My Lords, it is a great pleasure to open this debate. I was a little concerned that, because of today’s Tube strike, our numbers might be devastated, but I am pleased to see that they are not—too much.
I am grateful to all noble Lords who will be taking part, many with a long experience in health. I am particularly delighted to see the noble Lord, Lord Mawhinney, in his seat and taking part in the debate.
Health is determined by a complex interaction of individual characteristics; lifestyle; and physical, social and economic environment—that is, your genetics, your epigenetics and your lifestyle. To keep the citizens of a nation healthy needs a strategy with appropriate policies and resources to address all these interactions. A system that keeps the citizens of a nation healthy needs to be a partnership of individuals, the wider community and the state.
While the state has a role in all aspects of health—prevention, healthcare and social care—the limits of that role have to be clearly defined and can be arrived at only by a wide consensus that includes the public, wider stakeholders and the state, each recognising and accepting their responsibility. What we have today in the NHS is primarily a service that treats patients when they are ill—some say a “sickness service”. It is clear that, when it comes to prevention, both the state and the individual need to do more—and I would say that the individual has a greater responsibility.
The consequences of not tackling disease prevention are grim, in terms both of individual misery and state resources. It is also clear that a changing demography—with a population increase—and increasing life expectancy will lead to an increase in the number of people needing social care.
The association of lifestyle with disease is well known, and yet in the UK 70% of the population is inactive, and 26% is obese, which will increase to 40% by 2025. This will result in 4 million people with diabetes. Some 70% of the population have poor diet and 21% smoke. Some 27% of men and 18% of women drink alcohol well above the safe limits. Some 40% of disease is related to lifestyle, including cancers and Alzheimer’s. The scale of preventable illness is staggering. An effective national plan—dare I say, which we do not have—for preventable illness could reduce mortality by 25% by 2025. Otherwise, the impact of lifestyle-related diseases and changing demography will put an even greater strain on resources.
The projected scenario is that there will be, apart from diabetes, 2.9 million people living with a long-term condition and 4 million living with cancer. By 2026, 1.4 million people will have dementia, costing about £3.5 billion a year. Some 4.5 million people will need help with daily living and 17 million people will have arthritis and other joint conditions. Providing social care will take a greater proportion of resources. The cost of care alone could consume 2.5% of GDP. A survey that showed that only 26% of older people think that they need to make provision for their social care demonstrates a lack of public concern and involvement.
I now come to the current state of the NHS: the care part of the health equation. The founding of the NHS, 67 years and four days ago, was heralded as a great piece of social legislation—and so it was. The public’s love affair with it has not diminished. At its launch, the annual budget was £280 million. In 2013-14, the NHS spend was approximately £116 billion—close to 9% of GDP—and the pressure on resources continues. The demand for care is not diminishing. Financial problems are now endemic among NHS providers. Even the previously best-performing trusts are heading towards deficit. Some 89% of trusts are forecasting deficits, faced with increasing demands, cuts in tariffs and the withdrawal of performance payments. Provider deficit could top £20 billion this year. The FiveYear Forward View of Simon Stevens was a commendable document that I will return to later because it tries to address some of these issues. It predicts a need for extra funding of £8 billion a year by 2020-21. I know that the Chancellor yesterday said that he will fund it by £10 billion—but he included £2 billion already given to the NHS.
At the same time, the service has delivered already in the last Parliament £20 billion-worth of efficiency savings, mostly through limiting staff salaries, cutting administration costs and the lucky break of blockbuster drugs coming off patent. An ambition to deliver further efficiency savings of £22 billion a year by 2020-21 through productivity gains of 2% to 3%, if it can be achieved, will be challenging. Further reducing staff salaries and holding pay to 1% for the next four years, as announced yesterday, and reducing the price paid for treatment is an option likely to lead to a further decrease in morale and less commitment from staff, leading to poorer-quality care, poorer outcomes and, dare I say, less likelihood of getting the productivity gains proposed.
Historically, the NHS has never achieved productivity gains above 0.4% year on year. Achieving productivity gains of 1.5% will result in a shortfall of £16 billion; there will be a £21 billion shortfall if the gains are only 0.8%. In this scenario, the NHS will need an annual budget of nearly £200 billion by 2030 and one-fifth of the nation’s entire wealth by 2060.
The current financial pressures are despite more than 20 major reorganisations and policy changes, mostly to cut costs, over the past 20 years—and these continue. Most recently, further policies to cut costs include: the reversal of safe nurse-to-patient ratios; the removal of some clinical targets; reducing the cost of agency nurses; and reducing the cost of having consultants and the pay of senior managers. The recent Carter report addresses efficiency and productivity gains that could—I use the word “could” because that is what the document says—save £5 billion in procurement per year. We have had three previous reports on procurement in the NHS.
Not only do we have financial pressures but the performance of the NHS in terms of outcomes is not good. Although the NHS is rated very highly by the Commonwealth Fund for several parameters—no doubt the Minister will remind me about that—it is also rated second from bottom for avoidable deaths. Recent similar findings have been reported in a Health Foundation report for cancers, vascular disease and lung disease. There are 25,000 excess deaths associated with diabetes and 2,000 child deaths can be avoided. There is great variation in care throughout the country.
Primary care does not fare any better, with long waits for appointments in some areas, late diagnoses leading to an increased number of deaths, and a dwindling workforce. It is difficult to see how a seven-day service in both the primary and acute sectors can be delivered without higher costs, with patients with long-term conditions resorting to attendance at A&E because of the lack of community care. The separation of community care from hospital-based services and social care inhibits integration, makes the delivery system weak and fragmented, and thwarts innovation in care. The NHS has never been great at innovating for service delivery. While I accept that not all is bad in the NHS—we must not throw away all the good things that it has—the system as a whole is not performing well.
Is the current system sustainable? There are some who would say, “Yes, but it needs more resources”. Others would say, “Yes, if only we can produce the efficiency and productivity that is there to be had. It needs to improve”—there is room to do so, I agree—“and cutting waste will solve some of the problems”. Others feel that we need to look for a new settlement, for more durable, long-term solutions that will keep the citizens of this nation healthy for as long as possible in their life—a new system where prevention, care and social care are a continuum; in which the individual, the community and the state have a commitment and a shared responsibility; where people with long-term conditions are able to manage their own illnesses; where individuals plan for their own health and are helped to plan for their social care if they need it; and which can adopt new ways of care and embrace innovation.
The history of the past two and a half decades tells us that political parties will continue to manage the health service according to their ideology—managing scandals and giving a bit more money—but with no long-term planning as there will be no political consensus. We need a wider dialogue with the public, stakeholders and politicians to explore a new settlement, a new way of delivering care and social care, and, above all, a strategy to prevent illness. We need a national consensus that recognises and accepts that individuals, communities—including employers—and the state have a role in health and contributing to it. To do this, we need an independent national commission that is free to look at all the issues, not just at financing the service. The current system is not sustainable. I have no doubt that changes will be brought about. If we persist in the same way as we have done for the last 20 years we will see a gradual shift to a two-tier system: those who can pay will get care; those who cannot will not. The variations in care will get wider.
I hope that today’s debate can start a wider conversation. If that happens, I, for one, can imagine that the logical conclusion will be that we need an independent commission to explore a new way, a new settlement for health that is compassionate and caring, and where all citizens have a stake to contribute to make their life healthier. I think that Simon Stevens’ FiveYear ForwardView is a good strategy and a good point on which we can build.
I have two simple questions for the Minister. First, does he agree that the current system is unsustainable? Secondly, does he agree that all I have said about current and future scenarios is true? I beg to move.
My Lords, first, I congratulate most sincerely the noble Lord, Lord Patel, on his speech and on the debate. He talked about exactly the kind of issues that we should be talking about, and which the public generally should be talking about. As he might imagine, what he said about a commission was music to my ears. We should take note of what he also said about the financial problems in the NHS, which are endemic.
It is spending not just today about which we should be concerned—although I congratulate the Chancellor of the Exchequer on the resources he has made available—but spending in the future. For far too long, there has been a political preoccupation with structures and organisations to the extent that today there cannot be one person in 100 who could say how the National Health Service is actually organised. That includes quite a number of people working in the health service.
I hope that the debate can now change and tackle the obvious problems that we face. The principal one is clear. We all want a health service free at the point of delivery so that people are not denied healthcare because of a lack of income. That is basic. However, we also know that the costs of the health service are increasing because of medical advance, rising expectations and an increasing elderly population. The question is: how can we finance this increasing demand? That is an appropriate question on the day after the Budget. It is also appropriate because it seems to me that the dangers are clear. We are funding health through general taxation but what is crystal clear is the pressure on public spending. That pressure will continue. At the same time we find that large areas of public spending are exempt from economies and reductions. Health, of course, is one of those and 60% of social security spending is another.
The Government are forced to look at the areas not protected for reductions, such as the 40% of the social security budget. It is for such reasons that they are driven into eccentric policies, such as putting the costs of the over-75s television licence fee on to the BBC. I say “eccentric” although I could put it rather higher than that—I might on Tuesday when we debate this issue. The fact that the Government are driven to such policies shows just how uncertain the position is. It raises the question of whether public spending will be sufficient to meet the emerging needs in the long term, and whether we can keep going on the same basis and keep going back to the same departments to make economies.
I raised that issue in the Queen’s speech debate, but received what I term a dusty ministerial reply from the first Conservative Government for nearly 20 years, which was that Derek Wanless had gone into all these issues a few years ago. I find it slightly odd that the Government should rely on a report commissioned by Gordon Brown, published in 2002 and prepared by Derek Wanless and the health trends review team of Her Majesty’s Treasury. It is particularly odd when you consider that the report looked at the resources required, but said quite explicitly:
“Its remit was not to look at how those resources should be financed”.
It also said that there should be further and regular reviews.
To my mind—and I very much echo what the noble Lord, Lord Patel, said—what is required at the start of the new Parliament is a thorough, independent and authoritative review of the financial pressures that the health service will come under, and at the same time to set out the options for financing healthcare. We may find that funding it out of general taxation is the best and most cost-effective method—I certainly argued that it was a cost-effective service when I was Secretary of State—but we cannot have a sensible debate on the way forward without examining the other issues. We could have a ring-fenced health tax, or look at a potential system of health insurance. We should explore the part that charges could play: I always found it extraordinary that, for example, prescription charges caused so much upset, given that about 70% were prescribed absolutely free. We should look at economies that can be made in the drugs bill and a whole range of other things.
These are difficult questions, particularly given how health is exploited as a political issue—any change is alleged to mean the destruction of the heath service as we know it—but they are options that should be explored. That is why I believe that a royal commission, made up of independent members and working quite openly, would be the way forward. It would look at the resources needed to deliver a high-quality health service that is free at the point of delivery, but also examine how those resources should be financed. I am sure that many will say that this cannot be done and that it is politically too difficult. Frankly, however, we have an exceptional opportunity, at the beginning of a Parliament, to mount a thorough and open investigation into the financial pressures that the health service is and will be under and how they can be met. That would be supported by those who are concerned about not just the state of the health service today, but its future over the coming years. I very much hope that this is a challenge the Government will not duck.
My Lords, I, too, congratulate the noble Lord, Lord Patel, on introducing this important debate in such a powerful and impressive way. I, too, resonate very much with the idea of a royal commission. Indeed, I suggested it some time ago in a previous debate.
When the noble Earl, Lord Howe, was Health Minister he must have got used to me banging on about the parlous state of NHS finances, so I see no reason why I should not continue that theme with his esteemed successor, the noble Lord, Lord Prior. But I say at the outset that I do not go along with the “black hole” or the “bottomless pit” theory that we will never be able to fund the NHS adequately. The bottomless pit argument is faulty because, while we may not be able to afford everything that everyone wants, we can and should afford what they need. That is, we can afford a service that is widely regarded as satisfactory and which can meet all reasonable expectations at a reasonable level. Indeed, many countries manage to do this very well.
However, it is clear to virtually all observers that we are not in that position now. We are falling behind. I look back to the halcyon days of the previous Labour Government, when, by 2010, we were putting in almost 9% of GDP, we had got rid of the waiting lists, accident and emergency waits were down, GPs could be seen on the same day and patient satisfaction was high. Now we have problems in all those areas. We have cut the share of the national cake from more than 9% to around 7%. I understand the need for austerity measures, but may I ask the Minister: what is the justification for reducing the proportion of GDP spent on health? Bringing the share of GDP up to a reasonable level is something a country with as high a GDP as ours, and more billionaires per square inch, can afford. All the problems due to these stringencies have, of course, been spelt out in reports from the King’s Fund, the Nuffield Trust and the health service managers who are heading for huge deficits this year. I fear that these are just the conditions in which research and innovation are squeezed out. As the scientific adviser of the Association of Medical Research Charities, I find that particularly disheartening.
Of course, I recognise that there are more efficiency gains to be made. I want to provide one or two examples where the system under which the NHS labours is causing a terrible waste of money, and where efficiency has gone out of the window. I have a friend who is a distinguished gastroenterologist and who is desperately trying to do his best for his patients and at the same time save money for the NHS. Here, I must express my interest as a one-time gastroenterologist way back in the dark ages. My friend was trying hard to fulfil one of the major requirements of NHS England—to move much more care out into the community and reduce the cost of hospital care—so he started running out-patient consultations by telephone instead of bringing the patients up to the hospital. That saved them much time and effort, and they loved it. He also knew that the tariff paid by the CCG for each out-patient consultation was around £150, while a telephone or face-time consultation cost £29. That is a considerable saving to the NHS and a win-win situation. However, noble Lords might imagine how that was perceived in his trust. He was called in to meet a middle manager, who told him in no uncertain terms that he must stop this because the trust could not afford to lose the funding that his activities were causing, so he stopped for a while but has reintroduced the practice surreptitiously and is waiting for the trust to call.
My friend also wanted to set up a one-stop clinic for patients needing endoscopies, seeing them in the morning, treating them the same day and giving them their results later the same day. This saved patients waiting 12 weeks for an endoscopy and three more weeks for the results—just what the NHS should be about: efficient, convenient service. But again, the incentives for the trust got in the way. Trusts lose money when patients attend only once instead of three times.
I doubt whether this is a unique phenomenon, and it is a clear result of the disincentives we have set up in the internal market. So long as providers are desperate for funds from purchasers, we will run into this type of problem. So my question for the Minister is: is the internal market broken and counterproductive, and, especially when we are under such financial constraints, would not an integrated budgetary system be more suited to our needs? How do the Government envisage achieving their objectives of integrating community and hospital care, hitting savings targets and improving the care of patients while we have this dysfunctional internal market? The question is not whether we can afford a health service free at the point of delivery but whether we can afford one that is hidebound by disincentives in the way I have described. I look forward to his response.
My Lords, I, too, congratulate my noble friend Lord Patel on securing this debate and on his timely contribution.
I refer back to the 1942 Beveridge report and the six years it took for the politicians to agree the NHS Bill and launch the NHS. I have been privileged to serve the NHS for 60 years, during which time many reports have been published proposing changes to meet the needs of the times.
I looked back to 1948—three years post-war—when ration books were still in use and young men were called up for national service. One thing was very apparent in 1948—the NHS would not have to deal with obesity. My thoughts wandered further and I wondered if the Minister might consider treating the national obesity problem by reintroducing rationing and national service—one way of improving the general health of the population, but I fear it would not be too popular.
Since the inception of the NHS, much progress has been made in diagnostics and the treatment of disease, alongside progress in the fields of medicine, nursing, midwifery and professions allied to medicine. There have been changes in the management of the services, usually heralded by the dreaded word “reorganisation”. Some of these have been for better, and some for worse. The nursing and midwifery professions have had their share of changes in regulation, education, practice and management; again, some for better, and some for worse. I believe the nursing and midwifery professions have in fact weathered the changes with positive outcomes. Nurses always rise to the occasion and many might describe them as unsung heroes or heroines because they always go the extra mile, not just because of the NHS constitution or their code of conduct, as important as those are, but because they really care about the delivery of care to patients. However, the two professions are generally poorly understood, as explained in the recently published book by Davina Allen, The Invisible Work of Nurses. She writes:
“There is a widely held view that all systems tend towards disorder and that energy is required to maintain order. Nurses are the source of this energy in healthcare. Formal organisations have a tendency to overestimate their orderliness and the degree to which their activities are governed by rational systems and processes. Yet in so far as healthcare exhibits any order, the findings of this study show, this must be understood as a nursing order”.
It is timely for me to pursue this a little further as there is a great risk, as Ministers and the Government make decisions quickly in order to deal with the current financial issues, in looking for quick ways to solve the problems. In the current situation, the role and complexity of the work of nurses and midwives is poorly understood, especially the role of the registered nurse. There is categorical evidence that degree-level education of nurses is associated with lower mortality rates in hospitals. Suggesting that another level of registered nurses might be the answer ignores all the previous research, which demonstrated that the state-enrolled nurse was “abused” and “misused”. This was to the detriment of safe care to patients and unfair to the enrolled nurses, who were placed in impossible positions, leading to many mistakes. The opportunity to develop further the roles of the current workforce would be more appropriate, in order that new models of care could be introduced to assist in developing new pathways of patient care—integrated care, for example. The support to the registered nurse is vital, as is the work currently being undertaken by the noble Lord, Lord Willis.
Planning the nursing and midwifery workforce in a time of national economic difficulty and ensuring the safety and delivery of high-quality care is not an easy task. But it is imperative that it is guided by a proven evidence base. If the outcome is unaffordable then difficult decisions have to be made as to the level of service that can be provided, or money found to meet the costs. These are hard decisions but it is better to be safe than sorry. Another Mid Staffordshire, Winterbourne View or Morecambe Bay cannot be afforded and it would be wrong to exploit the nursing and midwifery professions against an evidence base. The largest single workforce in the NHS cannot be expected to sacrifice its professionalism for a political expediency at a high risk to patients. The Chief Nursing Officer, who is leading this piece of work, needs the full support of the professions and the understanding of the politicians. Where would the NHS be without the seven-day service given by nurses and midwives now and in the future?
My Lords, I add my comments to others that it is a great thing that the noble Lord, Lord Patel, has brought forward this debate today. As a former dentist, I was the first woman to be appointed to the former Standing Dental Advisory Committee for England and Wales, and later a member of the General Dental Council. As one of the very few dentists in the House, I felt that I should make one or two remarks about dentistry.
I was very disturbed to see the news that Manchester has a serious problem with children requiring full clearance of their deciduous teeth under general anaesthetic. The cost to the local NHS budget is a serious issue and a bed shortage has been created because these children are being hospitalised for a considerable time. I have suggested in this House that such cases could be dealt with in day treatment centres, but as a result I have received some quite abusive emails about the risks that would be created for these children in substandard clinics. Why should they be substandard? I am suggesting a day centre that really is right up to standard.
I have just had cataract operations in a day surgery and they were splendid. The operations were done in a first-class specialist London hospital, the Western Eye Hospital in Marylebone, although I am sure that there are many such hospitals. Some of the operations are done under local anaesthetic and some under general anaesthetic. As patients we spent a day at the clinic and did not take up any beds. I met some people having their second operation whom I had seen when they had the first one, and when we compared notes we saw that we had all made good recoveries. A day centre that is fully staffed with a competent general anaesthetic specialty available would be so much better, not only in terms of saving money for the NHS, but also for children and their families. It is quite frightening for a small child to be stuck in a hospital for a night, so to do so unnecessarily and at great expense is, I think, really too much.
I want to make one other point about Manchester. When the city gets all these new powers, I hope that it also gets a bit of sense. The real problem with Manchester in dental terms is that there is a great deal of opposition to the fluoridation of the water supply. I ask Questions about this subject all the time. The worst performer in the whole of the UK, according to the decayed, missing and filled teeth index, is Manchester, while Birmingham is the best. The Question I ask every so often to keep it before the House is this: what is the difference in other health patterns between Birmingham and Manchester? There is no difference. The really significant difference is to be found in people’s dental condition. Fluoridation could result not only in much better prevention, as advocated by the noble Lord, Lord Patel, it could also mean the saving of a great deal of money and easing of pain and discomfort for the children who are going through such a bad time at the moment.
I agree with the noble Baroness, Lady Emerton, about nursing—I have always had a bit of a thing about this. State enrolled nurses were a very valuable force in this country. Speaking as a former chairman of one of the big London teaching hospitals, I know that some of our best nurses were state enrolled nurses. They were often people who could never have met the academic standards now required for the only qualification we have for full-time trained nurses. We now believe that they should all be university graduates. This means that we are devaluing the caring element of nursing, but I think that there is a place for it. Everyone wants to be called a nurse; no one wants to be known as a care assistant. We should definitely keep up a medium standard of training. Indeed, the Minister who answered a Question for Oral Answer earlier today said that he had views about this issue and that it probably would come back again. I hope that that is the case.
I would like to have retained free dental examinations. In your Lordships’ House, I won a vote on an amendment on that which then went to the Commons, where they attached financial privilege and we were not allowed to debate it again. Had we retained free dental examinations, we would have picked up so many oral conditions so much earlier. Lots of people would have been saved horrible deaths from mouth cancer and others would have known that it was time to go. Even now, I believe that in any day centre that we have, someone should be looking quickly in your mouth and, if there is something abnormal, telling you to go in for a proper consultation. These things are just handled too casually.
There is so much that can be done. It can be done sensibly and well, and does not have to cost a fortune. This is an excellent debate today and anything we can do to make the NHS more sustainable is very welcome.
My Lords, I thank my noble friend and congratulate him on instigating this debate, which is necessary but of great concern. I must declare an interest, as I use the NHS and it saved my life after a traumatic injury. Sustaining the NHS is vital but it has many challenges. There are so many demands on the service, which is struggling to keep its head above the water.
What can be done about the PFI hospitals? They are getting into serious debt, and is it not a fact that they may have to pay out more? This would be a disaster. Some of these hospitals are cutting services relating to patient care and closing wards to try to save money.
There are many more demands on the service as the population grows older. Money needs to be saved so that it goes to patient care. If one looks at the lists of well-paid managers, many of those posts could be merged, saving money. Something must be done to make locum doctors and nurses’ posts cost less. It has got out of control. It is vital to have good, well-trained front-line staff, but if too many are from agencies it means that there is not continuity of care, which is so important. Perhaps hospitals could have their own staff banks. I agree that patients must take responsibility for their hospital or GP appointments but they must be able to contact the hospital or surgery. This can be difficult. Communication throughout the NHS should be improved.
I feel that it is such an expense to the NHS when things go wrong. Patient safety should be top of the agenda. I hope that the duty of candour will help. There has been a culture of cover-ups for too long, which I hope will be changed to one of openness and honesty. An apology and correcting the mistake is often what is needed and that would help to lessen the need for litigation, which costs the NHS far too much. However, compensation should be paid when there is disability which is very expensive to live with.
On Monday, I attended a meeting on orphan drugs and rare and ultra-rare conditions. We discussed the extreme stress that parents and loved ones have when their family member is denied a drug which can save their life or improve its quality. There should be co-operation with charities, the NHS and industry working together to find ways of funding these vital drugs. I wish that the Prime Minister would help over this matter. He is a person who understands these very heartbreaking situations of life and death. There should not be discrimination for the people who need the NHS more than anyone.
Multidrug-resistant bacteria result in extra healthcare costs and productivity losses of at least €1.5 billion per annum. Each year, about 25,000 patients die in the EU from an infection caused by multidrug-resistant bacteria. London has been named the capital for TB in Europe. It is a serious public health and economic threat, demanding a concerted response.
As president of the Spinal Injuries Association, I end by saying that delay in admittance to a spinal cord injury centre when there is a spinal injury with paralysis can lead to an increased risk of acquiring avoidable complications such as pressure ulcers, contractures and infections. These secondary complications not only are an additional health hazard to the patient but have been shown to result in longer lengths of stay and present a real risk to the functional outcome for the patient and an extra cost to the NHS. NHS England should be doing more to help and should communicate better with the specialist units, which do a difficult job and need a boost to their morale.
My Lords, I, too, congratulate the noble Lord on securing this timely debate. As usual, his analysis was impeccable and very much to the point. We have just completed an election campaign in which undying love was professed by all the parties for the NHS and more money was promised—£8 billion to be precise, as the Chancellor said yesterday, for the period to 2020. Nevertheless, we have to move quickly now to tackle the rapidly deteriorating NHS finances, even with an extra £2 billion in prospect for the current financial year. We must also seriously up the tempo of service reform, because we have a linked cash and care crisis.
On the care side, we at least have a plan—the five-year forward view—and a chief executive capable of implementing it, if he is allowed to do so. But the NHS has to be turned round very fast indeed, with much more emphasis on preventing ill health and much more care and treatment being provided in the community rather than in hospitals. Staff need to work in radically different ways, with much greater use of technology by a too-often luddite NHS. The budgets and care delivery of the NHS and social care must be integrated rapidly, both nationally and locally. Unchanging and failing providers have to be replaced much faster than we have been willing to do so far, with a willingness to use competition to do this. It is worth remembering that 60% of the public simply do not care whether their NHS services are provided by the public or the private sector.
The key question now is whether the five-year forward view will resolve the NHS’s major productivity problem, whereby it produces the wrong services in the wrong way and in the wrong places. It needs an annual productivity gain of at least 2.3% stretching over the next decade. The best it has achieved in any recent year is 1.5%, and the average for the last Parliament was under 1%. Most of that was achieved by curbing staff pay, a policy that is to be continued for the rest of this Parliament. The acute and specialist hospitals are the worst offenders, with an annual productivity gain averaging 0.4% over the last Parliament—do not believe me, believe the Health Foundation.
Unconditionally pumping more money into an unreformed NHS is probably the worst thing any Government could do, not least because the public have rumbled NHS inefficiency. The 2014 British Social Attitudes survey shows that over half the public thought the NHS wasted money. They have not yet rumbled the NHS’s track record on avoidable deaths that the noble Lord, Lord Patel, pointed out.
We must always remember that the best predictor of future behaviour is past behaviour. The jury must definitely be out as to whether the NHS, even under its new leadership, is capable of delivering, or willing to deliver, the £22 billion of productivity gain by 2020 promised in the five-year forward view and now apparently being relied on by the Government.
If the NHS fails, as I think it will, do the Government increase borrowing, cut other public services further or raise taxes? Without any of these, they will have to face up to finding new streams of revenue or reducing the NHS service offer. Those are the hard facts of economic life. Even if—it is unlikely—the Government manage to wriggle their way through to 2020 without making hard choices on the NHS, the Office for
Budget Responsibility forecasts show that the NHS financial challenges will last very much longer than this Parliament.
Our tax-funded, largely free at the point of clinical need NHS is rapidly approaching an existential moment. The voices of dissent and outrage will no doubt be deafening but a wise Government should begin now the process of helping the public engage in a discourse about future funding of the NHS. To do that requires a measure of cross-party consensus on some form of authoritative independent inquiry that could produce analysis and a range of options for a way forward. As the noble Lord, Lord Fowler, said, the start of a new Parliament is the right time to start this process for both Government and Opposition. Let us try to avoid weaponising the NHS—to use a phrase—and show a bit of political maturity from both Government and Opposition.
My Lords, I, too, join in congratulating my noble friend Lord Patel on introducing this vitally important debate in such a thoughtful way. I declare my own interests as professor of surgery at University College London and chairman of University College London Partners’ academic health science system.
The question of sustainability regarding the NHS is not merely one of how we preserve existing services in a prolonged period of further austerity, but rather how we develop a new framework that can deal with the changing environment in which healthcare will have to be delivered, with expanding need that will exist for decades to come. We have already heard in this insightful debate that the 1.9 million of our fellow citizens currently living with more than one long-term condition will increase by 2018 to some 2.9 million. The number of people living with arthritis will double by 2030, and the number of those living with diabetes, and of those living with dementia, will double by 2050. Success in healthcare through the application of technology, advancements and the application of knowledge derived from medical research have resulted in greater cancer survivorship, for example, but those who survive malignant disease are more likely to see a specialist in any given year and to avail themselves of general practice services. Wherever we look, we will see increased demand.
Much thought has been given to the need for change and innovation among providers of healthcare services, and a consensus now indeed exists. There was recognition only recently of the need for greater flexibility to be given to healthcare providers to ensure that they can start to address these challenges. The review published by Sir David Dalton last year began to address this issue. It rightly identifies the need to ensure that clinical services are consistently delivered across the country, but in focusing on variation it potentially consolidates a cultural problem that makes it difficult for providers to show the courage to experiment and introduce into clinical practice new models of care, some of which may succeed and some of which may fail, but with those that succeed adopted more broadly across the system to improve clinical outcomes and drive efficiency.
In the past, part of the proposed solution to improve the performance of providers was to introduce new legislation. The hope was that such legislation would improve the opportunity for providers to show greater flexibility and to be more innovative. Examples include the introduction of foundation trusts in 2004, and the ability for a multiplicity of providers to offer services afforded by the Health and Social Care Act 2012. Do Her Majesty’s Government believe that the current legislation, which offers significant opportunities for providers to show flexibility and innovate, is being fully exploited by healthcare providers in both the public and private sectors? Do they believe that further legislation is the answer to improving the ability of providers to innovate? What evidence is there that, two years after their creation, academic health science networks, which were designed to enable the introduction of innovation at pace and scale across health economies, are delivering the advances, improvements in care and efficiency improvements that were anticipated? In this regard, I remind noble Lords that I chair an academic health science network associated with University College London.
Beyond legislation and driving a culture change regarding innovation, there has been increasing emphasis on trying to determine how our NHS sits in comparison with other healthcare systems. There appears to be some disparity in the conclusions reached. For instance, last year the Commonwealth Fund published its regular analysis of 10 healthcare systems and concluded that the NHS remains the number one healthcare system in terms of safe, effective, patient-centred care. As we have heard already in this debate, the Quality Watch report by the Nuffield Trust and the Health Foundation, which was published last week, concludes that among 14 OECD countries with similar increases in demand in their healthcare system, the NHS does not perform as well, with relatively high mortality rates at 30 days for stroke and myocardial infarction and relatively poor survival rates at five years for malignant disease. What role do Her Majesty’s Government believe that international comparisons play, and what methodology is the most effective for us to refer to in trying to analyse where our healthcare system sits in comparison with others?
What analysis have Her Majesty’s Government made of other healthcare systems that are committed to equity of access and universal coverage—such as those in Germany and the Netherlands—but which use different models of funding that care, and what can we learn from those models? Have they addressed similar challenges in a more effective fashion? Have those models and systems of care been more effective at dealing with prevention as well with the management of patients with chronic conditions, at providing autonomy for healthcare providers, and at ensuring that innovation can be applied and adopted in the most effective and rapid fashion?
Finally, how do Her Majesty’s Government propose to go about building the long-term consensus that all noble Lords who have contributed to this debate believe is vital if the longer-term sustainability of our healthcare system is to be secured? Do Her Majesty’s Government believe that there is need for an independent commission to establish cross-party consensus on this matter and to inform public debate, which is vital if we are to carry our fellow citizens with us as we address what will be one of the most challenging and important questions facing those responsible for public policy in the coming years?
My Lords, I, too, congratulate the noble Lord, Lord Patel. I very much appreciated his kind personal comment at the beginning of his speech.
This debate is about the sustainability of the NHS, not its desirability. If you talk about its sustainability, hard words about the NHS are likely to follow. Those who issue hard words might conceivably be charged as not being as supportive of the NHS as they ought to be, so I want to make two personal statements before I start. First, for the majority of this year I have been in the intimate care of the NHS. I owe my life to Steven Tsui and to the doctors, nurses and technical staff who have looked after me so well over the past few months. Anyone who has been through what I have has to be an NHS fan. Secondly, for the record, apart from the years when I lived and worked in the United States, I have never had any private health insurance; I have been an NHS man all my life.
I start by setting a context. When the NHS started, in its first year it employed 144,000 employees. On
I turn to money. The recent King’s Fund report said that,
“financial problems are now endemic among NHS providers, with even the most prestigious and well-run hospitals forecasting deficits”,
this year. Are we relaxed about that? More than 25% of trusts are in deficit, some in deep deficit, and most of the rest of them are heading in that direction. In the seven years between 2006-07 and 2012-13, over and above the normal financial arrangements, the department slipped about £1.8 billion worth of cash to hospitals in addition, just to keep them going. There is one hospital in this country that in the last few years was in receipt of £1 million per week over and above its normal financial arrangements, just to keep going. I am told that one of the London teaching hospitals is £200 million in debt. Monitor predicts that by 2021 the NHS will be £30 billion in debt—and if there is one thing you can say about that figure, it is that it will be an underestimate when we get to 2021.
“the current healthcare system is not delivering good enough healthcare for older people”.
I noticed the president of the Royal College of Emergency Medicine saying recently that the treatment of patients at A&Es is “inhumane”. I noticed the Alzheimer’s
Society saying that GPs are reluctant to diagnose patients with dementia because they feel there is nothing that the NHS can do. And it is a disgrace that if you go into hospital at weekends, you are 15% more likely to die than if you go in during the week.
We have had a lot of nice things said about the NHS Five Year Forward View. I shall read one sentence from it:
“The traditional divide between primary care, community services, and hospitals”,
increases the barrier to the type of care that people need. None of that even hints at sustainability.
The NHS is not only a sort of religion, it is a political football. If I were a Labour Member, I would be really pleased that we had started it. As a Conservative, I am really pleased that we have looked after it for more years than anyone else. Both sides have played their part in keeping this political football moving backwards and forwards, but it is time to blow the whistle—it is time to stop. I want to be the third ex-Health Minister, and there may be more yet to speak, who says that it is time for an independent review. It is time for an independent national commission to recommend how we should move from unsustainability to sustainability. Will the Minister’s department undertake to put pressure on the rest of the Government to set up a royal commission, or would it prefer that an independent commission was set up, independently generated?
My Lords, like others, I agree that the noble Lord, Lord Patel, is right about the need for a fresh look, going beyond politics and all the experts. We need to reframe the arguments and get others into the debate, and to take a long-term view.
I agree with the many people who have spoken, starting with the noble Lord, Lord Fowler, about the importance of understanding and reviewing how the NHS is financed. However, I want to take these arguments a bit further and think about sustainability in the round. Sustainability is not just a financial issue. I shall give two examples. Barely 50% of children have met all their development milestones by the time they start school. This influences children’s future physical and mental health and their ability to learn. The second example is that social isolation and loneliness in old age have the equivalent health impact of smoking 15 cigarettes a day. Moreover, loneliness very much slows the rate of recovery. Your Lordships can see where I am going with this argument. I have deliberately chosen two issues that are not directly about healthcare yet the NHS has to pick up the pieces; in most cases it cannot have a direct impact on these issues, although others can.
Sustainability is wider than that, too. If the NHS and social care are the formal healthcare system—and we have heard the figures for what that costs—the latest figures from carers’ associations is that if we were to monetise what carers provide, we would see that they provide about £120 billion worth of care. If you add into that what civil society, volunteers and all the NGOs and so on do, you see that there is a vast informal care system. My point in raising that is that what happens in the informal care system impacts on the formal care system, and vice versa. If the informal care system gets weaker, it puts more pressure on the NHS, and if the informal care system gets stronger, it takes some pressure off it. These are important points about sustainability, and any future commission needs to be thinking about these as well as how to finance the NHS.
A lot has been said about prevention, but we also need to think about this in a different way as being a positive term, sometimes called “health promotion”. It is about the creation of a resilient, healthy population and society. The Minister knows that I have a debate—later in the autumn, I hope—on what I call “health creation”, which is precisely what we are talking about here. There are two simple points here, and I will not go any further: we need to think about sustainability in the round, and the NHS itself cannot make itself sustainable—others have to play a major role in that.
My second point is that looking at financing is right, and clearly we need to chase improved efficiency at every level. However, we should not hope for too much from a review of a new financial model. I will give just two examples from around the world—again, I do not have time for more. Holland changed its system with great fanfare about five years ago so that it consisted of private insurers which then purchased from anybody. The net result of that, which was probably predictable, was that unit costs have gone down and volumes have gone up, and Holland, which now spends 25% more than we do, is spending more than it did. That was an experiment in changing the financial arrangements.
I will not talk about co-payments—that is, getting people to pay as well—other than to say that all the studies show that if they are to be big enough, they will affect both the poor and the rich: they affect the behaviour of the rich, who then go elsewhere, while the poor cannot afford to pay for services. You can have small co-payments, but large ones have those impacts. My point is that we must look at how the NHS is financed—I understand and agree with that point—but we should not hope for too much from what others around the world have done.
My third and final point is that in the short term you cannot take politics out of the NHS. To go back to Holland, the Dutch Government do not directly run hospitals, but the Dutch Health Minister gets all the questions about hospitals in his Parliament anyway. However, we can have a cross-party consensus about the longer term.
I will quote from a Portuguese report—if noble Lords allow me, I will say it in English; indeed, your Lordships may prefer me to do so. Portugal is trying to transition from today’s hospital-centred and illness-based service system where things are done to or for a patient to a person-centred and health-based one where citizens are partners in health promotion and healthcare. It will use the latest knowledge and technology and will offer access to advice and high-quality services in homes and communities as well as clinics and specialist centres. It will provide a better service with lower infrastructure costs. That is Portugal’s aim over 25 years. It will not be difficult for us to construct that sort of consensus and vision about where we are trying to go, but we need to understand that that is a radical change. If we are to have a radical change and we are pointing in that direction, we need a clearer longer-term plan than the five-year plan we have, and we need the sort of transition fund that some people are arguing about.
My final point is that I absolutely agree with the proposal of the noble Lord, Lord Patel, that there should be an independent reframing of the arguments, which will bring other people into the argument so that the same people are not having the same arguments, which has often been the case in the past. To do that, the starting point is to create that shared vision of where we are going, so at least we have something to steer towards, and we need to understand that sustainability is about these wider social impacts, not just about the efficient management of money within the NHS, important as that is.
My Lords, it is a great pleasure to take part in this debate, which was so splendidly introduced by my friend, the noble Lord, Lord Patel. We have had many conversations about this in the early morning in the Truro Room, so I was very confident that he would make a splendid speech, which he did. This is a refreshing debate because it has been marked by consensus. I single out the speeches of the noble Lord, Lord Warner, and my noble friend Lord Mawhinney, both of whom, in slightly different words, made the case for saying, “The time for using this as a political football is over”. We need to work from both sides of the House. No substantial difference of opinion has been expressed so far during this debate, and I hope that I will not depart from that.
When I first entered another place 45 years ago I was a very humble PPS in the Department of Health and Social Security, where a very few Ministers—one in this House, three in the other place—looked after the whole of health and social security. When I reflect on that, I reflect on how far we have moved away from that tight-knit and rather efficiently run pattern. Of course, we now have a much larger population and a much larger surviving population. When I entered the other place I did not have a single constituent with artificial knees or hips, or with a transplant. I even wrote to those who attained the age of 80, which would not be possible now. We have moved on.
As the noble Baroness, Lady Emerton, reminded us, it is well over 70 years since Beveridge, and 67 years since the NHS came into being. The sort of commission or inquiry which has been called for today is therefore desperately overdue. It is not the first time that a commission has been called for in your Lordships’ House. I made the call in earlier debates introduced by the noble Lord, Lord Turnberg, in which the noble Lord, Lord Patel, participated. We need an inquiry or a commission, and I would favour the latter. It must be an open-ended inquiry, with an open agenda. Nothing must be off-limits. My noble friend Lord Fowler made that plain in his speech. All forms of funding must be looked at. We have to have a plurality of funding if we are to have a sustainable NHS. Whether the extra funding comes from compulsory insurances or certain charges matters not, but it has to come—we have to have a quality service that does not lurch from crisis to crisis, from one application of sticking plaster to the next. It is crucial that we attain that.
I have a great deal of confidence because my noble friend Lord Prior, who will answer this debate, was himself very recently a notable and innovative chairman of the Care Quality Commission. I hope that he will bring the experience he acquired in that important role to his role as a Minister in the department. He succeeds a greatly loved Minister in our noble friend Lord Howe. Let us now, freed from the constraints of coalition government, have the sort of boldness that the Chancellor expressed in the Budget speech yesterday. Let us have a commission or an inquiry that will look at every aspect of the NHS and of care, and which will in particular look at funding.
All of us here believe in the NHS. There is not a politician of sense or sensitivity in any party who does not believe that. However, we must not be constrained by outmoded philosophies. We must look at the NHS and at the society it serves, and see what we can do to give it the quality service that will take us through this century and into the next. Today we heard the statistics; we know how many people will develop difficult conditions that need very sensitive treatment, sometimes for years. Many of the problems we talk about today were not problems when I was elected to the other place, because not only did some of the drugs and techniques not exist, but people then would have died long before they needed the attention we are now calling for.
I hope that we will have a positive response from my noble friend on the Government Front Bench and that at the very least he will tell us that he will have serious conversations with the Secretary of State on this. However, if it comes to naught, which I hope it does not, we in your Lordships’ House should establish one of our special committees to look at these issues. I know, looking across and around the Chamber, that we have enough expertise; many of the people who could contribute to such a committee have spoken today. This problem will not go away. It must be addressed, and we must make sure that it is. A commission and inquiry is an idea whose time has come, and we must ensure that it happens.
My Lords, it is a pleasure and a privilege to follow the noble Lord, who has such vast experience in both Houses.
I thank my noble friend Lord Patel for introducing this debate. I think that I have spoken in every health debate that he has initiated. He is quite right to say that there ought to be a royal commission, but I expect that the Government will pour cold water on that. Any royal commission appointed any time soon would report around the time of the next election, and no Government want a royal commission report on their hands when they are trying to fight an election. Perhaps, as the noble Lord, Lord Cormack, said, we will continue this debate—and perhaps all the debates in your Lordships’ House on the National Health Service, collected together in one volume, might by themselves tell us a lot about how to cure the NHS.
As a lot of people have said, there is a consensus that we all love the National Health Service. A number of individual experiences, including those of the noble Lord, Lord Mawhinney, tell us that it is extremely helpful and valuable to our lives. At the same time, in all the years that I have been in this country—more than 50—there has never been a time when people have not said that the NHS is in crisis. We can sustain the National Health Service only by believing that it is perpetually in crisis and that something has to be done about it.
We tend to look at the NHS from the supply side, which involves asking how we can get more money and increase productivity, and how can we reorganise it. Every party reorganises the health service when in power and, when in opposition, criticises any reorganisation carried out by the Government. We have sustained a good National Health Service but, in my view—I have said this before in your Lordships’ House—so far we have not done anything on the demand side. Because we promise to deliver healthcare for free to whomever demands it, we have taken it for granted that all the adjustments have to be on the supply side, not the demand side.
I believe that there are a number of things that we ought to be able to do, as some noble Lords have mentioned, to, as it is called, “nudge” the behaviour of the public who demand healthcare. If there is ever a health commission, it ought to examine how to bring about behavioural change, perhaps by providing incentives to people to change their behaviour. Yesterday, the Chancellor revived the idea of using vehicle excise duty for road building. I had always thought that the Treasury did not like hypothecated taxes but here we have a hypothecated tax. There is no reason why the Chancellor should not tax sugar and salt and link the tax quite explicitly to the health service—even though it would finance only a very small proportion of the costs. We are worried about obesity and diabetes but we do nothing about salt and sugar in food. However, there is absolutely no reason why we cannot do this. We ought to urge the Government to explore things that will influence behaviour.
Another suggestion that I have made before in your Lordships’ House is that, although we do not want anyone to feel that they are being charged for using the health service, we ought to make clear to people the cost of providing it. People think that because it is free, it is costless—but it is not. We often worry about people missing GP appointments, so I propose a sort of health Oyster card for every citizen. Every time they used the National Health Service, they would have to swipe their Oyster card and a certain number of points would be deducted. The Oyster cards could be recharged. At the end of the year, people would get a bill showing how many points had been used and on which health service facilities. If people missed a GP appointment, 15 points would be deducted rather than two—things like that. Perhaps something like that could be done to make it clear to people that a free National Health Service is not a costless one. If we can somehow get people involved as patients and potential patients so that they modify their behaviour in demanding healthcare, it may solve some of the problems of the National Health Service.
My Lords, I, too, congratulate my noble friend Lord Patel on obtaining this debate, yet again confirming his wisdom, his expertise and his commitment to an issue about which I know he cares deeply. As a mere NHS user, I hardly dare add my voice to those of the many experts who are contributing, my only qualification being that, for two years, I chaired the Hillingdon Hospitals NHS Foundation Trust, having my noble friend Lady Flather as one of my non-executive directors.
Before making two points about the sustainability of the NHS, perhaps I may share the first of two wishes. I once worked for a general who banned the use of the words “significant”, “vital” and “basic” because they were merely pejorative and signified nothing. A distinguished psychiatrist said the same, in clinical terms, about the Home Office’s use of the words “dangerous” and “severe” to qualify a personality disorder. If I could ban one word from politics it would be “change”—pejorative for doing the opposite of what the other side did, under the delusion that it is a hallmark of political virility. In fact, change for change’s sake often leads to little more than unnecessary and expensive disruption, particularly when its consequence has not been fully assessed. In the public sector, evolution is invariably a better, or more appropriate, route to improvement than revolution. The debacle following the coalition Government charging ahead with change in their pre-planned Health and Social Care Bill, before examining the books and seeing what was possible or necessary, is a classic example of what I mean. Above all, it flew in the face of the priority plea of practitioners, which is for stability.
Sustainability depends on maintaining and not squandering resources. Quite clearly, the biggest problem facing the NHS is the rising cost of meeting the physical and mental health needs of an ageing population. My first point is that affordability requires the ruthless elimination of anything unnecessary or wasteful, such as silo working when more than one ministry is involved. There are two examples from the criminal justice system. First, I hoped that prisons and probation would be represented on local health and well-being boards, resulting in improved support for offenders. Not only are they not represented on all, but fewer than 20% of clinical commissioning groups realise that they are responsible for meeting the physical and mental health needs of those undergoing supervision in the community. Secondly, expensive lack of co-operation between ministries is exemplified by the Ministry of Justice’s proposal for what it calls a “secure college”, detaining 320 children aged between 12 and 17, the vast majority of whom have mental health or emotional well-being problems, on one site in the middle of Leicestershire, while at the same time NHS England’s Children’s Mental Health and Emotional Well-Being Task Force is piloting a scheme to ensure that such children are kept in their home areas to ensure consistency of treatment. The Chancellor must be fuming.
My second point concerns senseless waste of equipment and drugs. Almost four years ago my wife had four vertebrae fractured in a car accident and had to wear a plastic body brace for some weeks. When she asked the issuing NHS hospital what she should do with it when it was no longer needed, she was told that, because they did not re-use such things in case infection was passed on, she should throw it away. In the event, she was assessed by a consultant in a private hospital, who, on hearing this, asked whether he could have it because it was worth a lot of money and could be used many more times. Only last week I tried to decline a once-prescribed box of pills which I did not need, only to be told by the pharmacist that there was no point in handing it back because, once issued, it had to be destroyed. Individually these may be small items but, aggregated across the country, they add up to a considerable sum which the NHS surely ought to be able to find ways of saving. I hope that the current work of the NHS Confederation, working with other national bodies to explore how to make savings, will demonstrate to the Government the value of an NHS-led approach to this.
One of the qualities that I most admired in the marvellous people who worked at Hillingdon was applied common sense. Sadly, common sense is often a victim of adversarial party politics. That is why my second wish, in the interests of stability and sustainability, is that in addition to the independent commission called for by my noble friend and many others, the future of the NHS should be subject to cross-party consensus.
My Lords, I, too, associate with other noble Lords in thanking the noble Lord, Lord Patel, for this very timely debate.
I have, on many occasions, talked to visitors from overseas who have used the NHS and who have told me how impressed and indeed amazed they were by the fact that the treatment had not cost them a penny. Free at the point of delivery is the bedrock principle of the NHS and admired throughout the world, and I will have more to say about that. This sits alongside the unpalatable fact that it is generally agreed that, by 2020, there will be a £30 billion deficit, in addition to all the deficits running at that time.
I strongly favour a royal commission. Arguably, its most important effect would be to take the NHS out of politics to enable the whistle to be blown, as my noble friend Lord Mawhinney has said—though whether it can remain in that condition is a future challenge for abilities greater than mine. I suggest that its brief should address, among other things, the question of free at the point of delivery. This is not only an admirable ideal in itself but, over the past three or four generations, has come to be regarded as a fundamental birthright. In political terms, frankly, no party would dare to question it. However, with a royal commission, politically unfettered and drawing on many government departments other than health, there appears to me to be a once in a lifetime opportunity to address this issue. I suggest to your Lordships that such a commission would have the unbiased authority that would enable it to address the unthinkable of some form of selective contribution by patients for treatment—the noble Lord, Lord Crisp, has obliquely referred to this—moving towards the ultimate goal of a financially viable National Health Service.
The other point that I hope the royal commission would address has fortunately been answered already by the noble Lord, Lord Kakkar, who made the point of the need to address the national healthcare services in other OECD countries, and the noble Lord, Lord Crisp, has given some examples.
In 2002-03, general practices were offered a new contract—personal medical services—which offered better funding if they undertook more services. Those that took up the new contract tended to be the more entrepreneurial practices. In central London, to take one example, take-up was around 50%. The national policy has been to reduce PMS funding to that of GMS, the pre-existing contracts. I quote a doctor friend, who is one of the people concerned:
“They say that they will return any saving from PMS reviews to the local health area. There is no guarantee that that would substantially make up for lost funding. In one area I know of practices that stand to lose over £400,000 pa, which will cripple them”.
His own practice stands to lose over £300,000—we are talking about west London. He continues:
“At a time when primary care is being promoted as a means of achieving substantial savings, by enhanced and new ways of working, it seems counterproductive to make swingeing cuts in often the most innovative and high quality practices”.
I suggest to your Lordships that this is a very short-sighted measure.
My Lords, I am speaking in the gap because I was not sure that I would be able to stay for the whole debate. I want to make a very short contribution. First, I thank the noble Lord, Lord Patel, who is, if I may say so, the right person, at the right time. He is the right person, because nobody can in any way doubt his commitment to the National Health Service, and it is the right time, because it is outside what has been probably the longest general election campaign, courtesy of the five-year Parliament. That refers to the point people have made about the National Health Service being used as a political football. I do not think that it will ever be taken out of politics, because politics is a series of moral choices about the commitment of scarce resources to infinite demands. But it can be taken out of party politics, and I think that today’s conversation begins to do that.
Let me make my position very plain. First, like everyone else here, it goes without saying that I am committed to the National Health Service, not just ideologically but, like the noble Lord, Lord Mawhinney, for very practical reasons—it saved my life over 50 years ago. Secondly, I am sure that there are efficiencies that can be carried out in the National Health Service. Some have already been mentioned, but I merely mention the fact that, in procurement, even in non-medical areas, there are more than 40,000 people purchasing for the National Health Service and most of them do not know the price being paid for a particular commodity by the person sitting next to them—the other 40,000. In an age where we can “compare the market” for everything and of one-click purchases through Amazon, it seems to me incredible that that is the position in the National Health Service.
Thirdly, I am not one of those who is opposed to the use of outsourced private services. I think that a diversity of suppliers, where appropriate, is a good thing—again, that is not just ideological, but because it was central to reducing the huge waiting lists, which were mentioned earlier, and waiting times. The provision of that range of services, appropriately used, can be efficacious in removing the pain of people who had to wait in pain for so long. However, I do not believe that the solution lies in an insurance-based system. Witness the fact that 10 years ago, when I was Secretary of State, we were spending 6% or 7% of GDP, going up now to 9%. In the United States, at that time, they were spending 17% or 18% of GDP on the combination of a private-based and supplemented system—it will be even more now with Obamacare—and over 20% of that went on bureaucracy. We have to get the balance right.
Having said all that, the real issue is that the betrayal of the National Health Service does not lie in addressing the fundamental challenges; it lies in ignoring them and hoping that somehow this will go on sustainably and indefinitely, with a hugely increased demand. We all know why that is happening. There is an increased population, people are living longer, diseases and illnesses will become more chronic, and new treatments and technologies will be invented every day, all at a cost and rate that is above inflation. As I say, I believe that if we are committed to the National Health Service, our duty is to address this question in the long run, not to avoid it. That is why the noble Lord, Lord Patel, has opened a conversation today that does us and the National Health Service a service.
My Lords, this has been an excellent debate, so ably introduced by the noble Lord, Lord Patel. It is quite clear that the NHS is a national treasure and something that is dear to the hearts of all noble Lords. The principle that it is free at the point of need is something that all political parties continue rightly to support.
Every one of us has cause to be grateful to the men and women from all nations who work in the NHS. We rely on their skills and knowledge, and those from abroad contribute enormously to it. That is why I start by asking the Minister whether he will work to persuade the Home Secretary that her determination to send home some foreign nurses who earn less than £35,000 per year is unjust and detrimental to the NHS and the people of this country.
The prediction is that costs in the NHS will rise at 4% per year, and more and more health trusts are going into deficit, as we have heard. Yet voters are reluctant to pay for this from either raised taxes or cuts in other public services—hence today’s demand for a royal commission, which I support. The Government’s Five Year Forward View needs to act as a catalyst to create new models of delivering care that are better suited to modern health needs and promote more efficient use of NHS resources, contributing to a more sustainable health and social care system.
I think of the NHS as an inflatable bucket with a hole in the bottom. It is impossible ever to fill up such a device with enough money. It is inflatable because the demands on it are constantly growing as we live longer and the birth rate increases. Life expectancy is going up. The number of those aged 65 to 84 will increase by more than a third in the next 20 years, and the number of those aged over 85 will double—I hope to be one of them. In addition, with ever more wonderful developments in treatment, there are more demands for them to be available for patients, but they are usually very expensive.
The hole in the bottom of the bucket is the fact that as we learn to treat, and even eliminate, certain diseases, other preventable diseases are increasing in prevalence because of our lifestyles. Even though the Chancellor promised more money for the NHS in his Budget yesterday, there will still not be enough unless we stop up the hole in the bucket. So I think there are three watchwords: integration, innovation and prevention—the demand side referred to by the noble Lord, Lord Desai.
On prevention, we need to get people to take more responsibility for their own health—the noble Lords, Lord Patel and Lord Crisp, called for that—and support them in doing so. We need to ensure that young people and their parents understand what a healthy lifestyle looks like and are given the means to live it, with exercise facilities, access to fresh, nutritious food, and warm, dry homes. We need to eliminate child poverty, since poverty is the major factor leading to the health inequality which decreases lifetime opportunity. We need health education to be carried out well in all schools, and public information and treatment programmes so that those adults who missed out on such education can still get the message.
Public information programmes work well—one only has to look at the public information programme on HIV set up by the noble Lord, Lord Fowler, all those years ago to understand how well. In Australia, you cannot move without seeing information about protecting your skin from the sun and skin cancer. We could do with one of those campaigns here. Such programmes are also cost effective because many preventable diseases cost a great deal of money. Smoking costs the NHS £5.2 billion every year, but smoking prevention programmes and anti-bullying programmes in schools can return as much as £15 in savings on physical and mental health for every £1 spent. Obesity costs the NHS £4.2 billion per year and lack of exercise costs it £1.1 billion per year, according to the King’s Fund. Yet despite the fact that every £1 spent on free use of leisure centres returns £23 in reduced NHS use, quality of life and other gains, many local authorities are having to close centres rather than give free access to them. Musculoskeletal problems such as back pain and arthritis are the most common conditions that limit people’s daily lives and the largest single cause of loss of working days. They affect 8.3 million adults in England. Some, but not all, of these problems are preventable by keeping to a healthy weight and taking moderate exercise. The costs to society of poor air quality, ill health and road accidents induced by road transport exceed £40 billion per year. It has been calculated that getting one more child to walk to school can save £768. All these things can be done fairly cheaply and prevent a lot of burden on the NHS.
Most of these preventable diseases are focused on by local authorities in their public health programmes, so I ask the Minister whether any of the extra billions of pounds for health services announced by his colleague the Chancellor yesterday will go towards prevention in the form of the vital public health programmes run by local authorities and schools. A short-term approach which reduces prevention activities, such as we have recently seen, will have a longer-term impact on healthcare services in the future, putting additional and avoidable costs on the health and social care system. Cardiovascular disease is a good case in point, where obesity and lack of exercise cause a great many of the 33,000 premature deaths from that disease every year. Here we see another problem. According to the British Heart Foundation, there is wide variation in both access to and quality of care for patients across the UK. This is of particular concern given the range of evidence-based interventions, commissioning guidance and NICE guidance that exist but which are not universally adopted across the system, resulting in suboptimal care and avoidable use of NHS resources. Significant opportunities to identify and optimally to manage patients are too often missed. Think how much could be saved if the worst lived up to the standards of the best.
Prevention also includes vaccination and screening programmes. There is good news and bad news here. There are still parents who are reluctant to have their babies given the triple vaccine and the measles vaccine despite all the reassurances that have been given by experts, and we now find that whooping cough and measles are rising again. I was shocked to hear that the very good uptake of the human papilloma virus vaccination has recently fallen. This is a group of completely preventable diseases, so what are the Government doing to encourage all teenagers to have the vaccination?
I heard a bit of good news at a presentation in your Lordships’ House recently. I was told about plans for a bowel scope screening programme for all 55 to 64 year-olds. The pilot schemes have shown that this reduced people’s chances of developing bowel cancer by a third and reduced the death rate from this disease by 43% because of early diagnosis. This has the potential to save the NHS £300 million each year plus great human misery. Can the Minister say when this programme will be rolled out across the country and whether it will become available also for those over 64? The breast screening programme has also saved many lives, including mine, but it ends at age 70. Given that we are all living longer, are there any plans to raise the cut-off age for routine screening?
Prevention also requires patients to be vigilant about their own health and to go to their GP promptly if they are worried about symptoms. It then requires GPs to recognise the signs and refer people to specialists as soon as possible. Some GPs are reluctant to do this until they have commissioned more tests, but this could cause serious delay to those with disease, on the one hand, and waste a lot of needless tests, on the other, where a specialist might have recognised right away which patients needed tests and which did not. I refer particularly to skin cancers, where it can be difficult for the non-specialist to distinguish the benign from the dangerous.
Early diagnosis is, of course, both a life saver and a money saver. However, it is worrying to note that the uptake of NHS health checks is currently at a disappointing 48%, well below Public Health England’s target of 66%. Some diseases are estimated to be grossly under-diagnosed. For example, four in 10 adults with hypertension, estimated at more 5 million people in England, are currently undiagnosed. This is a preventable killer disease which responds well to treatment and lifestyle changes, so we need to get on top of this under-diagnosis.
I am pleased that the Government plan more support for British scientific and medical research. Britain has the potential to lead the world in the discovery of new personal genomic treatments which match the patient’s DNA with new drugs. As an integrated healthcare system with tens of millions of patient records, the NHS is well placed to exploit the immense potential of genomics. But these treatments have many barriers to breach before they reach the patient, and we know that the United States has a much better track record when it comes to approvals of new drugs. So I would like to hear from the Minister about the progress of the accelerated access review which was initiated in response to this situation by his noble friend Lord Freeman but about which I have not heard much recently. Can the Minister tell the House what progress has been made on that?
My Lords, as we are touching on procurement, I declare an interest as president of GS1 and the Health Care Supply Association. I, too, warmly welcome the debate of the noble Lord, Lord Patel, and the excellent way that he put forward his arguments. Of course, the issue of sustainability has been asked almost every year since the NHS’s formation in 1948. Right from the start, voices said that public expectations were too high and called for explicit rationing of services. We know that almost as soon as the NHS was established, our friends in the Treasury were keen to see the introduction of charges. Indeed, in the early 1950s, charges for spectacles, dentures and then prescription charges were introduced. This was followed by the 1953 Gillebaud commission. At the time, it was thought that NHS costs were spiralling out of control and Gillebaud was asked how we could reassert control over NHS spending. In fact, he came to the conclusion that there was a popular misconception about a vast increase in costs and ended up recommending a big increase in capital expenditure.
Through the years, we have had many other reports. Harold Wilson in opposition did not think much of royal commissions. He famously said that they took minutes and wasted years. But he was very fond of them in government and set up a royal commission on the NHS. Interestingly, its brief included the possibility of a greater reliance on other means of funding the NHS. But it was not convinced of that, and said that the claimed advantages of insurance, finance or substantial increases in charges—or co-payments, as we now call them—would outweigh the disadvantages in terms of equity and administrative cost. Mrs Thatcher had another go. Patrick Jenkin set up an internal review to look at the sustainability of the NHS, with potential restrictions of coverage, but it never published the results and no change took place. Now again, we are debating the sustainability of the NHS and the suggestion that a royal commission should be established.
I do not doubt that the challenges put forward today are formidable, but I agree with my noble friend Lord Turnberg that the NHS is still sustainable. For all the problems that we face, the US Commonwealth Fund’s analysis of the NHS two years ago, on comparative terms, as the number one health system in the world at least gives us some confidence that we have something that is worth preserving—albeit one that needs developing as we try to deal with some of the issues that noble Lords have raised.
That does not underestimate the financial gap and the productivity challenge facing the noble Lord, Lord Prior, in his new responsibilities. We talked about the £30 billion gap by 2020. We have heard the forecast from NHS England that if we achieve a 2% to 3% per annum rise in productivity, we could reduce that to £8 billion. The Government have promised that £8 billion, but I doubt that it will be seen until the 2020-21 financial year, judging by the documents published alongside the Budget yesterday. We know that historically the NHS has achieved a 0.8% productivity gain, so that would make the gap £21 billion and not £8 billion. More recently, in the last Parliament, there was a 1.5% productivity gain, but that dipped in the last two years because of the post-Francis impact of increased staffing and, because there had been cuts in training commissions, agency costs spiralled out of control.
Then we had the report of the noble Lord, Lord Carter. My noble friend Lord Reid is quite right: clearly, in relation to procurement, there is money to be got. But even if we implemented the whole of the Carter report, which includes some brave decisions about the employment of staff midweek on wards, it would produce only £5 billion. Put all that together and clearly there is a big gap. Last year provided deficits of £822 million: this year they are projected to be £1 billion.
Alongside that, the Government are actually increasing demand rather than discouraging it. Understandably, more people want access—but 24/7 access? The NHS Choices website is always encouraging people to use the service more and more. It was right for my noble friend Lord Desai to ask the noble Lord about the tension between this desire to give greater accessibility and the issue of demand management. We are reaching a difficult point where the two are not deliverable.
I hope that the Minister will say how he thinks productivity will be improved, but another issue that is vitally important is the quality of management and leadership in the NHS. The challenge is daunting: the productivity gap, the move to seven-day working without the use of agency staff—let alone health and social care integration. At the same time, we know that at the moment performance is deteriorating. Clearly, we need the best possible managers and leaders. I am sure that the Minister has read the Health Service Journal report on leadership, chaired by Robert Naylor, which came out last month. It said that a third of trusts have either vacancies at board level for key leaders or were employing highly expensive interns. There is a 20% vacancy rate for financial directors and chief operating officers. One in six trusts has no substantive chief executive. One in 10 has retained the same CEO for more than a decade, but the median time in post for a trust CEO is a mere two and a half years. One in five CEOs has been in post for less than a year.
“has a chilling effect on the willingness of chief executive officers to take bold initiatives and encourages a passive and responsive culture”.
In other words, the fact that chief executives are in fear of losing their jobs encourages the kind of culture that will make sure that we cannot deliver the productivity challenge. I agree with my noble friend Lord Warner that there is no chance whatever that the Government will get to 2020 with a 3% to 4% productivity gain with the current culture—a blame culture with incessant interference by the regulatory bodies and supervising bodies into the work of NHS trust chief executives
I know that the Minister has huge experience—apart from CQC, he chaired a highly successful trust in Norwich, Norfolk—and I know that he understands this. At heart, Ministers set the tone and culture. I appeal to him to start to change the culture. He will have to put much more trust in people in the field to achieve this change. Of course we have to intervene, as my noble friend Lord Warner said, when an organisation is clearly failing, but if we carry on the way we are doing at the moment we will simply not achieve what we need to achieve, and I believe that the health and social care system will fall over.
I know why noble Lords wish to see a royal commission established—on the face of it, it is very attractive. But I sound a note of warning. My experience of the NHS is that the moment you set up a committee of inquiry, it is always used as an excuse to put off difficult decisions. In a sense, we have in the Five Year Forward View a challenging and agreed programme—agreed by almost everybody—for the way forward. If a commission were established, it would have to be clear that its remit accepted the five-year forward plan as the way to go. I fear the killing effect of a royal commission that took two years and then a Government taking another two years to make up their mind about challenging funding issues such as co-charges. We have already had the Barker commission, set up by the King’s Fund, which went into most of the issues that noble Lords raised.
At the end of the day, I agree with my noble friend Lord Reid that the political process will always come to the fore. The sustainability of the NHS ultimately depends on political will. In the end, it is down to Governments to make sure that the NHS provides what the public want. Do the public want the NHS to be sustained? Yes, they do.
My Lords, I thank the noble Lord, Lord Patel, for introducing this fascinating debate, which has covered a very wide range of subjects. I hope noble Lords will forgive me if I do not address all their questions; I may not even be able to refer to all of them by name. That is not because I did not note what they were saying but because there is just not enough time to go into what they said in detail. I do have a speech here but I am putting that to one side because I do not think it does justice to the issues that were raised today. I have some notes here instead. I will come back at the end of my speech, if that is acceptable, to discuss whether or not there should be an inquiry and, if so, what kind of inquiry or investigation it should be.
I have a reputation at the Department of Health for being a bit of an Eeyore character because we often hear about great changes that are going to happen in the NHS but they never quite materialise. Perhaps we should stand back from the NHS for a minute. Every healthcare system in the developed world is facing almost exactly the same issues of sustainability that have been posed in the debate today. Most extreme is probably the United States of America, where healthcare accounts for over 16% of GNP. I worked in America for some time in the 1970s and I saw the cost of healthcare, which was largely loaded on to employers, literally destroy large parts of the steel and car industries. We may wish to explore alternative charging systems or different funding systems, but just moving the cost away from the state—from taxation—to insurance has not actually solved very many problems.
Ironically, perhaps, in the light of today’s debate, the NHS is probably one of the most affordable healthcare systems in the developed world. It consumes between 7% and 9% of GNP. In Germany and France, healthcare takes between 10% and 12%. We are about average across the OECD countries but among our peers we have a relatively cheap and successful healthcare system. I was talking to people from the Mayo Clinic recently and they rate the British system as the highest-value healthcare system in the world. So we should not get too depressed about the NHS. Noble Lords have referred to the Commonwealth Fund report, Mirror, Mirror on the Wall. In every category bar one the British system is first, and that is comparing it with all the other best healthcare systems in the world.
As my noble friend Lord Mawhinney pointed out, in 1947-48 we were spending 3.5% of GNP on healthcare—£400 million in the first year—and employing a few hundred thousand people. Clearly, since then the resources going into healthcare have expanded exponentially, and will continue to grow. The demographics, the cost of new drugs and procedures, and rising consumer expectations will drive that increase. We have heard a lot today about the importance of early prevention. That is an area we ought to explore further. As the noble Lord, Lord Crisp, mentioned, that kind of assessment should go well beyond traditional health topics.
These pressures are common to all developed systems. It matters not how you fund the system, the pressures will still be there. My noble friend Lord Fowler was not impressed by the mention of Derek Wanless. I will quote just one small part of his report. He concluded that:
“Private funding mechanisms tend to be inequitable, regressive … have weak incentives for cost control, high administration costs and can deter appropriate use”.
If the noble Lord does not like Wanless, I will quote him the recent OECD report, which is only months old. It says that,
“no broad type of healthcare system performs systematically better than another in improving the population’s health status in a cost-effective manner”.
There is at least no evidence to suggest that a tax-funded system is less effective or efficient than any other system. Indeed, tax funding allows the collective pooling of financial risk across the whole population for collective benefit. It is this pooling of risk that makes the NHS probably one of the lowest-cost systems in the world. I see that the noble Lord, Lord Lawson, has just arrived. That reminds me of his quote:
“The National Health Service is the closest thing the English have to a religion”.
Actually, you do not need just belief to think that the NHS is an efficient system—there is plenty of evidence as well.
The real question is: which healthcare systems are best equipped to beat this rising level of demand over the long term? In most industries, the forces of change that have driven productivity improvement—because in the long run everything depends on productivity improvement—have been driven by globalisation, by competition, as the noble Lord, Lord Warner, mentioned, and by consumer choice. But those drivers are weak in healthcare. The previous Labour Government tried to bring in more competition and a lot more private sector involvement. They would probably have to admit that they were disappointed by the impact. Actually, the market does not work as well for healthcare as perhaps they would have wished.
The market does not work so well in healthcare—in any country—because there is information asymmetry in the market: the patient will always be less well-informed than the professionals in the system. It is difficult to measure the quality of care. Even in a very transparent system, as we are moving to in this country, it is difficult for patients to determine which professional in which hospital is delivering the best care. It is very difficult to assess relative quality across providers when systems are so complicated. The market structure is difficult. Inherently, there will be natural monopolies, which limit choice and competition. You cannot have two or three A&E departments operating in close proximity. There are very significant barriers to both market entry and exit. Finally, of course, there is the nature of the good itself. It is very hard to rectify things—you cannot just “send it back” when you have experienced death or serious harm in a hospital. The market will always be limited in healthcare.
How are we going to get these improvements? How are we going to drive the kind of productivity improvement we need in the health service in the absence of a market? This is the crucial question as to whether or not our system is sustainable. If we are not able to get the productivity improvements set out in the NHS Five Year Forward View, the sustainability of our system is very much in question. The answer that we are supporting in the five-year forward view is multifaceted. We want to see new models of care.
The noble Lord, Lord Turnberg, gave an interesting example of how in his own speciality of gastroenterology the tariff structure can lead to completely the opposite result to the one that was intended when the tariff was introduced. The only answer to the question that he posed is a much more integrated structure, where capitated payments are made and there are integrated models of care. The days of the stand-alone acute hospital are gone—if they were ever there. No man is an island; no acute hospital is an island. There may be a few hospitals—perhaps in London or Cambridge—which have tertiary and teaching income and can plough their own furrow, but I would argue that the vast majority of acute hospitals must integrate much more with their local healthcare and social care systems.
A number of noble Lords pointed out the deficits that are currently mounting up in acute trusts. It is interesting that it was a Labour Government who introduced foundation trusts. Perversely, although it was not the intention at the time, foundation trusts make it more difficult to integrate. Rightly, in many ways they are obsessed with their own profit and loss accounts and balance sheets and are unable to look more broadly across the system. We will see new models of care.
The noble Lord, Lord Reid, a former Health Secretary, made reference to purchasing. In his review, the noble Lord, Lord Carter, looked at purchasing, workforce, patient flow through hospitals, medicines management and estates. The review has looked at the whole spectrum of where cost savings could be achieved, and has come up with a figure of approximately £5 billion. That figure is small in relation to £22 billion, but the noble Lord went on to say in that interim report that he believes there are many more savings to be had from getting better patient flow through the system. He has drawn attention in various meetings to the fact that some 20% of patients who are medically fit to be discharged are still in hospital beds. That goes back to the issue of better integration. If we can crack patient flows through the system, I am sure that the productivity benefits will be substantial.
I am not as pessimistic as other noble Lords who think we cannot make those savings. The noble Lord, Lord Desai, talked about the demand side, which we have to address as well. Through a combination of supply-side and demand-side measures, we have a good chance of achieving the kind of savings set out in the Five Year Forward View. There is considerable consensus around that document. Although the Labour Party did not commit itself during the lead-up to the election to the extra funding required, there was certainly concern on the Liberal Democrat Benches and on our side—and I suspect on the Labour side as well. It would be a great pity if we were to ask for another review now, when we have considerable consensus around the Five Year Forward View.
The noble Lord, Lord Patel, raised the fundamental issue of the balance between the state taking responsibility for healthcare and individuals taking responsibility. We have often been long on rights and short on individual responsibilities. Other noble Lords have mentioned alcohol, smoking, diet, exercise and personal responsibility. That issue would benefit from more debate. There is a social contract between the state and the citizen—a contract which often seems to be very one-sided.
There is a strong moral argument for the NHS. In the latest opinion poll on the question whether people wish to have a tax-funded system, free at the point of use, providing comprehensive care to all citizens, about 90% of people were in favour of what we have. To some extent you can phrase the question to get the answer you want; however, it is remarkable that a state-run monopoly, after some 70 years, still has the degree of public support that the NHS has. To some extent, we tinker with the NHS at our peril. It is one of the only institutions we have that provides the same care—or service—to rich and poor, the lucky and the unlucky, to people born with a good genetic inheritance and those who are not. It is part of the glue that holds our society together, and I would not wish to be responsible for weakening those links. So, we have to be very careful in the messages that we give out as politicians.
However, I have listened to the debate and the strength of feeling about whether we should take a longer-term view that goes way beyond this Parliament. The sustainability of the health service is an issue that extends out 20 years, probably, but it is one that every developed country faces. I would like to meet the noble Lord, Lord Patel, and maybe two or three others, to discuss this in more detail to see whether we can frame some kind of independent inquiry—I do not think that it needs to be a royal commission. We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund. The issue is: what will the long-term demand for healthcare be in this country in 10 or 20 years’ time? Will we have the economic growth to fund it?
At heart, our ability to have a world-class health system will depend on our ability to create the wealth in this country to fund it. I am personally convinced, having looked at many other funding systems around the world, that a tax-funded system is the right one. However, if demand for healthcare outstrips growth in the economy for a prolonged period, of course that premise has to be questioned.
In conclusion, perhaps I might address issues such as whether there should be an independent inquiry with the noble Lord, Lord Patel, after today’s debate. I thank all noble Lords who have contributed to the debate for raising some very important issues.
I thank the Minister for his response, and I am encouraged by his last comments. A 10% gain is still a gain—I would not have expected him to agree. By the way, I did not use the words, “royal commission”. I asked for an independent commission. I understand why political parties may not like the idea of a royal commission, but I am encouraged by what the Minister said.
I am grateful to all noble Lords who have taken part. It has been an excellent debate and the stature of those who have spoken indicates the interest in the subject. I do not think that the matter will be left today, just for another debate. I have to say to the noble Lord, Lord Hunt, that I get the feeling that political parties want to keep the health service in some trouble all the time, so they can use that for the next election.