National Health Service (Mandate Requirements) Regulations 2017 - Motion to Regret

– in the House of Lords at 7:39 pm on 6th September 2017.

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Moved by Lord Hunt of Kings Heath

That this House regrets that the National Health Service (Mandate Requirements) Regulations 2017, and the associated Mandate to NHS England, do not require that in 2017–18 NHS England meets its obligation to ensure that 92 per cent of patients are treated within 18 weeks of referral; believes that failure to meet this target is a breach of the rights of patients outlined in the NHS Constitution and of the statutory requirement laid out in the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012; and calls on Her Majesty’s Government to publish the advice they have received on the legality of their actions (SI 2017/445).

Photo of Lord Hunt of Kings Heath Lord Hunt of Kings Heath Shadow Spokesperson (Cabinet Office), Shadow Spokesperson (Health), Shadow Spokesperson (Education)

My Lords, I am moving this Motion because I believe that NHS England is failing to comply with its statutory requirement to ensure that a minimum of 92% of patients wait no more than 18 weeks for treatment from their day of referral. I believe that the Government are clearly complicit in that failure.

Governments often drop inconvenient targets when they are not being met but it is a little more unusual to see them airbrush one out of existence without any public acknowledgement, let alone report to Parliament, as has happened with the 18-week wait. This is one of the key targets for the NHS. It is important for patients to be treated promptly, and the target is also important as an overall barometer of the National Health Service, which is reeling from underfunding, rationing and a Government who are intent on wilfully letting standards slip.

Why have the Government allowed this to happen? Surely it rests with their lamentable failure to deliver on the key standards set out in the NHS constitution. We should look at their record. The current four-hour maximum A&E standard has been missed for the past three years, with performance deteriorating every year. The 62-day maximum treatment wait for cancer has been missed every year since 2013-14. As for elective care, the 18-week standard has not been met now for 16 months. Therefore, the Government are so lacking in confidence that they have just decided that they will drop one of the targets. This first came to light in March when, in unveiling his progress report on the five-year plan for the NHS, Simon Stevens, NHS chief executive, admitted that patients can expect to face,

“longer waits for operations such as knee and hip replacements in a ‘trade-off’ for improved care in other areas”.

The Government have been rather coy about this but the reality is that, behind closed doors, they agreed with Simon Stevens effectively to downgrade the 18-week standard. However, they forget to tell Parliament and the public that they had done so. Remarkably, there is no reference to that in the regulations we are debating tonight. The mandate for 2017-18 is equally silent on it. It is true that on page 19 of that mandate there is reference to the 18-week wait as a goal for 2020. But when you look at the list of deliverables for this financial year, it is completely missing. All we have, on page 20, is a vague reference asking NHS England to “meet agreed standards”. We should compare that with the 2016 mandate which says that NHS England is “required” to meet the 18-week referral for treatment standard.

Let us go back to the NHS England document of 31 March this year, Next Steps on the NHS Five Year Forward View. Chapter 7, on page 47, states that,

“over the next couple of years, elective volumes are likely to expand at a slower rate than implied by a 92% … incomplete pathway target”.

Those are wonderful words, which basically say that NHS England has dropped the 18-week target. Everyone in the NHS knows that to be the case. Not only is that letting NHS patients down, I believe that NHS England and the Government are in breach of their statutory responsibilities. The key standards are pledged in the NHS constitution and are backed up by legislation imposing a duty on NHS England to meet maximum waiting time standards. I refer noble Lords to Regulation 45 of the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012, which is headed, “Duty to meet the maximum waiting times standards”.

In July 2015, the Government explicitly stated that the NHS constitution,

“reflects a series of fundamental standards, below which care must never fall”.

Part 3 of the handbook to the constitution states a number of rights, including the right to start consultant-led treatment within a maximum of 18 weeks from referral for non-urgent conditions. Therefore, it is my view that NHS England and the Government are required in statute to seek to achieve the objects that have been laid down, including the 18-week standard. The 2017 mandate that we are debating tonight does not include the 18-week target as a list of deliverables or requirements in 2017-18. The question to the Minister is why? I put it to him that the Government essentially agreed with NHS England to fail in its statutory duty to uphold the 92% referral for treatment target.

Lest the Government hide behind the non-urgent nature of these operations, I remind the House of the evidence given by the Royal College of Surgeons, which has cautioned that we risk going back to the time when patients faced excessive delays for surgery, leaving them to suffer pain for even longer. As the Royal College of Surgeons says, patients have to live with the consequences of debilitating conditions for longer with all the anxiety that that brings. In commenting on the removal of the 18-week target—everyone in the NHS knows that this target has been removed—the BMA says that it is indicative of the unsustainable pressures on the health service. Yes, there are great pressures on the health service. NHS Providers has pointed out that it is probably the toughest financial year the NHS has faced for many a year. We also know from work that the Nuffield Trust published a few days ago that the underlying debt of the NHS last year was a whopping £3.7 billion, as compared with the reported £791 million. Putting it all together—the underfunding of the NHS and the poor performance on the core targets—it is no wonder that the Government have connived to drop a crucial target.

Interestingly, today the Government issued a statement in which they said they remained committed to the target. A spokesperson went on to say:

“The standard remains a patient right, embedded in the NHS Constitution and underpinned by legislation. We have no plans to change this”.

If the Government are still saying that the 18-week target stands for this financial year, why do they not issue a direct and public instruction to NHS England to insist on the target being delivered? Otherwise, we know that this target will not be delivered. We know that the NHS believes that this target does not have to be delivered in the current financial year. Of course, it is important that Governments and services meet targets but the real impact is on NHS patients. As the Royal College of Surgeons reported, 3.78 million patients were on the waiting list at April 2017. That is 180,000 more than the same month the year before. It is well over a year since the 18-week target was met. I see my noble friend sitting on the Privy Council Bench and think of the efforts we put in over a number of years to get rid of the lamentable waiting list that we inherited. It is a tragedy for me to see the NHS starting to slip back. That is why the signal the Government have given about the 18-week target is so important and why I have initiated this debate tonight. I beg to move.

Photo of Baroness Walmsley Baroness Walmsley Liberal Democrat Lords Spokesperson (Health) 7:45 pm, 6th September 2017

My Lords, we on these Benches support this Motion.

This debate shines a spotlight on the existential quandary facing CCGs and NHS Providers. I am sure that at the end of the debate the Minister, in his usual courteous and thorough way will, as he always does, give us lots of figures about how much more the Government are spending every year and how many more treatments are being delivered and how well the STPs are doing. With demand rising, naturally the raw numbers are higher, but the Government have chosen an RTT target in percentage terms and they must live with that decision and fund the consequences. Over recent years, the increase in funding for the NHS has not kept up with rising demand. This year we have a lower increase than before, and so now is crunch time. As the noble Lord, Lord Hunt, said, nobody is even pretending that providers will be able to deliver the targets while remaining within their budgets. So there is no point in the Government watering down the targets and pretending that no one will notice. The noble Lord, Lord Hunt, and many others have noticed, and I am grateful to him for giving us the chance to have an honest and open discussion about this.

NHS staff work hard and do their best to meet the targets under difficult circumstances. It is not their fault that the RTT targets have not been met for 16 months. But changing the targets is a political decision, whether it is being done openly or not, and that is only right. It should certainly not be left to local decision-makers, in a postcode lottery, to quietly ignore them or try and fail to live up to them and then take the flack when people criticise. If the Government choose to change the target, they should take the responsibility for the consequences. But the trouble is that patients will live with the consequences, living longer with debilitating and painful conditions. Having those conditions worsen and requiring more complex and expensive treatment, they may even become untreatable, and their quality of life and perhaps their mental health will deteriorate. So although the 2012 Act was intended to pass the blame on to anyone but the Government when things go wrong, everybody knows that the Government’s NHS mandate is the Government’s NHS mandate and nobody else’s. The NHS can spend the money only once, and the Government should not be expecting two treatments for the price of one. The bald facts are that, this year, demand was expected to rise by 5.2% while the funding is only going to rise by 1.3%, which is 2.3% less than last year—which was too little anyway. So this is a deliberate choice on the part of the Government.

Waiting lists are projected to rise to almost 5 million by 2020, and clearing this backlog will require not only funding but appropriately trained staff. With staff who are EU citizens leaving in droves because of Brexit uncertainty, and UK staff leaving because of overwork and stress, NHS Providers is finding it impossible to deliver waiting time targets. At the same time there is spare capacity in the private sector but it charges more than the NHS, so that is a hard choice for managers to make. I therefore ask the Minister a simple question: what assessment did the Government make of the potential impact on patients and waiting lists of deprioritising elective care and taking the decision to relax the 18-week target?

The RTT is not the only target the Government have changed, as the noble Lord, Lord Hunt, mentioned, and this is looking rather like a habit. For example, NHS England and NHS Improvement are reportedly setting new targets for CCGs and providers for bed occupancy levels, to keep them below 92%. This is significantly higher than the recommended safe limit of 85%. The Royal College of Surgeons has warned:

“Anything over this level is regarded as riskier for patients as this leads to bed shortages, periodic bed crises, and a rise in healthcare-acquired infections such as MRSA”.

This is another target that was routinely missed last winter, and the latest figures show that the overnight occupancy rate for general and acute beds hit a record high in the fourth quarter of 2016-17, averaging 91.4%. If the Royal College of Surgeons is right, this high level of bed occupancy is not a measure of efficiency but could lead to greater costs and crises, which put patients in danger.

Is it not time for the Government to stop pretending that all is well and that they have all the right answers, and set up a cross-party commission on the funding of health and social care, as recommended by my right honourable friend Norman Lamb MP? We on these Benches would be enthusiastic about taking part in such discussions. I think that the public are very fed up with health and care being a political football and would like to see us working constructively together. They want some honesty and realism. Of course we do not want to go back to the 1950s: I was waiting for a tonsillectomy and after two or three years, when my mother was fed up of waiting, she discovered that I had been taken off the list on the assumption that I had grown out of it. Actually, I had, but we need to be a great deal more ambitious for the NHS than that.

I know that the Minister makes the best of his brief but I would like to think that he will go back to his department and use his considerable powers of persuasion to stop the Secretary of State from burying his head in the sand.

Photo of Lord Reid of Cardowan Lord Reid of Cardowan Labour

My Lords, I join with this regret Motion, not as a matter of formality but because of deep and genuine regret at the position that the Government have now, by hook or by crook, engineered, which is the effective abandonment of the 18-week target.

I will briefly recall to the House where we were before that target was introduced. With respect to the noble Baroness, Lady Walmsley, we do not have to go back to the 1950s. We can go back less than 15 years, when my predecessor, Alan Milburn, became Secretary of State for Health. The maximum waiting time then was not 18, 24 or 52 weeks for elective operations but three years. Due to his sterling efforts and, I have to say, his adviser, who also advised me—Mr Simon Stevens—we reduced that, but not nearly as much as I thought was necessary in a civilised society.

Therefore I admit a conflict of interest in this debate: I introduced the 18-week target, against some considerable opposition—not in principle but because, I was constantly told, “it couldn’t be done”. But we did it. I remind the House that at that time the number on the waiting list, waiting for as long as three years, was the horrific figure of 1.2 million. It is now 2.7 million and it is estimated that it may rise to 5 million. Therefore there are more and more people, and undoubtedly, once this target has been effectively removed, those pressures will immediately start a process whereby it will go well beyond 18 weeks and we will go back to where we were some 15 years ago.

I will make a couple of points about this situation; the first has already been alluded to. These targets were also to reduce MRSA—hospital-acquired disease —in hospitals by 50% over four years, which we did, despite the fact that we were told that we could not do it. It was also to take hundreds of thousands of people off the waiting list. This was an effective way, not of making a political point but to remove people from pain, distress, discomfort and, above all, the insecurity of not knowing when and if they might have the condition treated. I recall that at the formation of the National Health Service one of Labour’s greatest heroes, Nye Bevan, produced his framework in a pamphlet that was not called “In Place of Pain” but In Place of Fear. The fear that people had for their families, their senior citizens, their children, of the prospect of waiting several years, even with what might appear to others to be relatively small difficulties and medical conditions, is inestimable. Therefore this was, more than anything else, about the relief of human discomfort and insecurity.

Secondly, having been there, I know that this is not easy. It is never easy. I have a great respect for Simon Stevens as a person and an administrator. However, he is caught between all sorts of conflicting demands—an increasing population, people living longer and, I have to say, a relative reduction in resources as well as a shambolic reorganisation which was the worst use of money I can think of in the health service in the past several decades. So I do not blame him, but it is the Government’s job to face up to difficult tasks, and it will take political will.

It may not surprise the House to hear that as Secretary of State I demanded the target to be reduced to 12 weeks over a four-year period. I was told that that was impossible. I had long discussions, as the Minister will have had, and a fortnight later my officials came back and told me that it was still impossible—they had tried everything. In a rather obstinate act of will, I announced that I was going to declare it as a target anyway on a given date. They said, “You can’t do that because it is raising expectations that can’t be met”. I explained to them how I was going to meet it, which was by arranging 7 million operations and 6 million scans through the private sector. It was taking six months to get results from scans. I have to tell the Minister that that was not easy to do, especially when you had to explain to a Labour Party conference that you were purchasing all that from the private sector. However, my intention was not ideological; it was objectively to relieve the pain of the people who were waiting that length of time for operations.

Therefore, the Minister will be told that it is very difficult to reduce the target but I can tell him that it is essential for the following reason. The context in which this is happening is rather the reverse of the slogan “every little helps”, used by a well-known supermarket. I can tell the Minister that “every little threatens” as well. When you abandon the four-hour target for accident and emergency, when you allow trolley waits to increase, when the number on the waiting list goes from 1 million to 2.5 million or 3 million, and when you then abandon the 18-week target, you do not do so in isolation; you do it in the context of a whole series of problems arising in the NHS which, as I said, will be exacerbated by a lack of resources.

The Minister could reverse that tonight by giving us a little help and announcing that he will make absolutely sure that, whatever the other pressures, the time that people in this country who desperately need an operation have to wait for it will be maintained at an outer limit of 18 weeks. That is not ideal and it is not what I would have wanted during my time as Secretary of State, but in a civilised society it is the maximum time that people should wait to be relieved of the pain, the disturbance and, above all, the fear and insecurity that comes with prolonged waiting for a necessary operation.

Photo of Baroness Redfern Baroness Redfern Conservative 8:00 pm, 6th September 2017

My Lords, I rise to speak on this regret Motion tabled by the noble Lord, Lord Hunt, who I am sure, like me, together with all users of the NHS, will acknowledge that the NHS has a unique place at the heart of our society and is by some distance the institution that makes us most proud to be British. However, it is regrettable that the NHS has become a bit of a political football year-in, year-out.

I would like to talk about the many positive areas in the NHS and about how people are working very hard to move towards these targets. Yes, pressures, including seasonal pressures, are all in the mix, yet despite these pressures the NHS approaches its 70th year delivering outstanding care, and it is important today to acknowledge and thank all staff who work in the health service, as well as encourage and support a healthy morale for our future workforce. As we all know, the NHS depends on a strong economy. A strong NHS can contribute to the growth of that strong economy, especially in health and life sciences, not just now but in the future.

We see plenty of pluses. We are getting healthier but we are using the NHS more, with life expectancy rising by five hours a day, as the noble Lord, Lord Reid, alluded to. The need for care in a modern NHS continues to grow apace. The number of people aged over 85 has increased by 40%, and the number of patients receiving elective treatment grew from around 14.2 million in 2012-13 to 15.7 million in 2016-17—an increase of 11%. That is a fantastic result. Calculations indicate that over the next 20 years we shall see the percentage of people over the age of 85 double. I note also that the total number of people on the elective waiting list in April 2012 was 2.5 million. By March 2017 this had increased to 3.7 million—an increase of 51% and another fantastic result. I note also that when Labour left office, including Members on the Benches opposite, more than 18,000 people were waiting more than 52 weeks to start treatment. Now, the figure is under 1,700.

Only last year, the CQC in-patient survey showed continuous improvement over the past five years, with 62% of respondents saying that they were satisfied with the running of the NHS. NHS funding is being increased and we will see over £0.5 trillion being injected from 2015 to 2020, but with more cash injection the NHS must show that it can spend that cash wisely and efficiently. Therefore, I look forward to a strong and sustainable NHS fit for purpose and fit for the future, where all parties can work together, so that we have a safe, patient-focused health service that is the best in the world.

Photo of Lord Clark of Windermere Lord Clark of Windermere Labour

My Lords, the noble Baroness is absolutely right to sing the praises of the National Health Service, and she is quite right to point out that we are undertaking more operations than we have in the past. She is also right to say that, as we grow older, more of us will need the health service. That is a fact that we have to face and accept and about which we have to persuade people—who do not need much persuading—that something has to be done. My noble friend Lord Reid and I served in the Blair Cabinet and we spent hours trying to bring about the political will to make sure that waiting times, which caused so much grief and pain in the 1990s, were cut. So we are talking about political will.

There is an interesting public opinion poll produced by YouGov and published today on behalf of the Royal College of Nursing. It shows that 72% of the general public believe that the NHS lacks sufficient staff to enable them to do their job properly. When we talk about altering waiting times, it is worth remembering that healthcare is a labour-intensive industry in all its aspects. We all know that, and we all know that the NHS achieves what it does only through the dedication and commitment of the staff and the hours that they work, from the consultants through to the nurses, the healthcare assistants, the porters and everyone. We have to try to assist them because they are getting towards breaking point. The Royal College of Nursing has balloted its members and is talking about taking industrial action. Therefore, we look to the Government to have the political will to act.

I accept that there is no magic wand. This Government bear a lot of responsibility because they were the key partner in the coalition that cut the number of nurses in training after 2010. The onus is now on them, and they are beginning to increase the numbers, but they must do more. However, it obviously takes a long time to train consultants, doctors and GPs. There are shortages everywhere, including a shortage of 40,000 nurses. I do not know the figure, but there is a shortage of GPs running into the tens of thousands. There is a shortage of hospital consultants and shortages everywhere.

So what do we do? It is not easy, because more nurses are leaving than entering the profession. We cannot do anything about the training, as that will take a number of years, but we can do something about retaining people in post, by persuading GPs to carry on a bit longer and persuading nurses to stay in post as it is worth while doing what they do. That is what we should be doing. It would be a great help if the 1% cap on wages could be lifted, because that has meant that the average nurse is probably 12% worse off than they were a few years ago. That would be one way of making it easier to retain people.

Then there is the other point that was made by my noble friend who introduced the debate, whom I thank, about the number of nurses and doctors who have worked in the health service who are from the European Union. Can we offer them something to persuade them that we want them to stay in our country? For example, as the Minister knows, anyone from the European Union who has spent five years working in this country, which includes people in the health service, can apply for the right of permanent residency. But we cannot get the Government to say what that means. Does permanent residency mean that they can stay here, or will they be sent back to Europe? That increases the uncertainty and anxiety. I urge the Minister to go back to his colleagues and say, “All right, if we can’t or won’t make a commitment to the European Union citizens to stay in the health service, let us say that at least those who have gained permanent residency can stay”. That would help the issue.

I return to my basic point. This now requires political will. I do not doubt the Minister’s commitment. I know where the Minister stands and how much he believes in the health service. He has made that quite plain in a number of debates that we have taken part in. But we need political will and we are looking to the Minister to try to argue his corner and punch above his weight and give every support that he can to try to make health staff in the health service more satisfied so that they stay in their jobs and help us to reduce waiting times.

Photo of Baroness Masham of Ilton Baroness Masham of Ilton Crossbench

My Lords, I want to ask the Minister about the better care fund, which is for health and social care working together, which also comes under the mandate. The better care fund document was not available for scrutiny purposes, as it was not published until 15 days after the instrument was laid before the House. All relevant documentation should be available. Without that, effective scrutiny is not possible. What is the present situation, as this deals with some very vulnerable people?

Photo of Baroness Thornton Baroness Thornton Labour

My Lords, I draw the attention of the House back to the resolution on the Order Paper moved by my noble friend. I hope that the noble Baroness, Lady Redfern, will forgive those of us on this side if we look sceptical because the reason that my noble friend, when he was Secretary of State, had to set the targets that he did was because of the record of her party’s Government over many years. If we are a little sceptical, it is because there is form on this.

Being a veteran of the passage of the Health and Social Care Act 2012, like my noble friend, I recall that there were many assurances given about the legal framework that would make the reorganisation work, particularly on the importance of the mandate. Therefore, I would be most interested to hear from the Minister on the last part of my noble friend’s resolution, which calls on the Government to publish the advice that they have received on the legality of their actions. Did they seek advice about the legality of their actions, given that they had been so keen to have that legality exist during the passage of the Act that set this framework and, if so, what did that advice say?

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Crossbench 8:15 pm, 6th September 2017

My Lords, I declare all my interests as a clinician. I worry that, if we keep on changing the way that we collect data, we have no way of monitoring what is happening. One thing about the figures as they are at the moment is that they are monitoring process. In addition to that, there must also be monitoring of outcomes—both clinical outcomes and outcomes in terms of the patient experience.

I worry that, if we start saying that the demography has changed and we have an elderly population, it makes it sound as if we are blaming people for living well and living longer, which we must not do. Actually, if people remain well, they are not a drain on the NHS at all. One of the most important predictors of poor outcomes is loneliness. If we have a population of people who are kept relatively well and mobile, they look after each other in communities. Good work on compassionate communities is happening around the UK already.

When we look at this question of targets and what the Government are doing, a worrying message is being sent. The Royal College of Emergency Medicine contacted me yesterday because its members are worried that they will not be able to cope with winter pressures. They are going into the winter with absolutely no wiggle room at all. They are at capacity. There has also been a change in the way that people behave. For an urgent appointment, they go through A&E, so the number of emergency department attendances has gone up as well.

In that group are those people who have been waiting for a time and during that time they have deteriorated. As they have deteriorated, something else has happened and they collapse—a bit like a stack of cards. Multiple problems arise and then those become more complex for the NHS. So it is not as if people are stable during their 18-week wait. If they have a disease that is progressing, they may well be deteriorating. Even worse for them, if the diagnosis in the original referral was wrong, they may need a complete review of their diagnosis. So simply talking about treating them is not correct.

My other concern is this: at what point does the clock start ticking? In some clinical commissioning groups, we are seeing groups being set up to look at the so-called appropriateness of the referral on paper. As a clinician, that worries me greatly, because I do not see how one can assess on paper. I know from many years of looking at referrals coming through on paper that they are only a very rough guide. Too often, I might see a referral that does not sound urgent and the patient in front of me should have been seen yesterday. Another one might sound urgent but actually is not. There is a real worry that, if we fiddle around with when the clock starts to tick, some people who really need to be seen urgently will be in a no-man’s zone before they are even properly referred because there have been delays. We hear about delays in access to primary care as well. The delay in being seen by a GP must be added on to any delays in being referred.

We also need to remember that, when we talk about 10 years ago, medicine has changed enormously. There are a large number of procedures now that, if they are done early, can be done in out-patients or as day cases. The days of needing to be admitted are not there, so that is all the more reason why we should be able to get more patients through more quickly if they are seen earlier.

I have a real worry that, as has been expressed very well by the noble Baroness, Lady Thornton, this flies in the face of reassurances that we were given during the passage of the Health and Social Care Bill through this House. Also, this sends a message to the service out there that, actually, we cannot cope. I worry that it will also disincentivise finding ways of treating people more speedily—as day cases and so forth—which could, with a little more investment, help to address the problem.

Photo of Lord Beecham Lord Beecham Shadow Spokesperson (Housing), Shadow Spokesperson (Communities and Local Government), Shadow Spokesperson (Justice)

My Lords, the impact of the cuts which are being debated tonight—and here I congratulate my noble friend on bringing forward his Motion—are not confined to the health service. They also stretch to social services departments and social care. The most rewarding period of my fairly lengthy political life was as the chairman of social services in Newcastle from 1973 to 1977 when we transformed social care in that city. Much of what we did in those days is now being undone as the result of pressures on the social care budget and a lack of adequate funding for the problems which many of us are becoming increasingly familiar with. What are the Government going to do about that impact of the decision, as it would appear to be, not to adhere to the 18-week period? What estimate have they made, if any, of the impact on social services and social care in a climate where local government budgets are extremely hard pressed? The two things are inseparable. It was a Health and Social Care Bill, now an Act, and we need to look at the social care implications of this extended period because, undoubtedly, it will put increasingly impossible pressure on local authority social services departments and other organisations involved in supporting people in the community.

Photo of Viscount Bridgeman Viscount Bridgeman Conservative

My Lords, we have a health service which is endeavouring to meet an ever-present and probably ever-growing demographic challenge. I was interested to hear the remarks of the noble Baroness, Lady Finlay, on the effect of the number of older people accessing the service, but there are many more people growing old and it is surely self-evident that there is bound to be an increase in waiting lists.

Perhaps I may leave your Lordships with two statistics. It is remarkable that last year the NHS carried out 11.6 million operations, some 1.9 million more than in 2009-10, and 61 million out-patients were seen, again 1.9 million more than in 2009-10. The health service is not perfect and there is certainly no room for complacency, but perhaps I may remind noble Lords that the 2016 GP patient survey showed that 84.6% of respondents rated their overall experience as good, while the 2016 British Social Attitudes survey showed a historical high level of satisfaction. This is a service which is endeavouring under very strict budgetary pressures to improve the lot of the nation.

Photo of Lord O'Shaughnessy Lord O'Shaughnessy The Parliamentary Under-Secretary of State for Health

My Lords, perhaps I may first thank all noble Lords for their contributions and indeed thank the noble Lord, Lord Hunt, for bringing about this debate and giving me a chance to defend the Government’s record on the NHS. We are very proud of our record on the NHS at a time when it is treating more people than ever before. We have protected and increased health funding, with real-terms increases every year since 2010, with more doctors, nurses, midwives and GPs working in the NHS, so people can get the care they need when they need it. This is the first Government to have got a grip on NHS spending and really prioritised those areas of the service in need of investment. We are investing in general practice, an issue that has been raised in the debate, allowing GPs to open for longer so that more people can access the services that they offer. Some 17 million patients have already benefited from evening and weekend appointments through our seven-day NHS, which is a considerable achievement. Investment in general practice will increase from £9.5 billion in 2015-16 to more than £12 billion in 2021, a 14% real -terms increase. By 2020 there will be an extra 5,000 doctors working in general practice, as well as 5,000 extra staff.

This is also a Government who have given parity of esteem to the treatment of mental health in the National Health Service. The Five Year Forward View for mental health sets out our ambitious programme for further system reform: more skilled staff, the first ever waiting time standards, and an ambitious plan for children and young people’s mental health provision is in development. We have increased mental health funding significantly since 2010 so that we can deliver the services that people deserve.

I am proud that the NHS has been found by the Commonwealth Fund for the second time in a row to be the best, safest and most affordable healthcare system of 11 countries including the US, Canada, Australia, France and Germany. This is a tremendous achievement and I join with all noble Lords in congratulating our dedicated NHS staff on the excellent service that they continue to provide for patients.

Spending is of course important. According to the OECD, in 2014, UK spending on the NHS was 9.9% of GDP, which is above the average for both the OECD and the 15 countries which were members of the EU prior to May 2004. I would also gently remind Members of the previous Labour Government that this is a higher level of spending than at any time during that Government. Of course, we are not complacent and we understand that the NHS needs to change, develop and improve in order to meet the needs of the future. The mandate to NHS England that the Secretary of State is required to publish and lay in Parliament for each financial year therefore sets out the steps that the Government expect NHS England to take to ensure that the NHS offers the safest, most compassionate and highest quality healthcare in the world. The mandate for 2017 sets ambitious objectives for the coming year with the aim of delivering real improvements in patient care and outcomes. They include improving outcomes for maternity and diabetes, reducing health inequalities, improving patient safety and quality, moving more care out of hospitals, and supporting people to live healthier lives—all while delivering a balanced budget.

In his Motion, the noble Lord, Lord Hunt, has questioned our commitment to ensuring timely access to elective NHS services by arguing that the National Health Service (Mandate Requirements) Regulations 2017 and the associated mandate to NHS England make no reference to NHS England’s obligation to deliver the 18-week standard. I do not accept that and I see no grounds for making such a claim. On the contrary, we remain committed to a waiting time standard for non-urgent referrals whereby NHS commissioners must make arrangements to ensure that not less than 92% of patients have been waiting to start treatment for fewer than 18 weeks. That standard, the standard we are discussing tonight, remains a patient right that is embedded in the NHS constitution and underpinned by legislation passed, as the noble Lord pointed out, by a Conservative and Liberal Democrat Government. We have no plans to change it. Alongside the other priorities that the Government have set out for the NHS, maintaining and improving performance against core standards continues to be a commitment.

I turn now to the legislation itself. The Health and Social Care Act 2012, which we have discussed tonight, introduced a requirement for the Secretary of State for Health to publish and lay before Parliament a mandate in each financial year. It sets out the Government’s objectives for NHS England and may specify requirements that the Government consider essential for the objectives to be met. Any requirements must also be set out in regulations. The mandate for 2017-18 has been published in full accordance with the Act, including with the requirement in the Act to consult both NHS England and Healthwatch England on it. There is no question as to its legality. The mandate for 2017-18 sets a clear expectation that NHS England will maintain and improve performance against core patient access standards, and the annual deliverable in the mandate reads as follows:

“With NHS Improvement, to meet agreed standards on A&E, ambulances, diagnostics and referral to treatment”.

I now turn to the key facts on NHS waiting times performance, as indeed the noble Baroness, Lady Walmsley, said I would. As noble Lords know, the NHS faces increasing demand for health services as a consequence of the ageing and growing population, together with the costs of new drugs and treatments. Let me give noble Lords some figures on how many more people are receiving care from the NHS. Some 23.4 million people went to A&E in 2016-17, 2.8 million more than in 2010. Some 1.87 million people were seen by a specialist for suspected cancer, 973,000 more than in 2010. My noble friends Lady Redfern and Lord Bridgeman have given other facts and I could go on, but I will not. However, the NHS is doing more and better for more people than ever before.

Despite the record numbers of people being seen by the NHS, the vast majority are being seen within the waiting time standards, whether for A&E, cancer treatment or non-urgent treatment. If we consider the 18-week standard, which is the subject of our debate today, the referral to treatment standard for non-urgent care is that at least 92% of people are seen by a consultant-led team within 18 weeks of referral, most commonly by a GP. I am very well aware that the NHS is not currently meeting the standard for 92% of patients to wait a maximum of 18 weeks from referral to treatment. The standard was last met in February 2016. The Secretary of State reflected this in his annual statement on NHS England for 2016-17. It has been laid before Parliament —we do not hide or resile from it. In the latest published monthly figures national performance was 90.3%, which is clearly lower than we would like.

The noble Lords, Lord Reid, Lord Clark and Lord Hunt, took us back to a time when Labour was in government. I certainly recognise the changes they made to reduce the number of people on waiting lists, but it is important to recognise as we go back in time that if we choose this particular measure, in 2007—I think the year that both the noble Lords, Lord Hunt and Lord Reid, were running the Department of Health—performance against that measure was around 80%. It was not hitting the target and there have been years for a range of targets and healthcare where a Labour Government—indeed, all Governments—did not hit their targets. That does not mean they are not committed to achieving them, but that is what happens when you run a health service with a number of competing priorities at any one moment.

Even so, of the million patients starting non-urgent treatment every month, the majority are seen and treated within 18 weeks. The average wait is six weeks if you are being treated as an out-patient and 10 weeks if you need to be admitted to hospital for treatment. Fewer people have to face long waits than ever before. My noble friend Lady Redfern pointed out that last year only 1,700 people—in fact, fewer than that —waited over 52 weeks for treatment, a 10th of the 2010 figure.

The NHS is busier than ever before, but patient satisfaction with the NHS remains buoyant, as reported in the 2016 British Social Attitudes survey, which my noble friend Lord Bridgeman mentioned. Furthermore, the noble Baroness, Lady Finlay, talked about not just processes, but outcomes. Indeed, the CQC in-patient survey measures satisfaction and has shown continuous improvement over the past five years. Furthermore, an Ipsos MORI poll from January 2017 showed that there has been a 13 percentage point increase since 2013 in the number of people who agree that the NHS provides a high standard of care to patients. This progress is testament to the hard work of NHS staff.

The Next Steps on the NHS Five Year Forward View document, published in March 2017, charts a clear path for the acceleration of local service redesign and integration that will support better care and longer-term sustainability of the NHS. NHS England and NHS Improvement are particularly concerned about A&E performance—an issue highlighted tonight—which is why they have prioritised recovery of A&E performance, setting out a clear plan and trajectory for improvement. In effect, the NHS is making the same prioritisation decision nationally that Governments have made in the past and that we would expect our clinicians to make: balancing the needs of a patient with an emergency condition that requires immediate treatment with the needs of a patient with a routine condition. NHS England has set out very clearly in the Next Steps document the considerable financial and operational challenges faced in returning elective care performance to the standard we want to achieve.

Building on the Five Year Forward View, the Next Steps document sets out how care needs change to ensure the NHS remains sustainable for the future. It acknowledges that, in 2017, while we,

“remain committed to short waits for routine operations … there is likely to be continued pressure on waiting times for routine care and some providers’ waiting times will grow”.

Of course our expectations for recovery of the standard must take account of this current reality, but let me be clear: our commitment to getting back to standard is unwavering. We are committed to solving the financial and operational constraints that inhibit delivery of the standard and to recovering it at the earliest practicable moment. This is why I welcome the actions that NHS England and NHS Improvement have already set in train to improve the quality of GP referrals and to improve hospital productivity. They will continue to require organisations to submit trajectories for their expected performance against waiting time standards and are continuing to monitor commissioners and trusts for delivery, intervening where necessary with the most challenged trusts to make sure they recover.

To come back to the mandate, it reiterates the Government’s commitment to supporting NHS England and the wider NHS in delivering its own reform programme, and the multiyear approach we have taken to NHS England’s mandate objectives and budgets provide a solid basis for its implementation. It is clearly vital that the NHS responds to the challenges posed by a growing and ageing population, that we succeed in transforming the way services are delivered so that outcomes improve and variation is reduced, and that the NHS continues to deliver savings at the same time as improving standards.

I turn briefly to some of the specific points made by noble Lords. The noble Lord, Lord Clark, asked about staff morale—not just British staff but European staff. We have done everything we can to set out what we want to happen for the future of European citizens here. We are waiting for that to be reciprocated by the Commission and the EU in our discussions.

The noble Baroness, Lady Masham, and the noble Lord, Lord Beecham, asked about social care. As they know, there is more money going into social care. One of the ways that that will help the NHS is with the delayed transfers of care, to make sure there is that flow through hospital beds to provide the beds that are needed for those who are going through A&E and those who are going through elective treatments.

I shall end with another point from the noble Lord, Lord Reid—a distinguished former Health Secretary. He talked about the 2012 reorganisations. The Labour Government went through a number of reorganisations themselves, as he knows, but that should never distract from focus on the kinds of targets we are talking about. I am sure it never did in his time.

Although I fully recognise and share the belief of the noble Lord, Lord Hunt, in the importance of ensuring that patient rights in respect of waiting times—indeed, all the rights set out in the constitution—are met, I do not accept that the mandate for NHS England or the regulations that support it have been undermined in any way. The mandate makes clear that core patient standards remain in place, yet the challenges are real and cannot be denied, which is why we are working to improve them.

As I close, it is important to bear in mind that this Government have increased spending on the NHS year on year since 2010. The NHS will receive around £10 billion a year additional funding in real terms by 2021. NHS spending as a percentage of all public spending is going up all the time while we are addressing the £150 billion black hole in the public finances that we took over in 2010.

Photo of Lord O'Shaughnessy Lord O'Shaughnessy The Parliamentary Under-Secretary of State for Health

That is the truth.

Next year the NHS turns 70. As my noble friend Lady Redfern said, it has a unique place in our society. The mandate to NHS England for 2017-18 goes further than ever before to ensure that we not only continue to deliver the best care and support for today’s NHS patients but also deliver the reform and renewal needed to sustain the NHS for the future. We know there is more to do, which is why we have put our commitment to support NHS England and the NHS in delivering the five-year forward view at the heart of the mandate. We will continue to do so. I hope that I have persuaded all noble Lords, including the noble Lord opposite, that their fears are unfounded, and that the noble Lord now feels in a position to withdraw his Motion.

Photo of Lord Hunt of Kings Heath Lord Hunt of Kings Heath Shadow Spokesperson (Cabinet Office), Shadow Spokesperson (Health), Shadow Spokesperson (Education)

My Lords, that is one of the most remarkable speeches I have heard in your Lordships’ House. I have to say that if the Government really think that the NHS is in the healthy position that the Minister says it is, I feel very sorry for them and sorry for NHS patients. Talk to anyone on the front line and they will tell you of the pressures, of the hopelessness of the changes the Government made and of the Brexit impact on staff. The NHS is facing a critical time and to have this litany, this list of so-called achievements, does no good at all to the health service or to the credibility of the Government.

I shall make only two points. The Minister said at the beginning that the Government are still committed to the 18-week target, but towards the end of his speech he quoted the same words as I quoted, which made it clear, as Simon Stevens has made clear and as is made clear in Next Steps on the Five Year Forward View, that actually the Government have given up on the 18-week target this year. They have said that,

“elective volumes are likely to expand at a slower rate than implied” by the 92% target. That was an open admission that the target is no longer set in stone. Talk to any chair or chief exec in the NHS and ask them whether the 18-week target is a firm target in this financial year and they will say no. Of course the NHS faces pressures. In the days of my noble friend Lord Reid the demographic changes were taking place just as fiercely as they are now, but he made a dramatic impact in reducing waiting times.

My point is this: if the Government believe it is so difficult to manage the health service in such a challenging time, they should be open and honest and say that the target has been taken away; but they have not been honest, they have not been open and patients will suffer. My Lords, I beg to move.

Ayes 169, Noes 104.

Division number 1 National Health Service (Mandate Requirements) Regulations 2017 - Motion to Regret

Aye: 167 Members of the House of Lords

No: 102 Members of the House of Lords

Ayes: A-Z by last name


Nos: A-Z by last name


Lord Hunt of Kings Heath’s Motion agreed.