Department of Health and Social Care and Ministry of Housing, Communities and Local Government

Sarah Wollaston Excerpts

Monday 2nd July 2018 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

It is an honour to speak in this estimates day debate on the 70th anniversary of the NHS. I am privileged and proud to have worked in the NHS for 24 years before coming to this place, and I would like to start by saying thank you to all those who work in the NHS. The principle behind it is as strong now as it was on the day it first opened its doors: it should be free at the point of delivery, available to all, and based on need, not the ability to pay. That is as important now as it ever was; it is truly the thing that makes us most proud to be British. This is not just the anniversary of the NHS, however; it is also the 70th anniversary of the National Assistance Act 1948, which swept away the poor laws and introduced our system of social care, so it is absolutely right that we should be having this joint estimates day debate.

I absolutely welcome the uplift in funding announced by the Prime Minister, but I would like to talk about how we will get the most from those funds, and also how we will pay for this. One of the key challenges that we have long faced is that although the NHS is free at the point of delivery, social care has been means-tested from the outset. That has created a huge challenge in bringing the systems together and providing the integration that patients expect but often find, to their surprise, is not there. Moving towards more integration would have great benefits for patients, and would create savings and a much more logical, patient-centred approach for both systems. I urge the Minister to look closely at the report of both Committees into social care, in which we touched on that issue and made recommendations, which I will talk more about later.

[Kevin Foster (Torbay) (Con)]

My hon. Friend is providing an excellent introduction to this debate. Does she agree that both Front-Bench teams could look at the example of Torbay Council—the local authority we share—which now has an integrated care organisation that brings together adult social care and the NHS for the benefit of our local residents?

[Dr Wollaston]

Indeed; Torbay has led the way. When the Health and Social Care Committee visited Norway and Denmark, we were shown slides from Torbay, because its approach, referring to a Mrs Smith and actually trying to envisage how everything would work around the patient, has been hugely influential abroad as well as at home.

[Chris Green (Bolton West) (Con)]

Health and social care within Greater Manchester has been devolved to the Mayor. Does my hon. Friend agree that Greater Manchester will hopefully lead the way in demonstrating the opportunities presented by combining health and social care?

[Dr Wollaston]

Yes, and I am going to say more about that, because Manchester has benefited from transformation funding. I want to talk about not only the benefits of integration, but how we can ring fence transformation funding. I welcome my hon. Friend’s comments.

Returning to the recent announcement, a £20.5 billion a year uplift by 2023-24 for NHS England is welcome and represents a 3.4% average increase over five years. Importantly, it is front loaded, with 3.6% in the first two years, and comes on top of £800 million that has already been promised to fund the Agenda for Change pay rises. However, the announcement should not be the end of the story, because it refers only to NHS England and does not include social care, public health, capital or, importantly, training budgets—staffing is crucial to making all this work.

Of course, the Prime Minister acknowledged that and promised to come forward with a settlement for social care and public health in the autumn. However, we need to be clear right from the outset that we must have a social care settlement that reflects demographic changes, because we will need an increase of 3.9% in funding just to stand still. If we want to do something to address quality and to allow social care to do more, we need to go substantially further. That will be essential if we want to get the most out of the settlement that has already been announced for NHS England.

[Diana Johnson (Kingston upon Hull North) (Lab)]

Returning to the hon. Lady’s point about public health not being part of the recent announcement, has she seen the 2017 review that highlighted that there is a return of over £14 for every pound spent on local and national public health policies? It therefore makes economic sense to invest in public health, not to cut it in any future announcement.

[Dr Wollaston]

I absolutely agree. This is about not just funding for public health, but the policy levers. We do not need lots of talk about the “nanny state” that denigrates important national public policy drivers, because although we need funding for local services, as the hon. Lady says, this is also about the policy environment that is necessary to make important changes. Investing in public health makes a huge difference for people.

One of the problems here is that when the public are asked where they would like the priorities to fall, we often hear, understandably, about the importance of cancer outcomes, mental health and emergency waiting times. Public health is often bottom of the list because nobody necessarily knows when their life has been saved by a public health policy. The reality is that the major changes and achievements relating to life expectancy have arisen largely thanks to public health policy, but we rarely turn on the television and see a programme called “24 Hours in Public Health”, which is a shame.

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

In the air quality debate last Thursday, I touched on the need for health in all policies. From active transport to quality of housing, is that not where we need to drive public health?

[Dr Wollaston]

The hon. Lady is absolutely right. Health in all policies means using every opportunity to maximise public health. When Departments work together, such as on the childhood obesity strategy, we need maximum engagement across the whole of Government to make that effective. The way it was put to us when the Committee visited Amsterdam was that it should be viewed as a sandbag wall, and if any part of it is missing, we are not going to achieve what we want. That applies to all of public health.

[Luciana Berger (Liverpool, Wavertree) (Lab/Co-op)]

To echo the point that has just been made, the hon. Lady will be aware that I presented a ten-minute rule Bill in April about having health in all policies. Does she agree that the Government should reinstate the Cabinet Office Sub-Committee on public health so that the entire machinery of government can come together to ensure that we do everything possible to keep people well, rather than having a service that treats people when they are sick?

[Dr Wollaston]

Absolutely. It is essential that we use every mechanism at our disposal to ensure that Departments work together. Public health is mostly delivered in the community, so we need that to happen at the local level, too. Councils should be reaching out into their communities and ensuring that they use every opportunity to deliver health in all areas when it comes to prevention.

One of the most welcome aspects of the funding settlement is that it is long term. For too long we have limped from one short-term sticking plaster to another, so I particularly welcome the fact that we now have certainty over five years combined with a 10-year long-term plan. In the Minister’s response, I ask her to reflect on the recommendation from the House of Lords Select Committee on the Long-Term Sustainability of the NHS for an office of health and care sustainability to do long-term horizon scanning. That means not just future demographic challenges, but long-term workforce planning, which has always been a huge challenge within the health service. Brexit, for example, has implications for not just the workforce, and there are many other challenges ahead, so it would be helpful to have an independent body that could consider such things and help to work out the necessary long-term funding.

My final points are about how we fund the new system. I would be delighted if there was a Brexit dividend, but I am afraid that I do not believe that there will be. I think there will be a Brexit penalty. The difficulty with people thinking that everything might be solved by a mythical future fund means that we are not levelling with them right at the outset that we are all going to have to pay for it. The challenge should be about how to distribute the cost fairly. That is the key point here.

I want to stop here to thank the citizens’ assembly that worked with my Committee and the Housing, Communities and Local Government Committee. I also thank the Chair of that Committee, the hon. Member for Sheffield South East (Mr Betts), for the Committee’s diligent work on this issue.

Going back to fairness, when I was in practice, it always came as a huge shock to my patients when they realised that if they had what might be really quite modest assets, they would have to fund all their social care. That shock was striking when the citizens’ assembly considered the matter. If we are to move to a properly funded system, it must look at the quality of social care, which is precarious in nature, and at the provider challenge. We must be realistic, and we have to make it clear that somebody has to pay. We cannot just put it off to future generations; we have to think about it and explain to the public what that means.

That is why, unusually, our Select Committee makes recommendations to both Front-Bench teams, because the failure to address this has been a political failure. On the one hand, measures suggested by the Labour party have been denounced by my party as a “death tax” and, on the other, my party’s suggestions have been denounced as a “dementia tax”, and that means we get nowhere.

If we are to avoid having the same discussion in five years’ time, we need to be clear about how we will get this across the line. That will require, particularly in a hung Parliament, the co-operation of both sides of the House. I therefore urge both Front-Bench spokespeople to commit to working together.

Members on both sides of the House have repeatedly said that we are prepared to form a parliamentary commission to go out and engage with the public, rather as Adair Turner did on the difficult issue of pensions, regarding what fairness means. We cannot offload this entire cost on to a relatively shrinking pool of working-age employed adults. We need to have a conversation that reaches out to everybody and asks, “What is the fair payment?”, and in return we must make sure those extra payments are earmarked for the NHS and do not just disappear into wider Government funding.

How we do that will mean conversations about national insurance with the self-employed, and it will mean conversations with people in retirement about their own contributions. We cannot put the cost entirely on to young people, many of whom are already, in effect, paying a graduate tax of 9% on everything they earn over £25,000. That would not pass the fairness test.

I am afraid that least fair thing of all would be for us to duck this challenge and leave even more people without the care they need, with disastrous consequences for them, for their loved ones and for their carers, because it falls into the “too difficult” box. This is difficult, but we need to grasp it, explain it to people and come to a decision.

[Several hon. Members rose—]

--- Later in debate ---

[Dr Wollaston]

I again thank all the staff who work in health and care, and the carers and volunteers who work as partners with our health and care service. I thank the Minister for her constructive response to the debate and colleagues from all parties for their contributions.

We are all looking forward to seeing the detail of the 10-year plan in November, and we look forward to that plan being worked up with those working in the service and those who represent patients, so that we get the very best from the funding we have. May I leave the Minister with some thoughts? I really hope that transformation funding will be ring-fenced. It is about not just the money that we put into social care but how we make sure that when we change the packages of care better to suit individuals, the transformation is there. We have seen how effective that is in areas such as Manchester. I hope that the Minister recognises that the workforce lies at the heart of everything that is delivered in health and social care. In thanking again the health and social care workforce, in this 70th anniversary year, I ask the Minister to put them at the heart of everything that we do.

Question deferred (Standing Order No. 54(4)).