My Lords, I am extremely grateful for the opportunity to open this debate and delighted that so many noble Lords have agreed to speak. I very much look forward to the maiden speech of the noble Baroness, Lady Watkins of Tavistock. I am only sorry that speakers have only three minutes to express their views.
It seems entirely possible that one or two noble Lords might draw attention to the parlous state of funding of the NHS. They may even echo Matthew Parris when he wrote:
“Our health service is heading, if not for the rocks, then for the sandbank of chronically sub-optimal performance and monthly threats of insolvency”.
It is tempting to say that this cannot go on. But of course it always does, because of the people in it—the nurses, the doctors, the physios, the porters and so on—who work their socks off to do their very best, despite the lack of resources. They regard it as a privilege to work in a service that aims to care for people and their ills, as indeed did I during most of my working life. When the NHS works well, there is nothing quite like it and the public know that. But when staff morale is at a low ebb, as it certainly now is, and when we have a Secretary of State who seems quick to lay blame but is quite incapable of showing the least sign of appreciation of the staff, then that impacts directly on patient care.
I would not want to be ungrateful for the bit of light relief provided by the Chancellor in the recent spending review, even though that was partly achieved by robbing the budgets for public health, education and NICE. It is hard not to feel, as do the Health Foundation and the Nuffield Council, that this is just another emergency bailout—a temporary fix—when the basic underfunding continues apace as the NHS tries to cope with an ever increasing demand. Having said all that, I hope that I do not disappoint the Minister if I say that I will not be taking that line, at least not yet. What I want to do is to lay out what would be an ideal system for providing total care for the population in the community and in hospital. None of what I say will be entirely foreign or original. Perhaps you know what they say about originality: it is the art of concealing your sources. My sources will be obvious.
The ideal service would have to be completely joined up, with social services, general practice and hospital care integrated. That is so often talked about but rarely achieved because it requires the integration of management and, often, the budget. The silos of primary and secondary care would disappear as GPs were able to work as a team across the divide, in and out of hospital, perhaps even under the same management. This may be a pipe dream, and many—perhaps most—GPs would object, but enough may see the advantages, especially now when they are under such unsustainable pressure that so many are thinking of giving up. Health visitors and district nurses, as well as social workers, could be employed by the hospital so that they could be completely integrated. They would be able to see their patients in hospital as easily as in general practice and the community, without this delaying referral system we have set up.
We had a debate before Christmas about the problems of the care home sector. A number of significant private providers are threatening to go out of business with the potential loss of a large number of care home beds. Currently, about one-third of acute hospital beds are already occupied by patients who would be better cared for in the community. Even more pressure may be put on those beds as care homes are lost.
Would it not be much better if hospital trusts opened their own care homes? A bed in their care homes would cost them about half what a hospital bed costs them, and the trusts would save money and beds—a no-brainer, you might think. Your Lordships may ask where these care homes might come from, but most trusts have obsolete stock that could be rescued, and what about the homes that private providers may vacate? It would need a little capital, but the potential rewards are enormous.
What about those isolated mental health services? At the moment they are far from providing the equity of esteem with physical illness services that everyone talks about. Would they not stand a better chance if they were more joined up with other health services?
There are two other elements in this brave new world that I should touch on briefly. First, why do patients who need to be checked up from time to time by their consultant always have to spend hours travelling to and from the hospital and waiting to be seen? Consultants and patients have telephones, for heaven’s sake. We could do much more if we could get round the tariff system that rewards hospital trusts for out-patient visits but not for telephone calls. The noble Lord, Lord Prior, and I have discussed this before. We are making nowhere near enough use of IT, the internet, remote monitoring devices built into vests and so on. Patients deserve much better.
The other area I should briefly mention is medical research. I should express my interest here as scientific adviser to the Association of Medical Research Charities, which puts around £1.3 billion a year into research. Research should underpin our integrated NHS, and we must take advantage of our excellent basic research capacity and link it with our unrivalled access to the whole NHS population. It is worth remembering that about 50% of our increasing lifespan is the result of advances gained from research.
I suspect that noble Lords will have noticed that much of the full integration I have described requires local authorities and hospital trusts to agree to a single management system and, where possible, a merged budget. That is something that has eluded successive Governments for ever, it seems. What about the idea of patients being given their own personal budgets, which could ease the transition? Perhaps the Minister could say where we have got to with that.
It is not difficult to see why there is resistance. Social services and GPs are reluctant because they see their precious limited resources being used to prop up the hospitals, while the hospitals have historically seen themselves as providers of acute care and only reluctantly as having a responsibility to the community. It does not help when both are financially squeezed. So is it an impossible dream? It seems to me that we do now have an opportunity to go some way along that route, with increasing recognition by all parties that they cannot go on as they are. It will be difficult, but I did not just dream up these ideas.
We have had excellent example of good practice around the country in Torbay and a number of other places for ever, it seems. But most of my ideas have emanated from Salford Royal Hospital, where David Dalton, its chief executive, has already set up much of this integration and has agreement for more. Here I must admit to some pride in speaking about that hospital, because it is where I spent most of my working life as a professor and consultant. It used to be called Hope Hospital, and has obviously taken advantage of my leaving to do great things.
The hospital trust has been employing its own health visitors for some time. It even has two general practices in its employ, one providing out-of-hours services and the other with responsibility for looking after all the residents of care homes in Salford—both in addition to their normal practice.
Incidentally, all 49 of the other general practices in Salford are linked into the hospitals electronic case records system. The hospital is now virtually paperless, and GPs and hospital staff have access to all the clinical information about their patients wherever they are. From April this year, agreement has been reached between the trust and the local authority that adult social care, including domiciliary and residential care, will come under the trust’s management with a merged budget—remarkable. Perhaps equally exciting is the fact that the mental health trust will in April be contracted through the new single integrated care organisation, a chance to see much better cohesion between mental and other services.
Salford Royal no longer sees itself as simply a hospital but as part of the community for which it provides for the health and care of all of Salford’s 250,000 residents. All those remarkable developments have been possible only because of inspired leadership in both the trust and the local authority, and it has taken many years of patient negotiation between them, and much legwork with the GPs. Salford is of course a nice, circumscribed, if deprived city which sees itself as progressive, and it has the big advantage of having just one CCG.
None of that has required another health Bill to reorganise or, as Ray Tallis has put it, to redisorganise the service. I have lived through no fewer than eight NHS Bills during my 16 years in this House; that is one every two years, and we certainly do not need any more. I have spoken about the Salford experience because that is what I know best, and it may well not be replicable everywhere else, but Sir David Dalton’s report for the Government of a year ago presented a series of different ways in which closer integration has been able to occur. It does not have to be the hospital trust that manages the budget. It could, for example, be some form of unified joint management system. Much more important is inspired and inspiring leadership—not available everywhere, I fear. It has been that leadership that has produced the essential elements of team-working together, with all members feeling appreciated for doing a good job. That is something that the Government could take to heart.
We have heard about the 25 so-called integration pioneers that NHS England talked about last year. Can the Minister update us on them, and on the pilot schemes in east London announced recently? Then there is the much heralded devolution of budget to Greater Manchester, of which Salford is of course an important part. That is clearly the route that the Government want to take, but therein lies the rub. First, in devolving responsibility, the Government get themselves off the hook if things go wrong. That is what devolution means.
Secondly, merging two inadequate budgets by itself may improve efficiency but is unlikely to be sufficient. It would be a huge blow to the Government’s devolution agenda if Greater Manchester failed for lack of funds. It would mean a big step back for the integration that we desperately need and would put off anyone else thinking of taking the same route. It is inevitable that money must come into it, and, to their credit, the Government have recognised that and have now agreed to provide transitional funding for Greater Manchester of £450 million over four years—just over £100 million a year. Whether that will be sufficient remains to be seen, but it is undoubtedly helpful and should be welcomed.
Although it is good to know that the Government are aware of the need for some temporary funding, there remains the more serious, longer term sustainability of the NHS and, in particular, social care. Almost everyone recognises that the UK spends one of the smallest proportions of GDP on health of almost all European countries: about 6.5% of GDP, compared to an average within the EU of about 9% or 10%. Social service funding is even worse off. All of that is in the face of increasing demand from an ageing population and a frightening increase in the number of patients with dementia. Almost every day we read in the papers of yet another failure or crisis.
We can become more efficient, and I have tried to indicate one way that we might be able to do just that, but short-term injections will not be the solution. We must find a way to provide a more sustainable level of funding to bring our services up to the standards of our neighbours in Europe. It is true, as Mark Britnell describes in his book, In Search of the Perfect Health System, that nowhere in the world has a perfect system, and many Governments struggle. But that is no excuse for starving our own service and having to accept an increasingly inadequate level of health and social care. If we are to gain the advantages of integration that we can clearly see in a few places, we must have the sustainable resources to do it. Of course, there is a separate debate to be had about how we fund our health services, which is something for cross-party discussions, royal commissions and so on, and I do not want to get into it today, although I suspect that other noble Lords may do so.
Meanwhile, the Government must get into the habit of valuing their staff and not blaming them; they must try to show that they are supporting and not confronting nurses and doctors all the time. I am sorry to end, as I started, by decrying the low level of government funding and criticising their attitude to NHS staff, but I do so only against the background I described of what it is possible to achieve by an efficient system of integration. Mark Britnell in his book finds that the most important reason why people are proud to be British is the NHS. Its fairness and accessibility to everyone, regardless of ability to pay is a precious resource, and we must not let it fail.