My Lords, it is a privilege to open this debate on the long-term sustainability of the NHS and adult social care as the chair of the committee that produced the report. I begin by thanking most sincerely all those who contributed to the report: our specialist advisers, Dr Anita Charlesworth, director of research in economics at the Health Foundation, and Emma Norris, programme director at the Institute for Government; our committee staff, the clerk Patrick Milner, the policy analysts Emily Greenwood and Beth Hooper, and the committee assistants Thomas Cheminais and Vivienne Roach; and, of course, all the committee members, with their collective and individual wisdom and experience—a most agreeable and amiable group that it was my pleasure to work with. I think sometimes small lies are permitted.
Any difficulties that we had in our discussions were smoothed over with spiritual guidance from our resident Prelate, the right reverend Prelate the Bishop of Carlisle. We were sorry to miss the noble Lord, Lord Mawhinney, from most of our inquiry because of his illness, and I wish him well. The noble Lord, Lord Lipsey, is not happy that he will not be here today, but he is recovering from his illness. I wish him well and hope that he is back here soon. In the context of the debate, I am pleased to see the noble Lord, Lord Lansley, in his place. I wish him, too, a full recovery from his illness. We might have another time to discuss his reforms.
Now to the report. The inquiry started in July 2016 and lasted until December 2016—too short for us to cover all the issues in health and social care. Hence our call for evidence was targeted at the key challenges of the long-term sustainability of health and social care. We received more than 193 written submissions, amounting to 500,000 words. We took oral evidence from more than 100 key witnesses. We also received correspondence from more than 3,000 members of the public and hundreds of emails with personal experiences and heartfelt stories. I thank them all for writing to us. We also learned lessons as to how we might be able to engage with the public in future.
We published our report, which was 100 pages long plus annexes, with 34 key non-political recommendations, on
I also thank the chair of the House of Commons Health Select Committee, Dr Sarah Wollaston, who took evidence from me and four other committee members in a full session lasting over three hours, and also—in different sessions—questioned the Secretary of State and the Prime Minister on aspects of our report. All this gave the committee the feeling that we had done a reasonable job on the task given to us.
The long-awaited government response came in late February 2018. It is 39 pages long, and detailed and informative on current initiatives and developments, but a little short on addressing the report’s key recommendations. That is possibly because our important recommendations require a policy rethink and the Government need more time to consider them fully. Their subsequent response will—hopefully—be in actions. I am naturally kind and optimistic and I look forward to that.
This is an important year for the NHS. On
The weaknesses in the delivery structures of health and social care are made worse by winter pressures on services, as evidenced by daily headlines of bed blocking, queues at A&E, patients on trolleys in hospital corridors, cancellation of elective surgeries for months, and commissioning groups constantly rationing care.
Despite all this, the service, through its dedicated and hard-working workforce, tries to cope and to minimise hardship, and of course there are good initiatives and developments in the pipeline that will improve the service. What is needed, however, is a long-term fix.
A real celebration would be a political consensus, possibly delivered through an all-party commission—which has been asked for by many people, including politicians, political commentators and the media. Even our own Lord Speaker, in an article he wrote more than two years ago, asked for a commission to be established. The Government should initiate such a consensus. The Prime Minister’s legacy would then be the delivery not just of Brexit but, importantly, sustainable health and social care.
I now come to the report itself. It has seven chapters, ending with proposals for building a lasting political consensus. The inquiry found a lack of long-term planning. We were unkind enough to suggest a culture of short-termism. Everyone, it seems, is so absorbed in struggling with day-to-day troubles and with the uncertainty of year-on-year funding settlements that a culture of “here and now” has developed. Our comments, which were not designed to cause upset or to name and shame, should be taken as constructive.
We found that the five-year forward view of the chief executive of NHS England, Simon Stevens, was the only example of strategic planning for the longer term. By the way, if I might digress, in Simon Stevens we have somebody who has, in my view, been given the freedom and authority to be the change needed to build a healthcare system based on outcomes. I am glad that the Secretary of State asked in a recent statement for a five-year or even a 10-year forward financial settlement for the health service. This was one of our key recommendations.
The evidence we received pointed strongly to the fact that, at the heart of securing a long-term future for health is the need for radical service transformation: a change that involves a model of primary care moving away from the small business model to one of bigger group practices, properly resourced and able to deliver on diagnostics. GPs should have the power and authority to shape the delivery of primary and community care, linking with and, at times, being part of secondary care and even involved in hospital care—a model away from the overburdened, bureaucracy-driven current model that we heard about. The model should be attractive for young doctors to flourish in, which would make recruitment to primary care—as it was before—a problem of the past. Equally, it should be a transformation that involves reshaping secondary care, with specialist services consolidated.
Reform is also needed to reduce the bureaucracy and regulatory burdens that play little part in delivering better health outcomes. The current statutory framework frustrates this agenda, but change is needed. With the current focus on integrated, place-based commissioning, the need for two separate bodies, NHS England and NHS Improvement, has to be questioned.
Appropriate funding of the NHS remains the key issue. Years of cuts have led to the decline of services, demoralised the workforce and caused a crumbling infrastructure that in some cases needs the services of a bulldozer. No doubt we will hear of the extra funds given in the last Budget, and prior to that, but significant deficits in the majority of trusts continue. A settled funding plan, with a year-on-year increase linked to the rise in GDP, is our modest recommendation. A possible increase in funding to mark 70 years of the NHS was suggested by the Prime Minister, who mentioned it in her evidence to the House of Commons Liaison Committee. If true, this has to be welcomed: how much and what it will be used for will be the important question. We received clear evidence for maintaining a service free at the point of need.
The lack of any long-term planning for the workforce is the biggest internal threat to the sustainability of the NHS and adult social care. Much of the workforce planning is fragmented. Too much training of our clinical workforce is done through the old model, lacking flexibility and with poor opportunities to update skills. Lack of leadership leads all and sundry to believe that they are in charge of workforce planning and training. It is rather like a bus with too many conductors but no driver. We recommended a strong, independent, well-resourced role for Health Education England to plan for the long term and be accountable. Clear leadership is needed. I gather that our perceived criticism has been taken to heart and that change is on its way. All I can say is: good, and congratulations—may the force be with you.
Prevention of ill health was a key component of Simon Stevens’s five-year forward view, but it has received little attention. There seems to be apathy, centrally driven, around planning for a co-ordinated prevention strategy. A service centred on illness is not sustainable. Much of cardiovascular disease, stroke, cancer—40% of cancers—diabetes, mental health, lung diseases and possibly even dementia has a preventative aspect. We need to learn from models in other countries. I am sure that if the noble Lord, Lord McColl of Dulwich, had been here, he would have had much to say about our obesity epidemic. He has another arrangement in Hong Kong so cannot be here today.
The report also identifies the NHS as a poor adopter of innovations, unable to drive increased productivity, cut waste, use data effectively, reduce variations in care and, above all, reduce variations in outcomes related to inequality and deprivation. The difference in the life expectancy of people in Hackney and the West End of London is the same as that between those in England and Guatemala—about eight years.
Let me now come briefly to social care. Despite extra funding, pressures on social care and the NHS continue. Analysis conducted by the Health Foundation, the Nuffield Trust and the King’s Fund suggests a shortfall of £3.5 billion in social care by 2020. Our report makes a plea for a long-term settlement for social care. As the Government develop their Green Paper on social care for older people, I hope that they will look at all alternatives, apart from the cap, including models of funding that operate in Japan and Germany through a system of hypothecated social insurance, with a defined contribution based on age and income, paid for by all throughout life, with a small top-up contribution made by those who need it—a system that reinforces the principles of social justice, equality and social solidarity to which everyone contributes. Those principles are the bedrock of our much-loved NHS. This is not an ideological suggestion; it is a suggestion based on the one-nation principle.
Let me now turn to accountability. There is a clear need for parliamentary accountability based on transparent information. To this end, following much discussion and an in-depth audit of 16 independent and semi-independent bodies carried out by Emma Norris, programme director at the Institute for Government, we tested an idea with many witnesses and received broad support. We made three recommendations to establish an office for health and care sustainability with a clear and defined remit. The Government responded to this recommendation in 80 words and referred to two websites. The right reverend Prelate the Bishop of Carlisle may well take this further. It is an important recommendation, deserving greater debate and attention, and I hope we will have the opportunity for that at some time.
We are often told that our NHS is the best in the world. Why? Because the Commonwealth Fund, which is based in Massachusetts, places our NHS at number one. The fact is that the fund has its own agenda and uses a methodology to back it. Inconveniently, it also puts the NHS at number 10 for outcomes—and outcomes are what matter to patients. That is what they look for. On the other hand, the Legatum Institute, a London-based think tank, places the NHS 20th, Bloomberg places it 21st and the WHO places it 16th in the world. We need a service based on outcomes. Our outcomes in cardiovascular disease, stroke, cancers and lung diseases are not good compared with those of other, richer countries. A service that is considered accessible and low cost but is poor on outcomes is like having a coffee machine that is cheaper to buy but cannot make coffee.
Time has come for a political consensus to make our much-loved NHS a service that delivers the best care for all, is cost-effective and becomes the model of the best care in the world. We have been there before and we can be again. It is doable, as long as the NHS does not continue to be a political football for those who hope to win votes. I hope that this debate is the start of that political consensus. I beg to move.