As many Members have mentioned, we are approaching the 70th birthday of both the NHS and the social care system. I was shocked to work out that I graduated in the first half of that period, when the NHS was a youngster of only 34. That was a bit depressing; how did I get so old?
Most patients in all four UK health systems will have a very good experience, because they interact with dedicated and caring staff. But all four systems face three big challenges that we have talked about before: tight finances, workforce shortages and increasing demand. As others do, I welcome the £20 billion extra funding that will be there by 2023. Over the next five years, that equates to a 3.4% uplift each year. That is double the 1.2% that the NHS has been experiencing over the past eight years, but it is below the 3.7% that has been the average since 1948. So it is welcome, but to call it a windfall can make people complacent that the challenges within the NHS and social care have simply gone away.
I agree with Dr Wollaston that it is very disappointing that this is again only NHS resources, with no money for public health, for training or for capital or maintenance and, most importantly, no funding for social care. Trying to fund a health system without supporting social care is like trying to fill a bath with the plug out.
The other question is of course: where is the money coming from? I am afraid that I am also in agreement with the hon. Lady that I do not see much chance of a Brexit dividend; I know that I am Irish, but I do not really believe that there is a pot of gold at the end of the rainbow.
The Secretary of State for Health and the Secretary of State for Scotland have both mentioned that Scotland will get a £2 billion windfall through the Barnett consequential, and that would of course be hugely welcome, but in fact no detail has been sent back in response to the letter from our Finance Minister, and we will simply have to wait for the autumn statement, because the Barnett consequentials are not always as they appear. When NHS England got £337 million to prepare for winter pressures, naturally NHS Scotland was hoping for £32 million; in fact, by the time all the other cuts were applied to it, £8.4 million made it over the border.
The Scottish Government have increased health funding by 45% since coming to power in 2007, and despite an 8% cut in the Scottish budget since 2010, we still invest £163 a head more than is invested in people in England. We focus on things like quality improvement, and we have the first national patient safety programme. That has reduced costs, and it has a massively reduced mortality. It also helps to avoid litigation, which is at a much lower level in NHS Scotland than here in England.
The next issue is the workforce. There is no extra funding for Health Education England, although it is expected to educate 1,500 more medical students and train 5,000 more GPs. Despite 36,000 nursing vacancies, the nursing bursary has been removed, and this House voted to remove the postgraduate nursing bursary just last month, so it is difficult to see how we will tackle those challenges. Even before Brexit, we are losing EU staff. In the NHS in England, 19% of its EU doctors are in the process of leaving. Unfortunately, Scotland is also seeing 14% of its EU doctors going. We have registered a drop of 90% in the number of EU nurses willing to come to work in the UK system, and we have had the issue involving more than 2,000 non-EU doctors being turned away and refused tier 2 visas in the first five months of this year. I welcome the fact that that situation has now changed, but this is about the message that that sent out. It is about the need to have an immigration policy that will deliver the people we require. Social care workers will be a particular issue, because they will not qualify for tier 2 visas. They will not be classed as highly skilled enough, and they will not earn enough.
A further challenge is increased demand. Public health has received no extra money, and it has already faced cuts. That has resulted in cuts to services such as smoking cessation and tackling addiction, inactivity and obesity. I called earlier for health in all policies, and tackling issues such as poverty and adverse childhood experiences is really important. They drive a huge amount of mental and physical ill health. We often blame increased demand on the ageing population, but I would point out, having graduated in 1982, that I worked in Victorian hospitals, on Nightingale wards, and I remember the first CT and MRI scans. Since then, we have modernised not all but many of our hospitals and increased the availability of technology and expensive new treatments. We are now entering the age of gene therapies, which will be incredibly expensive. The chief medical officer in Scotland has formulated a policy called realistic medicine. It advises that, as doctors, we should not presume that every patient always wants the latest brand new treatment or to be put through an operation. We should not presume; we should just ask them what is important to them.
One of the things that is important for everyone is keeping their independence. I do not just believe in independence for Scotland; I believe in independence for older citizens. That involves not rationing hip, knee and eye operations, as is still happening here in England, but investing in them. If we delay people’s hip or, particularly, knee replacements, their muscles waste, the end result is poorer, and they will have become more dependent in the meantime. Rationing cataract operations, as is happening in two thirds of units in England, increases the risk of falls. That will simply cost more in the long term. We are trying to get people operated on at an earlier stage, so that they can stay more independent. If people can see and walk, and if we give them a bus pass and get them out and about, they will cost us less in the long term.
The most important missing item in the statement on NHS funding was, as has been said, funding for social care. Mr Prisk—I used to live there when I was a teenager—talked about providing free personal care. That is something that we do in Scotland. Someone in a care home there will pay accommodation costs, which are means-tested, but regardless of whether someone is in a care home or at home, we provide free personal care. That might seem more expensive, and indeed it is—we spend £113 a head more in Scotland than is spent here—but by comparison to being in hospital, it is incredibly cost-effective. Over the past five years, Scotland has seen just one third of the rise in A&E attendances and emergency admissions that has been seen in NHS England, and that is a cost that is worth getting back.
Members have talked about funding the service and the need to look at interesting ways to do so, and I agree that national insurance needs to be reconsidered. It used to be called national health insurance, but it of course covers many other things, such as benefits, pensions and so on. However, it is something to consider, because the threshold actually starts quite low when people are earning poorly and then starts to thin out when people are earning well. That does not seem fair. It is the same for retired people who have a generous pension and do not really go on paying national insurance. That cannot be right when they are entering the most important years.
In Scotland, we believe in integration, not competition. It is estimated that the healthcare market in England wastes £5 billion to £10 billion just in administration. The NHS in England faces reorganisation anyway as it moves through sustainability and transformation plans into accountable care organisations or systems or whatever they are to be called. Perhaps the Government should consider getting rid of section 75 of the Health and Social Care Act 2012 that forces services to be put out to tender, resulting in outsourcing and fragmentation. England needs integration and co-operation, not financial competition. Tariffs that reward a hospital only for admitting someone instead of trying to keep them home are counterintuitive.
I agree that place-based planning is the best approach for reorganisation, but it must be centred on patients, not budgets. It must start with designing what is required for the long term, not at the bottom line and then working back. In this next reorganisation, the Government should be radical and get rid of the healthcare market and, as the NHS turns 70, think of moving to a unified, public national health service.