NHS and Social Care Commission

Norman Lamb Excerpts

Thursday 28th January 2016 Commons Chamber

[Norman Lamb (North Norfolk) (LD)]

I beg to move,

That this House calls for the establishment of an independent, non-partisan Commission on the future of the NHS and social care which would engage with the public, the NHS and care workforces, experts and civic society, sitting for a defined period with the aim of establishing a long-term settlement for the NHS and social care.

May I take this opportunity to thank the Backbench Business Committee for granting this debate and Members on both sides of the House for expressing interest in, and support for, the motion? I tabled the motion alongside the hon. Member for Central Suffolk and North Ipswich (Dr Poulter), who sadly cannot be here because of a family illness, and the hon. Member for Leicester West (Liz Kendall). I want to be clear that I am making this case on a cross-party basis, because I believe that it absolutely transcends narrow party politics. I sought the support of, and have been working alongside, Steven Dorrell, the respected former Conservative Health Secretary, and Alan Milburn, the former Labour Health Secretary.

I have felt for a long time now that the NHS and the care system face a very real existential threat, and we have been drifting in that direction for many years. We have to get to grips with this before seriously unattractive things start happening to some of the most vulnerable people in our country. The motion obviously addresses the situation in England, but the position in Scotland, Wales and Northern Ireland is essentially the same; we are all facing the same demographic challenges and the same need to ensure that our health and care systems meet the needs of our communities today, rather than those of 1948.

There is an enormous belief in the NHS in this country, and it is a belief that I share very strongly. It engenders a sense of solidarity and the sense of the decency of this country that we all commit together to ensuring that people can access care when they need it, regardless of their ability to pay. That is a founding principle that has stood the test of time and should be sustained. That is what this debate is all about.

It was a great Liberal, William Beveridge, who put forward the proposition that there should be a national health service, and it was a great socialist, Nye Bevan, who then implemented it as Minister of State for Health. It is also fair to say that Conservative Governments since have sustained the NHS. We have always had our battles about funding levels, reorganisations, structural reforms and so forth, but the NHS has been sustained, with cross-party support, and it is very important that that continues.

As I have said, that principle has stood the test of time. The Commonwealth Fund concluded back in 2014 that, among the major economies it looked at, the NHS was essentially the best system globally, although it is worth noting that it did not score so well on outcomes or on premature mortality—those are, after all, quite important measures that we should not be complacent about. I have made the case that there is an existential challenge to the system, and I believe that it is time for what I call a new Beveridge report for the 21st century.

[Mr Andrew Mitchell (Sutton Coldfield) (Con)]

Is not the key point that the right hon. Gentleman has made, and that the House should consider today, that all parties support the NHS and that, therefore, it simply will not work to have one party chart the future? It would be much better, therefore—this is why I support his motion—to have a cross-party commission, although not a royal commission that would kick it into touch for three years, to try to bring everyone together to face what he rightly describes as an existential challenge to health in this country for the future?

[Norman Lamb]

I am grateful to the right hon. Gentleman for that intervention; he absolutely makes the case. Incidentally, I think that it is massively in the Government’s interests to respond positively, because any solution has to carry public support and support across the political spectrum.

Consider these points. Does it still make sense to maintain the divide that was originally put in place in 1948 between the NHS and the social care system? Is that serving patients effectively, particularly given that the big challenge of this century will be people living with long-term, chronic conditions, often multiple conditions, and often a mix of mental and physical health conditions? For those people, a divide between different organisations with different pools of money and different commissioning arrangements does not seem to make much sense. I think that that needs to be looked at.

Too often, the system gives the impression of being rather dysfunctional. For example, last October there were 160,000 bed days resulting from people whose discharges were delayed. These are predominantly older people, often with dementia, who remain stuck in hospital long after they are ready to go home or somewhere closer to home. This is not good care. We are letting people down by keeping them in hospital for longer than they need to be, which also makes it harder for them to become independent again. The figure went down a little in November, but it is still the second highest since the data on delayed discharges started to be recorded.

[Helen Whately (Faversham and Mid Kent) (Con)]

The right hon. Gentleman mentions the relationship between the NHS and social care and the problem with their being separate. Does he acknowledge that the “Five Year Forward View” contains several approaches to bringing them together, and that parts of the country are already working on further integrating them? Is it not important to press on with those approaches so that we can see how they work and move as quickly as possible on this?

[Norman Lamb]

I totally agree with the hon. Lady. I have always been a strong supporter of the forward view. Simon Stevens is a good leader of the NHS. He has a vision, and he recognises that the solutions to this challenge often lie beyond the NHS. Some of the models that are being trialled across the country are very interesting. I do not want what I am saying to be seen in any way as undermining the very good work that is under way in the so-called vanguards around the country.

[Geraint Davies (Swansea West) (Lab/Co-op)]

On bed blocking, when I was leader of Croydon Council it cost £300 a night to keep someone in Mayday hospital and £100 a night for us to provide a bed as a local authority. We had no money, so I asked the health authority to pay for our beds and save £200, and it did. However, that was an ad hoc strategy, and surely we want a holistic, integrated approach, as the right hon. Gentleman is so eloquently explaining.

[Norman Lamb]

I totally agree with the hon. Gentleman’s last point, but also his substantive point. The problem is that these are all ad hoc arrangements that are about good leaders doing something despite the system, not because of it. We have to mainstream this and align the incentives throughout the healthcare system so that everyone is focused on preventing ill health, preventing deterioration of health, and getting people better as quickly as possible.

Let me give an example of the pressure that the system is facing. It is fair to say, as a gentle challenge to the Government, that this year we are not seeing the data on accident and emergency pressures over the winter period, so the situation is slightly hidden from view. However, I heard that on Tuesday this week all the hospitals in Hertfordshire, north London, Bedfordshire, Northamptonshire and Leicestershire were on black alert, which occurs, in essence, when hospitals are completely full and under enormous pressure. One of the key system leaders in that area said that he had not seen anything like it for 20 years. This is happening at a time when there is no flu epidemic, and certainly no severe weather. This is one of the mildest winters on record, and yet we are seeing hospitals placed under impossible pressure.

[Chris Davies (Brecon and Radnorshire) (Con)]

I commend you for trying to bring the parties together to have a commission to look into the matter of the NHS, but we are now living in a devolved Great Britain. It is great to get the parties together in England, but how do you propose to get Wales, Scotland and Northern Ireland together? I will give an example. My wife works for the NHS. She worked for the NHS for 18 years in Wales. She gets treated by the NHS in Wales because we live in Wales, but she works for NHS England. Given that there are so many cross-border issues, especially in Brecon and Radnorshire, how do you propose to get the whole of Great Britain to work with this plan?

[Norman Lamb]

I said at the start that I am primarily focused on England because health is a devolved responsibility, but I also said that the same pressures apply everywhere, and so the case for a process of this sort in Wales, in Scotland and in Northern Ireland is just as strong as it is England. I would encourage this debate to take place in Wales as well. We must overcome the clashes between the parties to recognise that something bigger is going on and we need to work together.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I want to return to the right hon. Gentleman’s point about the data. Last June, we had a debate about moving from weekly to monthly data, and we were told that the NHS would still know what was going on. We now have a six-week delay in the publication of those monthly data, which results in a total of 10 weeks. Having asked about this at the most recent Health questions, I understand that people within the NHS can access the data, so why are they not being shared with this place? The last data we had was in November.

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[Norman Lamb]

I thank the hon. Lady—that is a very good point. I fundamentally believe in openness. It is much better if everyone understands what is going on, and then there can be a much more informed debate.

One of my big concerns is that despite some of the very good policy positions that have been taken nationally, too often, across the country, crisis management prevails. Because areas are so focused on propping up acute hospitals that are under the intense pressure I described, more and more money ends up being pumped into those hospitals while the preventive parts of the system are losing out and being cut further. It becomes a vicious circle, because the more we cut back on preventive care within NHS community services, general practice and social care, the more pressure we end up putting on hospitals. We cannot escape from this, and that is why we need the long-term solution that I have talked about.

In health and social care, demand keeps rising. This is unusual in public service terms when compared with, say, police and schools. Demand has risen at 4% a year throughout the post-war period. We all know the causes: we are living longer, new medicines and new technologies come on stream, we face challenges like obesity, and so forth. The cost pressures just keep going up. It is a well-established position that by 2020 there will be a £30 billion gap in NHS funding. The Health Foundation has said that in social care the gap will be £6 billion. Those are enormous figures, and they take no account of the £1 billion additional cost from increasing the minimum wage. In responding, the Government have identified an extra £10 billion for the NHS, but that leaves a £20 billion shortfall. This is based on scenarios set out in the forward view. However, the scenario of a £20 billion shortfall involves efficiency savings that are completely unheard of in the whole history of the NHS. Virtually everyone one speaks to—not just people who refuse to accept the need for efficiencies—says that achieving efficiency savings of 2%, rising to 3%, is unachievable between now and 2020.

[Mr Mitchell]

Is it not the case—I think this is a cross-party point—that although the NHS is under very great financial pressure, and we are trying, in effect, to get a quart out of a pint pot and have been doing so for many years, the people who work in the service are also under very great pressure? Whatever one thinks about the junior doctors’ situation, the information that has come out from across the service, and from across the junior doctors, is testament to the fact that they work under enormous pressure. This is not just a financial issue; it is also about the fact that the staff in the NHS are under unprecedented pressure that is not set to get any easier.

[Norman Lamb]

The right hon. Gentleman makes a very powerful point. Indeed, the staff are working under impossible pressure.

Incidentally, the assumptions about the funding gap by 2020 do not take into account the work that the right hon. Gentleman and I have done together to make the case for equality of access for people who suffer from mental ill health. This is about a historical injustice that has to be dealt with. Paul Farmer, who has led a taskforce for NHS England, has concluded that mental health will require an extra £1.2 billion a year by 2020 in order to ensure equal rights of access with everyone else. It is very hard to deny the justice of that cause and the right of people to get access to social care in the same way as everyone else.

[Geraint Davies]

rose—

[Norman Lamb]

I am conscious that you may start to get slightly irritated with me, Madam Deputy Speaker —

[Madam Deputy Speaker (Mrs Eleanor Laing)]

On a point of clarification, the right hon. Gentleman is doing just fine on timing. I appreciate that he has taken a lot of interventions, and people who intervene know that, later in the debate, their speeches will be shorter as a result of their interventions. He is doing nothing wrong, and he may proceed.

[Norman Lamb]

I am relieved. I sensed that I might be getting into trouble. I will give way to the hon. Gentleman.

[Geraint Davies]

Very briefly, in terms of aggregating the expenditure of health and social care, which, incidentally, is higher in Wales where there is an attempt to have a more integrated approach, the cutting of social care will increase the total amount, as undue pressure will be put on the NHS, which then cannot release beds, and it costs more per night to keep someone in a hospital.

[Norman Lamb]

The hon. Gentleman is absolutely right. Simon Stevens has made the point that if we cut social care, the £30 billion gap widens. There is no escaping from that. The brutal truth is that the whole system is under very substantial pressure. Analysis by the Office for Budget Responsibility, which is independent of Government, shows that between now and 2020, we are planning to spend a reducing percentage of our GDP on health. At a time when demand is increasing so dramatically, does that decision make any sense at all? Back in 2013, the OECD did an analysis of all OECD countries in the European Union. Only five were spending a lower proportion of their GDP on health than we do. The NHS is very good value for money, but it is under extraordinary pressure.

[Anne Marie Morris (Newton Abbot) (Con)]

The right hon. Gentleman is being very generous with his time. The picture that he is painting is one of a very reactive approach to the growing problems. I entirely support his call for this review. As a responsible society, we need to have a holistic, forward-looking, proactive approach, particularly with regard to social care. The Barker commission made a number of good proposals, some of which I agreed with and some I did not. To what extent does he agree with me on that point?

[Norman Lamb]

I totally agree with the hon. Lady. In fact, I think that I have agreed with every intervention so far. We will probably all just agree with each other. She is absolutely right and it goes to my point about crisis management. We are at risk of lurching from crisis to crisis, as we prop up a system that is under unsustainable pressure. Of course we always end up spending money at the repair end of the spectrum, rather than on preventing ill health.

There are some great initiatives in the west country, where volunteers, working with GPs, try to address the problems of loneliness, and that is helping to keep people out of hospital. That sort of thinking needs to be much more widespread.

[Tom Brake (Carshalton and Wallington) (LD)]

My right hon. Friend may be coming on to this point, but what I want to understand is how the commission, and the output of that commission, can help with some of the very difficult hospital reorganisations that we all face in our constituencies—mine being St Helier hospital—and how we can ensure that we strike the right balance between acute services and care in the community. How will the commission help with that?

[Norman Lamb]

My right hon. Friend comes to the central point. As someone once said, the NHS has the status of a national religion. In this partisan atmosphere in which we all work, there is a danger that anyone who proposes a change to the NHS will get condemned from on high, because of the political points that can be scored in so doing. If we are to think about what we need from a modern health and care system that focuses on prevention, and to make changes in a rational way, we must give Government the space to think afresh about how we can sustain the system and guarantee care for those who need it. We have a choice now: we continue to drift until, ultimately, the system crashes, or we grasp the nettle and come up with a long-term solution.

All parties should commit to the proposal. If we want a good example, we should look at the commission of Adair Turner, which was established by the Labour Government to look at the long-term sustainability of pensions in this country. He managed to secure cross-party buy-in. He came up with proposals that led to change and reform. It was a process that gave people the space to look at a very difficult challenge and to come up with solutions. That is one model we could follow. It should be strictly time-limited. Somebody made the point that we are talking about not a royal commission, which goes into the long grass for three or four years, but a time-limited commission of up to one year with the aim of coming up with solutions that are then implemented. It should engage with the public, with patient groups and, critically, with staff, who, as the right hon. Member for Sutton Coldfield (Mr Mitchell) said, often feel that they are under intense pressure and that they are not listened to by Governments of all political persuasions. They, together with unions and civic society, should be centrally engaged with this commission. At the end of the process, we should seek to come up with recommendations that can then be implemented and can give everyone in this country the assurance that there is a long-term settlement for the NHS and for care.

Finally, let me raise one or two things that the commission needs to consider. It needs to look at the divide between the NHS and social care and at the adequacy of funding. How much as a society are we prepared to pay to ensure that we have a good, well-functioning health and care system? At the moment, funding for our health and care system comes through three different channels: the NHS, local authorities and the benefit system. Does that make sense? Should we look again at that system?

We also need to look at how we, as a country, are spending money on our older people. Are we spending it effectively enough? Are we targeting it at those older people who most need Government help? We need to look at intergenerational fairness and at where the money comes from—a point very well made in a recent book by the respected former Cabinet Minister, David Willetts. We also need to consider how we can give power to people to help them to self-care. David Wanless, when he reported for the Labour Government, made the point that his projections about how much extra money the system would need was based on people being engaged in their health—I am talking about self-caring more effectively. That has not happened in the way that he proposed.

We also need to consider the case for a dedicated health and care tax, which can be varied locally. Even protecting NHS spending results in disproportionate cuts in other areas of Government spending, distorting sensible, rational decisions. As this is an area on which spending inexorably rises, there is a case for carving out such a tax.

[Helen Whately]

rose—

[Norman Lamb]

I am sorry, but I want to conclude my remarks now to give other Members a chance to speak.

This proposal has had very significant support. NHS Survival, which now encompasses 8,000 members—junior doctors, patient groups and so on—has strongly argued for such a tax. Forty chief executives of care organisations wrote to the Prime Minister to support the case. The chief executive of the King’s Fund, Chris Ham, has written a very helpful blog, making the case. Royal colleges of surgeons, pathologists and anaesthetists have all supported the call. I urge the Government to respond positively. They should stop and think for a moment before rejecting our proposal, because it might be an enormous help to the Government in resolving an intractable problem. This is the time for a 21st-century Beveridge report to come up with a long-term settlement for the NHS and for social care.

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[Dr Wollaston]

In this place, we sometimes push issues into commissions, which debate them endlessly and come to no agreement. I would say the urgency of this issue demands that the leaders of all political parties sit down together and agree.

[Norman Lamb]

I am very grateful to the hon. Lady for giving way, and I promise not to keep intervening. I feel that there needs to be a process to which everybody is committed. If there is just a desire for the party leaders to co-operate, the temptation to score political points when a crisis comes along will be too great and it just will not happen. We need to bind people into such a process, and they must be prepared to commit to it.

[Dr Wollaston]

I thank the right hon. Gentleman for his clarification. I agree that we are looking for a process to which everyone can commit. We are not looking for a commission that will go away and examine the problems. We know the issues, which have been set out in very stark terms. The King’s Fund’s excellent independent Barker commission set out the whole range of options. What we have always lacked is the political buy-in and determination to move forward. I would join in making a request for any process that will make that happen, but not for something that pushes it away for three years, because, as we all know, the closer we get to a general election, the more challenging it will be to have a genuine political agreement. It therefore needs to happen as rapidly as possible.

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[Valerie Vaz (Walsall South) (Lab)]

It is always a pleasure to follow the hon. Member for Stafford (Jeremy Lefroy), who is a great defender of the NHS, both locally and nationally. I congratulate the right hon. Member for North Norfolk (Norman Lamb), who was a very assiduous Minister; my hon. Friend the Member for Leicester West (Liz Kendall), who is not in her place but who was an assiduous shadow Minister; and the hon. Member for Central Suffolk and North Ipswich (Dr Poulter), who unfortunately cannot be here but who was also an assiduous Minister and a member of the Health Committee.

It is with great difficulty and a bit of sadness that I say that I do not support the motion. I know that it comes with great heavyweight backing from public figures—MPs and former Ministers—but I do not think that it will take the debate forward. When we set up a commission, it can feel like we are kicking something into the long grass, and that is what it feels like we are doing today. This issue has been going on for a long time, and it is, I feel, a lack of political will that is failing to drive the changes forward.

We have had the evidence. There has been a pilot scheme, which was set up by my right hon. Friend the Member for Leigh (Andy Burnham) in Torbay in 2009. The integrated care trust is operating. A former Secretary of State for Health, Stephen Dorrell, who was a very good Chair of the Select Committee on which I served, gave an interview on 22 January in The House magazine in which he recalls asking an adviser:

“What is the oldest quote from a health minister saying how important it is to join up health and care services?”

This answer came back:

“Dick Crossman, the Health Secretary in the late 1960s.”

That is how long this issue has been going on, and it has cross-party support.

I want to touch on what some hon. Members have been saying about cross-party support. Perhaps I have been on a different planet, or perhaps, a bit like Bobby in “Dallas”, I have woken up and it is all a dream, but I recall being on a cross-party Health Committee, ably chaired by Stephen Dorrell, that produced many reports, but never a minority report. We came up with a number of conclusions that Members are now saying that we should consider.

In our report on public expenditure, we said that very little of the money spent by the NHS on people with long-term conditions was spent in an integrated way, which meant that significant amounts of money were wasted. In our report on commissioning, we said the NHS Commissioning Board should work closely with local commissioning bodies

“to facilitate budget pooling and service integration to reflect patient priorities.”

In our 12th report of the 2010-12 Session on social care, we said that efficiency savings would not be possible without further integration between health and social care. That has been an aim of successive Governments, but has not been properly achieved.

In our 11th report of the 2012-13 Session, “Public Expenditure of Health and Social Care”, we said that

“health and wellbeing boards and clinical commissioning groups should be placed under a duty to demonstrate how they intend to deliver a commissioning process which provides integrated health, social care and social housing services in their area”

and that there was

“evidence, for example, that 30% of admissions to the acute sector are unnecessary or could have been avoided if the conditions had been detected and treated earlier through an integrated health and care system.”

In our seventh report of the 2013-14 Session, “Public Expenditure on Health and Social Care”, we said that

“fragmented commissioning structures significantly inhibit the growth of truly integrated services.”

In our second report of the 2014-15 Session, “Managing the care of people with long-term conditions”, we said that

“in many cases commissioning of services for LTCs remains fragmented and that care centred on the person is remote from the experience of many”

and that an integrated approach was necessary to relieve pressure on acute care.

Members of the Health Committee, including the hon. Member for Totnes (Dr Wollaston) and my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), who unfortunately had to leave this debate to go to a young carers’ meeting in her constituency, have all sat through that evidence. I know it is real, because it will be on the website of the Health Committee. There are pages and pages of evidence on where we can get things right.

In particular, our report on “Social Care” said:

“Although the Government has ‘signed-up’ to the idea of integration, little action has taken place... The Committee does not believe that the proposals in the Health and Social Care Bill will simplify this process.”

We called for a single commissioner with a single pot of money who would bring together the different pots of money and decide how resources would be deployed.

One thing we did as part of our inquiry into health and social care was to visit Torbay, which has not been mentioned today, where we saw integrated care in action. Mrs Smith, who is fictitious but could be any one of our constituents, has one point of contact: she only has to make one phone call. Mrs Smith has seamless social care up to the health service and back again. The health service workers have been upskilled and can help her through the whole system. The local authority and the local hospital worked together so that when Mrs Smith is unwell and has to go to hospital, she can be tracked through the whole system. That is integrated care in action in Torbay. One concern was what would happen and whether such integrated systems would work under the Health and Social Care Act 2012, but I have seen it working.

There is another interesting area where integrated care is working. Another visit we made was to look at integrated care in Denmark and Sweden. In Denmark, we saw the most fabulous building in which elderly people could be cared for, and where they could be visited by GPs. It looked more like a hotel than a home. We were told, “We are looking at your system. We are looking at Mrs Smith.” At that point, we nearly fell off our chairs, because we had come to Denmark to find out how its system works.

[Norman Lamb]

I appreciate the hon. Lady’s kind words. She is talking about all the various initiatives and the need for political will, but the conclusion is that none of those things has happened. There has not been the political will because of the acutely partisan environment in which we all work. Does that not make the case for a process—which the Government could buy into and all the parties could commit to—that will deliver change in a defined period?

[Valerie Vaz]

I think that the Health Committee structure has such a purpose.

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[Norman Lamb]

The Government have not bought into it.

[Valerie Vaz]

Well, they have. The Government have a responsibility to respond to the Health Committee. If the right hon. Gentleman waits until the end of the speech, he will see where I am heading. I agree with his idea that something needs to be put together. I do not like knocking good ideas on the head; I like to see such things taken forward. As the hon. Member for Stafford (Jeremy Lefroy) said, it is either “a commission or whatever”. It may be that the right hon. Member for North Norfolk has a good role to play in pulling all this together and taking forward the idea somehow, but at the end of the day, it is a political decision for the Government of the day to consider.

I want to move on to discuss my local hospital, Manor hospital, and the local authority. In Walsall, we are lucky to have a settled community, and we have one local authority dealing with the local hospital. Work is carried out by the local authority and the hospital together, and they can talk things through. When difficulties arose at the hospital in Stafford—the A&E closed, and we had to take on extra maternity services—it was much more difficult, taking on patients from different areas, to deal with local authorities in different areas. Such relationships had not been built up, but they can be built up and, with the best will in the world, I am sure they will be. We know that workers in the health service work very hard and extremely well together to ensure that such relationships exist. If that works for one local authority, I am sure it can work for other neighbouring authorities.

Interestingly, the right hon. Member for North Norfolk has involved two former Secretaries of State for Health, Alan Milburn and Stephen Dorrell, in his commission. If I was really cruel, I might say that they were Secretaries of State for Health, so why did they not do something about it then and why do they think they can do something about it now? As I have said, there is a way forward. Many Members have alluded to the myriad reports. The King’s Fund has produced a report, the Nuffield Trust has produced one and many universities have produced reports. There have been lots of words, but we need a little more action.

My only difficulty with the proposed commission is the accountability structure. I am not sure who it would report to and there would be no obligation on the Government to respond to it in the way that they have to respond to the Health Committee.

I want to touch on the issue of money. We had a reorganisation of the health service that cost £2 billion and counting. If the Government can sit down with a company to reduce its tax liability and, hence, what flows into the coffers of the Treasury, that has an enormous impact on the Mrs Smiths of this world and on all of us. That is why, as our second report of 2014-15 stated, the Government said in evidence to the Select Committee that

“the ambition of achieving integrated health and care services by 2017 had been given ‘quite a turbo charge’ by the introduction of the Better Care Fund”.

The then Minister of State, the right hon. Member for North Norfolk, said that

“by 2015 the whole country will be starting to see a significant change.”

That may be something that the Health Committee could look at and produce a report on or even that the “commission”—in inverted commas—or whatever it is that the right hon. Gentleman and his colleagues extract from the Government could consider.

We have the evidence—we have the care trust and the pilot—and, in the Government’s own turbo-charged words, we have the will, hopefully. Finally, I am not persuaded that a commission will bring about the change that all of us so desperately need.

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[Helen Whately]

I agree with the right hon. Lady that it is difficult in our election cycle to think further ahead, but it is not impossible. During the last Parliament, the NHS came up with the “Five Year Forward View”, which at the time was supported by all major political parties. With that experience behind us, it is possible to go ahead and come up with further long-term views. As I said, a debate, rather than aiming for a consensus, would be helpful. That is exactly the sort of thing that think-tanks, researchers and all sorts of organisations can, are and should look into.

I want to highlight the fact that this issue is political. The right hon. Member for North Norfolk mentioned an organisation called NHS Survival. I saw on its website that lots of clinicians are involved with it. It is fabulous that clinicians are involved in this discussion about the future of the NHS. That said, the founder of the organisation was also, according to its website, the person who initiated a petition calling on the Secretary of State for Health to resign. The right hon. Gentleman called on NHS Survival as an example of a body lobbying for a commission, but it is clearly very political. There is no way of taking the politics out of this.

[Norman Lamb]

I totally share the hon. Lady’s view that the politics should not be taken out of health. As others have said, we spend such a substantial amount of public money on the NHS and social care that it is absolutely right it should be subject to political debate. However, as others have said, in particular the hon. Member for Leicester West (Liz Kendall) and the right hon. Member for Don Valley (Caroline Flint), we do not ultimately, in the partisan environment we work in, confront the really difficult issues. They keep being put off. This is the whole problem. However much in theory she describes a perfect democratic situation in which these issues are debated and resolved, they are not resolved. We remain drifting into crisis because we are not confronting it.

[Helen Whately]

The right hon. Gentleman makes an important point about the need to look at and confront the long-term future funding settlement. I just do not think a commission is necessarily the right way to do it. The fact that we are having a conversation about it now, here in this House, is in its own right a good thing.

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[Debbie Abrahams]

We come from completely different perspectives, as I have just mentioned to my right hon. Friend the Member for Don Valley (Caroline Flint). My hon. Friend the Member for Walsall South said this had been mooted back in the ’60s, but if we think that now, just a few months after our debate on the Health and Social Care Act, something has suddenly changed, I would respectfully ask, what has changed?

Again, a commission would be a distraction from what we really need to have our eye on: what is happening in health and social care at the moment. We know that the decisions made about staffing and training, for example, have put our workforce plans in jeopardy. One reason why we have financial problems is that three out of four trusts are now in deficit—currently a deficit total of about £840 million, which will run up to £1 billion by the end of the year.

[Norman Lamb]

Is there not a danger with the approach that the hon. Lady advocates? We can continue to have a go at the Government and say how awful the pressure on staff and the deterioration of services are—I accept that a lot of that is happening—but is it not better to try to achieve a solution rather than wait in the hope that at some point in the future, a Government might take a decision to provide the necessary funding and other necessary changes?

[Debbie Abrahams]

As I teased the right hon. Gentleman last week at a Radio 5 Live interview, “so says the former Minister who was saying something quite different just a few months ago”! I do not want anyone to be under any illusion about this. I am not saying that we should not be planning for 30 and 40 years hence. I am saying that, given the vastly different ideological perspectives —I have provided one example, showing how much we disagree about the Health and Social Care Act 2012—trying to pretend that we can agree is naive.

In the last Parliament, I was chair of the parliamentary Labour party’s health committee, and we undertook an inquiry that looked into the effectiveness of international health systems—it is published on my website for everyone to have a look at. We were particularly concerned about quality and equity in access and outcomes, because we knew there was a vast difference in both those respects. The inquiry showed quite conclusively that where there was competition, privatisation or marketisation in the health system, health equities worsened. It revealed that there was no compelling evidence to show that competition, privatisation or marketisation improves healthcare quality. In fact, there is some evidence to show that it impedes quality and increases hospitalisation rates and mortality. This was peer-reviewed evidence—a review of a review of evidence—not one-off studies. It was the strongest type of evidence showing that marketisation and privatisation worsen health equity and worsen the quality of care.

We need to take a forward view, 30 or 40 years hence, about how to continue to fund the NHS and social care. This is a distraction, however, from the crisis that we have right now. We have seen A&E waits up 34% since 2015, failure to meet cancer 62-day treatment standards up 14%, and diagnostics up 36%. It goes on and on. Mental health cuts in 2014 meant the equivalent of £600 million-worth of cuts to mental health trusts. What has changed in the last few months? Delayed discharges reflect the care crisis, with £3.6 billion taken out of the budget for social care in the last Parliament. There is supposed to be £4.3 billion and a 2% precept, but it has been rightly said that it will not make up the difference. As my hon. Friend the Member for Leicester West said, since 2010, half a million fewer older and disabled people have received state-funded support.

In my constituency, I was doing my regular door knocks when I encountered an elderly lady in her 70s. She opened the door and presented me with a bubble pack of medicines and told me that she did not know what she had to do. She had never met me before. She was dishevelled and wearing a dressing-gown in the middle of the afternoon. This was a woman who clearly needed our help and needed support. She was all on her own and did not know what the medications were. I managed to get somebody there. I wonder, though, how much more this is likely to be happening up and down the country. The system is in a crisis, which is a real concern.

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[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I, too, attended the debate on 2 June last year, and I remember expressing my shock at the violence that was taking place between the Dispatch Boxes. I considered leaving the Chamber, because it did not seem to be a very useful debate and I did not see the point of taking part in it, but then I thought “No, let us get in and tackle this”, and I did make a comment. I said that, regardless of the differences in the way in which politicians would “do” the NHS, the public absolutely believed in it. We have had a fantastic debate today, because people have expressed different views and different outlooks, but have done so calmly.

As was mentioned by the right hon. Member for North Norfolk (Norman Lamb), the challenges of increasing demand caused by age and multi-morbidity are found not just north and south of the border, but throughout the developed world. We also face the challenge of not having enough doctors, in both primary and secondary care. That, too, applies throughout the nations of the United Kingdom.

There are some challenges that we do not face in Scotland. We have not experienced the fragmentation that resulted from the Health and Social Care Act 2012. Indeed, we got rid of hospital trusts back in 2004. We have gone, therefore, to geographical boards—we just have health boards—so there is no barrier between primary and secondary care, which people used to pitch across. Since April of last year our joint integration boards have become active. They ran in a theoretical way for about a year, but the vast majority of them went live last year and the last one will go live in April this year. That is putting the pot of money into a joint space where health and social care work together, break down the barriers and realise there is no benefit in sticking a person in a bed and then looking to see who should pay for it. What purse the money is in has often been the biggest problem.

We cannot develop integration if what we are actually developing is fragmentation and competition. That is why we have not gone down the route of outsourcing to private providers. It wastes a lot money and effort, and people are competing instead of co-operating.

We obviously have different systems in Scotland. We have free personal care, the level of which has been increased to allow us to keep at home people with more complicated conditions. That is important. Since June of last year we have been going through a national conversation. Whether we have a commission, a committee or whatever, it is important that the public and the staff are involved, as well as the people who have written all the reports—Marmot, Wanless, Barker, the King’s Fund, the Nuffield Trust. There must be a way of bringing these together and picking out the good bits to get a shape. Our piece of work is looking towards 2030; that is what we are working on at the moment.

We did a piece of work that started in 2011-12 called “2020 Vision”. It was very like “Five Year Forward View” and addressed where we wanted to be and what shape we wanted. That identified that the No. 1 thing was integrating health and social care.

Talking about the money for this and where it comes from is always going to be political. At the moment national insurance is bizarre; it starts when people earn £7,000 when we would not tax them, and it stops when people retire, although they might be incredibly wealthy. I do not think people see it as national health insurance, which is how it started. Where the money comes from and what it is put towards is a political decision.

To get some kind of shared view of where NHS England and indeed the NHS in all the nations want to be in 2030 could be a useful piece of work. I totally agree with the hon. Members who have expressed anxiety about kicking this into the long grass. I certainly do not think it needs to stop any piece of work going forward. To me, this provides a place where that can come. One of the features in Scotland in developing quality measures is bringing groups of people together for an annual conference; I am a great believer in getting people into a room—maybe not always a room like this one; maybe a more co-operative room—so that people can say “This is what we found difficult. This is how we fixed it. This is where we are stuck. I see you solved that.”

One of the projects that Nicola Sturgeon has taken forward is called “once for Scotland”. It is not eternally going through local projects and experiments that never get shared with anybody, and everyone reinvents the wheel. That is a huge waste of energy.

Obviously the Government have committed to the £10 billion and that has been welcomed, but more than £2 billion of that is already gone in the deficits. That increase is focused purely on NHS England, whereas normally funding is described in all the Department of Health responsibilities. The other responsibilities are facing a cut that is described as approximately £3 billion. The King’s Fund, the Nuffield Trust and the Health Foundation identify the increase as in fact about £4.5 billion—so not exactly the headline figure.

The “Five Year Forward View” has been mentioned, and that asks for £8 billion but it also identified £22 billion that had to be found. That is fairly eye-watering. Let us think about two of the things that were identified within that. One was a change in how people worked.

[Norman Lamb]

The hon. Lady is talking a lot of sense, as she always does. The “Five Year Forward View” set out three scenarios, but it did not ask for £8 billion; that is just the narrative that has developed. The efficiency assumptions on which the £8 billion—or £10 billion, or whatever we want to call it—is based are unimaginable. They are at least 2% to 3% throughout the period between now and 2020, and everyone knows that that is not going to be delivered.

[Dr Whitford]

I thank the right hon. Gentleman for his intervention. Even without recognising that no one has ever achieved those levels of efficiency savings, we need to acknowledge that a big chunk of this is about prevention. More than £5 billion of the £22 billion has been identified as relating to people not going into hospital and not getting sick, yet public health expenditure has been cut by £200 million in-year, with another £600 million to go. That amounts to a 3.9% cut. Lots of people will think that that just means less smoking cessation and less preventive work around alcohol, but public health should be much bigger than that.

I understand that there used to be a Cabinet Committee on public health in this place. Public health should be feeding into all the decisions that are made here. We also need to ensure that our directors of public health are strategically involved in local government, because the shape of our town centres will determine whether we have car-based or active transport, how we design our schools and whether we flog off our playing fields. All those things will interact with health.

It has been said that secondary care always gets the bigger bite of the cherry. We talk about fixing the roof while the sun is shining, but in fact, when the window has just come in or the door has just come off its hinges, that is what we fix first. That is very similar to secondary care, which is actually the national illness service. It responds to people who are already ill. We are developing more complex and expensive treatments that allow us to keep people alive, and we need to recognise that. People talk about the catastrophe of ageing, but I would like Members to focus on what the alternative is. People used to say, “Age does not come alone, and it is terrible.” In the field I worked in, however, not everyone gets old. Age is something that we should value, because wisdom and a sense of community come with it.

However, we need to be ready to develop the services around older people, and that means not always just patching things up at the end. We need more intermediate care to allow step-up and step-down beds, and we are working on that in Scotland. In particular, we need to focus on primary care, as the hon. Member for Stafford (Jeremy Lefroy) said. That is the real generalism. The GP is the person who is able to make a diagnosis because they have known the patient linearly over many years. However, GPs are on their knees and that is a UK-wide problem. They are under huge pressure because of the demand and the complexity. Within that, of course, we must talk about the lack of mental health services. They have been ignored for a long time, but that is beginning to change. In Scotland, we have a waiting time target for child and adolescent mental health services. Unfortunately, it is proving very challenging to meet that target, but we have doubled the number of staff in those services and we hope eventually to see improvements.

We need to be looking at these issues more broadly. The hon. Member for Oldham East and Saddleworth (Debbie Abrahams) and I—I am not very good at learning constituencies that have two names; I find one name a challenge with 650 people here—are members of the all-party parliamentary group on health in all policies. We have been taking evidence on the health impacts of increasing child poverty, of which we are going to see even more. We need to recognise that every decision we make feeds into whether our citizens are healthier, physically and mentally, or less healthy. That is about welfare. It is particularly about housing, which has one of the biggest impacts on health. The hon. Member for Stafford mentioned those impacts in our debate yesterday on supported care. If we lose supported care in the community, we are never going to get people out of hospital. I want to make the plea, as I did in my maiden speech, that we in this place should put health and wellbeing—meaning mental health—across all our policies and measure our decisions against those factors. Far too many decisions are made in a broken up, narrow way without looking at the ramifications for everything else.

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[The Minister for Community and Social Care (Alistair Burt)]

This has been a really great afternoon. I have thoroughly enjoyed listening to all the speeches. It has been the sort of debate that I think people outside this place appreciate. I thank the right hon. Member for North Norfolk (Norman Lamb) and his colleagues for securing the debate. I also thank him, as always, for the contribution he made when he was in the role I am now in. I thank all right hon. and hon. Members for their contributions, not least those with a medical background. We encourage them to remain in active medicine, because it brings an extra dimension to these debates. If I have time, I will address the comments from each Member. I will first respond briefly to the nub of the debate before responding to colleagues’ remarks and making some comments on the structure.

The sustainability of the NHS and social care system, whether financial or operational, is a key commitment of this Government. However, we do not believe that there is a need to launch an independent commission into its future. The NHS and wider health system has already examined what needs to be done to ensure the sustainability of the health and care system. Part of the purpose of making NHS England independent was to allow it to examine the circumstances of its finances and project into the future. It did so independently and came up with a figure. The Conservative party, uniquely, met that commitment at the last election and was able to carry it into government. It is important for the House to recognise that right at the beginning.

[Norman Lamb]

I just want to challenge the Minister on the suggestion that NHS England came up with the figure and the Government met it, because that is not actually what happened. NHS England and Simon Stevens painted three scenarios. The scenario that the Government have met, and on which both my party and his party stood at the election, is based on assumptions that are heroic in their scale and have never been met in the history of the NHS.

[Alistair Burt]

If I may say so, Simon Stevens said, “Look, it needs £8 billion.” It also needs £22 billion in efficiencies. We have met the challenge and put in even more than £8 billion—by 2020 it will be £10 billion. I understand the pressures in the system and fully appreciate the right hon. Gentleman’s remarks. The King’s Fund stated in its 2015 report:

“‘Business as usual’ is not sustainable. But that does not mean the NHS is fundamentally unsustainable.”

Simon Stevens recently said:

“The NHS has a huge job of work to do ensuring an already lean health service is as efficient as it can be—which, in my assessment, people are entirely up for.”

He recently told the Health Committee, “In headline terms, £22 billion is a big number, but when you think about the practical examples and do the economic analysis, we have some pretty big opportunities in front of us.” We know that the challenge is there; nobody denies that. However, NHS England put its assessment of what it needs to the political parties at the last election. We met that challenge and were elected.

We have spoken about a process, and I will return to that in a moment. What NHS England produced was developed by it, along with Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority. The Government back the plan, but we need a strong economy to be able to do that, as a number of colleagues have said. Without trespassing too much into other areas, that is the meat of political debate in this country. The public are not just asked to make a judgment on the delivery of one particular service, however precious it is. It is about whether they think that those who are promoting their view of a particular service have the economic background to deliver it. That question was also comprehensively answered at the general election. We now have responsibility for carrying that forward. People believed that we could put the money into it, and we have done so.

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[Norman Lamb]

After your intervention on the Minister, Mr Deputy Speaker, I will ensure that I keep my remarks extremely brief. For those who have been here throughout the duration of the debate, it is probably time to have something to eat.

This has been an extraordinarily good debate and we have heard very well informed contributions. I absolutely agree with the hon. Member for South West Wiltshire (Dr Murrison) that we should be ambitious and that we should have the mindset that what happens at the moment is not good enough. We should aspire to have the best health and care system imaginable and in comparison with other European countries.

I suppose that what is behind my plea for a commission, which I will continue to make, is the brutal truth that our political process has let people down. The hon. Member for Leicester West (Liz Kendall) made the point that an elderly person who does not get the care they need suffers when the political process fails. In a way, partisan politics has ducked the big issues, despite what some hon. Members have said about big political issues being determined in a partisan way. That has failed and let the people of this country down.

The shadow Secretary of State, the hon. Member for Lewisham East (Heidi Alexander), in many ways gave a thoughtful speech, much of which I completely agreed with. She had a little go at me about social care funding, but the truth is that none of the political parties confronted the funding needs of social care at the general election. There was a bit of a race over health funding, but social care was neglected, as it has been again and again. Until we confront that, people in this country will continue to be let down.

Opposition Members can choose to say, “It is all the Government’s responsibility.” The Minister clearly wants to keep it that way, and we could just attack for the next five years. When things get really difficult, we can go for the failures of the system. Alternatively, we could adopt a different approach and recognise that these are profound issues that, in a way, have not been thought about comprehensively since the foundation of the system back in 1948. In ’48, there was a process that garnered cross-party support, despite what the shadow Secretary of State said about that being impossible.

Sometimes, this country needs to reach big decisions together, whether it is about pensions or climate change, as my right hon. Friend the Member for Sheffield, Hallam (Mr Clegg) was saying, or about how we cope with an ageing population. I believe that this is the moment when it is necessary for us to come together to confront those issues. It is in the Government’s interest to think again and embrace the proposal. It is foolhardy to reject it, because I suspect that, with the projections that we all know about, during this Parliament, things will get very messy.

I will continue to campaign and I am very grateful to Members on both sides of the House for supporting that proposition. I thank all hon. Members for their contributions to the debate this afternoon.

Question put and agreed to.

Resolved,

That this House calls for the establishment of an independent, non-partisan Commission on the future of the NHS and social care which would engage with the public, the NHS and care workforces, experts and civic society, sitting for a defined period with the aim of establishing a long-term settlement for the NHS and social care.

[Mary Creagh (Wakefield) (Lab)]

On a point of order, Mr Deputy Speaker. In the past hour, we have had the news that the Lord Chancellor has scrapped the Government’s proposed legal aid reforms, which had drawn such huge protests from criminal solicitors across the country, including in my constituency. We had a debate on prison and justice issues for three hours yesterday, which would have given him ample opportunity to tell the House of the news. May I use your good offices, Mr Deputy Speaker, to ask whether it would be appropriate for the Lord Chancellor to come and make a statement to the House tomorrow, which is a sitting Friday?