NHS and Social Care Commission

Philippa Whitford Excerpts

Thursday 28th January 2016 Commons Chamber

[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.

--- Later in debate ---

[Dr Wollaston]

I thank my hon. Friend for mentioning the “Five Year Forward View”, but I would respond by saying that Simon Stevens has referred to prevention and social care as “unfinished business” from the spending review. If we are to deliver the plan, we need to listen to his views and be mindful of the fact that spending on social care actually saves the NHS money. We cannot separate social care from the NHS, and we should not ignore his wise words on the importance of prevention in delivering the “Five Year Forward View”.

[Dr Philippa Whitford]

Is it not the case that when Simon Stevens was before the Health Committee, he said that a quarter of the £22 billion of savings that were hoped for would have to come from prevention and public health, yet that is being cut?

[Dr Wollaston]

Indeed; I remember that too. I agree that unless we up our game and redouble our efforts on prevention, we will not achieve the savings that are required to close the gap in the “Five Year Forward View”. That is why I wanted to touch on prevention first.

There is another area that we need to do much more on here and now. We need to have a relentless focus on variation across the NHS. We hear examples of local systems that are making things work, but the NHS has a long history of failing to roll out best practice. The “Growing old together” report, which was published today by a commission set up by the NHS Confederation, gives examples of good practice across the NHS and social care in which integrated practice is not only delivering better care for individuals, but saving money. The only depressing aspect of that is that one has to ask why it is not happening everywhere. Rather than endlessly focusing on the negatives in the NHS, let us focus more on the positives and on facilitating their roll-out.

--- Later in debate ---

[Dr Phillip Lee (Bracknell) (Con)]

It is a pleasure to follow the hon. Member for Leicester West (Liz Kendall) and other colleagues who have spoken. I congratulate the right hon. Member for North Norfolk (Norman Lamb) on securing the debate.

I broadly support the call for some cross-party engagement to try to secure the future for the national health service, although I will come on to clarify that in my speech. The right hon. Gentleman may encounter some difficulties in seeking cross-party support for financing the NHS, not least because of some of the contributions so far. There are some profound challenges to financing health and social care, primarily because of the challenges that we, and all western societies, face with an ageing population. I remember the Intergenerational Foundation launch here in Parliament a few years ago. Only the former Member for Dulwich and I turned up. At the time, the subject was not much discussed, but I note that it is now increasingly being discussed. We are beginning to do the maths and realise that we cannot afford the current settlement for financing health and social care and that we will have to discuss it at some length. The problem is that one ends up talking about broadly different political philosophies and approaches. Some people, I suspect more on the Conservative Benches, will want to emphasise the need for personal responsibility; others, I suspect more on the Opposition Benches, will want to emphasise collectivisation and the like. That is why I suggest that discussing the financial settlement is possibly a road to nowhere.

I think there is scope, however, for discussion on the structural organisation of the health service: where our hospitals are located and what each individual hospital does. In a week when we have had yet another dreadful failure of the system with the 111 line and out-of-hours services, it is beholden on us to start to discuss what is offered in the out-of-hours arena: how the services are structured and where patients should go to seek the appropriate care for themselves or their children.

The context has been set out by other colleagues. We know that we have a problem of increasing demand, which is driven mainly by ageing, obesity and the welcome advances in surgical practice, technology and drugs. There is also a problem with the health-seeking behaviour of different generations. In my own clinical practice, I am seeing the passing of the stoic wartime generation. Their attitude towards health, and to symptoms of pain and suffering, is noticeably different from that of their children and that will bring increasing demand on healthcare services. If we consider that together with the large cohort who were born between 1945 and 1955, we have an equation that results in a significant deficit.

On the subject of deficits, since I have been here I have seen many faceless NHS bureaucrats come up with numbers relating to likely demand and shortfall. They are always wrong; the figures are usually underestimated. I said at the time that the £20 billion challenge in the previous Parliament was an underestimate of likely demand and here we are talking about £30 billion. What is next: £40 billion? I am glad that a shadow Minister for mental health has been appointed and that people are waking up to the importance of mental health because demands for mental health services in particular will increase the £30 billion figure.

On hospital structure, essentially we have 19th and 20th century buildings trying to deliver 21st century care. Medical and management staff are trying to do their best within this infrastructure, but to be blunt it is not possible to deliver the very best care in all hospitals and in all locations.

[Dr Philippa Whitford]

Is it not also, to some extent, a failure to engage with the public so that they understand how much 21st century medicine has changed? People who have a heart attack are not going to their local casualty department. They are being taken to a heart unit where they will have an angio and an angioplasty. People do not understand that the big boxy paramedic ambulance has everything that an old A&E used to have.

[Dr Lee]

The hon. Lady is right. Tomorrow I will be working as a doctor. I am very proud to be working as a doctor. I have been very public and open about it throughout my time here and I will continue to practise medicine for the foreseeable future. I encourage her to face down her internal critics, as well as those rather ill-informed external critics in the Scottish Daily Mail. I actually stood for election calling for the closure of my local hospital. I did not want my constituents going to an ill-equipped hospital, or thinking that it provided care that it did not. I have sought to educate my local electorate about the need for a 24-hour angio suite and for a 24-hour stroke unit.

We have made some progress on reconfiguration, particularly on stroke care. In London and in Greater Manchester, stroke services have been consolidated. That is why people are now surviving and survival rates for strokes are improving. Patients are taken to appropriate units and appropriately cared for. The appropriate intervention can be applied within the appropriate time. Sadly, that is not possible across the country. It is available only in areas where difficult decisions about reconfiguration have been taken. On oncology, there is a widespread belief that cancer outcomes are all to do with late diagnosis in primary care. Forgive me, but that is not necessarily the whole story. It is the quality of cancer care when patients reach the hospital—any delay in receiving radiotherapy and so on—that is having a profound impact on cancer outcomes. If we consolidated oncology services into fewer sites, we would get better clinical outcomes.

On out-of-hours care, when I turned up here I said that I would scrap out-of-hours care as it is currently constituted. Most people looked at me and thought, “Are you slightly nuts?” The answer is no. Having done many, many, many sessions in the primary care out-of-hours arena, I realised that there was the potential to delay the care of the acutely unwell in a way that could have an adverse impact and, in extremis, lead to someone’s death. I suspect, without knowing the details, that the case we heard about in the urgent question on Tuesday was such an example. I do not believe it is clinically possible to properly assess a sick child via a telephone. We can go some way towards doing it with an adult, because—guess what?—an adult can express themselves more accurately. With a child, we have to see them and touch them, and, in particular, we have to see the mother’s response towards the child, to assess how acutely unwell they are.

The problem, with all best intentions, is that with a telephone service these types of incidents are always going to happen. It was no different with NHS Direct; the medical profession used to get very frustrated with that, and 111 is the same. The symptoms of sepsis can be the symptoms of many things, so if we tighten the protocols we end up flooding the service with more and more people worried that their child has sepsis when, actually, it is not that common.

I would revisit the whole out-of-hours settlement. We could get away with having fewer doctors during antisocial hours primarily looking after the housebound and those who are terminally ill. The list of patients who could be visited by said doctor would be compiled by GP practices in that region. Patients would not get a visit unless the GP practice has said they are entitled to a visit because of a diagnosis of being either terminally ill or housebound. In future, I would put the resources into urgent care centres. For now, I would put one in each casualty to sift through. I would make sure it was a doctor. Forgive me, but doctors are taught to triage and to diagnose. No other healthcare professionals are taught in the same way. The best thing to do is to put one’s most experienced and qualified person at the front end, because then proper triage can take place.

[Dr Lee]

I thank my hon. Friend for her intervention because it allows me to elaborate. A couple of years ago, I had a meeting with the right hon. Member for Leigh (Andy Burnham)—all the polls were saying that the Opposition would win the election, so I thought I would have a meeting with him in advance. I said, “Look, Andy, you’re going to have a problem. We’ve got all these hospitals. We know some of them are not fit for purpose. We know we’ve probably got too many because of how healthcare has changed. Some 80% of care delivered in the NHS is for chronic conditions. Why don’t you have a cross-party commission so that all the parties can share the political pain of deciding which hospitals should be retained as acute hospitals, delivering the 24-hour stroke and angiography suites, the surgical interventions and the like, and then have more community hospitals, with urgent care centres attached”—the hub-and-spoke model. At the time, he looked at me and said, “Well, maybe”, and made no commitment.

My point was that it was extremely difficult for colleagues in marginal seats to come out and say what I said in my constituency, which was that the current local hospital settlement was not in the best interests of my constituents. It is very hard to do that in a marginal seat, be it Labour, Conservative or whatever, so, with a cross-party commission, we could all share the pain.

All the royal colleges, particularly the paediatricians and obstetricians, know that staffing in some district general hospitals is not ideal. It is extremely difficult to provide the level of care we know we can deliver. How do we get to that point? A couple of years ago, I thought that having all the parties and independent experts in a room would be one way of going from approximately 200 to 100 such hospitals in England and Wales. That is the sort of scale change I am talking about. I hope that that answers the question from my hon. Friend the Member for Twickenham (Dr Mathias).

[Dr Philippa Whitford]

In my constituency, we have hospitals that have grown organically and are not far apart, but we have also seen an increase in the number of modern community hospitals—what people would have called cottage hospitals. The hon. Gentleman says that many of our patients require the management of chronic diseases. We need to take that closer to the public. It is the highly specialised things that should be centralised. The public would accept that, provided they do not get the sense of their hospital disappearing and provided they are aware that other services are coming closer to them.

[Dr Lee]

Again, I agree with the hon. Lady—we are making a habit of this. I held a series of public meetings at which people were initially against my position, but when they understood that I was trying to provide more services closer to home, but that this might mean their having to travel a bit further for acute care, they accepted it and became broadly supportive.

I am under no illusions about the difficulty of all this, but if there is one goal we should all seek in the NHS, it is better clinical outcomes. At the moment, clinical outcomes are not as good as they should be. The much-trumpeted Commonwealth Fund report made that clear. Part of the problem—perhaps a significant part—is where the care is currently being delivered. The junior doctors strikes, which have just been paused; the consultant contracts; the nursing contracts to come—all these would be made easier with a structure in place that is more easily staffed. It would be easier to avoid husband-and-wife doctor teams being split if we had bigger hospitals with bigger staff pools to provide the cover.

We need to concentrate first on the structure of healthcare, and social care—I am conscious I have not spoken about social care, but of course it should be integrated; it is so obvious. But let us concentrate on the structure of healthcare first, as part of a cross-party approach, and then perhaps we can have a debate about finance. I suggest to the right hon. Member for North Norfolk, however, that finance might be a harder nut to crack than the hospitals, on which I think there is a broad consensus that we are all in it for the same outcomes: people recovering from their illnesses; people being treated appropriately when they have operations; and ultimately everybody, irrespective of means, leading long, health lives.

--- Later in debate ---

[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.

--- Later in debate ---

[Jeremy Lefroy]

My hon. Friend is absolutely right. In fact, last year Staffordshire County Council raised its council tax by 1.9% but ring-fenced that part for social care, so it was ahead of the game. I believe that it is looking at doing the same this year, possibly taking advantage of the Government’s welcome proposal.

[Dr Philippa Whitford]

My concern about the 2% precept is that wealthy areas will obviously get a lot more money than poor areas, and that will increase health inequalities. Would the hon. Gentleman consider, for example, combining tax and national insurance? National insurance has become an anomaly in that people pay it even when they earn very little and stop paying it when they retire, even if they are very wealthy, so should something more radical be looked at?

[Jeremy Lefroy]

I do propose something radical, but in completely the opposite direction, because I believe that national insurance is an incredibly good thing. I always listen to the hon. Lady with great respect, but let me argue the case for national insurance, and she may disagree with me by way of intervention or otherwise.

We have allowed national insurance to become less relevant, with the exception of the various eligibilities I mentioned. As a result, it has come to be viewed by Her Majesty’s Treasury as just another form of raising funds. There was a proposal for a consultation on merging income tax and national insurance. I would vehemently oppose that, because my perception is that our constituents still, understandably, see national insurance as something different from income tax in being their contribution to the NHS, pensions, and welfare. Indeed, about £60 billion a year of the national insurance money that is raised, although this is a bit of a fiscal fiction, still goes towards the NHS. That is far less than we spend on the NHS, but it is still there.

The notion that, as I contend, our constituents see national insurance differently from income tax was particularly evident when Gordon Brown raised national insurance in order to put additional money into the NHS. He rightly viewed that as the best way of raising additional money for the NHS because it was more acceptable than putting a couple of pence on income tax. The best way—I think the only way, but a commission would need to be very broad-minded in its views—to ensure that we can finance the NHS and social care properly in the long term is through progressive, income-based national insurance with a wider base, as Kate Barker said, whereby by it does not stop when people retire and does not stop at the upper national insurance limit, as it does at the moment at only 1% over it. Broadening the base of national insurance should make it possible to keep the percentage rate reasonable for all while paying for the services needed.

I welcome this motion and the proposal for cross-party work, whether through a commission or whatever, but I would plead that it be fairly focused. It should not cover ground on the details of healthcare that has been well covered elsewhere—probably better than we could cover it—but it should look at integration and, most important of all, future finance for the next 20 or 30 years.

--- Later in debate ---

[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.

--- Later in debate ---

[Alistair Burt]

I said that we have met the challenge that was put before us, which was to support what NHS England said it needed. We have done that through the financial commitment we have made. We looked very hard in the spending review to see what social care would need, and the Chancellor came up with the £2 billion social care precept, plus the £1.5 billion from other resources, so that is £3.5 billion extra by the end of 2020. We have put in place the financing that we believe will allow the delivery of health and social care over the next few years. But—and it is a big but, which I will refer to later—it is not just about the resources; it is also about how they are spent. Most colleagues have spoken about variability and how best practice is not always available elsewhere. We have to ensure that best practice comes in, and that is not just about resources; it is also about how things are done.

[Dr Philippa Whitford]

Is it not the case that the idea of seven-day-a-week, 8 am to 8 pm GP practice was not included in the NHS England estimates, and therefore the cost of that has been added on top? Will the Minister commit to taking the evidence from the pilot studies on whether that is a good use of money?

[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.

--- Later in debate ---

[Alistair Burt]

I think that engagement with all involved is essential. When I am away from Westminster, engaging with patients, the public and staff is fundamental to the visits that I make to the services for which I have responsibility.

There is nothing to stop any of the work that the right hon. Member for North Norfolk is suggesting from starting. It is essential that everybody is fully involved. I do not think that the Government or the Opposition will make any of their decisions on the NHS or its expenditure by excluding anyone.

The hon. Member for Walsall South (Valerie Vaz), in a turbo-charged contribution, also spoke of the importance of getting integration right. She reminded us that Dick Crossman started it all off. I am sure that we have all had election manifestos that have spoken of an integrated transport system and integrating health and social care. Now we just have to make sure it happens. She made the point that no amount of talk or number of recommendations relieves someone of the burden of doing it. At the end of the day, it is doing it that counts. That is the role of the Government, while being appropriately challenged by all others.

I am delighted that my hon. Friend the Member for Faversham and Mid Kent (Helen Whately) spoke of the importance of the workforce, particularly the workforce in social care, who have a very difficult time of it. They have great skills and need to be on a career pathway where they can acquire more. They also need to be valued. Again, my hon. Friend believed that the current mechanisms were better than others for dealing with these difficult problems.

To conclude, I will give my sense of the debate. I found it slightly hard to distinguish what the foundations of the debate were—whether it was about the quantum of funding or how the funding was gathered into the health budget in the first place. The commission is expected to cover a breadth of issues, but I am not certain that it can bear the weight. Decisions need to be made, no matter how the information comes forward.

We do not need a commission to deliver the process or to take the heat out of the debate. We have to be careful about how we speak about these subjects. By and large, what happens upstairs gives the public a good sense of how we deal with witnesses who come in from outside, members of the public and each other. We can do much more of that without the need for a commission. We must remember to handle things carefully.

I am not sure that structural change could be handled through a commission. That is very much a local decision. This is not all about funding; it is about how the funding is used. We have to ensure that we do not get into the trap of measuring everything by what we put in, rather than by output. One of the most telling points was when the right hon. Member for North Norfolk said that in the Commonwealth Fund analysis that gave the NHS such a good rating, the one thing it dropped down on was outcomes—treating people and whether people stayed alive. To most people, that is probably the most important outcome of all. We have to make sure that, for all the other good things that we are doing, such as the work the Secretary of State is doing on transparency and all the efforts we are making to give people more information, we recognise the importance of that.

[Dr Philippa Whitford]

Just on the Commonwealth Fund analysis, the standard that the UK did badly on was actually healthy life expectancy. That is not the same as an outcome in hospital. We may have successful operations, but we have underlying deprivation and ill health.

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

I just say to the Minister that I did give him the nod. I have been very generous. When we say that he has “up to 15 minutes”, he is meant to take 15 minutes. As he can see from the clock, he has taken a lot longer.