As the Secretary of State has said, health and social care is delivered by people, and I would like to pay tribute to all my former colleagues across the UK who, regardless of system, are working their best to help patients.
All four UK national health services face the same challenges of increasing demand, workforce shortages and tight finances, but the NHS in England has faced almost 10 years of unprecedented austerity, with annual uplifts of about 1% for quite a significant part of the past decade.
The NHS Funding Bill will enshrine in law the Government’s plan to give £33 billion extra per year by 2023-24. Although that is a bit of a stunt, as the Government do not have to force themselves to act by law, I am sure that it will be very welcome after such a long drought. Of course, in real terms it represents £20 billion, and is therefore not additional new money but the extra funding already promised by the former Chancellor in 2018. It is claimed that it represents the biggest uplift ever for the NHS, but it amounts to 3.4% per year, which is actually still less than the average annual uplift across the NHS’s history. It should allow stabilisation of the NHS in England, but it is unlikely to provide enough money for major transformation projects.
The extra funding is again to be funnelled largely into the NHS itself, to make it sound like a bigger number, but it ignores the other responsibilities of what is actually called the Department of Health and Social Care. Public health funding has been cut by £850 million, with the 10 most deprived areas in England losing over a third of their central public health funding, while the least deprived areas lost only 20%. Prevention services, such as smoking cessation, which was mentioned by Sir Charles Walker, have been cut. That does not make sense, as £1 spent on helping someone to quit smoking saves £10 in treatment for lung and heart diseases later.
Similarly, although the plan includes an extra £1 billion for social care, the funding gap is currently estimated to be £6 billion. With cuts of up to 60% to their central budgets, councils simply cannot make up the difference. There is little point in pouring extra money into the NHS without also tackling social care—it is like trying to fill a bath without putting in the plug.
Although it was Labour that introduced private healthcare companies into the NHS and saddled all four UK health services with financially crippling private finance initiatives, it was the coalition Government’s Health and Social Care Act 2012 that created the full-blown healthcare “market” in NHS England. The NHS long-term plan proposes to unpick some of that, with legislation to remove the barriers to integration, such as by repealing section 75, which forces commissioning groups to put contracts out to tender, and getting rid of tariffs, which can act as a perverse incentive and encourage hospital admissions.
It was the competitive market that drove NHS trusts in England into debts totalling £2.5 billion within two years. That led to the closure of beds and to the downgrading and closure of A&E departments, and it has caused a marked decline in emergency care services, which have been consistently lagging about 10% behind NHS Scotland’s A&E performance since March 2015. It is important to focus on the data from type 1 emergency departments, as that is the most relevant definition—hospital-based A&E units that are open 24 hours a day, seven days a week. Diluting that with data from minor injury units and walk-in centres just masks the real situation.
Performance has deteriorated in all four nations this winter, but while one in six patients in Scotland are waiting longer, a third of those in England and Wales are waiting more than four hours in A&E. Unlike the three devolved nations, NHS England does not publish the total time spent in A&E by a patient. It restarts the clock to measure trolley waits for those needing beds. As was mentioned by the shadow Secretary of State, in December, nearly 100,000 patients waited over four hours, and often up to 12, for a bed. That time is on top of the original wait in A&E.
The Government’s plan seems to be to change the measure rather than dealing with the issue, but the four-hour target is the canary in the coalmine, warning of stress on the whole system—not just A&E, not just the flow through hospitals, but the assessment of what is happening in the community. Poor disease prevention rates and struggling primary care services lead to more patients going to A&E, while a lack of social care provision means that they can get stuck in hospital, which causes a lack of beds for emergencies. The Government list social care reform in their legislative programme, but the previously promised Green Paper is still nowhere to be seen, and no solution has been proposed.
The Scottish Government choose to invest £276 more per head in health and social care, because in a comprehensive health system a pre-emptive approach is more cost-effective. That provides significantly more GPs, nurses and beds per head of population. Free prescriptions ensure that people take their medication and control chronic conditions, while the fact that joint replacements and cataract surgery are not rationed helps older people to remain active and independent rather than needing more and more social care. Free personal care allows the elderly to stay in their own homes, rather than ending up in care homes or even hospital.
The workforce is the biggest single challenge facing health and social care services. That problem has been aggravated by Brexit, with a 90% drop in the number of EU nurses coming to the UK and a one-third increase in the number leaving it. As was mentioned earlier, the shortage of doctors has been acutely exacerbated by the Government’s changes in the annual pension tax allowance; some doctors are receiving tax bills for tens of thousands of pounds after working overtime. Many senior clinicians have been refusing to do extra shifts, for which they are financially punished. That is likely to have been a major contributor to this winter’s poor performance, as we have not experienced either a flu epidemic or severe weather. I wish the Government and the medical bodies well in sorting out an acute problem that will only make life for our patients worse.
We have been promised 50,000 extra nurses, but as only 31,500 will be new staff, that will not cover the 44,000 nursing vacancies in England, and as recruitment is spread over five years, the gap is unlikely to close. I am sure that the profession welcomes the Government’s U-turn on the nursing bursary—yet another disastrous Tory policy is having to be unpicked—but the promise is for only £5,000 a year, compared with £10,000 in Scotland, and nursing students here will still face tuition fees. The removal of the bursary led to a one-third drop in the number of nursing applications, and a 5% drop in the number of students starting each year. In contrast, 21% more nursing students have been starting each year in Scotland since 2016.
We have been promised 6,000 extra GPs to deliver 5 million extra appointments over the next five years, but we are still waiting for the 5,000 extra who were promised in the 2015 general election. There are actually 1,000 fewer GPs in England, so I will not hold my breath.
I welcome reform of the Mental Health Act—which is quite different from the legislation in Scotland—and, in particular, the focus on compulsory detention, but we need investment in mental health support and early intervention. It is good that we are talking much openly about mental health issues, including those of Members in this place, but we are still some way from achieving parity of esteem.
Having been a member of the pre-legislative Committee a year and a half ago, I welcome the Health Service Safety Investigations Bill. The aim is to copy the principles of air accident investigation, with a focus on learning lessons to prevent reoccurrence rather than apportioning blame to one person, particularly as “system failure” is nearly always a contributor and the chance to “design in” safety is then missed. While that will hopefully improve the learning from major incidents, it would be good to see more being done to prevent them from happening in the first place.
I was working as a surgeon in 2008, when the Scottish patient safety programme was set up. The first step was the introduction of a team approach to “pre-flight checks” in operating theatres to prevent surgical errors. As was reported in the British Journal of Surgery, that resulted in a 37% drop in the number of post-surgical deaths over approximately two years—among the largest reductions in surgical deaths ever documented. I was therefore surprised to hear from one of our Committee witnesses that the World Health Organisation pre-operative checklist was not standard practice in all surgical services in England.
The internationally acclaimed Scottish programme now extends to every aspect of healthcare and, despite dealing with increasing numbers of older and more complex patients, it has dramatically reduced hospital mortality by a quarter over the last 10 years. Reducing complications saves money, as well as being better for patients. For example, a one-third drop in bed sores since 2012 is estimated to be saving between £2 million and £5 million a year in Scotland.
The Government must accept that they got it wrong in 2012 with the Health and Social Care Act, and again in 2016 with the removal of the nursing bursary. They need to get rid of tuition fees, restore the bursary, and genuinely work to repair the fragmentation and damage done to the NHS in England by their “market” approach. The Prime Minister likes to attack the Scottish NHS. I gently suggest that he take the plank out of his own eye, read some statistics, and focus on sorting out the mess that his party has made of the health and social care system for which he is actually responsible.