their financial arrangements on the new non-block grant system. That is the urgency with which we must deal.
Alistair Burt
I accept that. I was not in this post in the period from 2012 to 2015. I am certainly ensuring that we are progressing. I am glad that we have sorted that out. The coalition’s involvement with and commitment to this issue have been immense, and I am very proud to carry that on in the way I am doing.
My hon. Friend the Member for Lewes (Maria Caulfield) brought her experience to this debate. She spoke about the integration of budgets for social care and for local authority expenditure in the national health service, which is absolutely crucial. For me, integration is not about getting two groups of people to sit down in the same room every few months or so to have a discussion. It really cannot be done without a combined budget. So long as there are perverse incentives for one budget or another, it will not work.
We are making progress on that and have clear plans to get it done by 2020. We will follow our progress with a scorecard to find out where we are. We have spoken for too long about finding the holy grail, but we are further towards it than anyone has been before. That is not a bad place to be, but we must ensure that we make progress. A lot of this is about relationships; it is not just about organisations being in the same room. Unless people really talk to each other and have a real sense of what can be done collectively, we will not get anywhere.
My hon. Friend made the heartfelt plea, “Leave us be from time to time.” That would certainly be echoed by virtually everybody I have ever been involved with in the public sector during the past 30 years. They just wish we would decide what is to be done and let them get on with it for a while before changing it again. I am quite sure that this Government have absolutely absorbed that lesson.
The hon. Member for Don Valley—[Interruption.] Will she forgive me? Once I have been in the House for a few years, I will get all such distinctions right. The right hon. Member for Don Valley (Caroline Flint) speaks from a position of great experience and great success. She spoke about the successes and the failures in the system, which we all know about, and about how the commission could look at them. Again, I am not quite sure that it could bear the weight of doing so.
The right hon. Lady addressed the political issues and how difficult some of them are. If she will forgive me for saying so, she made an intervention on the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) that exemplified the point. There are difficult political challenges within parties as well as between parties across the Floor of the House, and I noticed the little challenge that was made.
I must say to the hon. Member for Oldham East and Saddleworth, who spoke with great passion about her party’s commitment to a publicly funded or taxpayer-funded NHS with no deviation from the line, that that is simply not true. It suits her to say it, but it is not true. Let me quote from an article from the New Statesman of 27 January 2015, under the headline “Labour can’t escape its Blairite past on the NHS, so it should stop crying ‘privatisation’.” It said that Alan Milburn
“serves as one of many reminders that not so long ago, during the New Labour years, the Labour party was driving through dramatic reforms in the NHS and did not shy away from private money in doing so.”
There are variations on a theme, even for the hon. Lady, and she perhaps protested about the public nature of the NHS a little too much.