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 Dr Poulter, who sadly cannot be here because of a family illness, and 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.
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?
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.
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?
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.
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.
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.
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?
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.
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.
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 £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.
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.
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.
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.
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.
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.
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?
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.
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?
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 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 inter-generational 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.
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.
I thank Norman Lamb and pay tribute to him, particularly for his work as a Minister in the coalition Government and for his personal commitment to mental health services. I welcome his call for real focus and cross-party agreement on this long-standing problem. We need that if we are to solve the problem and create a health and social care service that is fit for purpose for the next century.
I would sound one note of caution. I am very relieved that the right hon. Gentleman is not calling for a royal commission, as there is no shortage of commissions in this place. We are just a year from the Barker commission, the highly respected independent commission set up by the King’s Fund, which very clearly laid out the problems we face and suggested a number of options. Hard choices will have to be made if we are to raise the share of our GDP that we spend on health and social care to 11%, which I know many Members would support.
We know the options. The difficulty is a political one. I question whether we need a commission, and would ask whether we do not in fact need a commitment from the leaders of all political parties in England to come together to look at the proposals seriously, and get away from the endless bickering in this place about the choices before us and the pretence that this is somehow not going to happen. Unless we make such changes, we will have to start thinking rapidly about plan B as an alternative.
What will be the consequences for all our constituents if we fail to reach a political agreement about the challenges we face?
If I understand the hon. Lady correctly, she supports a commitment, but not a commission, but would a commission not be a sign of such a commitment?
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.
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.
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.
I am not sure that there is that big a difference between my hon. Friend and Norman Lamb. My point is that as well as getting all the political parties to focus on this issue now, we need an extremely long-term approach. The House of Commons used to accept that we had to have a long-term, all-party approach to pensions, because of the length of time involved in such important decisions. We also need that in relation to this issue: as well as getting everyone to focus on it, we need to get them to focus on the importance of reaching agreement because this is such a long-term issue.
I agree with my right hon. Friend. However, in parallel with the process of looking at long-term funding arrangements and settlements, we must get on—here and now—with changes that are needed in the short term. I want to touch on a few such areas.
The first area is prevention. I absolutely agree with the right hon. Member for North Norfolk that it is bad practice to cut money from public health, simply because of the challenges we face. If we look at the NHS budget, we can see that 70% of it goes on helping those living with long-term conditions. We know that many future problems are brewing here and now.
Let us just take childhood obesity, which we discussed at length last week. A quarter of the most disadvantaged children now leave primary school not just overweight, but actually obese. Given the problems that that is saving up, in the personal cost to those children and the wider costs to the NHS—nearly 10% of the entire NHS budget already goes towards treating type 2 diabetes—how can we not be grasping that nettle as a matter of urgent prevention to save money for the whole system?
Does the hon. Lady agree that there is an inter-relationship between child poverty and obesity, and indeed between child poverty and other health problems that generate costs, and is not part of the solution to the dilemma of how to meet the costs of health and social care to look again at such demographic drivers?
Indeed. The data from Public Heath England are absolutely stark: from looking at the index of multiple deprivation and the incidence of childhood obesity, we can see that not only is there a large gap, but that that gap is widening. As part of the strategy, the Government must aim not only to lower overall levels of childhood obesity, but to narrow that gap, particularly by looking at measures that will help to do so. I thank the hon. Gentleman for making that point.
The right hon. Member for North Norfolk referred to the need for self-care, and we know that we need a much greater focus on how we can support people to improve their own health. If we are going to raise money for the whole health and care system, there are mechanisms to do so that will also help to prevent ill health in the future. One example is a sugary drinks tax, which could lever money into a very straitened public health budget to put in place measures that we know will help. We need the NHS to get on with prevention, and in my view we need more of the funding that is available to go into saving money for the future.
Order. I let the hon. Gentleman get away with it earlier, because I appreciate that he has not been in the House for very long, but when he uses the word “you”, he is addressing not the hon. Lady, but the Chair. I know he means his compliments not for the Chair, but for the hon. Lady, so he must refer to her as such.
I apologise profusely, Madam Deputy Speaker. We of course have great respect for you, too.
The “Five Year Forward View” plan is already under way, led by the former Labour adviser Simon Stevens. It is looking at reforming heath and care services, and is backed by the funding that the NHS has already said it requires. Does my hon. Friend feel that setting up yet another body would benefit the NHS, or would it be a hindrance?
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”.
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?
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.
My hon. Friend is talking about work that is being done on the problems in the health service and about approaches that can improve it. Does she share my concern that although there are big challenges, there is a risk that a commission such as the one proposed could prove a distraction from getting on with the many things that we know need to happen and the very good proposals in the “Five Year Forward View”? It could therefore be unhelpful, rather than helpful, despite its objective.
If that were the case, it would be a problem. I think that the two things could happen in parallel. We could work towards a consensus about future funding at the same time as focusing relentlessly on what needs to be done in the here and now. However, I agree that if it were a distraction, it would be a problem.
As well as continuing to have a relentless focus on tackling variation, we need to follow the evidence in healthcare. When money is stretched, we must be sure not only that we spend it in a way that follows the evidence, but that we do not waste money in the system. I caution the Minister on the issue of seven-day services, which we have discussed at the Health Committee. If there is evidence that GP surgeries are empty on a Sunday afternoon because there is no demand, and in parallel with that we are being told that out-of-hours services are in danger of collapse because, in a financially stretched system, there are not the resources or manpower to offer both, we must be led by the evidence and be prepared to change what we are doing.
When money is tight, we owe it to our patients to focus on the things that really will improve their care. There must be no delay in making changes when we know that something that has been put in place with the best possible intentions may be having unintended consequences. We must be clear that we will follow the evidence on best practice and value for money, so that patients get the best outcomes in a financially stretched system.
The Government have decided to make Saturday a working day in a regime where a couple who are both doctors can be sent, without a choice, to different parts of the country to practise in hospitals and only have family time together at weekends. Now that Saturday will be a working day, their situation will be virtually impossible. Does the hon. Lady agree that that needs to be considered in case it causes a further leakage of doctors and, therefore, less efficiency in the system?
I have to declare a personal interest here, because one reason why my daughter, who is a junior doctor, has spent a year in Australia is that there are sometimes difficulties with married couples—or, indeed, people in any relationship—being able to work in the same part of the country. There is far more that could be done to help junior doctors, in addition to the contract negotiation about money. However, as I have a personal interest, it is probably best if I do not comment further on that.
I want to draw attention to the role of the voluntary sector, which the right hon. Member for North Norfolk referred to. I pay tribute to the voluntary sector partners in my constituency—bodies such as Dartmouth Caring and Brixham Does Care. Across the constituency, a number of organisations are making a real difference to people’s lives, yet very many voluntary sector organisations are coming under extreme pressure. I could give examples of voluntary sector partners that have had to close, sometimes for the want of very small amounts of money, even though they have delivered enormous value. These are locally-facing organisations.
It was welcome that Simon Stevens gave a commitment to look at making the arrangements for commissioning voluntary sector partners easier. Even though those commissioning arrangements may have been made easier, often the resources are not there to fund such organisations. We need to look again at how we can deliver best value for patients by supporting voluntary sector partners across all our constituencies.
Those are the areas that I want the Minister to focus on in the here and now, but I agree that in the long term, we must look at funding. One challenge in this country—and I think it is a wonderful thing—is that almost all the funding for the health service comes directly from taxation or national insurance. We are almost unique in that. Only two other countries exceed us in that regard. Government funding for the NHS accounts for 7.3% of GDP and only an additional 1.5% is levered in from the private sector.
The choice before us is whether to expand the amount that we raise through charging and top-ups. Personally, I do not support that. The Barker commission did not support it either. Top-ups and charging do not raise as much as people imagine by the time the bureaucracy involved in collecting the money and the unintended consequences that are often found, such as widening health inequalities, are accounted for. I hope that we do not choose to go down that route. The most equitable funding mechanism is taxation.
There is an issue of intergenerational fairness here, as the right hon. Member for North Norfolk said, and we need to consider it. These are hard political choices, which can no longer be ducked. Given the demographic challenge and the challenge of complexity that we face, the alternatives are appalling. The alternatives are to abandon our older people. The pressures that our hospitals face from those who cannot be discharged into the community and those in the community who cannot get into hospital are mounting. We can ignore them no longer.
I call on the Government to consider very carefully working with our Opposition partners at scale and at pace to bring forward an agreement on how we will bring more money into the system as a whole, and in the meantime, to make sure that the money we do spend is spent in the best interests of patients.
It is a privilege to follow Dr Wollaston, who is always open to discussion and debate, and who speaks with great experience. I am sure I speak for many hon. Members in saying that we are all the better for it.
I support today’s motion not because I think we can somehow take the politics out of the NHS and social care. Services that are used by millions of people, employ more than 3 million staff and cost more than £130 billion of taxpayers’ money every single year will always be the subject of political debate and, in my view, rightly so. I support the motion because the NHS and social care face huge challenges—they are bigger now than they were at any point in our history. We must no longer ignore or downplay those challenges and expect services, staff and the families who need care to try to struggle through.
I agree with Norman Lamb that we need a new settlement for health and social care in England, and an independent commission involving the public, staff and experts could play an important role in helping us to achieve that goal. Cross-party support for such a commission is vital. As the former shadow Minister for care and older people, I know that it is extremely difficult for Front-Bench politicians, whether in opposition or in government, to be open about what it will take to ensure that our care services are fit for the future, how much that will cost, where the money will come from and, as importantly, what changes are needed to ensure that our care services are truly fit for the future. Front Benchers’ comments are likely to be leapt upon, twisted and exaggerated and end up as screaming headlines, but in the end it is not the politicians who suffer, but the patients, users, families and staff.
Many important reviews and commissions, and Green and White Papers, from both the Opposition and the Government, have addressed the issue in recent years. In particular, I give credit to the commission on the future of health and social care in England, set up by the King’s Fund and chaired by Dame Kate Barker, from which many of my comments today are drawn.
However, all those initiatives have failed to achieve genuine cross-party involvement and agreement. The commission proposed in today’s motion could help to create the political space and buy-in that we desperately need to agree a long-term settlement for the NHS and social care, whichever party or parties are in power.
The need for such a commission is urgent. As the Barker commission said, given the budget settlement that the NHS has had since 2010, staff have performed remarkably, but the NHS is now struggling to meet many of its waiting time targets: the target for diagnostic services has not been met for 18 months; the 62-day cancer waiting time target has not been met for more than a year; and A&E waits are back to the levels of the early 2000s. NHS finances are also under acute pressure, with a projected year-end deficit already of more than £2 billion.
The situation in social care is even worse. Some 400,000 fewer people are receiving publicly funded social care than received it in 2010, even though our population is ageing. Many of those who still get care are getting less support than they were. More than 1 million people who have difficulties in the very basics of daily living, such as getting up, washed and dressed and going to the toilet, now receive no formal or informal help at all. Last year, the Care Quality Commission found that one in five nursing homes do not have enough staff on duty to ensure good-quality care. The latest survey from LaingBuisson shows that, for the first time since it started collecting figures, more older people’s care beds closed than opened. Five of the largest care home providers predict significant provider failure within the next 12 to 24 months. Three of the larger home care providers have already withdrawn, or signalled their intention to withdraw, from providing publicly funded care.
Those problems are not going away. The NHS “Five Year Forward View” sets out how the NHS hopes to close a gap in health spending that is estimated to reach £30 billion a year by 2020. That will require efficiency savings of £22 billion, and at least an additional £8 billion a year of real additional funding, which the Government have committed to provide, but no health service in the world has achieved efficiency savings of 5% in one year, let alone for five years in a row. As Simon Stevens, the chief executive of the NHS, has repeatedly stressed, the very broad calculations in the forward view depend on social care receiving a decent level of funding, given that cuts to social care inevitably increase pressure on the NHS.
I do not believe that there is a decent funding settlement for social care. The Dilnot reforms, which have been postponed to the end of the Parliament, were not intended to address current underfunding, but to cap the costs of care to individuals. The better care fund, which is welcome, and the new 2% precept on council tax for social care, will not fill the gap either. Indeed, even with the precept, it will be harder for areas with the greatest need for publicly funded social care to cover their costs, because they raise the lowest amount from council tax.
Our population is ageing and demand for care will increase, so the question we face is not whether the money will be spent, but where the costs will fall. Will they fall on collective provision through public expenditure, or on those individuals and families who are unlucky enough to need care and support?
There is no shortage of proposed solutions to that problem. The Barker commission has called for changes to the national insurance system to help increase funding, including removing the complete exemption from employee national insurance contributions for those past state pension age, and raising to 3% the additional rate for those above the upper earnings limit. The commission also proposes restricting winter fuel payments to the least affluent pensioners, so that at least some of the extra costs of care are met by those above state pension age who have the means to contribute. In his recent interview in The Guardian, Simon Stevens called on the Government to consider the housing assets, benefits and other support received by older people to achieve
“more flexibility between current disconnected funding streams for older people, so that at times of need everyone is guaranteed high quality social care”.
I believe we must face up to the vital question of intergenerational fairness. The vast majority of older people have worked hard all their lives in paid employment and bringing up their families. They need and deserve support, and they do not want to end up having to sell the family home to pay for care if they need it, but I know from my own family as well as from my constituency that older people also worry about their children and grandchildren, and how on earth they will be able to afford to pay the bills or go to college or university, let alone have the chance to own their own homes. In my view, we simply cannot ask the working age population to shoulder all the extra costs required to properly fund the NHS and social care in future. I believe many older people would agree.
An independent commission with proper cross-party support that genuinely involves and engages with the public—after all, they are the ones who ultimately fund the NHS and social care—could finally help us to make progress on finding lasting solutions to these inevitably difficult and controversial questions. As the Barker commission says, the challenges we face are clear: more people in need are receiving no support at all; fewer people are receiving publicly funded social care; care home providers are closing in the face of rising demand; companies that provide care in people’s own homes are leaving the publicly funded market; individuals and families who are unlucky enough to need high levels of care continue to face enormous bills; and staff shortages are leading to a rise in neglect as good people are unable to deliver good care, piling further pressure on the NHS, which in turn is likely to lead to declining standards of patient care. That is not a future that anyone would wish for their parents, themselves or their children, but it is the future that is upon us. It is time for politicians on both sides of the House to act.
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.
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.
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.
In my constituency, the borough has a brilliant GP-led out-of-hours system that I would invite the Secretary of State to considering rolling out. I appreciate the idea of a commission, but we already have the vanguards and out-of-hours services, such as the one being led from Teddington memorial hospital, which I believe set the right standards. What can a commission do that we cannot do without one?
I thank my hon. Friend for her intervention because it allows me to elaborate. A couple of years ago, I had a meeting with 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 Dr Mathias.
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.
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.
It is a pleasure to participate in this debate, which I thank Norman Lamb for securing. We know he has a passion for this subject—in our many debates, we always take great account of what he says—so it was good to have him leading the debate. I think that other Members who have spoken—the hon. Members for Totnes (Dr Wollaston), for Leicester West (Liz Kendall) and for Bracknell (Dr Lee)—sat on a social care Bill Committee I sat on in the last Parliament, so we have some knowledge of the subject. I also thank Mr Clegg for kindly letting me go before him. I have a plane to catch, and sometimes these debates can go on.
Those who have spoken have brought a wealth of knowledge and experience to this debate, as will those who have not yet spoken, and I want to add a wee bit of that in relation to Northern Ireland, while commenting on the mainland as well. This year marks the 10th anniversary of the Wanless review of social care for older people. Since the review, there have been attempts, first by the coalition Government and now by the Conservative majority Government, to shift the policy direction and introduce new legislation to optimise healthcare provision and make the system versatile enough to cope with the increasing demand associated with an increasingly elderly population—my constituency has one of the fastest-growing elderly populations. I am going that way myself, but that is by the by.
Despite the welcome efforts by the Government, problems remain. The challenges, not least the financial challenges, are making it more difficult to provide services for the elderly, and these challenges will be around for a while. We will need to learn how to address them as the demographics of the country make service provision for the elderly more challenging. We can foresee these challenges, however, and it is encouraging that the Government recognise that. It is good to see the Minister in his place, and I look forward to reading his contribution. I apologise to him and the shadow spokesperson for being unable to stay for their speeches, as I have already said, but we are always encouraged to see the Minister on his feet, given his interest in this subject.
The importance of an integrated health and social care system is widely accepted. We have seen exciting innovative developments in Northern Ireland, where the former Health Minister, my party colleague Edwin Poots MLA, launched the “Transforming Your Care” programme, which was continued by the next Health Minister, Jim Wells, and now by the present Health Minister, Simon Hamilton. The initiative seeks to move care for elderly people from hospital into their homes wherever possible. That is the focus and goal of the strategy. Not only does this provide care closer to home and a nicer experience all round for the patient, but it has the potential to save the NHS and the social care system a lot of money in the long run. The Minister might like to note that programme as an example of what is possible. If it was replicated nationwide, it could save a lot of money in the long run and make for a more personal social care experience that would benefit the elderly.
With the financial challenges of austerity in our public services, we need to come up with innovative ideas to modernise our health and social care system and offer a first-class service in a financially difficult environment. Whether we like it or not, finance is part of the system we have to work within. The importance of integrated health and social care is widely recognised by health professionals and charities. We now need to turn this into a reality. Adult social care needs to be on a sustainable financial path if we are to maintain a world-class health and social care system, during a time of changing demographics, and we need to make sure that the pressures on the system are properly understood.
The integration of health and social care is crucial to provide a patient-centred service that makes the best use of resources. With care and caution, and with movement in the right direction, it is possible to do more with less. Innovative approaches such as the “Transforming Your Care” initiative are examples of how we can modernise the public sector to deliver real results with a tighter budget. Health and social care need to be seen as equal partners and provided with the necessary resources to deliver high quality services that actually serve the people. “Resources” does not necessarily mean increased funding. We know that we are living in tough times financially, and while funding is always desirable, success should be judged on results rather than the bill for the investment.
Social care is important in its own right. The Local Government Association claims there is a continuing lack of proportionality between additional funding for the NHS and adult social care. While much of the funding for the NHS is front-loaded, additional resources from the better care fund will not be available until 2017. Can the Minister say whether it is possible to consider implementing the better care fund on a shorter timescale? We will not be facing problems down the road in 2017; we are facing them right now, as Members have said and will continue to say. The Government need to make a greater effort to address the issue and ensure that the social care sector is adequately funded and resourced as we seek to make the appropriate reforms to make it a versatile and modern service that delivers for the people that it needs to.
I rise to support the motion, and I hope in my contribution I will be able to explain why. I should first declare my interest as a licensed medical practitioner, albeit one who is in awe of my colleagues in the Chamber who regularly see patients, which is something I thoroughly commend. I think most of the people out there—apart from those who write for some of the more scurrilous parts of our national press—appreciate the fact that there are people in this place who are still engaged in medical practice of all sorts. It makes us relevant, it makes us current and it gives us some authority, as we have heard already today, when we talk about areas of expertise.
There are some omissions in the motion, however. I suspect that its magisterial generality is probably by design; nevertheless, it fails to mention public health directly, which is an important part of the piece. If we are to consider the entirety of health and social care in this country, we need to talk about public health, which I think, if I am honest, has been neglected by consecutive Governments, largely because nobody fully understands what public health is. There is not really an accepted definition of “public health”. It means many things to many people. Some of us still believe, I suppose, that it is a rather old-fashioned thing, to do with the pre-1974 vision of medical officers of health, who dealt exclusively with infectious diseases. It is much bigger than that. Public health pervades all elements of the public service and needs to be addressed head on if we are to deal with some of the pressures we face in the acute sector, as well as ensuring that we meet some of the imperatives that apply to health in this country, which, as my hon. Friend Dr Lee has pointed out, should mean being focused pretty much exclusively on healthcare outcomes.
Norman Lamb mentioned outcomes almost in passing. Let me gently suggest that outcomes, mortality and healthcare experience throughout life are absolutely what we must be remorselessly focused on, and there the story is not a particularly good one, as the Commonwealth Fund made clear. Of course, the Commonwealth Fund report is quoted selectively by those who want to say that our system is the best there is, and that is fine: I trained in the NHS, I have worked in the NHS and I would be reliant on the NHS, so I defer to nobody in my admiration of the national health service and all that it stands for and does. However, it is naive to suppose that it is perfect in all respects, which is what I suspect really lies at the heart of this motion, as we look to the distant future.
The Commonwealth Fund says that outcomes in this country are not good, and I think our people deserve much better. I want outcomes in this country to be among the very best in Europe, not, frankly, in the lower quartile, as is too often the case with common forms of disease. We are betraying those who put us here if we demand anything less than that. The motion is relatively modest, because it tries to work out how we will square the gap towards the end of this decade. I think that, in the minds of those who wrote it, they are worried about the £30 billion—that will apply in five years’ time—but we are perhaps not looking forward to improve on where we are at the moment. There is too much talk, really, of marking time. The concern we have about the gap in funding makes us think that what we have now is good enough, but frankly it is not. We need to be much more ambitious, as we look ahead, about how we improve our health service right across the piece, including public health, to ensure that our health outcomes approximate the very best in Europe and not, in too many cases, the very worst.
Liz Kendall mentioned the Barker report, and she was right to do so. The Barker report was useful. The hon. Lady will not be surprised to hear that I did not necessarily agree with all its conclusions; nevertheless, Kate Barker produced some figures that were useful. She pointed out that spending on health in this country is less than in some of the countries with which we can reasonably be compared. She talks of Canada, France and the Netherlands, and suggests that by 2025 we will need to spend a great deal more of our national wealth on health and, by implication, social care, and I agree with that. She suggested 11% to 12%, which, given the demographics, is probably reasonably modest.
The dispute is about how we would deal with that, because £30 billion does not really come close, given what is happening. It does not come close even if we stand still, let alone seek to improve outcomes in the way I have suggested we must. The question then is how on earth we close the gap—whether we do it through general taxation, national insurance, some sort of hypothecated system or a mutual, as applies in France, for example, or whether we go for co-payment. I suspect there is pretty much a consensus in the House that we can discount some of the options fairly easily, but it is important that the commission that the right hon. Member for North Norfolk seeks to set up should examine all options, even if there is a general understanding that some of them will not be palatable, for a variety of reasons, be it fairness, efficiency or not being geared sufficiently well to the lodestar of outcomes. Nevertheless, we need to examine all options if we are to do this for the very long term, as I believe is the intention.
My hon. Friend the Member for Bracknell was right to focus on structure—something on which I believe there is a need for cross-party discussion and, I would hope, consensus. It is all very well talking about the NHS estate in general, but although what he described from his personal experience was terribly brave, I know from my personal experience that when that is translated into the specifics of our constituencies, for many Members it becomes extraordinarily difficult. It is the local that inspires many people in their love of the NHS. They would love to have their local hospital and local services that they identify with. When it comes to talking about the NHS estate, what we are really talking about is change.
Sometimes change is great locally, because it means a spanking new hospital, but too often it means at least a perception of loss, and people feel that acutely. One of the first things I did when I was elected here 15 years ago was to introduce a ten-minute rule Bill called the bed-block Bill. I find to my horror that, 15 years on, the issues remain. In essence, my Bill was designed to promote community hospitals—cottage hospitals. I had four in my constituency at that time and I felt that each was, for different reasons, under threat. I was a strong advocate for them, and the bed-block Bill, which was designed to promote them and unblock acute hospitals, was duly presented and, like all these things, duly drifted into the sand.
The issue remains relevant, but at the higher level we also need to talk about whether we are right-sized for acute or district general hospitals, and whether we should have these relatively small institutions across the country—far more than there would be in France, for example—offering, or attempting to offer, pretty much the same stuff. An example would be gastroenterology. The British Society of Gastroenterology has produced reports on this issue, pointing out that in many district general hospitals people are not guaranteed to have out-of-hours upper gastrointestinal endoscopy services available to them. I put it to the House that in the 21st century, not being sure that someone is going to be scoped if they have an acute upper GI bleed is simply not acceptable. That is bound to translate into poorer outcomes for a relatively common set of conditions.
It seems to me that the only way we can achieve better outcomes in that kind of situation is to think about whether we need to move towards regional and sub-regional specialist centres rather than continue with the pretence that we can mirror those services in each one of our district general hospitals. More commonly, people talk about stroke and heart attack—and the same applies. It is simply not the case that people will get the same treatment regardless of the hospital they go to.
This is professionally driven. It is the specialists themselves who are saying that we need increasingly to specialise. The day of the generalist is pretty well coming to a conclusion. In order to get that level of specialisation, we must have critical mass, and the only way of achieving that is by having a smaller number of what might be seen as “clinical cathedrals”—large centres offering highly specialist services, geared towards improving outcomes.
The downside is obviously where the cuts then come. Right-sizing the NHS estate inevitably means some will gain and some will lose in the process—in terms of the immediacy of services. Nobody wants to have to travel miles and miles to access services. We get complaints from our constituents about this all the time. There is a process of education for the public to go through. They need to make a choice. They have either immediacy of service just down the road to an institution that will give them sub-optimal care, or better outcomes of a sort that might reasonably be achieved in a regional or sub-regional centre. That is the choice.
Part of the work of the commission suggested by the right hon. Member for North Norfolk will encompass that work of education. That is one reason why, however, I think his 12-month timeframe is very ambitious. I would certainly not want to have a commission reporting in five or 10 years’ time, but the right hon. Gentleman will have to be more realistic about how long this will take if it is going to be an iterative process.
At a lower level, we need better step-up and step-down care. That is at the heart of our ability to unblock some of our acute centres. It is important to look at this issue again. The reason why community hospitals went ever so slightly out of favour relates to the costs of the services they provided, which occurred because the case mix was all wrong. Too often, this became a convenient way of relieving social pressures, admitting people ostensibly for medical reasons to a medical bed when those people primarily needed social care. It always comes back to social care, and if we put people requiring social care into what remains a medical bed, it will of course become impossibly expensive. That is why it did not add up. I am afraid that the onus is on the practitioners and the controllers of those places—general practitioners—to ensure that the case mix is correct. If we do that, community hospitals will become both effective and efficient.
One issue that has certainly come to light in Coventry when we are talking about bed-blocking—it is another factor associated with it—is that people cannot be released from hospital until they have a social worker arranged to look after them outside. Social workers are normally employed by the local authority, so if there is a shortage of social workers, the beds will be blocked again—at an additional cost. I think the commission should look at that.
The hon. Gentleman is absolutely right. It comes back to the issue of integrating health and social care. We have to say that some progress has been made in that respect.
At this point in my contribution, let me make it clear—despite the fact that this is intended as a non-partisan initiative—that I feel very strongly that without a strong economy, we will not make any progress at all. Improvement requires the sort of economy to which we aspire—not one such as has been sustained in Greece, Spain and Portugal. If we look at those three countries, whose healthcare systems were not comparable to ours before their respective crises, we should note what has happened subsequently, as their Governments have struggled to control their economic situation by making huge cuts. We need to be very aware that we have avoided that in this country. Without a strong economy, talking about improving public services across the board—and particularly in the huge area of healthcare—is, frankly, pretty pointless. There will not be the resources to sustain what we have at the moment, let alone the 12% increase suggested by Kate Barker in her report. That is fundamental.
I want to give credit to Ministers for sustaining the Stevens plan. We have heard some contributions today suggesting why that the plan might not turn out to be sufficient, but finding that sort of money at a time of austerity is a huge achievement, which should be acknowledged. I was proud to stand only a few months ago on a manifesto that supported the £8 billion spend. That allows us to have a service that is at least sustainable, notwithstanding my fears for the future and the inadequacy of our plans at this point in time, and should take us through to the end of the decade and beyond at a time when local government funding is being cut. That means that the pressure on social services, which was not anticipated by Simon Stevens, applies, while we also face further pressures on the public health budget, too. Together, those pressures will mean having a deficit by the end of the decade that will need to be addressed. Beyond that, looking to 2025 and even further as Kate Barker has done, we need to determine how to find the extra funds that she feels are necessary, notwithstanding the dispute about where the funds might come from. I imagine that these issues will be examined by the commission proposed by the right hon. Member for North Norfolk when it is set up.
Let me finish with a few more small points about public health. Among my distinguished medical colleagues in this place, I believe I am the only one with a post-graduate qualification in public health and the only one who has done a job with a significant public health input. I have a bit of a soft spot for this discipline, and I hope I understand some of what it is about.
“Healthy Lives, Healthy People” has, in my view, been a success. It has set public health on the right track, handing back to local government a function that it arguably should never have lost, and setting up Public Health England, which I think has done a good job on the whole. I suspect that the Minister, who will answer the debate shortly, will have fallen off his stool when he read the King’s Fund report a little under a year ago, which essentially said the same thing—that public health appears to be on the right track in this country at the moment and that the changes introduced in the White Paper five years ago have largely been successful.
However, there is absolutely no room for complacency, as I am sure the Minister will agree, particularly when we have healthcare indices on areas such as our rate of teenage pregnancy. Although it has improved, it remains among the very worst in Europe. We do just slightly better than Bulgaria, Romania and Slovakia. Nobody here would be satisfied with that, I hope, and while we have public health indices as disastrous as that, there is no room for complacency.
One of my worries about what has happened over the past several months is that we appear to have changed from a model in which healthcare is pretty much exclusively funded through general taxation—that is to say, national insurance and income tax—to one that is partly funded by local taxation, with all that means when it comes to cuts in hard times. In my view, the sort of public health interventions that are having bits shaved off them at the moment are not discretionary, but essential parts of healthcare.
We can all come up with wonderful figures to show why we need to invest in healthcare. By and large, public health investment saves money in the long term, but the potential for public health intervention prevention services to have a real impact on people’s lives is truly enormous. Very little of it is going to happen overnight, so it will not show up on people’s metrics—certainly not within an electorally obliging timeframe—but they nevertheless remain.
If we are setting up a commission to look at how we do healthcare in the very long term, we most certainly need to focus on public health. We need to ensure that resources for public health are maintained and sustained. Those resources are not discretionary, but an essential part of what we should be doing for healthcare in this country—although I accept that when it comes to making economies, it will always be tempting to shave bits off public health services rather than cutting an acute service, which would be much more obvious to the public.
I support the motion, and I congratulate the right hon. Member for North Norfolk on tabling it. He is right to say that party politicians meddle with this national religion of ours, the national health service, at their peril. If we accept that we face huge challenges in the long term, beyond 2020, it is important that we not only engage in a national debate so that we can address some of the difficult issues that we have discussed this afternoon—the estates, for example, and how we pay for healthcare—but try to gain that usually impossible goal of securing some level of cross-party consensus.
I join all those who have spoken so far in congratulating my right hon. Friend Norman Lamb on securing the debate. It concerns what is undoubtedly one of the biggest questions that we face as a country, as a Parliament, and as a political class: the question of how we can square the circle of an ageing population, and how we can put the NHS on to a sustainable financial footing.
My grandfather was editor of the British Medical Journal from the time when the NHS was founded until the mid-1960s, and I suspect that if he were around today, he would say that the challenges currently faced by the NHS would be entirely unrecognisable to his generation of medics.
It is right that my right hon. Friend is pushing us all to try to sketch out solutions on a cross-party basis. It could be said that he and I tested the virtues and pitfalls of cross-party working to destruction—some would say, unfairly perhaps, to self-destruction—in the last Government. Notwithstanding that experience, however, I think that issues such as pensions, long-term infrastructure investment, Europe, decarbonisation of our economy and, in this context, the sustainability of the NHS are not susceptible to single-Parliament, single-Government, single-party solutions. I therefore say, “All power to my right hon. Friend’s elbow”, and I hope that the Government will look kindly on his proposal.
I intend to dwell on an issue which I hope the commission will subject to real examination, namely the role of mental health in the NHS. We have come a very long way. I remember standing, eight years ago, a little way in front of where I am standing now, shortly after becoming leader of my party, and asking Gordon Brown a question about mental health during Prime Minister’s Question Time. I recall that I was heard in what was almost a slightly shocked silence, because at that time raising the subject of mental health was considered to be rather “novel” and brave. The extent to which the debate has advanced since then is fantastic.
There have been truly moving debates in the Chamber, when a number of our colleagues have spoken for the first time, very openly and movingly, about their own struggles with mental health conditions. Society and the media now talk more comfortably about mental health, and a barrage of celebrities have lent their considerable weight to that. The debate, the rhetoric, and the awareness of mental health as a major challenge that affects one in four of our fellow citizens have been transformed in recent years, which is a wonderful development. We have lifted the lid, lifted the taboo, and lifted the slight foot-shuffling embarrassment that used to overshadow the subject of mental health, which is a great step forward.
I am immensely proud of some of the things that our coalition Government managed to do in pushing the agenda forward and putting mental and physical health on the same legal footing. My right hon. Friend and I worked together closely on the introduction of NHS waiting time standards relating to mental health, which had existed in relation to physical health issues for a long time, and took many other important steps.
What worries me is the growing gap between the rhetoric about mental health and the reality of what is happening on the ground. There will always be a gap, because rhetoric is easier to deliver than change on the ground; there will always be a time lag between the moment when the debate and the policy prescriptions alter, and the moment when that change percolates down to the ground. However, I think that this gap is becoming dangerously wide. That is, of course, very bad for the many patients with mental health conditions who are not being properly treated, but I also think that if we do not address it soon and follow up the rhetoric with action, there will be real cynicism about what the political classes have meant during the journey that we have made over the past few years towards talking more comfortably and openly about mental health issues.
I know that many Members are already familiar with the scale of the problem, but I think it worth illustrating that scale with a couple of facts. Mental health makes up 23% of what is somewhat inelegantly described as the UK disease burden, but it accounts for only 11% of NHS spending, and the majority of people with mental health conditions still go untreated. On average, just 30%—less than a third—eventually gain access to treatment. If that applied to any physical health condition, it would be seen as a Dickensian state of affairs requiring urgent action. I hope that the cross-party commission will think carefully about the step change that is required in the organisation, because support and funding for mental health will be critical to its considerations.
Let me now invite the Minister to focus on three issues, in the short term and in the slightly longer term, because I think that there is currently a blockage that is preventing the rhetoric from being translated into the kind of action that most Members on both sides of the House want to see.
The first issue is that, last year, just before the last Budget of the coalition Government and the general election, I announced, on behalf of the Government, £1.25 billion in funds to transform what could be described as the Cinderella service within the Cinderella service, namely child and adolescent mental health services. It was the most ambitious blueprint ever set out by any Government to transform the service and, indeed, to fund it properly. As the Minister will know, that £1.25 billion equates to roughly a quarter of a billion pounds, or £250 million, to be invested in child and adolescent mental health services per year. Over the last financial year, however, the amount invested has been not £250 million but, I think, £143 million.
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.
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.
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.
I speak in this important debate as a nurse who is still working in the NHS, although not as much as I would like. I welcome the sentiments from both sides of the House about working towards a much more cross-party way of discussing the NHS and health and social care, but I am nervous about setting up a commission, because much of this work has been done already and what we need to do is roll the solutions out, not discuss the issues again and rehearse old stories. I speak as a nurse now, not a politician. My feeling—and the feeling of a number of my colleagues in the NHS—is that the interventions by a series of Governments over decades have got the NHS to where it is now, and if healthcare professionals and social care managers had been allowed to get on with their job we would not be in that situation.
No healthcare professional would agree that health and social care should be as divided as it currently is. If we had been allowed to get on with our job many years ago, that gap would be a lot smaller. That gap was created when the NHS was invented. There was a natural gap between what was deemed healthcare and what was deemed social care. That was compounded by the Nurses Act 1949 which clearly set out the view of what a nurse did, as opposed to what social care did. Over time, with the invention of various bodies and structures, both national and local, those rigid boundaries between health and social care have become stronger.
Funding streams have emerged, with NHS funding being protected and ring-fenced and increased over time. Social care has not had that luxury. Its funding is mainly given to local authorities, which have had to merge it with other budgets and also make cuts. They have not ring-fenced it. Many hon. Members today, including my hon. Friend the Member for Totnes
(Dr Wollaston) and Dr Whitford, have eloquently described how that has been a penny-wise and pound foolish approach, in that much of the preventive and public health work has been cut, with the NHS ultimately picking up the bill.
During my training as a nurse, we were taught an holistic model of care. We were taught that the patient’s physical care could not be separated from the emotional care, the spiritual care or the psychological care. However, when we practise in the real world, we are forced into separating physical care from mental health care and social care. When I was working on a ward, I would never question whether something was a nurse’s role or whether someone else should be doing it. If I was bathing a patient, getting them up in the morning or walking them in the hospital grounds so that they could get some fresh air, there was never a notion of “Is this the nurse’s role? Is this really healthcare?” It was all about looking after the patient as a whole.
As a result, when I was feeding someone, I was not only feeding them but looking at whether they had taken their medication that day, at whether they were eating, at whether they were perhaps a little bit more confused than they were yesterday or last week, and at whether there was an infection brewing. This is not just about ticking a box to say that that patient has been fed and had their medication. It is about holistic care, but the systems that are in place today do not allow us to practise that. In a hospital, we have the freedom to take on what is deemed a social role, but in the community we have no choice at all.
I know that things are changing, but we still see elderly patients who are struggling to stay at home, and they could have up to five visits a day from five separate people, and from five different people the following day. A nurse will go in to administer medication or to look after a catheter or a stoma, then someone else will come in to make a cup of tea or heat up a meal. There is no continuity of care, and there is no holistic care. That is simply because health budgets are run by the NHS and social care budgets are run by local authorities. It is no one’s fault; it is just the way that this has emerged.
I really welcome the work that has been done on NHS England’s “Five Year Forward View”. I also welcome the work of the Barker commission, which has not only identified the problem but come up with solutions and said that funding must be ring-fenced and combined. We cannot continue with separate funding for healthcare and social care. If we do, it will be a false economy and the constant divide will do nothing for patients and carers.
I welcome the notion of a commission and of cross-party working, but I am really nervous that we could undo much of the work that has been done. My local clinical commissioning group is doing fantastic work to ensure that the local authority and the local health services are starting to work together in a combined way. We hear a great deal about how hard it is to get social care packages together, and that is often why elderly patients get stuck in hospital. That is not always because of funding; it is often because we cannot get people to do the jobs. That is because there is no real reward in going in and having 15 minutes to make someone a cup of tea. It would be so much more rewarding if that person could have half an hour with the patient, in which they could help them to take their medication and not only make them a cup of tea but ensure that they drank it. However, the current system does not allow that to happen.
My nervousness about the commission is that we might undo many of the recommendations that we know need to be carried out, and that we could still be left with this divide between healthcare and social care a year down the line. The other cause of my nervousness is that a national one-size-fits-all model will not work. What works in my rural community of Lewes will be very different from what is needed in a London borough, for example. I therefore welcome the idea of local CCGs identifying what action is needed to merge health and social care and co-ordinating what will work best in that place.
Speaking as a politician, I urge other politicians to take a step back and allow health and social care professionals to take a lead on this. We have identified what the problems are and we have identified many of the solutions. We are committed to joint funding, so let’s get on and do it. Our role as politicians is to lobby if that funding does not come through, to enable healthcare professionals to get the resources they need. Our role is also to identify examples of good practice that could be rolled out in other areas where things might not be working so well. It is not our job constantly to debate what the issue is. We know what the issue is and we know what the solutions are. We just need to get on with it.
I welcome the comments made by my hon. Friend Dr Lee. I do not dismiss the need for a commission. A commission on health and social care is a great idea, but I think the timing is wrong. I think we have missed the moment. We need to have a cross-party debate about the structure of the NHS and about perhaps having fewer specialist units. Cottage hospitals were mentioned earlier. There are problems getting people out of hospitals and preventing them from going into them in the first place, but holistic care would enable them to stay in their own home. There also needs to be a step in between being at home and being admitted. We have moved away from that, at a cost not only to patients but to those who work in the healthcare sector.
I shall not repeat much of what has been said this afternoon. I am very supportive of cross-party working; I believe that we need to take the NHS out of the game of political football. I welcome all the comments that have been made today; I do not think that anyone has said that health and social care should not be combined either in practice or in relation to funding. However, my fear is that another commission would simply delay the good work that is starting and that needs to be carried on. I thank Norman Lamb for bringing forward today’s debate. I hope that we will not be standing here again in five years’ time, debating the matter further.
It is a pleasure to follow Maria Caulfield. We have heard from a few doctors this afternoon, so it has been good to hear the perspective of someone who worked as a nurse in the NHS. Judging by her comments this afternoon, I am sure that she keeps closely in touch with it.
I agree with the hon. Lady that much good work is being done in different parts of the UK on providing health and social care. However, we also know from the data and outcomes that that is not uniform. Some doctors, nurses and other health professionals are willing to rise to the challenge of putting public health on the same standing as treatment and of providing innovation in mental health services. Like all professions, however, it contains some who are not so willing to embrace change. They might, for different reasons, be stuck in a way of working that is not providing the outcomes that their patients want.
The hon. Lady rightly cited the example of people in our communities who need social care services and who are getting three, four or five visits a day from different people, all of whom feel that they have a role in providing for those individuals. When I listened to her telling that to the House, it took me back about eight years to when I went out shadowing some community matrons in my constituency. I spent time going out on the rounds with them and finding out what they did. The post of community matron was created to provide better links between hospitals and the support in the community. Each of them had a caseload of patients, all of whom had to have five or more conditions that were preventing them from getting the most out of their daily lives. Some of them were pensioners; some were not. Those women—the people I shadowed in my constituency were all women—formed the link between what was happening in the GP surgery and what was happening in hospital. If one of their patients had a fall, for example, and ended up in A&E, the people in A&E would look to see who their community matron was and get on the phone to them. Before the patient had even had their treatment in hospital, the hospital would be working with the community matron to arrange how they would be looked after outside. Sadly, all these years later, those community matrons no longer exist. We have to address the fact that some good ideas start off in the NHS but are gone in some years, for whatever reason, perhaps because they are used as political footballs.
Today’s motion is not about stopping the good things that are happening. A commission would not paralyse us and stop us continuing the good work in the NHS and the good parts of the forward view. When it comes to health and social services, five years is the blink of an eye. We need to be thinking about not just 10 but 20, 30 or 40 years down the road. What can we do today to determine what NHS and social care should look like in 50 years? That is the big challenge before us and it is why a commission would enable us to take some of the politics out of the debate and allow us to move forward together.
I was out visiting a GP’s surgery last Friday in the constituency of my hon. Friend Simon Kirby, which borders mine. There are still community matrons there. The matron on duty when I was there prevented a 90-year-old chap from being admitted to hospital for the weekend because she was able to fast-track a social care referral and get some help out to him on a Friday afternoon. A national roll-out does not always fit with what is happening locally. Some really good work is still happening at local level.
I hope that I have not given the impression that good work is not happening and good services do not exist. In my constituency not long ago, our district nurses were supporting treatment and care in the home for people who had problems with their legs and needed them bandaging. For a couple of months, those patients were incredibly nervous because they had heard that the nurses would no longer come to their home and they would have to go to the GP’s surgery for bandaging. Fortunately, it did not work out like that, but the stress about the future of their treatment caused those people a problem.
We can all talk about things that are working or not working in our constituencies. We can all point to good practice. It is a frustration of mine, not just in health, that best practice is not the driver for good practice everywhere. I do not know why we keep reinventing the wheel. We have to look at the bigger issues, and that is why I commend Norman Lamb, my hon. Friend Liz Kendall and Dr Poulter for securing the debate today.
We have an important role in this House. It is not only about holding this or any Government to account; it is about shining a light on the social problems that our country faces and offering solutions that are not just for one term of a Parliament. The motion helps to highlight an ongoing generational problem and proposes a path to find some sort of solution.
The UK is an ageing society. We are a society growing older. Looking around the Chamber today, I am tempted to say, “Put your hand in the air if you are under 50.” Five.
I think we are talking about a minority. We are here as politicians, but also as citizens with families and living in our communities as we discuss the policies and politics that will touch people’s lives. We are living longer, and that brings a lot of joy. We often talk about the things that are bad, but there is a lot of joy about living longer, too. It is not uncommon today to meet older people who are great-grandparents yet still active enough to look after their great-grandchildren.
The current generation of older citizens share some of the problems of previous generations. There is still poverty, and loneliness is ever more common, as those living longest outlive their lifetime companions, and as families no longer live in close-knit communities. But this generation are different from previous generations. They are less deferential—and rightly so. They expect more from life. They are not waiting for the grim reaper—they have lives to lead. Many will live 30 or more years in retirement. Not so long ago, that was half a lifetime. This generation rightly demand more. They are less likely to accept just what the state offers and lump it. If the options for their retirement, for their living arrangements, for their social care or other assistance are not to their liking, they will voice their protest. And they do so, as a generation who overwhelmingly own their own homes and want to remain independent, within four walls to call their own, for as long as possible.
Madam Deputy Speaker, this debate is timely because, less than a year on from the general election, none of the big, long-term problems facing the NHS, in particular the integration of social care and the fair funding of social care, is any closer to being resolved. We know that the NHS has always been an election issue, and we should not apologise for that. Nor should we expect that to change in the short term. We know that in the last election and the one before, the problem of funding social care, so that families do not always lose their homes to pay for long-term social care, has been an election issue. I recall in 2010 a Conservative billboard with a tombstone and the message, “Now Gordon wants £20,000 when you die. Don’t vote for Labour’s new death tax.”
I am not going to sound purer than the driven snow on this. Our party has also upped the ante on some of these issues. Yet today, one in 10 of the public can face bills of over £100,000 for social care. It makes a bill of £20,000 deferred seem a pretty attractive deal. But so nervous are Governments of this issue that this Administration have deferred the introduction of a cap on total costs from 2016 to 2020. And the cap is only on costs over £72,000. I do not want to spend time on the merits of the Government’s proposals. Suffice it to say that they are complex. They rely on local authority assessments. They create different thresholds and ceilings for contributions. Coming forward with proposals that are fair to all yet meet need, without unduly penalising those who saved for a lifetime, is not easy; it really is not, and the problems will not be solved by a five-year plan.
The challenge remains to put in place a social care funding system that is fair to people of different income levels, a system that can be embraced by all parties and, crucially, by successive Governments of different colours. For these reasons, I believe that the motion is so right today. We need an independent commission for those big long-term decisions. The same problem applies to some of the other challenges facing the NHS that colleagues have raised today. They include securing long-term funding for the NHS, particularly when successive Governments are rebalancing the Government’s income and expenditure to reduce and then eliminate the deficit and meeting the long-term challenge of demographic change, of the rising sophistication and costs of new medical technologies and of new pioneering treatments. At one and the same time, the potential for new and radical treatments is almost unlimited, but the budgets to meet them are not.
Added to that, as we look at how we devolve services in England, to which I am not opposed, we need to think about where the accountability lies, and whether there are the checks and balances to ensure that there is not only quality, but value for money. As a relatively new member of the Public Accounts Committee, I can already see that we do not have the accountability structures in place to ensure that those providing services regionally and locally are operating transparently.
When I was first elected in 1997, half the buildings used by the NHS predated its existence. Financial pressures had led to a huge backlog of investment in NHS buildings. Between 1997 and 2010, the Labour Government invested record amounts in new NHS buildings—from major hospitals to modern, multi-purpose health centres, walk-in centres and GP practices. One of the ministerial jobs that I was most proud to hold was public health Minister, because one aspect of providing better buildings in the community was moving services out of hospitals and closer to people. That was especially important in areas where health inequalities were evident, because it was a way of ensuring that the people there, who are often the most vulnerable and least assertive, could see in their community the services available to them.
If we are to plan for future investment, we need consensus, because while those buildings were welcomed, not least by NHS staff and patients, their private finance initiative funding has always remained contentious. Planning for sustained investment requires a consensus that gives future Governments—and, dare I say it, this Government —the courage to take big decisions. Only a truly independent commission with real expertise and weight will begin to unpick the real costs, options and pinch points facing the NHS, and deal with the hard choices about how we meet the future of health and social care.
Such a commission can also play a role in involving staff and the public. We need a grown-up discussion outside this place—we need one inside, too—about the challenges ahead. The public and NHS staff need to be involved, so that they can be helped not only to make decisions, but to understand the responsibilities that they might have in supporting a new NHS and social care service. Such a process would represent a worthwhile investment of public money if it could achieve a social contract between the parties and the British people to provide a new secure base for the future of health and social care.
This is about change. Today’s NHS bears no comparison with that created some 60 years ago. We need to face up to change and importantly, as part of that, to help people to cope with change, because that can be frightening. We want a better and stronger NHS, but let us also have a smarter NHS. I hope that Government and Opposition Front Benchers will respond positively to the proposal.
It is an honour to follow Caroline Flint, my hon. Friend Maria Caulfield, Mr Clegg and other Members who have spoken. Excellent points have been made in every single contribution to the debate. One reason why I support the motion is that in my first contribution during this Parliament I said:
“Let us use the five years of this Parliament to set up a cross-party commission to look at health and social care for the next 20 to 30 years.”—[Hansard, 2 June 2015; Vol. 596, c. 524.]
I believed that then and I believe it now.
A substantial reason why I believe that comes from my experience representing Stafford since 2010 and my involvement in the community in the years before that. In the previous Parliament, there was a tremendous coming together of people from all parties in Stafford so that we could protect our health services and respond to the serious problems that we faced. We made proposals to the Government, as well as arguing with them and opposing some of their ideas, but we wanted to support our area’s health services. It was a privilege to be part of process in which people from all the main political parties and none were putting aside their differences and working together. I know that a similar thing happened in other constituencies, but I was especially grateful that that happened in Stafford, given what we had been through.
Another reason why I strongly support a commission—or a commitment, or a way of bringing us together—is that there are incredibly important issues to decide. My hon. Friends the Members for South West Wiltshire (Dr Murrison) and for Bracknell (Dr Lee) made important points about the issue of specialism and generalism. There is a danger of going too far down the specialist route and thinking that everything must be in a specialty. According to the Royal College of Physicians, this country has something like 62 specialties, yet some of the royal colleges want to go even further. Indeed, I understand that there is a desire further to split up cardiology into interventional and non-interventional cardiology, although I hope that that is not the case.
By contrast, the RCP pointed out that in Norway there were just over 20 specialties—it is a more generalised system. Whereas I agree that specialties need to be concentrated in the way that my hon. Friends have suggested, we must not cast out general medicine. We must not cast out those who would like to work in a more general way in a more localised setting. For many people that can be a more satisfying route, seeing the broad range of health, rather than one increasingly narrow part of healthcare.
Does my hon. Friend agree that one solution might be to develop further the GPs with specialist interest model, which was started some years ago but, if we are honest, has never really found its place in our NHS?
That is an excellent point. I declare an interest, being married to a GP. Many GPs are already doing that—many have specialist interests. Perhaps there could be a specialism of generalism, if that is not a contradiction in terms—the idea that it is possible for someone to say, “I want to practise my medical career in a smaller place where I do a wider variety of tasks, but I have the knowledge to recognise the limits of my competence and when to refer onwards.”
I welcome the motion and the commission, although I will suggest some boundaries to it. The points that have been made about not going over old ground and not making the commission’s remit so broad that it is of no earthly use are valid. The Barker report has done some tremendous work in that respect and I will come on to that. There are other reviews going on, which I am sure have not escaped Members’ notice. The maternity review under Baroness Cumberlege, to which I have made a submission, is extremely important.
Here again, we see the contrast. On the one hand, we want the best possible care for mothers, pregnant women and their children when they are born; on the other hand, women want to be as close to home as possible. In some cases, and with midwife-led units, which we have just got in Stafford to replace our consultant-led unit, that can work for a limited number of women, but probably only about 30% of women will be able to go into such units; 70% will have to go further afield. We need to think about whether that is the right model. In the UK the largest unit, I believe, is in Liverpool, with more than 8,000 births a year. In Germany the largest is the Humboldt in Berlin, with about 4,500 births a year. Is there something to learn from that model, from the French model, from the Dutch model? I am hoping that Baroness Cumberlege’s report will show us that and give us a clear path for maternity and newborn care in the NHS.
I welcome the Government’s commitment to fund the five-year plan. That was not an easy step to take, but it was extremely important. As far as I can see, funding has been increased even since the election, but as others have said, it is a very challenging plan. Nobody has ever managed to achieve £20 billion or £22 billion of savings and we are already seeing some potential problems with that. I was lobbied yesterday by community pharmacists, who are seeing potential cuts in the sums allocated, which may result in the closure of pharmacies in the future. Of course, reform is needed, but the Government need to look carefully at that area.
I welcome, too, the additional money for child and adolescent mental health services. I chaired a roundtable of mental health providers in my constituency a couple of weeks ago. The additional money, the first part of which is just coming through, was welcomed and should plug some of the gaps in that service, although there remains an awful lot to do, as the right hon. Member for Sheffield, Hallam so eloquently pointed out.
I shall focus on two areas—integration and financing. At present the two main acute hospitals serving my constituents, the Royal Stoke and the County hospital in Stafford, are full. As other Members have pointed out, this is at a time when we have not had a major flu epidemic or abnormal winter pressures. We have something like 170 beds at the Royal Stoke with patients who should really be out of hospital but cannot leave, and in the County hospital we have around 30 beds. Of course, that means it becomes more difficult for their A&E departments to meet their targets.
I must say that the people in those departments are doing a great job. I urge Members to watch the little online video recorded in the Royal Stoke by The Guardian and see just how hard they are working in a hospital that this time last year was going through a very difficult time. It shows exactly what we are talking about, with people working long shifts and putting patients first, as they are in the County hospital and, indeed, in hospitals up and down the country.
We clearly have a problem in getting people out of hospital. As Members have said, that was raised 10 years ago, but we have still not fixed it. That is a real reason for integration. It is something the commission needs to look at, not to reinvent the wheel, but to look at where things are working and say, “Let’s get this right across the country.”
I think that the supported housing review, which was discussed in yesterday’s Opposition day debate, is critical. If a lot of the funding for supported housing goes as a result of changes to housing benefit, we will see a greater problem, with more pressure on A&E departments and in-patient services.
I very much endorse what Members have said about community matrons and district nurses, who perform a vital role. Only this week my wife was talking about the work of the district nurses in Stoke-on-Trent and how valuable and appreciated it is. However, not many of them are available at any one time, particularly over the weekend, which means a lot of juggling to see when they can go out to see her patients. Members have talked a lot about integration, and they have far greater knowledge than I have. I will just make the point that the commission needs to look at best practice.
I want to spend some time focusing on financing. It is absolutely right that the commission should examine all the options, but I have to say that, having looked at this quite carefully over a number of years, I do not think that we have too many options. I tend to agree with the Barker commission on that. Its report states that there should be a ring-fenced budget for NHS and social care, and it rejects new NHS charges, at least on a broad scale, and private insurance options in favour of public funding.
I have come to that view because I do not think that there is any other way in which the volume of extra resources needed will be raised. At the moment—I stand to be corrected on this—we probably spend between 2% and 3% less of our GDP on health than France or Germany does, which could amount to an additional £35 billion to £45 billion a year that we need to raise and spend.
I have to say that the NHS is a very efficient system. Given that efficiency, just think what would be possible if we came up with that extra 2% to 3% of national income, as our neighbours in France and Germany do. I am not talking about the 18% that the US spends, which in my view is far too much. A huge amount is wasted in the US system, and it does not necessarily achieve the right outcomes, particularly for people who are uninsured—thankfully that is changing as a result of recent reforms—or in lower income groups.
That is where we will run into political problems, which is why it is so important to put it into a cross-party, non-party political commission. In our fiscal system we lump together many different things and call them public expenditure, but what is called public expenditure is, in fact, made up of very different categories of spending. There is spending on state functions, such as defence, policing and education, and then there is spending on individuals, of which the biggest categories are pensions, welfare and, of course, the national health service, yet we are coming to a situation in which we talk about it all as if it is tax. So often in politics tax is bad, yet a lot of this spending is good; the two things do not make sense. In countries such as Germany, the latter forms of expenditure—the more personal ones—are often provided more through income-based social insurance. In the UK we started with that system more than 100 years ago, with national insurance, but over the past 50 years we have allowed national insurance to become less relevant, except in relation to eligibility for the state pension and certain benefits.
On finance, I know from talking to my local council leaders that because for the past few years there has been a cap on how much they can raise their council tax by, they have not been able to raise it in order to pay for social care. I speak to residents who say that they would be more than willing to pay more if it was ring-fenced for social care and meant that there were more home helps and more services available. I welcome the announcement in the spending review of the 2% ring-fence for social care because the NHS has had to pick up the bill due to the inability to properly fund social care.
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.
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?
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 to 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.
It is always a pleasure to follow 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 Liz Kendall, who is not in her place but who was an assiduous shadow Minister; and 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 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
“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:
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 Dr Wollaston and my hon. Friend 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.
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?
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 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.
It is an honour to follow my hon. Friend Jeremy Lefroy, who made some very good points and helpfully referred to the Barker report, which deserves to be debated. We must take a grip of some of its proposals. Although I am sure we do not all agree with everything in the report, it is a good thing to talk about.
It is also an honour to follow Valerie Vaz. I am now a member of the Health Committee, so it is good to hear about her experiences on the Committee and to reflect on what I might do with my fellow Committee members to make sure that we are effective in driving forward the agenda of the integration of health and social care, about which she spoke so powerfully.
I thank Norman Lamb, Liz Kendall and my hon. Friend Dr Poulter for calling for this debate. It has been a good, wide-ranging and productive conversation about the future of the health service and social care. There have been extremely interesting contributions from my hon. Friends the Members for Totnes (Dr Wollaston) and for South West Wiltshire (Dr Murrison), Mr Clegg and my hon. Friend Maria Caulfield, among others.
I share the desire and aspiration of the right hon. Member for North Norfolk to take the politics out of the NHS and discussions about the health service and social care. There are certainly situations, particularly in the run-up to elections, when there is very unhelpful scaremongering from all sides about what is going on.
I agree with the hon. Lady. We need to look at this matter for the long term. Whoever makes such statements during election campaigns—whether it is us or the Government—the talk of death taxes and such things is not particularly helpful, because we need to form a cross-party view, given that we require long-term measures that will cost money. There is no way of getting out of that.
The hon. Gentleman might want to hear what else I have to say before he agrees entirely with what I am saying, but we share the view that scaremongering is unhelpful.
In a health system that spends £135 billion of taxpayers’ money every year, that employs 1.3 million staff and that has over 60 million users in the British population, there is no way in which this issue cannot be political, as the hon. Member for Leicester West said. It just is political. It is no bad thing that it is political, because it means that there is a debate about it and, out of debate, we get better answers. It also means that the public are given a choice.
One concern I have about the proposed commission is that there appears not to be a consensus on what it should be about among those who support it. I have heard this afternoon that it should be about the future funding settlement for health and social care, but also that it should be about public health, the structure and configuration of the NHS—the estate solutions—the future role of mental health in the health service, prevention, and the integration of health and social care. To me, that is a problem. If the commission is to be effective and short—a period of one year is proposed—and if it is to lead to something concrete, it cannot possibly be that wide-ranging. I worry that those involved in the commission will spend a huge amount of time working out, and disagreeing among themselves about, what the commission is looking into. That process would be an enormous waste of time, money and attention—there is a limited amount of attention, brain power and resources to put into such a discussion about the future of health and social care, which is an opportunity cost.
To the extent that the commission might focus on future funding for the long term of health and social care, that is important and should be given a huge amount of attention. We need to look further out, but if anything is political, it is that question. Questions such as how much as a society we should spend on health and social care, what proportion of GDP or what amount per person we should spend, and how it should be funded—should it be taxes, charges or co-payments—are important, but they are very political. They are questions of value. It would be incredibly difficult to take the politics out of them.
In fact, it would be wrong to come to a consensus. We need a debate and we need to disagree. We need to give the public a choice. Just as the current funding settlement through to 2020—the £8 billion or £10 billion in this Parliament—was put to the public last year at the general election as part of an overall package of Government spending, taxation, debt and deficit proposals, future funding for the health and social care system should be put to the public at a future election. It is not something that should be agreed by insiders in a commission between now and the next election—the suggestion is that it should move quickly. That is a worrying proposal if I have understood it right. The public should decide that and it should be debated in the run-up to an election.
Does the hon. Lady really believe that the public would be happier with a confused and disagreed choice that has been argued over between parties rather than an agreed and long-term choice that puts real priorities and undertakings in front of them?
The public would rather be given a choice. We will have a debate about Europe in the run-up to the forthcoming referendum, which voters voted for in the election. We should respect voters and put choices to them on which they can take a view.
I understand some of the hon. Ladies points and have heard contributions about all aspects of health this afternoon. The central point of the motion is funding. The truth is that no political party in the past 40 or 50 years has put before the electorate a clear framework of what the state will pay out of the pooled funding we get from national insurance and income tax, and what people will add on top based on their income or assets to fund the future of social care. We have never had that proposition because it is not within the mix of a general election. In the bustle and the back and forth, a debate on that has not been allowed to happen. We, as politicians, are to blame.
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.
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 Liz Kendall and 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.
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.
I agree with my hon. Friend that the “Five Year Forward View” was a landmark document in that it set out the NHS’s own plan for its own future, supported by political parties. The more it can be encouraged and enabled to have that autonomy—and for organisations within the NHS to have that autonomy —to determine its own future, the better.
Another proposal is that the commission should focus on the integration of health and social care. In many ways that is already in progress, with many different models being pursued—it is one of the important features of the “Five Year Forward View”. One thing I am wary of is that the commission might come up with a one-size-fits-all model for integrated health and social care. If we have seen anything in recent years, it is that one-size-fits-all is not a good idea. One of the good things going on at the moment is the development of different models, whether in Manchester or in a local vanguard area such as down the road in Whitstable, looking at different ways of doing things. That is healthy. Each area could and should work out for itself the way to bring health and social care together. What we, and Government, should do is enable, support and encourage areas to move forwards and be bolder, and not necessarily impose a single template of how it should be done.
I am very mindful of the problems and outcomes challenges the NHS has on a national level, but in my constituency I have two trusts in special measures. My 100-year-old grandmother is, right now, in an acute hospital. If the system was working better, she would not be there. The health service has many problems, as well as many strengths. We should focus on how the NHS can get on with things that are in the pipeline. There have been many allusions to recent reports and evidence of best practice that is not being replicated enough across the system. There is a lot going on: the development of the vanguards, devolution, integrated care organisations and so on. All that good stuff is happening and we just need to get on with it.
We need to shift care, especially primary care, out of hospitals and, as people who can hold the Government to account, we need to make sure that the funding follows that shift. That is something that concerns me, and let us keep an eye on it. We also need to shift towards, and provide the funding for, parity of esteem for mental health and to improve the quality of care through transparency, technology and developing a learning culture in the NHS, with a greater focus on outcomes. This is happening, but we need more of it.
I am particularly concerned about the terrible morale among the NHS workforce. About 80% of junior doctors have said that they do not feel valued by the organisations they work in, and the figure is similar for other members of the healthcare workforce. That is an enormous problem. If I was to call for a commission on anything, I would call for one to look into why the workforce is so downbeat and demoralised. That is a fundamental but specific issue about which something could be done.
Overall, the NHS needs to get on with achieving the productivity opportunity that it identified and committed itself to in the “Five Year Forward View”. Many people are sceptical about the NHS’s ability to make £20 billion of efficiency improvements in the coming years. To do that, it needs to be bold and make the most of technology to reduce the enormous wastage in the NHS. It needs to solve the problem of patients not being discharged or coming to hospital unnecessarily. It needs to join up with the social care system around the NHS and address the shortage of nursing beds, for instance, which is an acute problem in my constituency and one of the major reasons patients are in hospital unnecessarily. I want all these things happening more quickly, on a larger scale and with greater boldness. The NHS and the social care system need to direct their energies at doing that, instead of being distracted by a commission covering the wide range of subjects mentioned today.
To conclude, I welcome our having a conversation that feels a lot less party political than many conversations about the NHS and which looks to the long term, as well as the near future, but I do not support the commission proposed by the right hon. Member for North Norfolk.
I congratulate Norman Lamb, my hon. Friend Liz Kendall and the other Members who secured this debate. We have heard some thoughtful speeches and different views from both sides of the House. I reflect on the comments of Helen Whately, whom it is a pleasure to follow. I, too, believe that the commission, although in principle a good idea, would be a distraction.
My hon. Friend Valerie Vaz talked about what was different in 2009. In 2011, just after the coalition Government formed, we had the opportunity to hold a cross-party round table. It was proposed by my right hon. Friend Andy Burnham, but rejected by the coalition. It comes down to what many people have said about the difficulty of taking politics out of such a debate. It is down to political will.
There are a few points I want to talk about. Dr Lee made the point—and, although coming from a different viewpoint, I fundamentally agree with him—about having different ideological perspectives. I want to focus for a moment on the Health and Social Care Act 2012. I served on two Bill Committees with Jeremy Lefroy—who really embodies the term “honourable Gentleman”, so I am sorry I disagree with him on this point. At the time, the Opposition made real efforts to explore and provide the evidence base for the implications of the Bill and what would happen, and I am afraid that much of that has come true.
All this is based on the fact that the Government, and at that time the coalition Government, have a different view of the NHS and, I suspect—although I cannot recall whether this is on the record—how it should be funded. We believe absolutely passionately—we fought the general election on this basis, as we did on a number of issues—in a publicly funded NHS, funded through general taxation, with the NHS as a preferred provider. We have committed to repeal the Health and Social Care Act, because we believe that its basis—section 75, which compels all providers to put their contracts out to tender—is wrong, and it has been proven wrong.
My hon. Friend is right: we do support a publicly funded NHS, but it has also been Labour party policy in social care that we think people should make a contribution. The problem with the politics is that we cannot come to a defined space where we can all agree on what is a reasonable contribution. We have to be up front about these things, because we need a system, particularly in social care, where we have to look at other models of how we provide those services and what will be expected for people to finance them, do we not?
I would not disagree with my right hon. Friend, but to pretend—and that is what it would be—that we could reach that conclusion on a cross-party basis would be an illusion. That does need to happen, but we come from completely different perspectives, and that needs to be considered.
In the first year of the legislation, contracts worth £16.8 billion of public money went out to tender under the Health and Social Care Act, with 40% going to private healthcare companies. We could track that because it was on Supply2Health, a public website that was taken down, which meant we could no longer monitor it. Care UK won 41 contracts worth £110 million; and again, the association of donations to different political parties is on the record. Some £5 million has been wrapped up in funding for competition lawyers. In my constituency in Oldham, my community trust, which also provides our mental health services, has said that the amount of time and money wrapped up in competing for tenders has increased inexorably. That is a distraction, and having a commission, getting away from these central points, would also be a distraction. As I say, we come from different ideological perspectives.
Given what my hon. Friend has said about the impact of the legislation in the last Parliament, does she believe that a commission would have a more adverse impact on the long-term future of the health service than that legislation is having, which is based on the old way of doing business?
We come from completely different perspectives, as I have just mentioned to my right hon. Friend 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.
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?
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, 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.
In many instances around the country, the use of care co-ordinators and the existence of a single point of contact are not only providing better care for individuals, but saving money for the whole system by avoiding the need for admissions and allowing people to go home early. We should focus on the good examples, and on how services can be made available in a more co-ordinated way.
I entirely agree. That was another of our manifesto pledges. I also thought that what the hon. Lady said in her speech was spot on.
Let me return to what I was saying about distractions. We also need to look at the issue of funding and resources. Dr Wollaston said something about that as well. Real-terms growth in spending in the last Parliament was the lowest in the history of the NHS, at less than 1%, whereas between 1997 and 2009 it was about 6%. The figure in the last Parliament was about 7.5% of GDP, slipping below the European Union average. We are now moving towards the bottom of the league, which is where we started in 1997.
So far, we have not even talked about devolution. I am a Greater Manchester Member of Parliament. The devolution offer to Greater Manchester was £6 billion, although the current collective health and social care economy is worth £10 billion. There has been no talk of contingency arrangements for, say, a flu pandemic. It is an absolute disgrace.
I also agree with the hon. Member for Totnes about the lack of an evidence base for decisions. I have provided an evidence base: our committee looked into resources and funding and how both quality and equity could be improved, and found vast disparities across the country, as well as disparities in outcomes for different groups of people. We should repeal the Health and Social Care Act and ensure that the NHS is the preferred provider.
The hon. Lady spoke of repealing the Act. As a former NHS employee, I am frustrated by the fact that there has been too much reform, reorganisation and reinventing of the wheel. I issue this plea: please do not make any more structural changes.
I have chaired a trust, I am a former public health consultant, and I entirely agree with the hon. Lady. In the run-up to the election, we committed ourselves to repealing the Act without a reorganisation, because we thought that we could integrate and bring together health and social care in a better way that would not have required that reorganisation.
We need to feel confident that our NHS and care system is there for all of us, and for our parents and our children. It should be based on people, not on profit.
Several hon. Members rose—
Order. The winding-up speeches will begin in 15 minutes. I call Dr Philippa Whitford.
I, too, attended the debate on
As was mentioned by 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.
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.
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 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. 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.
It is a pleasure to follow Dr Whitford, and I congratulate Norman Lamb on securing the debate today. I thank all the right hon. and hon. Members who have contributed to the debate. It has been an important and well-informed one.
Many hon. Members have spoken about the seriousness of the financial challenge facing our health and care system. They are right to do so. Many hon. Members have also been right to say that we need a big, honest national debate about what excellent care services look like and how we might pay for them. I have been the shadow Secretary of State for Health now for just four months. In that time, it has become obvious to me that the NHS and care system is facing unprecedented challenges—huge hospital deficits, care home providers on the brink of failure, older people in hospital because they cannot get the support that they need at home, more critically ill people waiting longer than ever before for ambulances and large chunks of the workforce so demoralised that they want to up sticks and leave for the southern hemisphere.
For many people who use the NHS, this picture may sound unfamiliar. For the majority, the NHS still provides excellent care and it is important to recognise that and to thank the thousands of dedicated staff who ensure that that happens. But the system fails many others, and the risk is that it starts to fail more and more people as time goes on.
When I was asked to do this job, I knew that the NHS and care system was under pressure. I knew that demographic change and the march of technology, both in and of themselves good things, were placing demands on a system designed for a different century. As a constituency MP, I have visited isolated older people, many feeling like prisoners in their own home, surviving with the help of a meagre care package or the support of family and friends if they are lucky. As a local authority councillor, I saw the soaring demand for adult social care, and the woefully inadequate budget to deal with it. Demand is growing because our population is ageing but also because advances in medicine enable babies who previously might not have survived to live not only into childhood but into adulthood.
On a personal level, I knew that in my own family, my grandmother had spent the last few years of her life in and out of hospital on an almost weekly basis, driven as much by crises of loneliness as by a deterioration of her chronic obstructive pulmonary disease. I knew that my other nan was forced to sell her home to pay for her care when she developed vascular dementia, meaning that all but £23,000 of her £140,000 estate disappeared. All these things I knew before I became the shadow Secretary of State, but it was only when I visited hospital after hospital up and down the country in the past few months that my eyes were really been opened.
The image of frail, elderly people, perched alone on beds in emergency admissions units or in rehabilitation wards is the abiding picture that stays with me following my first four months in this job. It made me feel uncomfortable. As a childless 40-year-old woman, I asked myself whether that would be me in 50 years. Was it the best place to be? Was it the best we as a country could do? The image may have been uncomfortable, but the numbers say it all. One in four hospital beds are occupied by people with dementia. Half of all people admitted to hospital are aged over 65. More than 300,000 people aged over 90 arrive at A&E by ambulance every year.
When we get older—and it will come to all of us, hopefully—hospital will sometimes be necessary, but it should not become the norm. I know that we have to address this problem. The system needs to be redesigned so that it gets the right sort of support to people at the right time and in the right place to prevent problems from escalating.
We have to be honest, however, about the fact that this involves a price tag. While savings can still be made and there will be ways to make the system more efficient and less wasteful, there are simple underlying pressures that cannot be wished away. With every day that goes by, more older people are living with increasingly complex and often multiple conditions. Some say that family members need to step up and care for elderly relatives, but others say that that is unrealistic. New drugs and treatments also become available every day, yet at not insignificant cost. It might be tempting to brush these uncomfortable truths under the carpet, but we cannot, and we would fail generations to come if we were to do so.
That brings me on to the proposal that we are debating: the establishment of an independent, non-partisan commission to determine what a long-term financial settlement for the NHS and social care system might look like. I understand the superficial attraction of the proposal. I have been stopped on the street and in the gym by people I have never met who say, “Why can’t the politics be put to one side when it comes to the NHS?” I understand that sentiment, as politicians are not always the most popular bunch and we are too often seen to be advancing our own parties’ interests rather than those of the public. However, the way in which we fund elderly care is the most deeply political question that our country faces in the next decade, and it is political because it is about who pays and who benefits.
While the NHS is a universal, taxpayer-funded system that is free at the point of use, social care provision is a mixed bag. Those with money pay for care themselves, while those without rely on councils to provide what support they can. There has been a “make do and mend” approach to social care in recent times, but our changing population means that that is no longer an option.
I spoke earlier about my nan, a woman of limited means who experienced catastrophic care costs because she developed dementia. My family is not a rich family, but we are not a poor family either—we are like many families up and down the country. When I was growing up, my dad decided to take us on a two-week holiday to Spain each year instead of paying into a pension. He has never bought a brand-new car in his life, but he never let his children go without either. The costs of care faced by my nan and my family fell randomly. Is it right that a woman of limited means who dies of dementia at the age of 85 passes nothing meaningful on to her family when a wealthy man who dies of a heart attack at the age of 60 does? What about those who plan their financial futures having invested in expensive tax advice to avoid the costs of care? These are deeply political questions.
If the NHS and care system are to be adequately funded in the future, the truth is that a political party needs to be elected to government having stood on a manifesto that sets out honestly and clearly how we pay for elderly care, and how we fairly and transparently manage the rising costs of new treatments, drugs and technology. No matter how well researched, intentioned or reasoned an independent commission’s recommendations may be, someone at some point will have to take a tough decision.
Given the cross-party work that has been done in this area in the past, I think that I can be forgiven for being cautious. Let us take the discussions that took place between by my predecessor, my right hon. Friend Andy Burnham, and the then Conservative and Liberal Democrat Opposition prior to the 2010 election. Just weeks before the election, the Conservatives pulled the plug on those talks, and accusations of “death taxes” were suddenly being hurled around. So much for a grown-up debate to answer the difficult questions. Take also the attempt at cross-party agreement in the previous Parliament which led to some of the Dilnot proposals on capping the costs of care. Those proposals were in the Conservative party’s manifesto, but were swiftly kicked into the long grass just weeks after the election.
I am not sure that attempts to take the politics out of inherently political decisions have worked. Even in the case of something straightforward—a new runway, for example—an independent commission has not exactly led to consensus on how to proceed. It has just led to more delay. As the well-respected Nuffield Trust has said, “Experience shows that independent commissions into difficult issues can have little impact if their recommendations do not line up with political, local or financial circumstances.”
How we pay for elderly care is one of the most difficult decisions facing our generation. It will require political leadership. A political party needs to own the solutions and be determined to make the case for them. I am not ashamed to say that I want the Labour party to lead that debate. I want us to build on some of the excellent work that has already been done in this area, in particular the work of Kate Barker and the King’s Fund. I want the Labour party to spend time talking to people up and down the country about the kind of health and care service they want to see, and to have a frank and honest discussion about what some of the different options to pay for that service might be.
I must be honest, though, and say that I think it was a profoundly political decision in the previous Parliament to cut the amount of money available to councils to pay for adult social care. I say gently to the right hon. Member for North Norfolk that he stood at the Government Dispatch Box and defended the cuts that his Government were making to social care. He dismissed many of warnings that my hon. Friend Liz Kendall was making when she was the shadow Care Minister about delayed discharges, cuts to home care, and reductions in other vital services, such as meals on wheels and home adaptions. It is neither realistic nor right to pretend that we do not have fundamental differences on this issue. Any attempt at finding consensus must begin with an acknowledgement of the damage done to social care over the past five years.
I am grateful to the hon. Lady for giving way, particularly as I was not in at the very beginning of her remarks. It is most gracious of her. I have been listening carefully and she is making a powerful case. Then she came over all partisan. Does she not accept that fundamental to spending on healthcare, as with the rest of our public services, is a sound economy? Does she accept that this Government have had to make some extremely difficult choices in order to get that economy back on track?
I accept that difficult choices have had to be made, but some of those choices have impacted enormously on some of the most vulnerable people in our society. The hon. Gentleman was not in the Chamber for the beginning of my speech, when I recognised the seriousness of the problem and the need for urgent action to tackle it. I want to find a solution that works and delivers the change that is needed.
The public are crying out for honesty in this debate. They understand the pressures created by rising demand and new technologies, and they want to be treated like adults. To suggest that this can be all neatly sewn up by an independent commission with the politics taken out of it sounds attractive, but I worry that it will not deliver. For the millions of people who depend on our NHS and social care system, I agree with the right hon. Member for North Norfolk that we cannot afford to have another Parliament where we fail to grasp the nettle. I know his proposal is well intentioned, but I fear that it is not the answer.
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 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.
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.
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.
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.
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 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 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 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 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.
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 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 Dr Murrison. No commission can get us over that sort of problem.
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.
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.
The right hon. Gentleman is being a little over-sensitive. I bent over backwards to say that it is entirely understandable that there is always a lag of time between rhetoric and delivery. All I will say, in the most consensual, cross-party, non-finger-pointing way, is that there is a real delay now between the pilots that were started back in 2012 and the paucity of the number of mental health trusts that have placed their financial arrangements on the new non-block grant system. That is the urgency with which we must deal.
I accept that. I was not in this post in the period from 2012 to 2015. I am certainly ensuring that we are progressing. I am glad that we have sorted that out. The coalition’s involvement with and commitment to this issue have been immense, and I am very proud to carry that on in the way I am doing.
My hon. Friend Maria Caulfield brought her experience to this debate. She spoke about the integration of budgets for social care and for local authority expenditure in the national health service, which is absolutely crucial. For me, integration is not about getting two groups of people to sit down in the same room every few months or so to have a discussion. It really cannot be done without a combined budget. So long as there are perverse incentives for one budget or another, it will not work.
We are making progress on that and have clear plans to get it done by 2020. We will follow our progress with a scorecard to find out where we are. We have spoken for too long about finding the holy grail, but we are further towards it than anyone has been before. That is not a bad place to be, but we must ensure that we make progress. A lot of this is about relationships; it is not just about organisations being in the same room. Unless people really talk to each other and have a real sense of what can be done collectively, we will not get anywhere.
My hon. Friend made the heartfelt plea, “Leave us be from time to time.” That would certainly be echoed by virtually everybody I have ever been involved with in the public sector during the past 30 years. They just wish we would decide what is to be done and let them get on with it for a while before changing it again. I am quite sure that this Government have absolutely absorbed that lesson.
The hon. Member for Don Valley—[Interruption.] Will she forgive me? Once I have been in the House for a few years, I will get all such distinctions right. Caroline Flint speaks from a position of great experience and great success. She spoke about the successes and the failures in the system, which we all know about, and about how the commission could look at them. Again, I am not quite sure that it could bear the weight of doing so.
The right hon. Lady addressed the political issues and how difficult some of them are. If she will forgive me for saying so, she made an intervention on Debbie Abrahams that exemplified the point. There are difficult political challenges within parties as well as between parties across the Floor of the House, and I noticed the little challenge that was made.
I must say to the hon. Member for Oldham East and Saddleworth, who spoke with great passion about her party’s commitment to a publicly funded or taxpayer-funded NHS with no deviation from the line, that that is simply not true. It suits her to say it, but it is not true. Let me quote from an article from the New Statesman of
“serves as one of many reminders that not so long ago, during the New Labour years, the Labour party was driving through dramatic reforms in the NHS and did not shy away from private money in doing so.”
There are variations on a theme, even for the hon. Lady, and she perhaps protested about the public nature of the NHS a little too much.
I am grateful to the Minister for giving way as he did not challenge me when I made that point. Does he, however, accept that Labour stood on the platform of saying that the NHS should be the preferred provider? As other hon. Members have said, we have learned how important it is that policy driving the NHS should be based on evidence. We now have evidence that a health system with an internal market, or a marketised or privatised health system, which is what this Government are seeking, does not help to improve quality or to reduce inequity in healthcare. That was our platform.
Well, the platform was clearly stunningly successful. I am not embarrassed by being reminded of the Labour party’s NHS platform at the last election, because it did not succeed. For one reason or another, the public did not believe the stories run about us and the NHS, and they did not believe in Labour’s competence to handle the NHS. As we know, the amount of private sector involvement in the NHS is extremely small, and I am not sure that I accept the hon. Lady’s description of how it has all turned out. This is an example of how careful we must all be in dealing with such issues. We must not pretend to our publics that we are something we are not and that our opponents are something that they are not.
My hon. Friend Jeremy Lefroy—he has great experience, given the work he has done with the NHS—spoke about best practice. He wanted the commission, but again added more pressure in the things it would be doing and considering. I would make the point that such a commission happens at a point in time. I know that it would be designed to look ahead, but it would inevitably consider the circumstances pertaining at the time. We need a process for discussing the NHS and its funding—where the money is coming from and how it is spent. We need to make the process work, rather than thinking that one push into the grass will do the job. Again, I am not sure that the weight will be borne in that way.
Earlier in his remarks my right hon. Friend talked about having a discussion within the confines of the Palace of Westminster. He appears to be moving in that direction again. Does he agree that there is a need for a more iterative process with the public at large?
A commission of the sort that the right hon. Member for North Norfolk has proposed might go some way towards that.
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.
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 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.
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.
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.
I beg your pardon, Mr Deputy Speaker. I have tried to accommodate interventions but I entirely take your point. I am just about to finish and am grateful for your generosity.
I take the hon. Lady’s point, but in conclusion, the Government take advice from a lot of sources on everything connected with health. If the right hon. Member for North Norfolk wants to do exactly what he suggested, he can do it, and we will listen very carefully to him, as we do to others. However, I am afraid that, at the moment, I cannot see a Government-sponsored commission. If we have more debates such as this one, the public will be better served and the House will have done its job.
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 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. 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, 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 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.
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.
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?
I have been given no notice today of any statement, and it is very late in the evening and we are about to finish. What I can say is that it is certainly on the record and the Government are certainly able, if they wish, to make a statement tomorrow. The hon. Lady is able to put in for an urgent question if she feels it is appropriate. I cannot promise anything, but those avenues are open to the Government and to the hon. Lady.