National Health Service: 75th Anniversary
(4 months, 4 weeks ago)
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Lord Hunt of Kings Heath
That this House takes note of the 75th anniversary of the National Health Service and its performance in waiting times.
Lord Hunt of Kings Heath (Lab)
My Lords, I refer the House to my membership of the GMC council. I was privileged to lead a debate 25 years ago in your Lordships’ House to celebrate the 50th anniversary of the NHS. My noble friends Lord Brooke and Lady Pitkeathley spoke in that debate, and I am delighted that they are speaking today—they are great survivors.
In 1997, the Labour Government inherited an NHS in crisis, with low morale and long waiting times. I was privileged as a Minister to contribute to a complete revival of the service’s fortunes. I pay tribute to my colleagues, to the right reverend Prelate the Bishop of London, who played a pivotal role as Chief Nursing Officer, and to my noble friend Lord Prentis, who took up the post of general secretary of UNISON at a very important time in the turnaround in the service’s fortunes.
The NHS plan of 2000 was a programme of huge vision: 100 new hospitals built; major investment in the workforce and an agenda for change; new services such as NHS Direct and walk-in centres; maximum 18-week waits for elective treatments; maximum four-hour waits for A&E; patients were actually able to see their GP. In 2010, the British Social Attitudes survey showed satisfaction with the NHS at over 70%, the highest rate it has ever recorded. Today, satisfaction has plummeted to 29%—the lowest figure ever recorded. The main reasons for this dramatic drop are waiting times for GPs and hospitals, staff shortages and lack of government spending.
How did the coalition and then the Conservative Governments throw away such a brilliant inheritance? The evidence is very clear: austerity was to blame, based on a small-state ideology and introduced just as the economy was recovering to a 2.2% growth rate in 2010. Growth was killed off by the coalition Government, who devastated public investment. The huge social cost of this self-imposed harm is plain to see. By 2020, poverty in working families had reached a record high. Life expectancy increases stalled for the first time in this country in 100 years. In 1952, the UK had the seventh-highest life expectancy at birth in the world. OECD data shows that, by 2020, it had fallen to 36th.
Austerity targeted local government the worst. It had a huge impact on adult social care and, today, has left half a million people waiting just for an assessment, let alone any support. We now have the prospect of the Home Office wanting to restrict care workers coming from abroad by increasing the salary requirement and restricting dependants. The obvious solution—to pay care staff more—is not viable because, as Juliet Samuel wrote in the Times this morning, the same Government are the care sector’s main customer and will not pay up. You could not make it up.
The NHS has been through the longest financial squeeze in its history. Its annual growth from 1948 to 2019-20 was 3.6%, but under the coalition Government dropped to a miserly 1.1%. Any increased funding that came post Covid has been eroded in real terms due to high inflation, resulting in a very stretched NHS. It is no wonder waiting lists are now a record 7.8 million people. In 2022-23, only 56% of those attending A&E were admitted, transferred or discharged within four hours, compared to 98% in 2010.
What has the Government’s response been to all this? First, we had the costly disaster of the Health and Social Care Act 2102, which enforced a wasteful market on all clinical services, disrupted collaboration and the integration of services, and cost millions of pounds. Earlier this week, the Minister was here bringing in a regulation to get rid of the whole wretched thing. We also had a former Prime Minister’s pledge on 40 new hospitals, which was exposed as a deceit early on. Even the current Prime Minister some time ago, in one of his many pledges, promised to cut NHS waiting lists, but that has been downgraded because NHS leaders have been told to prioritise controlling costs. Up and down the country, the NHS is stopping schemes to cut waiting times because it cannot get the funds; for instance, for new equipment to increase productivity.
The NHS has faced two major periods of crisis in its history. The first was in the early 1990s and the second is now. The common cause is a long period of Conservative government. We fixed it last time and we can do it again, but it will be tough. As Paul Johnson from the IFS commented after the Autumn Statement,
“a combination of high spending on debt interest, low growth, and the demands of an ageing population mean that there is little scope to increase spending on hard-pressed public services … growth is the only way out of this”.
But this Government’s dismal performance offers little hope of that. Interest rates are set to remain high according to the Governor of the Bank of England who, two days ago, said that the UK economy’s potential to grow is
“lower than it has been in much of my working life”.
How do we go forward from here? We need a Government who will drive through a huge modernisation programme. Inescapably, funding will have to keep pace with demography and technical advances, but we also clearly need to get the most out of every pound we spend.
Data from the Office for National Statistics reveals that more working-age people are self-reporting long-term health conditions, with 36% saying that they have at least one. The case for investing health resources to get those people back to work is convincing and ought to appeal to the Treasury. Wes Streeting has suggested that we also need cultural change which gives local services much greater freedom to reform and to try new and different ways of providing healthcare while embracing the latest technology. This is really important: productivity will not be improved by beating a big stick so, please, we do not need any restructuring, crony contracts, wasted payments on management consultants, rip-off outsourcing or agency bills—all characteristic of the current Government’s approach.
The NHS needs to plan with multiyear revenue settlements, and it needs investment in capital. We are years behind other countries in investing in capital. The result, as the NHS Confederation reported this week, is a less productive service, still hampered by
“Victorian estates, too few diagnostic machines and outdated IT systems”.
We need system reform. Primary care is overstretched, with too many patients ending up inappropriately in A&E. Planned treatments get cancelled as a result. Patients’ conditions deteriorate and hospitals then find it difficult to discharge them, owing to pressures on adult social and community care. Add in mental health demands and it is no wonder the system is falling over, but we need a whole-system solution to deal with that problem.
Ministers are fond of talking about integration but, for patients, the experience of seamless care between primary, secondary, tertiary and social care is a distant dream. We also need to take advantage of our fantastic science base, and our pharma and medical technology sectors. The problem is that investment in R&D and clinical trials has dipped. We must get that back and ensure that the NHS adopts the innovations being made in this country to get the advantage to patients and improve productivity. This is key to what we have to do in the future.
Our workforce is all important. The Institute for Government was absolutely right in arguing that an improved approach to setting pay, workforce planning and enhancing working conditions would help to reset the relationship with our staff and start to resolve recruitment and retention problems. We will have to pay particular attention to the lowest-paid staff and try to align social care staff more to NHS terms and conditions.
We know that there is a huge demand for healthcare professionals globally. It is very unlikely that countries’ demands will totally be met, so we have to look at the smart use of AI and technology to liberate clinicians from the clunky and frustrating IT systems found littered across the NHS.
We need a stronger preventative process to reduce health inequalities and improve life expectancy. We need social care to be given a fundamental boost. Do your Lordships remember that Prime Minister Johnson promised to fix social care? That went well. As a minimum, every vulnerable person should expect an assessment and some form of care and support. In the long term, we have to end the lottery of care which leaves many people who are above the means-tested level none the less struggling hugely to pay care home fees.
Primary care also needs a reset. I commend Sir John Oldham who, under the last Labour Government, did fantastic work in helping GPs to improve their effectiveness. Primary care has to become a place again where GPs want to work and where if patients want direct access to their GP, they can get it.
There must be no delay in bringing legislation to reform the Mental Health Act 1983. The failure of the Government to bring the Bill before us because it is not a measure that would show a gap between them and us is deplorable. That Bill has consensus support and was produced by an expert. We know the way forward, but it has been delayed yet again. I commend a report, A Mentally Healthier Nation, which was recently signed by dozens of organisations with an interest in mental health. It sets out a fantastic programme for better prevention, quality and support.
Finally, I will mention the people who I represented for a lot of my earlier life, when I did proper jobs—NHS managers and leaders. If we are serious about an improvement agenda, can we stop disparaging those people? Can we stop false economies by restricting the number we invest in and start to invest properly in their training, support and development? Amanda Pritchard, the chief executive of NHS England, gave evidence to the Health and Social Care Select Committee only a couple of weeks ago in which she talked about the patchiness of giving those crucial people the kind of support they need to do the jobs that need to be done.
I am grateful to so many noble Lords for taking part in our debate. I am convinced that, with drive and determination, we can turn the NHS around. Wes Streeting has described his reform programme as having three aims: hospital to community, analogue to digital, and sickness to prevention. They sound about right to me. Despite the Government’s dismal record, austerity funding and attacks from the right, the NHS’s founding principles—being comprehensive, free at the point of use and tax-funded—remain in place.
In ending, I think it is appropriate to give the last word to Nye Bevan, founder of the NHS. He said:
“The NHS will last as long as there’s folk with faith left to fight for it”.
There are plenty of people prepared to do that. I beg to move.
Lord Lexden (Con)
My Lords, following the splendid introductory speech by the noble Lord, Lord Hunt, which ended with a quotation from Nye Bevan, I will make a little historical contribution to this important debate, if I may. Other speakers will be dealing with the present and looking forward to the future; I hope a historian may be forgiven for looking back to the origins of the NHS, the 75th anniversary of which we are celebrating.
Cinemagoers in the 1940s learned much about public affairs from the widely admired Pathé News, which was shown before the main film. In March 1944, audiences who saw that month’s Pathé News heard the following words from the Minister of Health about the formation of a National Health Service:
“Whatever your income, if you want to use this service—nobody is going to try to make you unless you want to—there will be no charge for treatment. The National Health Service will include family doctors who you choose for yourselves and who will attend you in your own homes when this is necessary”.
The clipped, kindly, authoritative voice continued:
“It will cover any medicines you may need, specialist advice and, of course, hospital treatment, whatever the illness, special care for mothers and children and a lot of other things besides. In fact, every kind of advice and treatment you may need … We are out to improve the health of every family and the whole nation. If we cut out the money worries which illness brings, then there would be no reason to put off getting advice and treatment”.
That is how the nation heard that it could look forward to the provision of comprehensive health services, free at the point of use, from which it was to benefit so profoundly in the years that lay ahead.
The voice from which it heard about these radical reform plans was that of Sir Henry Willink, the Conservative Health Minister in Churchill’s wartime coalition. It fell to Willink to work out how to achieve this promised transformation of healthcare in Britain. He set about the task in a spirit of consensus, telling Pathé News viewers:
“It is not a cut and dried scheme. These proposals are for discussion in Parliament, and we want them talked about by everyone concerned, and you, everyone in this audience, are very much concerned”.
The nearer the scheme came to fruition, the more concerned the British Medical Association grew about the effect it would have on their members’ private practice. Willink made a number of concessions to the BMA, agreeing that doctors would not, as had originally been envisaged, be grouped as salaried employees into health centres under local authority control. This concession had far-reaching results, which the Labour Party had to accept when it found itself in charge of the legislation that created the NHS after 1945.
Today, Sir Henry Willink is almost entirely forgotten, his contribution to building our National Health Service unsung. Willink was a calm, modest, intellectual figure, later master of a Cambridge college, who had no taste for rough party politics, totally unlike the brilliant, flamboyant, combative Nye Bevan, who denounced the Tories as “lower than vermin” when the NHS was officially launched in July 1948. By the way, younger elements in the Conservative Party responded by forming Vermin Clubs, with little membership badges featuring ugly creatures. Miss Margaret Roberts, later Mrs Margaret Thatcher, had quite a collection of these badges.
Since Bevan carried the legislation through Parliament, it would be absurd to question his central role. But neither he nor the Labour Party deserve to monopolise the credit for the building of the NHS. Bevan’s biographer, Dr John Campbell, refers to
“the long and cumulative process by which the Service came into existence in 1948 … There can be no doubt that some form of National Health Service would have come into being after 1945 whoever had won the General Election”.
The Tories, who made a firm commitment to finish Willink’s work in their 1945 manifesto, made a cardinal political error as Bevan’s great NHS Bill was going through the Commons: Willink moved a hostile amendment, opposing the nationalisation of all hospitals, voluntary and municipal. This enabled Labour, in the rough and tumble of party politics, to portray the Conservatives as opposed in principle to the NHS, which was of course totally untrue.
Perhaps on the 75th anniversary of the NHS this year, it might be appropriate to remember Henry Willink as well as Nye Bevan. Willink stood for consensus; Bevan for conflict. Could it be that, over the last 75 years, the NHS would have benefited from a little more of Willink’s consensus and a little less of Bevan’s party strife? Would progress have been easier to achieve if politicians of all parties had worked together, in full partnership with health professionals, in that spirit of national unity, embodied in Churchill’s wartime coalition, from which our NHS emanates?
I will make just one point about the provision of health services today. I do so with sadness, disappointment and a little anger. In the debate on the King’s Speech, alongside the noble Baroness, Lady Donaghy, I drew the attention of the House to the compelling case that the Royal Osteoporosis Society, supported by parliamentarians of all parties, had made for government funding of fracture liaison services. A commitment appeared to have been given in this House in a ministerial reply to a debate on these services in September. It contained the following words:
“We are proposing to announce, in the forthcoming Autumn Statement, a package of prioritised measures to expand the provision of fracture liaison services and improve their current quality”.—[Official Report, 14/9/23; col. GC 241.]
The Autumn Statement last week contained no such announcement. Commenting on the U-turn, my noble friend Lord Black of Brentwood, who introduced September’s debate but cannot be in his place today, deplored the Government’s unwillingness to make what is, in reality, a tiny investment of some £27 million per annum in fracture liaison services. This callous decision will blight the lives of tens of thousands of people with pain and disability and put many people at risk of premature death. This was a deplorable position indeed in the year of the 75th anniversary of our NHS.
Baroness Walmsley (LD)
My Lords, I congratulate the noble Lord, Lord Hunt of Kings Heath, on his excellent introductory speech. He hit all the nails very firmly on the head.
As the NHS reaches its 75th year, it is a very different and much larger beast than when it started out. The challenges are not just greater but different. On the upside, to a great extent we have conquered infectious diseases through vaccination and sanitation. Because of the success of medical science, our population is ageing, leading to greater demand for healthcare. On the other hand, we have a high level of health inequality and poverty, and a food system that does not provide a healthy diet for many people. Preventable diseases are now the greatest cause of illness and death. In 1948, people walked everywhere; many did manual labour, so obesity was rare; they ate seasonally and cooked their meals at home, and ultra-processed foods did not exist. But the air was not necessarily cleaner, because we burned coal to heat our homes. Today, we lead a very different life.
So, post-Covid, the NHS has five major challenges. There is the state of social care, causing too many people to enter hospital and stay there for too long. Linked to that, there is a crisis in ambulance service response times and A&E waiting times, causing excess deaths and harm. Many diseases, including cancer, are being diagnosed far later than they could be, leading to poor outcomes. Long waiting lists for urgent and elective care are leading to damage to the economy as people cannot work while they wait. There is too little preventive work to help people lead healthier lives.
The Government’s response is a focus on increasing the front-line workforce while ignoring the poor communication and system planning in the service. While we certainly need to train and retain more health professionals, especially in deprived areas, they are not the only people the workforce plan should be focusing on. We need system planners and communications experts. The money available for the NHS to tackle these problems is not infinite, which means we need greater productivity.
Nobel laureate Paul Krugman said:
“Productivity isn’t everything, but in the long run, it is almost everything”.
A crude definition of productivity is the ratio of inputs to outputs. Some think this is all about individuals working harder, but NHS staff are all already working extremely hard. It is not about working harder but working smarter. It is about improving outcomes. It is also not just about national initiatives. There is bound to be poor buy-in for national initiatives when staff on the ground often have a better idea of what could be done better. That is not to say there is no room for national initiatives, but they do not need to be designed by McKinsey.
There are problems with measuring real productivity in the NHS: how to adjust for the mix and quality of outputs and recognising the difference between outputs and outcomes. The NHS produces a wide variety of outputs. GP appointments are not the same as hip replacements, but the service has quite sophisticated statistical ways of dealing with this. It is harder to adjust for quality. Doing two knee replacements rather than one looks productive, but not if the second was needed only because the first was botched; and especially, as in the case of a lady I know, if the patient has to see the consultant three times before he will accept that there is something wrong. Then we must ask, is the outcome better as a result of the NHS having done something? The lesson here is that it is productive to listen to patients. Unfortunately, the NHS has cut back on patient-reported outcome measures, which are a valuable way to assess outcomes. My first question to the Minister is: are there plans to reinstate or replace PROMs?
A recent internal paper about productivity said that NHSE is
“very good at generating ideas”
for efficiency initiatives but does not have clear processes to evaluate them. It added:
“The overall volume of initiatives means it is very likely that the system is overwhelmed, which means that initiatives are not as effective as they could be. Moreover, a lot of the initiatives we are taking forward lack the buy-in from front-line staff that is needed to make changes stick”.
The system and infrastructures that support waiting list management include IT and tools for proactive patient tracking, as well as the processes that staff follow to efficiently and accurately co-ordinate pathways for patients on waiting lists. Millions of hours of clinicians’ time are wasted due to inadequate IT systems. A recent BMA report found that four in five doctors believe that improving IT infrastructure and digital technology would help to tackle backlogs. Can the Minister therefore say whether systems analysts and IT and AI specialists are included in the workforce plan, as well as medical professionals? We did not just win the Battle of Britain using pilots.
Sadly, there are too many examples of the skills of our health professionals being wasted because of inefficient systems planning and poor communications. A recent example concerns former BBC journalist Rory Cellan-Jones, who suffered a broken elbow and facial bruising following a fall. He spent two unnecessary days in hospital and calculated that 90% of the staff time spent on his case could have been avoided with better planning and communications. It was eight days after his accident before he received appropriate treatment. It was not just a question of communication between staff, but communication with him. He says in his blog:
“Getting information about one’s treatment seems like an obstacle race where the system is always one step ahead. … But communication between medical staff within and between hospitals also appears hopelessly inadequate, with the gulf between doctors and nurses particularly acute. I also sense that, in some cases, new computer systems are slowing not speeding information through the system. On Saturday morning, as we waited in the surgical assessment unit, four nurses gathered around a computer screen while a fifth explained … all the steps needed to check-in a patient and get them into a bed. It took about 20 minutes and appeared to be akin to mastering some complex video game”.
It also took four hours to get the paperwork for his discharge.
My Lords, I have experienced a similar situation and it grieves me to see our skilled professionals not being used in the most cost-effective way. What are the Government planning to do about this?
Baroness Taylor of Bolton (Lab)
My Lords, I congratulate my noble friend Lord Hunt on securing this debate and on outlining not just current problems but potential ways forward, which is what we should be concentrating on. This is an important debate, because few issues are more significant for us as individuals and indeed as society. Our individual and collective health and well-being very much depend upon a robust NHS. The figures my noble friend gave, including the 7.8 million on the waiting list, showed very clearly that we do not have that today, I am afraid.
Time is always limited in these debates, and there are certainly many aspects of the current state of the NHS that warrant mentioning—alas, far too many to mention. However, unusually, I want to start by mentioning some of the briefings we have probably all received in the last few days since this debate was announced. I was particularly struck by the briefing paper from the Association of Directors of Adult Social Services. It highlighted that in August, more than 470,000 people were waiting for a care and support assessment to begin, up 8% on March of this year. It highlighted the almost universal view that increased pressures on the NHS will put even more pressure on adult social care—a significant and growing problem.
We also had an interesting paper from a well-known opticians, pointing out that greater use of the glaucoma referral system, with optometrists working with the NHS, can significantly benefit patients and the whole of the NHS service; a similar situation arises with audiology services. The Royal College of Psychiatrists told us in its detailed paper about the contribution that early support hubs can make. The Bowel Cancer UK group gave us striking figures that nine in 10 people will survive bowel cancer if diagnosed early, but only four out of 10 are actually being diagnosed early. The most significant point about all these examples is that they highlight issues that are not simply about asking for more funds. They are pointing out and giving examples of how early invention can not only benefit patients and individuals but reduce long-term costs.
All of those examples and that theme link up with what we were told by Universities UK, which has outlined the problems we are seeing with applications from students for positions in critical areas of nursing and the whole range of medical specialties. Even if we did get the increase in the number of students, we are also short of clinical academics and people to do the teaching to get the placements they need in our hospitals. This area is particularly critical to the way forward. Although the Government sometimes boast about increasing student numbers, there is still a very long way to go before we recover from the cuts made from 2010. That is one of the reasons why we are in such a serious situation.
I want also to mention one other issue that particularly alarms me. In October, just a month ago, the Care Quality Commission rated 65% of maternity services in England as inadequate or requiring improvement. Its report says, having inspected 73% of all maternity units:
“The overarching picture is one of a service and staff under huge pressure”.
Despite the efforts of staff, who are often praised because of their efforts by people on the receiving end, many women are still not receiving the safe, high-quality care they deserve. The CQC went on to say that this was particularly a problem for ethnic-minority women, for whom the service was particularly poor. Its overall assessment was that we have a deteriorating position in maternity services. All of us who have children know that the moment a child is born is one of the most important times of your life. It really is alarming that, in 2023, 75 years after the establishment of the health service, which was partly formed to improve maternity services, we have that situation.
I must just mention a related issue from my local area. Last week, it was reported that no babies have been born in Kirklees for around 18 months. Kirklees is one of the largest metropolitan council areas, covering Huddersfield, Dewsbury, Batley and lots of other smaller towns, yet there are no facilities for childbirth there. The units in Huddersfield and Dewsbury have been closed. Just imagine being a pregnant woman going into childbirth and having to travel potentially for an hour in those circumstances. The reason given is staffing issues. There are plans for the future, but in some cases it will take nearly two years before that service becomes available.
I have the figures for the increasing number of doctors, midwives and consultants under a Labour Government, but I end by echoing what my noble friend said: we fixed it last time; we are going to have to fix it again.
Baroness Pitkeathley (Lab)
My Lords, I too thank my noble friend Lord Hunt for introducing this debate in his typically tub-thumping and inspiring manner.
I owe my life to the NHS—quite literally. Without the NHS’s resources and the commitment and skill of those who work in it, I would not be standing here making yet another speech on health in your Lordships’ House to join the many I have made since I became a Member at same time as my noble friend. It is no exaggeration to say that it causes me emotional distress to hear the phrases that people are now using about our beloved NHS—“The NHS is not what it was”, or, “You can’t rely on the NHS now”—or to see friends in my village spending their life savings on paying for surgery in the private sector because they are no longer able to tolerate the pain in their knee, or cope with being off work for a year or even two because they cannot get their hip done. That is what 7 million on the waiting list means.
I will not repeat what other noble Lords have said about the length of the waiting lists. They must be fixed, but we cannot fix them without fixing what causes them. Is it any wonder that you have to wait at the front door of the hospital when you have a traffic jam at the back? The NHS and social care are inextricably bound together—how many times have we said that in your Lordships’ House—yet we are no nearer to solving the problem than we were 25 years ago. In fact, it has only got worse. As we know, people are living longer with more comorbidities. We should rejoice in that because it is an NHS success story, but, as we know, local authority budgets, which have been so constricted for so many years, are unable to provide the services we need. The problems in social care are just the same as they have always been: not enough money, too little integration and fragmented services. That is what a previous Prime Minister promised to fix. As my noble friend said, “That went well, didn’t it?”
I know that the Minister, when he comes to reply, will give us statistics on how much more money this Government have put in, but it is spent on the wrong thing: on hospitals instead of primary, community and social care, which are the services that keep people out of hospital. As the Association of Directors of Adult Social Services reminded us:
“National policy and investment has predominantly focused on addressing issues relating to discharge from hospital”—
there we go with hospitals dominating again. Consequently, people are sicker and have a higher level of need, so more resources are needed. ADASS says that we can fix this system only
“by shifting policy and investment towards early intervention and prevention”.
Hurrah for that, but preventive work—the stuff that keeps people out of hospital—is always the Cinderella when money is being dished out because it is long-term policy.
I have just had the privilege of chairing a special inquiry into integration between community and primary care services. Our report will be published shortly, and I hope it will not only give a useful insight into what the problems are due to a lack of integration are but draw conclusions about how they could be addressed.
Our focus on hospitals as the embodiment of the NHS blinds us to the other services, which are much more important to the patient and much more effective in sorting out the waiting list problem. Primary and community care services are what most people have contact with in the NHS. If we are really serious about improving NHS performance, then that should be our focus. Your community physiotherapist can prevent the need for a knee replacement, and your community occupational therapist can prevent the fall that results in hospital admission. I hope the Minister will assure the House that the Government understand the great importance of prevention in tackling any problems in the NHS.
I will mention two more elements in the NHS that we ignore at our peril when it comes to performance. The first is the voluntary and community sector, which provides so many services that contribute to good health, both mental and physical: the plethora of disease-specific organisations, support groups and information services, which are vital and make such an important contribution in healthcare, as we saw during the pandemic, that are now under threat because of a lack of funding from local authorities and pressure on their volunteers. Only one-third of directors of adult social services were able to invest in community and voluntary services.
Secondly, your Lordships would expect me to flag up the vital contribution of families to health care—those millions of unpaid carers. I quote from the State of Caring 2023 report from Carers UK on carers’ health and well-being. The report shows that
“carers’ mental and physical health is getting worse, and for some it’s at rock bottom”.
It says that
“42% of carers said they needed more support from the NHS or healthcare professionals, and …better recognition from the NHS of their needs as a carer”.
The report also says:
“35% of carers said they were waiting for specialist treatment or assessment, either for themselves or the person they care for”,
and that they were therefore worried about their ability to go on providing that vital amount of care. One carer, talking about the challenges with their mental health, said:
“I know I could ask for counselling, which I’ve had several times over the years through my GP and other organisations. But the waiting lists are very long”—
too long for me.
The Government’s vision should be that we have an NHS which is the most carer-friendly health service in the world, both for the unpaid carers and for the one in three staff who work in the NHS and are juggling caring responsibilities themselves. I hope that when the Minister replies, he will reiterate the Government’s commitment to having a clear and deliverable strategic approach to improving carers’ health and well-being, and the structures which enable carers to get the support that they so much need.
Baroness Hodgson of Abinger (Con)
My Lords, I welcome the opportunity to have this debate and thank the noble Lord, Lord Hunt, for having secured it. We are so very lucky to live in a country that has a health service, and we should celebrate the NHS on its 75th anniversary. I pay great tribute to the many dedicated doctors, nurses and health professionals who have worked in the NHS over the past 75 years, many of whom really are true heroes.
However, we are having this debate at a difficult time, as we have heard, with the NHS facing unprecedented challenges and the fallout of the pandemic still significantly impacting the system. There is also, perhaps, a generational change of attitude. I do not think we have ever before had doctors and nurses going on strike. On top of that, a number of very difficult situations have come to light, with maternity scandals, as we have heard, in hospitals such as Shrewsbury and Telford, Nottingham, Mid and South Essex, Morecambe Bay and East Kent—to name some of them—revealing huge failings in safety, as well as the realisation that hundreds of avoidable deaths occur in our hospitals. No longer can we say that the UK has the best survival rates for many cancers. All this paints a picture that the NHS is somewhat in crisis. As we have heard, a recent IPSOS survey noted that public satisfaction with the running of the NHS as a whole is at its lowest level for 25 years.
Time is short in this debate and it is such a huge subject, so I thought I would concentrate my remarks on the GP system and primary care. We had the most wonderful system, but since the early 2000s this too seems to have dramatically declined, starting with the change to the GP contracts. The British Social Attitudes survey found that the proportion of patients who were satisfied with GP services, in particular, has plummeted from 68% to 38% since 2019, with people often struggling to get the care that they need. Anecdotally, we consistently hear about the crisis of patients not being able to access their doctors. Many GP practices have taken on the system of triaging patients, but if you are really feeling unwell, you do not feel like fighting with the receptionist to see a doctor—the result being that people give up and go straight to A&E, which naturally has a knock-on effect on waiting times there and on the ambulance service, which cannot discharge its patients.
It is clear that GPs too are feeling under pressure. A report published by the Health Foundation charity paints a picture of high stress and low satisfaction with workload. Just one in four UK GPs are satisfied with the time they are able to spend with their patients and appointment times are among the shortest of 11 countries surveyed. I gather that the average doctor now has to deal with 41 to 50 patients a day. When asked, GPs feel that the right number is somewhere around 30, maximum, and this situation is leading to burnout. Only one in four GPs in England is now working full time; most work three days or fewer each week. A third of GPs are considering leaving within five years, with the Royal College of GPs claiming that it is “no longer feasible” to be just a GP, despite an average salary of over £100,000 a year.
Many doctors now do not know their patients. Talking to older GPs, I learned that the job satisfaction came from knowing whole families and caring for them throughout their lives. While not knowing your doctor may not be a problem for the young and healthy, if those with small children or the elderly know their GP that makes it much easier for the GP to treat them, without having to read through all their notes each time, thus cutting their time down. I have cited in previous debates the Norwegian study published in the British Journal of General Practice, which clearly demonstrated the benefits and stated that it can be lifesaving to be treated by a doctor who knows you.
Yet in the UK, GP practices are becoming bigger and the relationship between doctors and patients less constant. While patients over 75 in the UK are given a named GP, it would appear that some doctors interpret this as just having to look at patient records. I understand that patients who wish to be seen urgently cannot always see the same GP that day, but how can a doctor deliver appropriate and responsible care to a patient without ever meeting them?
What can we do, going forward? I believe we need to redesign the whole system so that it works for doctors and health professionals, and, most importantly, for patients. Training more GPs is one easy answer. I know that there was an increase of 25% in funded medical school places in the three years up to 2020, but clearly we need more. We must cut down the number of patients who doctors are being asked to see each day. We must make it advantageous for doctors to work in a practice, rather than being a locum. Smaller practices used to work better. Most importantly, we need to encourage doctors to know their patients again; this will lead to better outcomes, as shown by the Norwegian study, and help ease pressure on the whole system.
However, we need to do more to encourage people to take responsibility for their own health. Prevention is key: good diet and exercise are vital; health checks are important and should go on until an older age. We should also include mobility checks, as people who cannot exercise will put on weight, leading to diabetes, heart problems et cetera. That would help to prevent hip and knee problems. We need to encourage practice nurses to deal with more conditions and get qualified pharmacists to be able to give a wider selection of medication without a prescription. Community nurses are such an asset, and we need to ensure that doctors work closely with them. Those dealing with patients on the phone need to be trained to be kind and caring.
Mental health takes up more and more time. Are there better ways of dealing with this, rather than endless medication? Should we encourage people with certain conditions not to go first to their GP? For example, could those with back pain go first to an osteopath or a physio or a sports therapist, who can often sort them out? Good IT can really help with the whole system.
We must make sure that primary healthcare works better for patients, as well as being a job that is once again enjoyed and valued by doctors. This is so important, as, if we can once again restore good primary healthcare, that will ease the whole health system.
Lord Prentis of Leeds (Lab)
My Lords, 2023 is the year we celebrate 75 years of our National Health Service, and what is crystal clear, above anything, is the continuing strength of people’s attachment to our NHS. The vast majority of people—nine out of 10—believe that the NHS should remain free at the point of delivery, while eight out of 10 continue to believe that the NHS should be funded through taxation. This support extends across all political parties, across leave and remain voters, and across all age groups—and for me, personally. Twenty years ago, like millions before and after me, our NHS saved my life, and for that I will always be grateful. The health service is still there for all of us, 75 years on, from cradle to grave.
How did it come to be that the waiting list for treatment will exceed 8 million by December 2024? How did it come to be that the number of patients waiting for treatment and suffering real harm could double in three years to 7,900? We need to look no further than the recent OECD Health at a Glance 2023 report, whose international comparisons showed that the UK has among the lowest average growth in per capita health expenditure. We need look no further than the Care Quality Commission’s own works warning of the dangers of longer waits and reduced access, especially in maternity, ambulance and mental health, as already referred to.
We need look no further than this House’s own investigation earlier this year. The report was called Emergency Healthcare: a National Emergency. Emergency healthcare is facing a crisis. To quote from our report:
“Patients are delayed at every stage of trying to access emergency healthcare … Stories of ambulances being stuck outside of hospitals”,
which is “posing an unacceptable risk”. The impact on the workforce, according to the same report, is that there are
“significant challenges, including shortages, low job satisfaction and retention rates, and poor health”.
Ambulance staff were described as “overwhelmed … fatigued and depleted”. Our NHS is under unprecedented strain and our own House of Lords report drew attention to the 133,000 vacant posts in the NHS and the 91,000 vacancies in acute social care.
Anyone who uses NHS services knows that they are only as good as the staff who are treating them. These are workers who were on the front line during the long months of the Covid crisis. Many left—exhausted and shell-shocked by what they went through. If our NHS is struggling with the huge gaps in staffing and is struggling to motivate those who remain, our NHS will always struggle to deliver the quality of care that it wants to.
However, there is some good news on the horizon. The NHS Long Term Workforce Plan has finally, after many years, been published. Much of the plan is positive, particularly the focus on boosting the use of apprenticeships. But even this plan was massively delayed. Now, the challenge of providing a thriving and sustainable NHS workforce for the future has become even greater.
The biggest problem with the plan, as with so much of healthcare policy, is a continuing failure to provide any solution to the deteriorating situation in social care. The state of social care is appalling, with the number of vacancies now reaching 152,000 in England alone. It is a service kept alive by the use of migrant labourers, who legally can be paid 20% less than the existing workforce. There is now growing evidence of widespread exploitation of migrant staff in the social care sector. There is growing evidence of care workers from overseas having money deducted from their wages to cover dubious fees, facing demands to repay thousands of pounds when they try to move jobs and being forced to pay extortionate rents for sub-standard accommodation. It is an adult social care service that is not fit for purpose and is causing gridlock at the interface with the National Health Service.
As the Government have prevaricated and delayed, so the sector has moved further into crisis. There are questions that must be answered. We have a long-term workforce plan for the NHS, but why is there no corresponding social care strategy? We have a successful NHS social partnership forum, but why is there not one for adult social care? Why are the Government willing to participate in the NHS forum but stand aloof—conspicuous by their absence—from a social care forum?
What is needed more than anything is ambition and a proper overhaul of the adult social care system. In short, we need the introduction of the national care service that we on this side of the House are calling for. The vision that led to the creation of our NHS is as valid today as it was in 1948. Today, it treats 1.3 million people per day. It is productive, despite little investment in capital works. It gives value for money, but, as demand increases, so do the pressures. Innovation is vital—that goes without saying—but so is the NHS long-term workforce plan. NHS England believes it could mean an extra 60,000 doctors, 170,000 nurses and 71,000 more allied health professionals by 2036.
Such a transformation will be achieved only if the Government of the day have the ambition to see the plan as their priority and provide the resources needed. The vision that underpinned our NHS has stood the test of time. We have all benefited from the courage of those involved in 1948. It is our duty now to ensure that our NHS continues to evolve so that it is there for future generations. Like everybody, I would like to quote from Aneurin Bevan. My favourite quote has nothing at all to do with the NHS, but Nye Bevan said this, and I have always used it as a way forward: “If you walk down the middle of the road, you get run over”.
Lord Brooke of Alverthorpe (Lab)
My Lords, I am grateful to my noble friend Lord Hunt of Kings Heath for his—as expected—truly amazing speech. He is a man with great experience of the health service, both before he came into this House and, in particular, while he was serving here as a Minister. He is a man of great value; he is one of the few politicians around who resigned on principle on an issue. He resigned over Iraq. I was one of those who was on the wrong side and I admire him greatly for the work he has done and what he continues to do.
As he mentioned—as did the Baroness, Lady Pitkeathley—I also spoke on this way back in 2003. I also spoke in 2018, when we were celebrating 70 years. What particularly interested me then was that the standing of the NHS in the eyes of the public was very high. I thought it was a great opportunity for us to try to take this jewel. The NHS is something which binds us together. As the previous speaker just said, it is important that we go back to that and find ways in which the public attitude, as it presently stands, is reversed.
I suggested in 2018 that we ought to think about creating a national charity for people to participate in and leave gifts in their wills to, and so on. The Government said no, because some trusts already have their charities and that would undermine them. Well, some trusts do have them and they are very successful, but, if you examine it, you will find that the ones getting great amounts of money are in wealthy areas. In the dispossessed areas, where we have the worst health and growing rates of ill health, you will find that charities either do not exist or, if they do, not much money is going in. I would be prepared to put something in my will—not for Chelsea and Westminster, which I am close to, but for the NHS. The money would then be redirected to the areas of poverty where we need to be making the greatest changes.
If we look at what is happening, as my noble friend Lord Hunt pointed out, we are starting to see for the first time in near history that life expectancy is halting and going in the other direction. If you live in Westminster, your life expectancy is going to be of the order of 86 years, but if you are in Manchester it is down to 77 or 78—and this is happening against a background of general decline in many areas of the health service.
I hope the Minister might still give some thought to the idea that we should try to find ways of having far greater involvement of the public. The charity approach was one idea. When Alan Milburn was Secretary of State, he tried to find ways to get more people involved. They even explored the idea of shares in the NHS, so that people were making a personal commitment to it. I still believe there is merit in going back to some of those issues.
Covid has of course made a difference, and we should not deny that—the Minister will, without a doubt, labour this point in defending the state we are in. When we came into power in 1997, the health service was in a mess and, as was said, it is in a mess again. We have to find our way forward. Care in particular has to be addressed, and we have a plan there, but I believe that the way forward will be to try to involve more people in building a base for revising our approach to it. I appeal to the Minister: the Government made promises in 2019 but have not delivered on anything, so would they be prepared to consider working closely with the new Government, if Labour comes to power, to try to take care out of the Punch and Judy that we have had so much in the past—to come together and to shift care away from political disputes between the parties? I hope the Lib Dems might be willing to give their support to that entirely different approach to care, because it is so desperately needed.
I wonder why this review of Covid is going on until 2026. How much money will be spent on it before it is completed? Would it not be better spent on trying to address some of our current problems in the health service? With Covid, some underlying causes needed addressing. The first was age—and care is the way we start to address that properly. The second was the underlying cause of weight: 50% of the deaths attributed were attached, for a variety of reasons, to people being overweight. The Government have a number of proposals for change, but have fallen well short. They made a grave mistake in winding up Public Health England—at least it was seen as a focal point for campaigning, and it was coming out with strategies that were noticed. We have completely lost focus on where we go in campaigning on obesity, and I hope that, when my party comes to power, it will address that more than it has been addressed in the past. The third area that was identified in the Covid review was the disproportionate number of people of colour who suffered badly. As was mentioned, a recent report says that people of colour are still gravely disadvantaged in health terms compared with the white population. We need to find new policies to address that difficulty and to turn it around so that people start to feel that they are a better part of the community than they are now.
My appeal overall is to try to take certain areas where we are failing to make progress out of the Punch and Judy of politics, to develop new relationships that would move us forward on issues that we have all had policies on for years but have not made progress on. I hope the Minister spends some time, in responding, on the need to get the public more involved than they have been and to get some unity of purpose between the parties in the areas where we have still not made any movement but should have.
The Lord Bishop of London
My Lords, I declare my interests in the register. It is a privilege to participate in this debate about one of our most valued institutions and to follow some excellent contributions. One of the focuses of my work in this House has been reducing health inequalities. The NHS was founded in the face of extreme inequality, in the hope that financial means would not be the sole determinant of health. The universal service that is free at the point of use is something we can be extremely proud of.
The 75th anniversary of the NHS is very close to the 75th anniversary of the Windrush generation, which I will celebrate today. As we know, many of the passengers on HMT “Empire Windrush” took up roles in the NHS, which launched just two weeks later. When experiencing workforce shortages from 1948 onwards, British politicians visited the Caribbean as part of a recruitment programme that had 16 agencies in the British colonies by 1955. By 1977, 66% of overseas student nurses and midwives originated from the Caribbean. In the face of overt racism and unequal opportunities for professional development, their contribution has been truly extraordinary. Without it, the health service would not be what it is today.
I am sure much of our nation would say that the true treasure of the NHS is its workforce, whose example should be a great encouragement to all of us. In this House, I have not held back from highlighting the challenges that the workforce currently face: significant vacancies, sometimes poor working conditions and enormous pressure. The industrial action we have seen is a product of the erosion of trust between the front line and this Government. Since the passing of the minimum service levels Act in the last Session, what ongoing work is being done to build relationships of trust with the unions and other bodies to ensure that the concerns and needs of the workforce are truly listened to?
As I have said before in your Lordships’ House, the global majority heritage staff continue to face troubling challenges. The Care Quality Commission’s State of Care report highlights instances of tolerated discrimination and a lower chance of being represented in leadership and managerial roles. There are over 256,000 black and minority-ethnic nurses and midwives, but they are overrepresented in bands 1 to 5. When I was the Government’s Chief Nursing Officer for England, I commissioned the government Chief Nursing Officer’s black and minority-ethnic advisory group, which it was a joy meet with on its 22nd anniversary. The most recent race equality standard report from the NHS shows that there is progress heading in the right direction; although it is slow, it should celebrated.
Amid the celebration of this great institution, many challenges remain. The strain placed on the service is clear in key areas, including the number of people waiting for care and the significant workforce challenges. But there are also challenges with our health, distinct from our healthcare. Some 50% of people in the most deprived areas report poor health by the ages of 55 to 59, which is over two decades earlier than in the least deprived areas. It remains an injustice that where exactly you live can change the length of your healthy life in such a serious way. In light of this, what consultation has taken place with other departments to seize the opportunity of the Major Conditions Strategy to give new focus on health inequalities?
It is good to see the new integrated care systems becoming more established. I hope that we will see real progress in place-based and community-focused preventive care. Research published recently by the NHS Confederation shows that every £1 invested in community and primary care brings back £14 to the economy, compared to £11 per £1 for acute services. It is through working for a healthier population that the pressure will be lifted off the NHS and the opportunity to address health inequalities will be realised. I commend the small-scale projects happening in London, where I am. The community health and well-being worker model, which is being rolled out in Westminster, is already encouraging the uptake of health screenings that would otherwise not happen, management of low-level health conditions and promoting well-being. There is much to celebrate about the NHS but, as we have heard, there remains work to be done if we are to press ahead in the same spirit as the architects of the NHS 75 years ago.
Lord Cashman (Lab)
My Lords, it is a real pleasure to follow the right reverend Prelate the Bishop of London, particularly given her experience in the NHS—and, may I say, her recent intervention in Synod on the issue of same-sex unions. It is also good to look around the House and see Members wearing the red AIDS ribbon, a powerful reminder that tomorrow is World AIDS Day and of what research, awareness-raising and the saving of lives can bring about when we work together. I particularly congratulate the Government on the Secretary of State’s announcement yesterday on increasing opt-out testing for HIV/AIDS and hepatitis C. That brings me to my first point, which is that it is vital that we do not forget the lessons learned from the recent Covid pandemic and the importance of simple but effective preventive public health measures in helping to protect the NHS against the financial and logistical burden of seasonal and other infectious diseases.
Ministers will recall that a targeted hygiene approach was applied to control transmission of Covid-19 and other infections in public areas, at COP 26 in Glasgow, and at the 2022 Commonwealth Games in Birmingham. The approach was extremely successful. If the Government were actively to promote targeted hygiene among the public and with owners and operators of public spaces, it could deliver a threefold benefit: building public confidence in using communal spaces and, by preventing illness, reducing pressure on the NHS and boosting productivity in the workforce.
This brings me to my second concern: the complications following aesthetic surgery procedures abroad, a service now widely advertised in the United Kingdom. Demand for cosmetic surgery is increasing year on year. Recently in the United Kingdom, the British Association of Aesthetic Plastic Surgeons, or BAAPS, in its 2022 national audit, reported a 102% increase in cosmetic procedures performed nationally, accompanied by a growing trend in patients seeking cosmetic surgery abroad, resulting in an increase in complications on their return. The BAAPS 2022 audit found a 44% increase in complications following cosmetic surgery abroad, including life-threatening concerns necessitating emergency surgical debridement and intensive care admission for sepsis.
This national concern is twofold: first, the increased burden placed on the NHS; and secondly, the physical and psychological burden placed on the patient. The true burden on a young working female demographic has seen increased incidence of lost workdays, significant side-effects of renal impairment, hearing loss from antibiotics, repeat theatre visits to valuable emergency theatres, and A&E visits. There is also a real concern about the true cost to the nation and the NHS arising from multi-resistant bacteria. This is in addition to cosmetic deformity and psychological issues from permanent scarring.
There are many factors influencing patients’ choosing cosmetic surgery abroad, but there is little public awareness of the incidence of complications following such surgery abroad and the additional financial burden incurred on seeking treatment and corrective procedures, both privately and in the NHS. Study proposals are being drawn up by the British Association of Plastic, Reconstructive and Aesthetic Surgeons. The aim of this service evaluation, as the Minister may know, is to obtain retrospective and prospective data from all plastic surgery units in the United Kingdom relating to recent NHS and private clinic admissions for complications following cosmetic surgery abroad, the management of surgical and non-surgical treatment, and the country in which the primary surgery was performed. Therefore, I urge the Minister and his department to engage with BAPRAS on that proposal, and I look forward to his response.
Finally, I end with a quote from a senior aesthetic consultant:
“Problems remain: bad days, loss of workdays, side effects of drugs to hearing, kidney and liver function, loss of life and scarring and psychological effects of cosmetic surgery that has gone wrong. The real worry will be the introduction of multi-resistant bacteria to many specialist parts of our NHS, A&E, infectious diseases, plastic surgery, ENT and general medical longer-term needs. Our NHS lacks direction and leadership, due to the political football that is the NHS and the transient nature of the managers who run it and who are responsible for the spend in it”.
That is as damning as it is concerning, and it is clearly time for urgent intervention—and I have not even touched on the deeply worrying proposal for physician assistants. Yes, let us celebrate this amazing 75th anniversary. I have much to thank the NHS for, not least the love and care of my late husband in his 50th year, at the end of his life. But while congratulating the NHS, let us also take the necessary action and decisions to assure its continuation.
Baroness Taylor of Stevenage (Lab)
My Lords, it is a great pleasure to follow my noble friend Lord Cashman and pay tribute on this special day to all the work he has done on AIDS awareness. I am grateful to my noble friend Lord Hunt for introducing such an important debate to the House today, with a tour de force of a speech on the opportunities for and challenges facing our NHS.
We recently held an event in Stevenage to celebrate the 75th anniversary of the NHS, and we were privileged to be joined by my honourable friend the shadow Secretary of State for Health and Social Care. During that occasion, we looked back to days before the NHS existed and the insecurity that working-class communities experienced when their health failed. Ill health could bring about disastrous consequences for families not able to afford treatment, and home treatments and remedies often made matters worse—a situation, I can tell the noble Lord, Lord Lexden, that existed hundreds of years before a Labour Government introduced the NHS. We reflected on the current situation the NHS faces: the marvellous and heroic dedication of the staff being tested daily by increasing demands; an epidemic of mental health issues; digital and pharmaceutical treatments that are incredibly effective but extraordinarily expensive; and an ageing population. Then we considered what the future of the NHS might be with the development of AI technology, robotic surgery, and the aspect I would like to concentrate on for the purpose of this debate—a much clearer focus on prevention. But that will require considerably more partnership working, especially, but not exclusively, with local government, which is what prompted me to take part in this debate.
Local government has always played its part. The first Public Health Act was passed as far back as 1848, and much of the drive to local governance in Victorian times was exactly to tackle the public health issues arising in the overcrowded and squalid living conditions of Britain’s working cities. As recently as 2013, those responsibilities came to the fore again when public health commissioning was transferred from the NHS to local authorities, which took on responsibility for improving health in their local populations, including services to reduce drug and alcohol misuse, social prescribing, promotion of health and well-being through their leisure facilities, and direct intervention to tackle prevention priorities such as smoking and obesity.
An excellent report co-produced by the District Councils’ Network and the University of East Anglia showed that the engagement of just over 1 million of the inactive population of England in prescribed leisure services could provide significant outcomes over a 10-year period, such as 45,000 diseases avoided, giving a direct saving to the NHS of £314 million; 70,000 additional years of life in good health, with an economic value of £4.2 billion; and a reduction of 3.7 years in the healthy life expectancy gap.
In my own area, we set up a healthy hub to deliver rehabilitation programmes following strokes, cardiac episodes and cancer treatment. More recently, we instigated a young persons’ healthy hub to support our young residents, especially with their mental health issues. These services now sit alongside the adult and social care services which we have heard so much about in this debate and which are so key to keeping our vulnerable residents healthy and our hospital beds available to the most acutely sick. I hope no one here would deny the enormous role played during the Covid pandemic, as local government developed our relationship with our health partners even further to support our communities through the worst healthcare crisis for generations.
All this work in partnership with health colleagues is very much part of the NHS aim to deliver healthy communities. The figures are clear: it is set out in a report from the Public Accounts Committee that community sport and physical activity, such as social prescribing, brought an estimated contribution of £85.5 billion in social and economic benefits, including £9.5 billion from improved physical and mental health. The part played by local councils in saving costs to the NHS can hardly be disputed, but we have had cuts to local government funding, which has seen a 27% real-terms cut in core spending power since 2010, and the LGA predicts that councils will face an eye-watering £3.5 billion funding shortfall over just the next two years to keep services standing still. Councils’ role in preventive healthcare, public health, and adult and children’s social care, both of which face extreme pressures, is in jeopardy.
Much of healthcare, such as social prescribing, rehabilitation and preventive programmes, is delivered through council leisure functions but—it is a big “but”—most are funded as discretionary spend. The Public Accounts Committee warns that 70% of councils are considering scaling back their leisure services, not least because their energy bills have seen an increase from £500 million in 2019 to £1.2 billion last year. This comes on top of over £71 million already cut from leisure budgets since 2010, a 14% cut. Most sporting facilities in our towns and cities have an average age of over 30 years, with no funding available to improve or replace them.
Councils and councillors want to go on playing their part in supporting our NHS to keep our communities healthy and to tackle health inequalities. Indeed, the King’s Fund recently said that councils have a fundamental role in determining the health of their communities. But while relationships with the NHS are strong and the political will is there, the funding model is incredibly fragile and, should it come tumbling down, the consequences in additional costs and demands, both short and long-term, to our NHS are extremely serious. I hope that the Minister will persuade the Chancellor to consider this as he finalises the local government funding settlement in the next couple of weeks, and to invest to save in local government, in prevention and in a healthy future. As Nye Bevan said:
“There is no test for progress other than its impact on the individual”.
Baroness Tyler of Enfield (LD)
My Lords I start by expressing my heartfelt thanks to all NHS staff for the tremendously difficult and important job they do. I particularly pay tribute to the memory of close to 1,000 NHS and care workers who died while working to save others during the terrible Covid pandemic. We owe them a debt of immense gratitude. Like other noble Lords who have spoken today, I know that I and other family members owe our lives to the NHS, and that is why it holds such a central place in our country’s social fabric and in our hearts.
It is against that backdrop that I want to talk about the need for reform. As we mark the NHS’s 75th anniversary, it is right that we should reflect on its performance and what could and should be done to improve and renew it. We have already heard a lot of statistics about waiting times and numbers treated; I want to concentrate on the wider context for health and then look specifically at the thorny question of productivity.
It has been estimated that some 80% of the health needs of people across the country are not within the direct control of the NHS. We also see large inequalities in health outcomes between different groups and communities. The terms “NHS policy” and “health policy” are too often used interchangeably, but they are not interchangeable. Most policy which impacts the health of the nation—housing, transport, employment and so on—is made outside the NHS, which is why we need to focus on the wider determinants of health and devise cross-government strategies to improve health and well-being. It is also why it is so important to ensure that more money goes into prevention and public health rather than just into the NHS, a point just made so compellingly by the noble Baroness, Lady Taylor of Stevenage. Looking at health and well-being in the round, rather than simply at how we prop up the NHS in its current form, must be at the forefront of our thinking. We have already heard, and it is very concerning, that public satisfaction with the running of the NHS is at its lowest level in 25 years.
What is going on? In July this year, the chief executives of three health think tanks, the Health Foundation, the Nuffield Trust and the King’s Fund, wrote a letter to the three party leaders calling for an end to “short-termism in NHS policy-making”, warning that promising unachievable, unrealistically fast improvements without a long-term plan to address the underlying causes of the current crisis is a strategy “doomed to failure”. We would do well to heed that. The letter outlined four key areas to focus on: investing in physical resources; reforming adult social care; committing to a long-term workforce plan; and cross-government working on the underlying economic and social conditions affecting health.
Specifically, the letter pointed out three things. First, due to a decade of underinvestment compared to the historic average, and capital spending well below comparable countries, the health service has fewer hospital beds than almost all similar countries, outdated equipment, dilapidated buildings and failing IT. Secondly, despite long-term objectives to reduce reliance on acute hospitals and move care closer to the community, which I very much support, spending continues to flow in the opposite direction. Thirdly, while the NHS long-term workforce plan is to be welcomed, ambitious steps to increase the number of staff, through training, apprenticeships and international recruitment, et cetera, risk being frittered away if trainees continue to drop out and poor morale and sickness continue to drive staff to leave and retire early. In short, sustained action is needed to make the NHS a better place to work.
Finally, as we have said so many times in this Chamber, we cannot reduce pressures and improve the performance of the NHS without addressing the challenges faced by adult social care. I join the noble Lord, Lord Prentis, and ask, once again, what plans the Government have to provide a social care workforce plan to complement the NHS plan?
It is also worth comparing the NHS to the healthcare systems of other countries. The King’s Fund did this recently and concluded that, first, the NHS is neither a leader nor a laggard when compared to the health systems of 18 similar countries. Secondly, the UK has below-average health spending per person compared to those countries. Thirdly, the UK lags behind other countries in its capital investment and has substantially fewer key physical resources than many of its peers, including CT and MRI scanners and hospital beds. Finally, the UK has strikingly low levels of clinical staff, including doctors and nurses, and is heavily reliant on foreign-trained staff. All that is critical to productivity, which I want to turn to finally.
Respected commentators such as the IFS, the Institute for Government and the Health Foundation have been looking at what has been called the productivity conundrum. The Institute for Government report The NHS Productivity Puzzle found that despite increased spending, particularly since 2019, much of which has gone on increasing staff numbers, there has not been a resultant rise in productivity if measured against metrics such as the number of patients treated. It draws three conclusions. First and foremost, hospitals are running at above full capacity, they do not have enough beds, and too many of the beds they do have are full of people who should not be there. There is a lack of capital investment, low diagnostic equipment stocks, et cetera. Secondly, despite notable increases in the headline number of staff, the NHS is losing too many experienced employees, and they are being replaced with more junior people who are naturally less experienced and who need more support. Staff burnout, low morale and pay concerns are cited as key reasons. Thirdly, it says, the NHS is badly managed and all the changes over the last decade have made managers’ jobs a lot harder.
Finally, a recent IFS report came to similar conclusions about the reasons for the low productivity. It acknowledged it was difficult to measure productivity, and that point came out clearly when Amanda Pritchard was before the Health and Social Care Committee recently. She argued that it is hard to measure productivity, but what plans do the Minister and NHS England have to publish their own analysis of NHS productivity and ways to improve it?
There is much that we could and should be doing. My points and the IFS statement should not be interpreted as NHS staff working less hard. It is the other points that are most important. I expect they are many reasons, but the need to make the NHS an attractive place to work is critical and should be central to the NHS workforce plan.
Baroness Crawley (Lab)
My Lords, I too thank my noble friend Lord Hunt of Kings Heath for introducing this debate. Few are more qualified to discuss the significance of the 75th anniversary of the NHS than he is.
It was a sometime Conservative Chancellor who once described the NHS as a “national religion”. It must pain some of my colleagues on the Government Benches to see the extent to which the Government appear to have lost faith in that service and that religion. Anyone who read the recent Autumn Statement could reach no other conclusion. What is the old lyric? “They are only putting in a nickel, but they want a dollar song”.
Let us deal with the realities. As we have heard from noble friends and others in this debate, according to the BMA, some 7.8 million people are currently on NHS waiting lists. Over 3 million of these patients are waiting over 18 weeks. People who can ill afford it are pursuing private health provision instead of risking the long wait, as we saw last weeks in the figures that came out from the eye care sector. There are millions of people living in constant pain and worry, with no immediate alleviation to hand, including older people and their families waiting in bewilderment for dementia diagnosis and support. As a Dementia Friends ambassador, I know that support is so ad hoc and threadbare across different health authorities that the national infrastructure is just not there to implement any future medical advances in Alzheimer’s and dementia. Young people who cannot find peace of mind wait far, far too long for mental health services.
What does the Chancellor say to all this in the Autumn Statement? He says:
“That is why I want the public sector to increase productivity growth by at least half a percent a year—the level at which the size of our state starts to reduce as a proportion of GDP”.—[Official Report, Commons, 22/11/23; col. 328.]
What is he saying? “Let’s not worry about the industrial action of recent times. Let’s not be troubled by the healthcare buildings infected by crumbling RAAC. Let’s not be dismayed about the Government’s vanishing new hospital-building commitments. Let’s not fret about the stresses on beleaguered staff. Let’s just make nurses and doctors work so much harder in order to achieve our ideological goals”. As my noble friend Lord Hunt said, you could not make it up.
I invite the Minister to share this pledge: that nobody, in any part of this country, should ever be treated in a hospital corridor. If that is not a government objective by now, we certainly need a new Government. Meanwhile, I have to agree with Professor Ranger of the Royal College of Nursing when she commented on the Autumn Statement, saying:
“The NHS faces a multi-billion pound deficit—giving away at least £5 billion in tax cuts in place of health spending confirms the NHS is no longer a priority for the government”.
Let those words sink in: “no longer a priority”. A fit for purpose NHS seemingly does not fit with the Government’s ideological scheme of things. Even the NHS Confederation, hardly His Majesty’s Government’s greatest critic, had this to say about the Statement:
“There were no new major funding announcements for healthcare and existing settlements will stay the same in cash terms”.
This is despite the Nuffield Trust estimating that the NHS faces £1.7 billion deficit. Let us face it, a Conservative Secretary of State for Health—and there have been a few—is about as welcome to health professionals at the moment as James Cleverly would be today in Stockton North.
It is, we are told, the Chancellor’s stated goal to boost productivity in the UK—and so say all of us. Can one think of a faster route to increase productivity, as noble Lords have said, than a healthy workforce with few anxieties about seeing a consultant or getting treatment for a loved one?
The NHS is now 75 years old and remains probably our most stirring national achievement, the envy of the free world. This septuagenarian should invite both respect and support—and it does not appear to be getting either from this Government at the moment.
Lord Davies of Brixton (Lab)
My Lords, I join other speakers in thanking my noble friend Lord Hunt of Kings Heath for initiating this debate. I am going to focus on the issue of mental health and I declare as an interest my involvement with the Money and Mental Health Policy Institute. My remarks depend a lot on the excellent briefing note produced by the Royal College of Psychiatrists, and there is also the continued information provided by the BMA about the pressures on mental health services in England.
Looking back over the last 75 years, we have seen massive changes in this area. It has improved significantly since the NHS was launched. Treatment options have increased and access to treatment has improved. Most notably, of course, there was the closure of the large institutions—the asylums—and the welcome shift to emphasise treatment in the community. Attitudes have also changed. Social barriers are being broken down, mental health is being talked about more openly and positively than before, and in particular, as has been noted by NICE, young people have a different attitude and will drive the process of achieving progressive change.
Having said that, I endorse the remark made by my noble friend that it is deeply disappointing that we are still waiting for the Mental Health Bill which was first proposed six years ago. Despite all the work that has been done, the issues that prompted the reform process remain unaddressed. Detention rates continue to rise and the detention of black and racialised communities remains hugely disproportionate. I am pleased, therefore, that the Labour Front Bench in the Commons has given a commitment to introduce the Bill in its first King’s Speech, were it to win the next election. I call on the Minister to make a similar commitment. What goes in the manifesto is possibly above his pay grade, but perhaps he can assure us that he will urge it on his colleagues as a priority should we get another term from the Conservatives.
It is worth emphasising that, even without this major legislation, there is much that can still be done to protect people’s dignity, autonomy and human rights when they are subject to the Act. I hope that the Minister will give an assurance that active steps are being taken, failing the Act achieving this objective.
I turn now to where we are and waiting lists, which are highlighted in the Motion. There are a record 1.9 million people currently on waiting lists for NHS mental health services and record numbers of children with a mental illness. One of the main reasons for this is the shortage of staff. We have a workforce plan, but we still lack the ambitious and measurable commitments to expand the mental health workforce, in both hospitals and the community. There are also significant retention challenges affecting the mental health workforce, with professionals reporting high workloads, time pressures and poor work/life balance. Especially, there is the need to address racism and discrimination in the workplace, as well as recruitment.
The problems with staffing result, inevitably, in long waits in A&E, reflecting the difficulties that people have in accessing in-patient provision or community-based crisis alternatives. On top of this, adult acute bed occupancy has not fallen below 95% since May last year. Unfortunately, one of the reasons for this is that more than one in 10 people occupying an adult acute in-patient bed are clinically ready for discharge, but, due to a lack of social care and housing support, they remain in hospital. It also means there is still an unacceptable level of inappropriate out-of-area placements, so perhaps the Minister could say something about that.
There is a special problem with children’s mental health. Over the last few years, we have seen record numbers of children and young people with mental illness. To tackle this problem, it must be recognised that the first five years of life are crucial to a child’s development and to protecting them from future mental health conditions. The Government must invest in early intervention for children and young people—that is widely recognised. The mental health of under-fives should be a priority. The Royal College has identified the need for the urgent introduction of a national network of early support hubs.
Finally, there is the need to address the long-term disinvestment in mental health estates. The mental health sector has some of the oldest buildings across the NHS, with 15% of mental health and learning disability sites built pre-1948—older than the NHS itself—compared to about half of that in the acute sector. Despite this age, and more than 50 bids from mental health trusts for the Government’s “40 new hospitals scheme”, only two were allocated to a mental health trust. Mental health faces the most substantial shortfall in capital investment in cash and percentage terms across all trust types, which is part of a sustained trend in recent years. I hope that the Minister can give us some reassurance in his reply that capital will be put where needed.
Baroness Finlay of Llandaff (CB)
My Lords, I declare all my interests as listed in the register, including having worked throughout my life in the NHS. I congratulate the noble Lord, Lord Hunt of Kings Heath, both on securing this debate and, more so, on all the work he has done in his many years of service to the health of this nation.
Perhaps we should have called this debate “In Place of Fear”, the title of Bevans’s own short book. As Gordon Brown said:
“The astonishing fact is that Bevan’s vision has stood both the test of time and the test of change unimaginable in his day. At the centre of his vision was a National Health Service … a uniquely powerful engine of social justice”.
To know where you are going, you must know where you have come from. Bevan had seen directly how the mother in the average family suffers when there is an absence of a free health service and how financial distress excludes those with the greatest need from accessing even minimal care. Yet poverty still blights our health and care, particularly when serious illness hits and the main carer in the household is a child or young person. According to Bevan:
“The collective principle asserts that the resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them; that medical treatment and care should be a communal responsibility; that they should be made available to rich and poor alike in accordance with medical need and by no other criteria”.
Seventy-five years ago, so many physically and mentally wounded were returning from war, penicillin had only just become available and, compared to today, there were relatively few interventions in medicine. The concepts of evaluating the efficacy of clinical audit and the frontiers of medical research that have revolutionised practice were just a dream for many. People now want to be cared for and know that they will get better care in research-active services.
My mother-in-law, as a young GP, gave penicillin injections to a critically ill woman with pneumonia; the response was miraculous. This recovered patient gave her a teapot as a wedding present, and we still have the “penicillin teapot” in the family today. Yet now we face huge threats of antimicrobial resistance, as these precious resources have been misused. Over-the-counter sales of antibiotics in some countries and their use in animal husbandry are threatening our survival from life-threatening infections. Drug-resistant TB is now a major threat.
Some of our failure to value adequately the importance of health to the country’s economy has resulted in too little effort being put into health promotion and public health, as others have said. Yet amazing advances have been made. The polio of my childhood has almost been consigned to history, diphtheria is rarely seen here, and other vaccines have transformed disease incidence, from measles to carcinogenic HPV, and many more. Yet we still see Dr Julian Hart’s inverse care law in play, that the availability of good medical or social care tends to vary inversely with the need of the population served.
With so much more that is treatable, and with social problems creating more avoidable disorders, we must tackle the social determinants of health if we are even to begin to tackle growing waiting lists. The NHS cannot be the final repository for all that is going wrong in society. Our collective responsibility is through care and well-being in communities, better nutrition, and through supporting people to look after their own health and to respect a health service that is not simply a demand service—it is not like online shopping.
As we push for more care in the community as people are moved out of hospital, we have to remember that the local family structure that previous generations depended on is just not there. Discharging people from hospital to loneliness does not aid recovery. Does the Minister acknowledge and value the excellent work undertaken by all those in the community, particularly district nurses and care staff, and the ever-increasing pressure on them?
We need to tackle public health more than ever, and the misinformation that blights its use and interventions. Prevention runs through everything, including preventing complications and care failures. Nye Bevan recognised that it is obviously preferable to prevent suffering than to alleviate it. We often know what to do but are just not doing it. We understand analgesics yet too few people with advanced disease are accessing the expertise they need, including in my own discipline—I declare an interest in specialist palliative care.
Our emergency departments are under such pressure that staff talk of leaving as we hit a downward spiral in access for those with greatest need. Disease does not respect the clock or the calendar. If we do not use our resources better—the greatest resource being our staff—we will never tackle increasing waits.
We live in a seven-day society so we need to make it easier for staff with children to work on different rotas, use term-time flexible hours and weekend childcare resources so that we can use our theatres with high-intensity teams, and use diagnostic scanners and so on much more efficiently. These are human resource issues. Staff at every level can care only if they feel cared for, supported in difficult decisions and valued for all they do, with meals available, on-call rooms, and private areas to have private conversations. Without the tools and the space they need to treat people and care for people, we cannot expect them to do well.
There are many apparently high-cost interventions now available that result in remarkable long-term savings. Failure to invest in these is short-termism at its worst. Investing in capital and training, as the noble Lord, Lord Hunt of Kings Heath, said, is essential. We need to rethink our health economics model to ensure that we meet need, in the short and long term. There are different ways of working. Technology can help but it is not the only answer to current issues. A healthy nation is a productive nation.
Lord Dubs (Lab)
My Lords, exactly 75 years ago today, I was as a child ill in Stockport infirmary, and I am totally taken by the memories of that day. In the morning, the consultant came by with his entourage of doctors, matrons, and so on. Consultants were very important in those days; they still are, but in those days, one did not speak unless one was spoken to. I said to him, “Excuse me—I have a question to ask”. He turned around. “What is it?” “Are we having a party today?” He asked, “What for?” I said, “The hospital is ours—it’s a great day”. He was not very impressed and walked on. Later on, they asked me at the other end of the ward, “What’s going on?” and I explained how the hospital was ours and what a great day it was. It was a privilege to be ill on the day the health service started.
Since then, I have served on an area health authority and on a mental health trust. It is no secret that I spent two months in Charing Cross Hospital earlier this year—the danger is that anybody in this House who is asked how they are can spend 20 minutes telling people about their health conditions. I am going to resist that, except to mention it in passing. There I was in intensive care at three in the morning, it was noisy and one could not sleep. The doctor came up and looked with interest at the books I had my table—which I could not read—and she said to me, “We know who you are”. I hope I had the presence of mind to say, “Yes, but please don’t tell anybody”. This is a good moment to thank the brilliant staff, nurses, doctors, nurses, physios and cleaners of Charing Cross Hospital, who are absolutely first rate. I was delighted to remember that when the Government threatened to close Charing Cross Hospital some years ago, I had gone on every demo imaginable to save it. Little did I think that I would be the beneficiary of that campaign.
The NHS, for all its weaknesses and faults at the moment, still works well once one is in the system—I was in the system, and it looked after me brilliantly. There was also excellent follow-up; physios and OTs came home, and so for another two months I had great support. That was pretty good, and I am grateful to all those who helped. I am also grateful to the many organisations who sent excellent briefings, which are helpful for the debate today.
There is one fundamental problem, among others, for the health service. It is too vulnerable to a Government who want to cut the service and save money. It is a real political difficulty with the health service that one decision by a Government can damage it. We have to find some way around that. Perhaps having a Government who do not believe in cutting the health service is the simplest answer.
There is another problem: the imbalance between those of us who are lucky enough to be ill in London and those who are unwell in other parts of the country. We are so lucky, if we are ill in London, to have excellent hospitals very close. In other parts of the country—I know the Lake District pretty well—it is a long way to a hospital and the quality is perhaps not quite as good as it is in London, where we are pretty fortunate.
Social care has been mentioned by my noble friend Lady Pitkeathley, who has spent a lot of time campaigning for better social care. In my experience, the people getting discharged are the ones who have family support in their homes. People who do not have family support are taking up hospital beds because there is not that much social care support. We cannot say enough about voluntary carers, the millions in this country who work for a pittance—I think it is £75 a week—and who keep this country going. We owe them such an enormous debt.
My son has MS. That has made me clear that MS needs far more focus. We need more neurologists. In France and Germany, there are seven neurologists for every two in the UK. We have a paucity of experienced neurologists and we are way down the list of countries. There is therefore a legitimate claim that there should be a neurology task force, as many NGOs working in this field say, to pull all this together: the NHS, social care, professional bodies and the voluntary sector. I also make a plea for MS nurses or neurological nurses. I believe they would not be an extra cost burden but would save money, because they would provide one place where people suffering from MS could go to get help, probably reduce the pressure on GPs and might be good value for money.
I say very clearly, in case there is any misunderstanding, that what I am about to suggest is not Labour Party policy—they are all sitting up on the Front Bench. It is certainly not Conservative policy. We are obsessed with saying that we must reduce taxes. I am obsessed with improving public services. We cannot have the two together. For all the propaganda that taxpayers want the money in their pockets because it is their money, it is also our health service and our public services. My living standard, my quality of life, probably depends much more on public services than it does on whether the taxman takes a bit more money from me or not in a particular year.
I repeat that this is not Labour Party policy, in case anybody starts hitting it on the head with this one. I do not see how we can deal with the difficulties in the NHS without providing more money for it. One obvious way is to have an increase in income tax, hypothecated to the NHS and social care, so that we can say to people, “Yes, we want you to pay a bit more, but every penny of that extra money will go to the NHS and social care”. We would all benefit much more from that than from this obsession with cutting taxes. That is my suggestion.
Baroness Donaghy (Lab)
My Lords, I thank my noble friend Lord Hunt of Kings Heath for initiating this debate. There are three factors which will ensure that the NHS survives, and the Minister has no control over any of them: finance, social care and decently funded local government. The NHS Confederation has said that that constitutes 80% of health needs, so we are really talking to the Minister only about the remaining 20%. The levels of funding are below those needed to serve an ageing society. It is as simple as that. The absence of long-term funding cycles prevents capital investment. The NHS Confederation states that nine out of 10 health leaders believes that underinvestment in capital is undermining their ability to tackle elective backlogs.
The Government’s complete failure to fix social care has led to acute problems around hospital discharge and an increase in human misery and fear. No sustainable system for care homes means unexpected closures for some and private equity landlords for others. Local government has more and more responsibility piled on it for less and less funding. Whatever happened to the civic pride in the Conservative Party? Without a sustainable local government service, the NHS will continue to bear the brunt of social care failings, and the population will continue to experience inequalities in treatment.
I am sure that other speakers have received numerous briefings; my noble friend Lady Taylor referred to some of them. I appreciate the trouble they have taken and thank the House of Lords Library for its background document. Even allowing for their individual advocacy, they reveal the deeply worrying state of the NHS, whether in capital spending, mental health, skills training, cancer treatments, maternity care or the virtual collapse of GP and dental services in some areas.
I will speak about osteoporosis, to which the noble Lord, Lord Lexden, has already referred. We know that there were talks between the Department of Health, the Treasury and the Royal Osteoporosis Society about funding fracture liaison services in the Autumn Statement. The Minister, Maria Caulfield, made a commitment to action by the end of the year. As the noble Lord, Lord Lexden, said, the noble Lord, Lord Evans of Rainow—who I see in his place—announced in a debate initiated by the noble Lord, Lord Black of Brentwood, that osteoporosis care would be improved, saying that the Government were
“proposing to announce, in the forthcoming Autumn Statement, a package of prioritised measures to expand the provision of fracture liaison services and improve their current quality”.—[Official Report, 14/9/23; col. GC 241.]
However, that statement was withdrawn 24 hours later.
Come the Autumn Statement, it became clear that Ministers had broken their promises to fund fracture liaison services as it contained no references to fracture liaison. NHS England has also confirmed that no expert steering group has been set up or is even in the planning stage. Osteoporosis has been excluded from the advisory groups and working groups of the Government’s major conditions strategy despite being the fourth-worst cause of disability and premature death. Failing to deliver on what was thought to be a commitment will waste £88 million on preventable fractures, including 150,000 hospital bed days. Every year, 81,000 working-age people suffer fractures due to osteoporosis, with a third quitting their job due to long-term pain and disability. If the Government honoured their promise, 74,000 fractures could be prevented in the next five years, including 31,000 life-threatening hip fractures. What plans does the Minister’s department have to honour the ministerial promises made on osteoporosis?
My direct experience in the health service is varied. I was a ward orderly in the 1960s in a Warwickshire hospital, traipsing up and down wards with a cow gown on and pulling a trolley of urine bottles—I must admit, I felt like the bee’s knees in those days. I went on to become a non-executive director at King’s College London and a champion of elder care. However, I still cannot quite get over being older than the National Health Service. I know that the Minister cannot do anything about that but, with the 20% of things he can do something about, can he improve osteoporosis care or is he effectively reduced to rifling in that trunk in the attic marked “reorganisation, reconfiguration, privatisation, efficiency gains and distance medicine”? He is a hard-working and sincere Minister who commands the respect of the House—at least this side of the House. I hope that his expertise will continue to be used in whatever happens in future.
Lord Drayson (Lab)
My Lords, I thank my noble friend Lord Hunt of Kings Heath for securing this debate and for his truly excellent speech. I draw the House’s attention to my declared interests and previous experience, including my current roles at Appella AI and Freevolt Technologies Limited and my previous roles at Sensyne Health plc, PowderJect Pharmaceuticals, the University of Oxford, the BioIndustry Association and the Royal Navy, as I will speak on procurement of technology and innovation in the NHS.
As we have heard today in this debate, there is now compelling evidence and widespread concern about the declining performance of the NHS. Often, the adoption of new technology, including most recently AI, is cited as the key to improving standards of care and NHS productivity in future. Statistics highlighting the inferior levels of technology in the NHS compared with other countries, such as in the low numbers of MRI and CT scanners and proton beam machines, the obsolete software systems used by NHS trusts and anecdotes about paper records and fax machines, provide clear evidence that the NHS is a laggard in adopting modern healthcare technology.
Poor procurement of technology by the NHS is at the heart of the problem. It is currently a balkanised and fragmented process across the hundreds of trusts and other siloed groups involved in procurement at the national and local level. It lacks a joined-up approach based on evidence and it lacks a clear, long-term strategy. There is a shortage of expertise in the NHS in technology adoption and management, and an overreliance on external management consultants charging huge fees. Failures in NHS procurement not only undermine the quality of care and waste taxpayers’ money but create a barrier to businesses and investors wishing to invest in UK healthcare.
Life is particularly hard for small companies, which are often the shock troops of innovation. The unwillingness of NHS trusts to accept evidence from other trusts means that companies spend ages repeatedly doing pilots in multiple trusts, never getting to a critical mass of business in the UK market. It is why many investors shy away from businesses that seek to have the NHS as a major customer. The fact is that the NHS determines the fate of our UK life sciences industry, an industry in which we have a great track record of science and innovation but we lack scale. Just look at the life sciences sector on the London Stock Exchange now compared with 20 years ago; it is a shadow of its former self.
Protectionism is not the solution. We should welcome foreign companies and investors coming here, provided that they adhere to our values. However, we must care about where the work is done, where the skills are developed, where the health data is stored, where the profits are made and where the tax is paid. The recent decision of the NHS to purchase Palantir software from the US for its new federated data platform was another opportunity missed. Why did the NHS not choose a system that would help to grow our UK skills base and a system built on open source software that would enable innovation to flourish? Why did it not choose a system that would provide confidence to patients in how their health data will be shared and used?
Much is being said about how artificial intelligence will have an enormous impact on our society in future. In fact, it is already happening, and in healthcare the effects will be profound. If the UK does not develop the onshore expertise to create software systems aligned with the values of the NHS and our society, the NHS will have no choice but to buy systems which, like Palantir’s, were developed elsewhere, with the AI algorithms trained on patients cared for under different healthcare systems. We will then import the biases and constraints that are embedded in those systems and our NHS will become less fair and less aligned with the values of our society, and the wealth created by the AI wave will accrue elsewhere.
There is a better way. Back in 2005-06, the Labour Government, in which I was a Minister, published a defence industrial strategy and a defence technology strategy that provided the Armed Forces and the defence industry with clarity on the sovereign capabilities that the UK needed. As a result, we maintained the skills and industrial capacity required to design and build submarines. Some 17 years later, not only are we still making submarines for the Royal Navy but, for the first time in years, under the AUKUS project we will soon be exporting them to our allies. That is what long-term strategic planning, backed by consistent investment in onshore skills and technology, can achieve.
We need to invest in a well-staffed, well-trained NHS procurement body that sets national standards, defines requirements and buys intelligently on behalf of the taxpayer. We need a technology strategy for the NHS, aligned with an industrial strategy for the life sciences industry, that will deliver UK sovereignty over the technology that will affect how patient care is delivered in future. These strategies will provide the global life sciences industry with clarity on what the NHS requires, highlight the opportunity for investing here, and provide our own life sciences industry with the ability to create the skills and the wealth that our economy desperately needs. Only then can we be sure that the core values of the NHS, set out 75 years ago, will survive the coming wave of technological change, deliver the high-quality healthcare our people want, and help create the wealth needed to pay for it.
Lord Allan of Hallam (LD)
My Lords, I am not able to go back to the foundation of the NHS like the noble Lord, Lord Dubs, but I will start by going back half way, to 37 and a half years ago, when I was starting to travel the world, having just left school. I got into those conversations where you compare countries, and I was asked what was so special and interesting about the NHS. I could not say that it was all public, because it has always been mixed, and I could not say that it was all free, because there have always been charges for some elements of it. The best way I found of explaining why the NHS was special was that, in the UK, we can go to bed not worrying about getting help if we fall ill in the night, or if something happens to our parents or, God help us, to our children. That is certainly not true in all parts of the world. This reflects the promise that was in the newsreel that the noble Lord, Lord Lexden, cited at the beginning of our debate. It is a wonderful freedom that we enjoy, and it means that most of us can change jobs, move across the country, have children, and live far away from our families, all without worrying about whether those decisions will harm our healthcare and that of our families. These freedoms are underpinned by knowing that the NHS is there.
By contrast, a family member in the United States brings home to me what it is like not to have this freedom when he jokes that he has to stay with his spouse because of his health insurance—funny, but not funny. When I left my job with a US company in 2019, access to healthcare was irrelevant to my decision. It had a private health insurance policy, which meant it could get me back to work quickly because it needed me there, but I was much more interested in the free food; I did not see the private health insurance as essential because I had the NHS. I compare that with former colleagues who live in the United States or other countries, for whom the loss of their job vastly increases their health risks.
The NHS represents a significant form of freedom, but this applies only as long as it passes a key test: that we feel that it is sufficient and that we do not need something else. That proposition is holding up remarkably well, even though it has been under severe pressure many times. However, it is not certain that it will hold for the next 25 or 75 years without herculean efforts. In his introduction, the noble Lord, Lord Hunt, rightly talked about previous phases when there were herculean efforts. I was at the other end in the Parliament of 1997, and the work that Labour Ministers did then was remarkable and necessary. I feel that we are in that phase again and we need remarkable efforts to hold up.
The front-line staff have rightly been praised in this debate as critical, but I hope we also take a moment to recognise those who do the hard work of prioritisation. Administrative staff who manage waiting lists do not do fashionable or glamorous work, but it is essential to making sure that people feel that the service can deliver. Staff at the National Institute for Health and Care Excellence spend their time evaluating new forms of treatment and are often only in the headlines when they are being criticised, but their work prioritising new treatments means that that promise can be sustained. My noble friend Lady Walmsley mentioned IT staff, with whom I have a particular affinity, having been one for some years of my professional life; they keep the information flowing that allows patients to keep flowing and people to maintain confidence in the service.
There is no world in which some form of rationing of finite resources becomes unnecessary, but the key is the right allocation of those resources to where most people agree, most of the time, with the way the services are being prioritised. That is the key point I want to make in my contribution: that trust and confidence depend on not allowing the gap between people’s reasonable expectations and their actual experience of the service to grow too wide. Neither side of this equation is static, but will evolve over time.
Expectations are very different today, as we live longer and patterns of behaviour have changed, but we have also changed our expectations in wanting more information about and involvement in decisions. It is often said that the age of deference is dead. That is certainly true: we are in a very different world from 1948, when you were grateful for whatever the doctor gave you; now, people want to question and be involved in decision-making about prioritisation. My main ask of the Minister in this debate is for him to focus on that link between information and trust. It is about not data as an end in itself, but how we can turn data into useful information that feeds into a good process of deliberation, which means that we reach decisions about the allocation of NHS resources that win widespread trust and confidence.
I declare an interest in open data—I realise that I also spoke on this earlier in the week—as I am a non-executive director of the Centre for Public Data, which is a not-for-profit organisation campaigning to make more data public. I joined that organisation because of a long track record of believing in the value of open data, precisely because I think that transparency and not black boxes leads to trust in our much more inquisitive, non-deferential age.
We need to flesh out the narratives, as well, and not just get the raw data. It is interesting to know how many GPs there are—the Government just tell us that we have X number of GPs—and how many appointments they are serving but, for a complete picture, we need qualitative information, as my noble friend Lady Walmsley mentioned. We need to know how many of those GP appointments were useful, how many would have been better directed to other healthcare professionals, how many urgent consultations were stuck in a queue behind less urgent ones, and what could be done about improving the identification and prioritisation of those appointments.
I hope the Minister agrees that we need this kind of open, informed and above all honest discussion about how choices and prioritisation are done to maintain public confidence. This is not an alternative to providing additional resources, as many previous speakers have said, but is complementary to it, as people will feel that the additional resources they are putting in will really make a difference, according to their priorities for what they want to get out of the service.
On honesty and transparency, I note that the focus of the Government’s Autumn Statement on simply tax cuts, without telling us what impact they will have on public spending, was extraordinarily unhelpful. Certainly, the choices have been noted as a reflection of the Government’s priorities.
The prize here is that our children and grandchildren enjoy the same freedoms we have—freedom from worrying about getting help for their own health and about whether their elderly parents or young children will be cared for. This is a huge benefit in which it is worth investing, but it can easily slip away. Trust takes years to build, and the NHS still has bucketloads of it, despite the many challenges it has faced.
But if we as political leaders allow this trust to leak away, the drip may turn into a flood. Every detail matters in this debate, and in preventing the horrible outcome of a lack of trust in our National Health Service—and I know the Minister is a details man. I hope he will commit today to taking the measures needed to maintain trust, and that he is willing to agree with the proposition that a British Government, of any political colour, will have failed if the people of this country can no longer go to bed at night free from worries about where they will get healthcare when they need it.
Baroness Merron (Lab)
My Lords, I start by thanking my noble friend Lord Hunt for his visionary introduction. We share the privilege of both being former Health Ministers and are therefore also fortunate to have the benefit of insight into how things can be, with the right approach by government.
My noble friend Lord Dubs spoke of the value of quality public services. As he was doing so, and while we were having such a passionate and intelligent debate, I was sorry to hear the sad news of the death of Alistair Darling, a giant of public service and former Member of your Lordships’ House. May his memory be for a blessing.
In the wake of the Second World War, the Labour Government founded the National Health Service through the leadership of Prime Minister Clement Attlee and Health Secretary Nye Bevan. While the values on which it was founded still survive, its ability to deliver on them, as we have heard today, has been greatly diminished by the biggest crisis in its history and by stagnation; while the world, the whole of our country and the expectations and demands of the people in it have changed around it, not least through the widening inequalities in healthy lives and access to healthcare that the right reverend Prelate the Bishop of London so clearly identified. The current situation is so dire that leaders at the King’s Fund, the Health Foundation and Nuffield Health felt a need to write on the 75th birthday of the National Health Service to the leaders of each major political party, urging change.
The content of their letter was stark and bears reflection. According to it, the NHS has insufficient resources to do its job, fewer beds than almost all similar countries’ services, equipment that is out of date and inadequate, buildings that are falling down, and inadequate IT systems to do the job. It does not have enough staff, so people’s needs are not being met, whether they are patients on the receiving end or staff seeking to do the job; and it does not matter how hard-working those staff are because they are struggling to deliver care of a quality that people need and deserve. As my noble friend Lord Prentis emphasised in speaking about the whole team, whether we are talking about the cleaner or the consultant, all play their part. The letter also said that any plans to move care from hospitals to closer to people’s homes have seen movement in the opposite direction only. All of this, while public satisfaction is at its lowest level in 25 years, with no let-up in sight.
This is the key question that I always think of when we discuss waiting lists and the other challenges for the health service: can the Minister explain to your Lordships’ House how the Government got us to this stage? They have had 13 years in which to improve things; it is impossible to ignore the role of government—the role this Government have played since 2010.
Of course, I am sure the Minister will point to the pandemic. My noble friend Lord Brooke acknowledged, as I would, that it is clearly a factor. However, even prior to then, between September 2009 and September 2019, waiting lists almost doubled to 4.4 million. Now, that waiting list stands at 7.8 million, which is an all-time high. The waits are felt across the National Health Service. In A&E, nearly one in three people is waiting over four hours. Category 1 ambulance calls take almost two minutes longer than the seven minutes that they should, and the 62-day cancer treatment target has not been met since 2015.
Unsurprisingly, the failures are not limited to the most high-profile areas, as my noble friends Lady Taylor of Bolton, Lord Cashman, Lady Crawley and Lady Donaghy all referred to. To name just some, nearly 2 million people of all ages are waiting for mental health treatment, with about three-quarters of that number of people being out of work with mental illness just between January and March this year. The economic as well as the individual impacts of this failure are quite clear.
In ophthalmology, patients wait for surgery to address preventable sight loss, while patients are also being lost to follow-up with no route back to primary care if treatment has started. In social care, as highlighted by my noble friends Lord Dubs and Lady Pitkeathley among others, the autumn survey of the Association of Directors of Adult Social Services found that 250,000 people were waiting for an assessment of their needs, and almost the same number again were waiting for their care and support to begin or to be reviewed. What are the Government doing to address the lesser talked-about areas that still have real significance to people’s lives and well-being?
Returning to waiting lists, the Health Foundation believes that, by next summer, the list could be over 8 million. What is the Minister’s response to this prediction? Have the Government done their own modelling on the length of waiting lists? What responsibility do the Government take for the impact of their policies, and therefore what action will they take? In the spirit of co-operation that has been mentioned in this debate, perhaps I could offer a suggestion to the Minister, who is, of course, welcome, as he knows, to adopt any of the commitments that have been given by Labour. To take immediate action to cut these waiting lists, what about paying staff extra to provide the extra clinics and appointments that patients so desperately need? If this Government will not do it, if Labour is in government, we certainly will.
That is just about the immediate. As we have heard today, the UK’s population is undergoing a massive age shift. More than 11 million people over the age of 65 are living in the UK now, and in a decade this is expected to rise to some 22% of the population. As my noble friend Lady Pitkeathley said, it is to be celebrated that we have an ageing population. But, sadly, growing numbers of older people are experiencing poverty, discrimination and poor health in their advancing years. This, therefore, requires a reset, but primarily in health and care, with a new focus on prevention and community care, driven by technological advances that we can take advantage of today—as my noble friend Lord Drayson highlighted.
Training more GPs, district nurses and health visitors, harnessing technology and AI, giving NHS and care workers fair pay and fair terms and conditions, joining up services and giving patients the choice that they want to help achieve these things: that is what a Labour Government would do. Why have this Government not done this?
The noble Baroness, Lady Finlay, and other noble Lords called for a change of focus from dealing with sickness to prevention. This is not only common sense; it makes economic sense too. Research by the Centre for Health Economics at the University of York found that spending through public health functions in local government is up to four times as cost effective as NHS spending—something my noble friend Lady Taylor of Stevenage brought her great wisdom to. The Government clearly know this, as their own 2019 Green Paper said:
“The 2020s will be the decade of proactive, predictive, and personalised prevention”—
but they simply have not followed through. As my noble friend Lord Davies highlighted, the failure to provide for the reform of the Mental Health Act—something that Labour has committed to doing if in government—is the clearest example of not following through. However, as we have heard today, there are many other examples.
At 75 years, the NHS, its workforce and all the people it serves deserve better. If this Government will not fix the crisis they have created and give the NHS the reform and support it needs, somebody else will have to do that. We stand ready to do so.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)
I would like to start by giving our side’s condolences to the family of Alistair Darling. I echo the points on him made by the noble Baroness, Lady Merron. The noble Lord, Lord Brooke, talked about the cross-party working. Alistair Darling was one of those people who, while clearly a Labour politician, approached things in a very objective, cross-party manner. I know he will be missed by all of us.
I thank the noble Lord, Lord Hunt, for tabling this debate, which has been fascinating. It started off with a very informed and fascinating history of the NHS from my noble friend Lord Lexden, which enshrined the point that the noble Lord, Lord Allan, made: it has given us all that wonderful freedom to go to bed at night and feel secure, and to make life choices about where we work and who we live with without that being a worry. I agree with the basic premise that that is the duty of any Government.
I am also kind of—I am not quite finding the right words to say, but I was really marked by the point that the noble Lords, Lord Hunt and Lord Brooke, and the noble Baroness, Lady Pitkeathley, were at the 50th anniversary and took part in these conversations. That is quite humbling, particularly since I found out, strangely enough, that I am currently the longest-serving Health Minister. I am not sure that I will make it to the 100th anniversary, but I will take the advice of the noble Lord, Lord Prentis, by trying not to walk in the middle of the road and get hit. If I do make the 100th, I will definitely follow the idea from the noble Lord, Lord Dubs, of having a party.
I welcome the debate. While I will try to answer the points raised, given the 75th anniversary, and as others have mentioned, it is important that we try to make this forward-looking and look at the innovation agenda, which the noble Lord, Lord Hunt, and the noble Baroness, Lady Taylor, mentioned.
I will also address squarely and up front the funding point, which was mentioned by the noble Baroness, Lady Crawley, and others. Rather than only putting a nickel into this, we are putting in 11% of GDP—by far the highest amount in history. Tony Blair has been mentioned a lot. I well remember the Wanless review in the early 2000s, which talked about increasing the spend to about 8%—my memory might not be quite right, but it was about 8% of GDP. I do not think that anyone would say today that 11% does not absolutely show our commitment.
It is comparable to all other European countries. In fact, there is only one country in the world which has a significantly higher spend: America. I want to put that record level of investment on the record. As many have mentioned, it is of course important that we allocate that and use those resources as well as possible. I was very struck by the points that the noble Baroness, Lady Tyler, made about the productivity conundrum, so to speak, and those that the noble Lord, Lord Drayson, made on the technology agenda and innovation. I hope to address some of those points a bit later.
I put all this into the context of our knowing today that a digitally mature trust will be 10% more efficient. We have done quite a bit of work on this; it will be 10% more efficient than other trusts in its output and efficiency. Since a few people mentioned the new hospitals plan, I should say that we know that a new hospital where you unite the best in technology with the best in physical real estate will be 20% more efficient in its output. That is not just in productivity; more importantly, probably, we are also seeing a 20% reduction in the length of stays. The one statistic that has impressed me the most, as I have gone around in the year or so that I have been in this job, is that for every week a patient spends in hospital they lose another 10% of their body mass if they are elderly, so their ability to go home—back to the normal environment—degrades day by day.
We have been talking about what we are trying to do with the technology agenda and the new hospitals programme, but we are all here because we care about patient care. That is vital. We all want people to get back into their home environment sooner. We all know that the problems often come when you are locked in for too long. Then you need a social care space and can get into the downward spiral that we all know about.
As someone actively involved in the new hospitals programme, I assure everyone that there are action steps happening on all 40 of those new hospitals. They are all very real. I will happily talk to anyone about any of them if they should wish it, and show them my photos from visits to many of them as well.
The noble Baroness, Lady Donaghy, made a very good point: often, it is the short cycles which are hard. One thing that has not been spoken about very much, but was very much part of our new hospitals plan and the announcement in May, was our moving to five-year capital cycles. That will be really important for that long-term planning; work is going on as we speak around having 25-year to 30-year capital cycles.
I am trying to address the points raised. The noble Baroness, Lady Merron, understandably mentioned the waiting lists, as others did. Obviously, that is an area of concern but we have made good progress in the area of two years and are making good progress in the area of 78 weeks. We are focusing on those areas where there is the most impact. Undoubtedly, industrial action has impacted this, which is why I think we are all pleased that we now have a likely deal with the consultants. I am hopeful that it will extend to the junior doctors as well, but we have been working hard on that. We are trying to get on top of it: in terms of supply, there are the 130 CDCs with their 5 million tests. There is also the use of technology, such as patient choice with the app and the FDP, and we will see big improvements in what that does.
Through all this, we have been talking about the 13 years in which Conservatives have been in charge of the NHS in England. Of course, there have been 25 years that one party has been in control in Wales. I noticed that no mention has been made of Wales. While none of us is happy with the waiting lists, I know for sure that they are a lot better in England than in Wales.
I turn to the 62-day backlog for cancer. We all know that time is of the essence in cancer. We are seeing a 27% reduction in that backlog since 2020 and a record level of referrals; we are treating 12,000 people per day. We are starting to hit the 75% target of diagnosing people within 28 days. To put this into context, we are treating 32% more people for cancer than we were prior to the pandemic. We know that fast diagnosis is key.
One of the key differences in inequalities in life expectancy, as raised by the right reverend Prelate the Bishop of London, is lung cancer. Of the nine-year disparity, one year is caused by lung cancer. That is why we have things such as mobile screening, which we take on the road to areas where lung cancer is most prevalent—for example, in some of the mining communities. Rather than the majority of people with lung cancer not being found until stage 4, when it is too late, in the areas where they have been doing this we are finding the majority of people in stage 1 or 2. That is so much better in terms of life chances. That is how we will achieve the target of detecting 75% of cancers by stage 1 or 2 by 2028. To give some context to that, we estimate that it will mean that 55,000 more people will be surviving as a result by then.
There has also been talk about waiting times for ambulances and A&E. While they are too high, I am glad to say that they are improving. We have been making sure that we have learned lessons. We are taking action for this winter by increasing supply, with 800 new ambulances, 5,000 more beds to increase capacity and the 10,000 virtual ward beds we will have in place. We are using technology, which I will come to later, to make sure that they are being most effectively used. We are making sure the hospitals are digitised. We have features such as those I saw in Maidstone, such as flight control, where you allow the clinicians to manage the flow of patients right the way through.
Key to all this and to the length of stay is discharge and the adult social care end. Quite rightly, as the noble Lord, Lord Prentis, said, the flow is important. It is vital not only on the social care side, but for the whole hospital and the UEC—urgent elective care—waiting lists. I have seen at first hand the impact of step-down areas. Patients can be put there early on, and everything is organised around that. I have seen the improvements that makes to the flow.
We are trying to learn the lessons of last year by getting the money and commitments out early. That is why we are making a commitment of £600 million extra spend. We told the local authorities and systems that in the summer, so they could plan now rather than hearing about it too late and not being able to impact it then. That is all part of an increase of up to £8.1 billion over the next two years—a 20% increase. Staff are at the centre of that, as mentioned by the noble Baroness, Lady Pitkeathley. It has been a difficult area, but we are now up in terms of staff versus last year. I accept that there is still a long way to go. My notes show that we have about a 15,000 increase in staff, but clearly, we need more within that.
Mental health is obviously a key part of this. As the noble Lord, Lord Davies, and others mentioned, now more than ever we are seeing a massive increase in the number of young people with mental health issues—we had a good debate on this the other day. As I have said, I am determined that we understand the reasons underneath that. Covid might be part of it, but there are also long-term reasons, such as social media, that we need to understand. As the noble Lord, Lord Davies, mentioned, we need to make sure we diagnose those early, because that is crucial, particularly for young children. As noble Lords know, I have personal experience of the importance of acting early on this.
On the mental health Bill, we are committed, as mentioned, to do as much as we can without the legislation—hopefully we can explain a lot of that when we have the round table. Although getting it in the manifesto might be above my pay grade, I personally agree to make sure that all my colleagues understand its importance today and in a year’s time or so, if we were to win a general election.
Many noble Lords—the noble Baroness, Lady Tyler, and the noble Lords, Lord Prentis and Lord Hunt, to mention a few—raised the importance of staffing and how everything is underpinned by it. The noble Baroness, Lady Walmsley, and the noble Lord, Lord Hunt, in particular picked out—and I completely agree with them—that it is not just the clinicians but the managers, the admin and the non-clinical staff who are key to this as well.
I am a bit of a data anorak, and one of the things I did when I first came into my post was to try to understand all the differences in hospital performance, looking at certain areas’ demographics and whether they happened to have more funding through a quirk of the formula. I put in all sorts of variables, but we could only ever explain 50% of it—for the data anoraks, I say: the r² never came out higher than 0.5. The only conclusion that I and others could come to from that was—this is not earth shattering—the management and the leadership. I have had the privilege of visiting a lot of hospitals, and when you walk into one you know early on about the leadership—you can tell it on the tour and through the reaction, less from the leaders and more from the staff. You get a vibe about a place. I totally agree about the importance of that.
I come to the specialist areas. The noble Baroness, Lady Taylor, mentioned optometrists, and, funnily enough, I had this conversation with one the other day, and they mentioned that many of the early, indicating warnings are picked up when they take retina scans. That is why the long-term workforce plan is important, as are the extra training places. But, as the noble Lord, Lord Prentis, said and as I know from my experience with my mother, the other routes, such as apprenticeships, are just as important if we are going to get them there, because you should not need to be a graduate to be a nurse or clinician. As the noble Baroness, Lady Finlay, mentioned, it is vital that it is a rewarding and accommodating profession. Training and development are obviously part of that. I hope to talk more to noble Lords soon about using the estates for a lot more housing, because we know that can be a key recruitment and retention tool. Then there are things such as flexible rotas—hopefully, we will be able to use technology for that.
In terms of talking and working with the staff, I have to say that is something that is early days, but we are seeing the style and the engagement of the Secretary of State already and it is very welcome. Underpinning the long-term workforce plan, which many noble Lords have mentioned, is the move away from hospital treatment and into primary care and prevention. We know that that is the first line, and we are now close to achieving the 50 million increase in appointments—but we know, given the demand, that that is still not enough. That is where the Pharmacy First scheme will make a material difference, in expanding the supply of places where you can get the advice and treatments that you need.
I have seen some great examples of prevention, also mentioned by the noble Baroness, Lady Pitkeathley. Funnily enough, just yesterday I was talking to one of the doctors—I am sure that many of you know him—Sam Everington from east London. He was talking about how he was taking type 2 diabetes treatment totally out of the hospital environment, and the difference that it is making there. I have mentioned before the Redhill frequent flyers, looking at the people who are having the most hospital treatments and how they can get upstream of it all. Screening is important to that, which is exactly the point that the noble Lord, Lord Cashman, was making about the HIV screening programme. That needs to be welcomed—making sure that many more people are seeing that and understanding it.
The noble Baroness, Lady Taylor, talked about an active and healthy lifestyle and its role in social prescribing, which I completely agree with. I know that all noble Lords are on the same page here. The anti-smoking legislation that we are talking about is the biggest single thing that we can do towards that active lifestyle going forward.
I have mentioned it a few times, but I really believe that what we do in terms of technology and the app will be key to this, in terms of people’s access to primary care. People can use the app as their front door, from which they will be guided to the right service—to the 111 service—and then directly make an appointment, be it with a doctor or nurse or with a pharmacy. We have seen already that because people are reminded on the app, the numbers of “do not attend” have gone down by 10%, when people make their appointments digitally in that way. Of course, that means a much more effective use of time. Talking of time, I notice that I am out of it, so I shall quickly finish up. I see massive ability in the app for people to take control of their health and give us that sort of data, so people have the information and trust behind it.
I could have written the speech made by the noble Lord, Lord Drayson, myself—and I quickly acknowledge everything that he said about the problem. He said that we have great examples of innovation and really difficult cases of how to scale that up. I am exaggerating slightly to make a point, but when they have a great example in one place, they say, “Fantastic, it works in X hospital, how can we get it elsewhere?” It is like, “Here’s the telephone directory with 140 trusts and the buyers—good luck”. A lot of what I am trying to do, as the noble Lord, Lord Drayson, mentioned, is to look at how we scale that up, and have a way to buy sensibly from the centre and get that spread out. In the area of digital therapeutics, that is obviously vital.
Given the time, it is probably time for me to sum up, as I say. As ever, I shall write to noble Lords in detail. I have not answered the points that the noble Lord, Lord Cashman, raised about international cosmetic operations, and others. Likewise, I have not addressed the fracture liaison services, and the points made by the noble Baroness, Lady Donaghy, and the noble Lord, Lord Lexden, so I shall make sure that that is properly followed up in writing.
I finish by echoing what the noble Lord, Lord Brooke, was saying, which is to try to take this out of the Punch and Judy and make it as cross-party as possible—
Lord Hunt of Kings Heath (Lab)
My Lords, does the Minister understand that I will have no time at all to respond?
Lord Hunt of Kings Heath (Lab)
I have only a minute now to respond: I understand that the clerk will time us out at 2.56 pm.
All I will say then is, first, that I thank the Minister and my noble friend Lady Merron for their tributes to Alistair Darling, who was such a formidable colleague, Minister and public servant.
Secondly, the conclusion I reach is that we have to have a whole-system reform; we need a Government who are determined to do it; I do not believe that the current Government can do it at all; I look forward to a Labour Government who are going to do the business; and I beg to move.