Future of Health and Care

Tuesday 23rd February 2021 Lords Chamber

Statement

The following Statement was made in the House of Commons on Thursday 11 February.

“Mr Speaker, I come to the House today to set out our White Paper on the future of health and care. The past year has been the most challenging in the NHS’s proud 72-year history. The health and care system as a whole has risen in the face of great difficulties. Throughout, people have done incredible things and worked in novel and remarkable ways to deliver for patients, and we in this House salute them all—not just the nurse who may have had to care for two, three or four times as many patients as he would in normal times, and not just the surgeon who may have been called to treat patients beyond her normal specialism, but the managers across health and care who have come together in teams, as part of a health family, at local and national level; the public health experts who have been needed more than ever before; and the local authority staff who have embraced change to deliver for their residents—and from all, a sense of teamwork that has been inspiring to see.

As a citizen, I care deeply for the whole health and care family, the values they stand for and the security they represent. They are there for us at the best of times, and they are there for us at the worst of times. As Health Secretary, I see it as my role sometimes to challenge but most of all to support the health and care family in their defining mission of improving the health of the nation and caring for those most in need.

I come before the House to present a White Paper based firmly on those values, which I believe are values that our whole nation holds dear. The White Paper is built on more than two years of work with the NHS, local councils and the public. At its heart, this White Paper enables greater integration, reduces bureaucracy and supports the way that the NHS and social care work when they work at their best—together. It strengthens accountability to this House and, crucially, it takes the lessons we have learned in this pandemic about how the system can rise to meet huge challenges and frames a legislative basis to support that effort. My job as Health Secretary is to make the system work for those who work in the system—to free up, to empower and to harness the mission-driven capability of team health and care. The goal of this White Paper is to allow that to happen.

Before turning to the core measures, I want to answer two questions that I know have been on people’s minds. First, are these changes needed? Even before the pandemic, it was clear that reform was needed to update the law, to improve how the NHS operates and to reduce bureaucracy. Local government and the NHS have told us that they want to work together to improve health outcomes for residents. Clinicians have told us that they want to do more than just treat conditions; they want to address the factors that determine people’s health and prevent illness in the first place. All parts of the system told us that they want to embrace modern technology, to innovate, to join up, to share data, to serve people and, ultimately, to be trusted to get on and do all that so that they can improve patient care and save lives. We have listened, and these changes reflect what our health and care family have been asking for, building on the NHS’s own long-term plan.

The second question is: why now, as we tackle the biggest public health emergency in modern history? The response to Covid-19 has accelerated the pace of collaboration across health and social care, showing what we can do when we work together flexibly, adopting new technology focused on the needs of the patient and setting aside bureaucratic rules. The pandemic has also brought home the importance of preventing ill health in the first place by tackling obesity and taking steps such as fluoridation that will improve the health of the nation. The pandemic has made the changes in this White Paper more, not less, urgent, and it is our role in Parliament to make the legislative changes that are needed. There is no better time than now.

I turn to the measures in detail. The first set of measures promote integration between different parts of the health and care system and put the focus of health funding on the health of the population, not just the health of patients. Health and care have always been part of the same ecosystem. Given an ageing population with more complex needs, that has never been more true, and these proposals will make it easier for clinicians, carers and public health experts to achieve what they already work hard to do: operate seamlessly across health and care, without being split into artificial silos that keep them apart.

The new approach is based on the concept of population health. A statutory integrated care system will be responsible in each part of England for the funding to support the health of their area. They will not just provide for the treatments that are needed, but support people to stay healthy in the first place. In some parts of the country, ICSs are already showing the way, and they will be accountable for outcomes of the health of the population and be held to account by the Care Quality Commission. Our goal is to integrate decision-making at a local level between the NHS and local authorities as much as is practically possible, and ensure decisions about local health can be taken as locally as possible.

Next, we will use legislation to remove bureaucracy that makes sensible decision-making harder, freeing up the system to innovate and to embrace technology as a better platform to support staff and patient care. Our proposals preserve the division between funding decisions and provision of care, which has been the cornerstone of efforts to ensure the best value for taxpayers for more than 30 years. However, we are setting out a more joined-up approach built on collaborative relationships, so that more strategic decisions can be taken to shape health and care for decades to come. At its heart, it is about population health, using the collective resources of the local system, the NHS, local authorities, the voluntary sector and others to improve the health of the area.

Finally, the White Paper will ensure a system that is accountable. Ministers have rightly always been accountable to this House for the performance of the NHS, and always will be. Clinical decisions should always be independent, but when the NHS is the public’s top domestic priority—over £140 billion of taxpayers’ money is spent on it each year—and when the quality of our healthcare matters to every single citizen and every one of our constituents, the NHS must be accountable to Ministers; Ministers accountable to Parliament; and Parliament accountable to the people we all serve. Medical matters are matters for Ministers. The White Paper provides a statutory basis for unified national leadership of the NHS, merging three bodies that legally oversee the NHS into one as NHS England. NHS England will have clinical and day-to-day operational independence, but the Secretary of State will be empowered to set direction for the NHS and intervene where necessary. This White Paper can give the public confidence that the system will truly work together to respond to their needs.

These legislative measures support reforms already under way in the NHS, and should be seen in the context of those broader reforms. They are by no means the full extent of our ambition for the nation’s health. As we continue to tackle this pandemic, we will also bring forward changes in social care, public health, and mental health services. We are committed to the reform of adult social care, and will bring forward proposals this year. The public health interventions outlined in this White Paper sit alongside our proposals to strengthen the public health system, including the creation of the National Institute for Health Protection, and last month we committed in our mental health White Paper to bringing forward legislation to update the Mental Health Act 1983 for the 21st century.

This landmark White Paper builds on what colleagues in health and care have told us, and we will continue that engagement in the weeks ahead, but it builds on more than that: it builds on this party’s commitment to the NHS from the very beginning. Eagle-eyed visitors to my office in Victoria Street will have noticed the portrait of Sir Henry Willink, who published from this Dispatch Box in 1944 the White Paper that set out plans for a National Health Service, which was later implemented by post-war Governments.

Throughout its proud 72-year history, successive Governments have believed in our health and social care system and strengthened it for their times. I believe the NHS is the finest health service in the world. I believe in the values that underpin it: that we all share responsibility for the health of one another. Its extraordinary feats this past year are unsurpassed even in its own proud history. Once again, we must support the NHS and the whole health and care system with a legislative framework that is fit for our times and fit for the future. We need a more integrated, more innovative and more responsive system, harnessing the best of modern technology and supporting the vocation and dedication of those who work in it. This White Paper is the next step in that noble endeavour, and I commend this Statement to the House.”

19:05

[Baroness Thornton (Lab) [V]]

My Lords, I thank the Minister and declare my interests as a former member of a CCG and a non-executive director of a foundation trust.

The Lords Labour health team—myself and my noble friends Lady Wheeler and Lord Hunt—are veterans of the infamous Lansley Bill, which became the Health and Social Care Act 2012. Many noble Lords will take part in the new legislation—including, of course, those on the Lib Dem Benches, who supported the Lansley Bill. I hope that they have come to their senses since then.

We cannot sweep under the carpet, as the Secretary of State and the Minister would have us do, the fact that many of us warned that the huge bureaucracies and implementation costs of something like £3 billion would be a terrible waste of public money and time. They resulted in a loss of initiatives and innovations that lies at the Minister’s door. Some indication of lessons learned would be welcome.

We are in the middle of the biggest public health crisis our NHS has ever faced. Staff on the front line are exhausted and underpaid. The Royal College of Nursing says that the NHS is on its knees. Primary care and CCG staff are vaccinating and will be doing so for months ahead. Today, we learn that 224,000 people have been waiting more than 12 months for treatment. The Secretary of State and the Government think that now is the right moment for a structural reorganisation of the NHS. It might be significant that, in the Statement, I cannot find a single explanation of how patients will benefit from this reorganisation. It is all about systems.

Apart from the timing, some very serious matters need to be addressed. This is a Conservative NHS plan, and it shows. Without the money, none of this is worth discussing seriously. Without a workforce plan funded by that money, it will not work. This Bill should not go ahead in its current breadth until the solutions for social care and public health are also set out. Although reform of the Mental Health Act is welcome, it also needs to fit into the wider solution that is missing around social care.

Why does the White Paper not include an option simply to delete Part 3 of the existing Act, thus abolishing the market and competition regimes that created the burdensome bureaucracies and which, it must be said, many CCGs and ICSs have worked hard to get round in recent times? Let us take some time to work out the rest, bring forward the promised social care reforms, let our exhausted NHS recover and have a system co-created with local government.

I suspect that the need to move powers to the centre is a poisoned chalice. Is the Minister proposing simply to dump the Lansley structures and bring back the situation where the Secretary of State has the power of direction over all and any parts of the system? Although I welcome the place-based commitment, it is woefully undefined. This plan ought to be co-owned and co-developed with local government nationally as well as locally, with real parity of esteem. Far more is needed to remove barriers, but the biggest local barrier now is the absence of any solution for social care and public health.

Looking at the NHS’s history, we should be sceptical of structural reform necessarily leading to changes in care delivery that make services more integrated and benefit patients. We know from Wales, Scotland and Northern Ireland that integrated care systems have not brought about integrated care. It is necessary to remove system barriers but not sufficient. The bigger challenges lie around culture and vested interests, which are not even mentioned in this White Paper. It is all far too complicated, with health and well-being boards and HealthWatch still in place as well as the proposed new structures. It needs a clear explanation of who controls the money. Can you have two boards at the same time and call it integrated, and be sure where the accountability sits and whether good governance can be assured?

There is little about how decisions are made on who sits on these boards. Is it proposed to bring back independent appointments commissions to guarantee the diversity required? Will staff representatives and patients have a seat where it matters? Surely there can be only one body with the power to set the local strategy and sign off the plans that bring the money. This proposal seems to have many bodies, meaning that governance and accountability are at risk. Having providers, and even independent providers, with a place in the decision-making about resource allocation is clearly unacceptable. If there are to be some contracts awarded by competition, there must be clear rules about who is entitled to compete. These organisations and companies must pay their taxes, for instance, and must offer fair and comparable terms and conditions to their workforce. For example, we know that social enterprises totally fulfil those conditions, but one must ask why we need competitive tendering when you can hand out contracts to chums from the stables, the golf course, and the pub, as we have seen in the last year.

The White Paper is silent on the future of foundation trusts, silent on the role of governors, silent on a whole range of potentially competing governance issues which will have to be resolved. How much acute and tertiary care can be brought into locality-based structures? Integration of primary, community and social care is clear, but, as everyone knows, the acute side is far more complex and a single solution, as proposed in this White Paper, almost certainly will not work. The big players such as teaching hospitals do not fit into any single locality, or even single ICS, but are vital players. Will there be extra layers of governance above the ICS, which is not defined at all?

We will of course study the legislation carefully when it is published, but the test of reorganisation is whether it benefits patients and communities, brings down waiting lists and times, widens access, especially for mental health care, drives up cancer survival rates and improves the population’s health.

[Baroness Brinton (LD) [V]]

I am grateful to the Minister for the short-notice briefing just as we were rising for recess.

If you had said to most people in the health and social care sector three weeks ago that the Secretary of State for Health and Social Care was announcing a new White Paper, virtually everyone would have assumed that it was the extremely long overdue White Paper on social care, promised by the Prime Minister in his party’s manifesto in the 2019 general election and repeatedly further promised at the Dispatch Box over the last 14 months. This Statement refers to it appearing at some point later in the year.

Instead, we have a comprehensive White Paper that focuses, despite the references to care, on the NHS and health systems, undoing some but not all of the 2012 Lansley reforms. This White Paper talks grandly of integrated systems, but you cannot integrate systems if one of the key parties is on its knees as a result of appalling neglect for many years. We agree that our clinicians, managers and associated health and social care staff have great ambitions for moving our health and care structures into the 21st century, and we compliment them, and Ministers, on their ambition, but we have been here before. A decade ago, the Government announced and legislated for a Dilnot-style cost model for social care, which, unfortunately, was later scrapped. We went from a point where all three main political parties were in agreement, but, sadly, the Conservatives withdraw from that agreement. As with manifesto promises on the care sector over the last three general elections, when will the Government start the long-promised cross-party talks to find a solution for the care sector? We remain ready and waiting.

The Statement makes the point that the pandemic has brought the structural difficulties in the care sector into sharp relief. That much is true. With more than 25,000 care home deaths, 10,000 of which have occurred since the lockdown started in January, what will it take for the Prime Minister to make good on his promise to fix social care? Why did it take weeks longer to arrange for residents and staff in care homes to get testing, whereas the NHS had reliable access as soon as it was available? Worse, the care sector’s experience of the Department of Health and Social Care taking its orders of PPE out of lorries and diverting them to protect the NHS first—which happened—and the NHS discharging Covid patients into care homes, while reassuring care staff that it was not doing that, has undoubtedly damaged trust. I do not deny that there has been a really strong attempt to get people to work cross-department, but this sort of behaviour has really not helped.

The Statement talks about making Ministers accountable again. A good step would be for the Secretary of State to come to Parliament and explain why he did not publish PPE and other contracts within the appropriate timeframe. There are concerns, too, about cronyism and possibly even corruption. So I say to Ministers: beware of what you wish for.

A further problem of the White Paper in front of us is the need to undo some of the perverse bureaucracies and expenses created by the 2012 reforms. The “internal market” was one such. I cannot see the logic of having a CCG of GPs overriding NICE and a hospital team on a medication pathway because it wants to spend the money elsewhere. The Minister told me that there will be changes and that there will be some representation from trusts, but, from what I hear, it is not enough to leave the clinicians who are expert in charge able to follow the advice of NICE.

The Statement also talks about the portrait of Sir Henry Willink, who published the 1944 White Paper from the Dispatch Box. But Sir William Beveridge’s report that led to that White Paper, and then to the post-war Labour Government’s creation of the NHS, had a clear structure. The five great evils that Beveridge, as a Liberal, set out could be tackled only by a cross- departmental approach, of which health was a vital component but not the sole driver.

When my grandfather was dean of St Mary’s Hospital Medical School, he always used to say that it took only 20 years for the NHS to move to a “national illness service”, as demand and costs in hospitals increased exponentially and any budget that was not for hospitals was squeezed. That is why, in the 2012 reforms, we in coalition wanted at least elements of public health moved to local government, where it could more effectively work with the other parts of the system fighting Beveridge’s five great evils and, through the health and well-being boards, be accountable at a local level. The examples of the excellent directors of public health during this pandemic have shown that it can and does work, despite the NHS finding it difficult to delegate to them. It is no surprise that inequality is one of the greatest predictors of serious Covid illness or death. Can the Minister reassure us that, whatever happens to public health, it will have its funding ring- fenced to tackle these inequalities?

Next week, we have the Budget, in which the Chancellor will have to face the highest levels of national debt since the Second World War. After the publication of his report, Beveridge expressed concern, saying that the Government should be bold:

“Now, when the war is abolishing landmarks of every kind, is the opportunity for using experience in a clear field. A revolutionary moment in the world’s history is a time for revolutions, not for patching.”


Now, too, is the time for such revolutions. This pandemic has left us with a health and social care system that needs not just reform but proper funding. Without it, integration and effective joint working will fail. Can the Minister assure us that there will be bold actions to ensure that any changes are fully funded? Without it, Atlee, Beveridge and Willink will be turning in their graves. Worse, these proposed reforms will fail the UK people, whether patients or just those living in their communities—the very people who need it most.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)]

My Lords, I thank the two noble Baronesses enormously for those thoughtful and helpful questions. We are at a very early stage in the process of this important legislation, and the questions from both the noble Baronesses, Lady Brinton and Lady Thornton, are extremely helpful and make a good challenge. I will attempt to answer them as best as I can.

I reassure the noble Baroness, Lady Thornton, that we have all read the debates around the Lansley Bill carefully and learned an enormous amount from them. We greatly look forward to reminiscences from all those who were there in those days. There are some things that the Lansley Bill did that left an important and lasting legacy, and it would be wrong to overlook those. The establishment of Healthwatch and a focus on outcomes was a cultural inflection point in the history of the NHS. The overall importance of commissioning will not be lost in any changes introduced by this Bill. Lastly, this Bill massively builds on the establishment of NHS England in its measures. These are some examples of where the Lansley reforms made huge advances.

However, as the noble Baroness, Lady Thornton, rightly pointed out, some of those reforms have had their day and it is now important to move on to the next round, building on those reforms while fine-tuning some of them. One of the most important areas of development is around collaboration. By that, I mean that the challenge of modern healthcare is to bring a huge amount of expertise and extremely complex resource to bear on individual patient challenges. The sheer complexity of some of the treatments and therapeutics that can benefit the patient requires not just simple clinical analysis by an individual but teams across many disciplines, sites and, sometimes, institutions. It is the bringing together of that huge amount of collaboration that the Bill focuses on.

The noble Baroness is right that we face massive challenges in the period ahead. The vaccination programme is absorbing a huge amount of resource. There is a tremendous backlog in almost every area of the NHS and getting through it is a great challenge. NHS staff themselves are tired and exhausted; they deserve a break. This should not hold us back from doing exactly what the NHS had planned to do before the Covid epidemic, what stakeholders in the NHS repeatedly tell us that they want to do and what the huge amount of engagement that we have done tells us is right to do. I remind her that the core of the White Paper is the proposals made by the NHS to the Government in September 2019 to help the NHS deliver its long-term plan.

NHS England and NHS Improvement carried out a huge engagement process before making those recommendations. That exercise had over 190,000 written responses from individuals and organisations representing different parts of the health and social care system. Those recommendations were supported and endorsed by key leaders across that system, including NHS Providers, UNISON, Healthwatch, the Local Government Association, the Royal College of Nursing and many others. The recommendations made by NHSEI also built on recommendations made by the Health and Social Care Select Committee in June 2019.

The Bill will have been thought about and prepared for over many years. It is the thoughtful application of important reforms and therefore deserves the close analysis and support of noble Lords. There are tremendous benefits to patients. The noble Baroness, Lady Thornton, specifically asked what the tangible benefits are, and I will pull out three in particular.

First, there are some specific public health measures in the Bill. As the noble Baroness, Lady Brinton, rightly raised—I will come back to it, in a moment—public health is central to the outcomes of the Bill. Fluoridation is the iconic measure, but a thick red thread of public health runs throughout the Bill. Secondly, the constitution of the Healthcare Safety Investigation Branch—HSIB—will, with statutory muscle, bring about the important investigatory element to promote the patient safety agenda, which my noble friend Lady Cumberlege wrote about in her report. Thirdly, the bringing together of GP and social care services into integrated care systems will bring much closer the decisions about patients which often cross barriers that, I am afraid, are huge obstacles to effective care today.

I will address the question of social care directly because the noble Baronesses, Lady Brinton and Lady Thornton, challenged me on this point: why have we not in the Bill brought about a wholesale financial rebooting of adult social care? The measures on adult social care in the Bill are just one aspect of a wider reform agenda. Our wider objectives for social care are to enable an affordable, high-quality and sustainable adult social care system that meets people’s needs while, supporting health and care in joined-up services around people. The Prime Minister has been crystal clear about his agenda for reform. A broad range of options are being explored on how best to accomplish these reforms and we want to ensure we get that reform right. Engagement with the sector and the public will be an important part of that.

We are still considering a number of funding reform options. However, the leading options, such as a cap and floor, are already provisions in the Care Act so they require only secondary legislation to enact. For this reason, we do not require anything on charging reform to be included in the Bill. However, the Bill should be considered as an important paving stone to wholesale social care reform.

I entirely agree with the noble Baroness, Lady Brinton, that culture is important. We are absolutely committed to putting social care in exactly the same hierarchy as the NHS. We believe that local authorities have a central role in the provision of social care; that is envisaged to remain the same. The noble Baroness, Lady Thornton, asked specifically: who will sit on the boards? That is exactly the kind of question that I look forward to debating here in the House and engaging on with noble Lords.

The noble Baroness, Lady Thornton, asked about competition, and she and the noble Baroness, Lady Brinton, raised deep-seated and heartfelt concerns about cronyism and corruption. I take those concerns very seriously. Huge amounts of taxpayers’ and voters’ money have been employed during the pandemic in the fight against Covid, and very large sums of money were spent on PPE in circumstances where there was a huge rush and difficult arrangements were being put in place. However, I remind both noble Baronesses that when they attack the Government and make accusations of cronyism, chumocracy and corruption but have no foundation for those attacks, they are interpreted as attacks on the very NHS and social care staff who have worked extremely hard to procure the right services and products, who have the interests of patients in mind, and who are working so hard to save lives. Attacks on the integrity of the system are extremely damaging to their morale and the integrity of that system. I kindly ask the noble Baronesses, Lady Thornton and Lady Brinton, who have made these attacks repeatedly over the last few months, to think very carefully about the way in which they make these accusations.

In particular, I will address the question raised by the noble Baroness, Lady Brinton, of PPE being taken from lorries that was destined for social care and sent instead to the NHS. If she indeed has evidence that such a thing happened, I would be very grateful if she would write to me. But if she does not, I would be extremely grateful if she did not raise this anecdote again, because it is a damaging image which hurts very much those who work in social care and the NHS, and is not necessarily fit for a debate such as today’s.

In terms of the PPE contracts that were the subject of a recent action in the law courts, I will repeat the sentiments expressed by my right honourable friend the Secretary of State for Health. Every waking moment of every day for everyone involved in the procurement of PPE was dedicated to getting the right kit to people on the front line to save their lives. If the paperwork was done two weeks late, that is an entirely proportionate and reasonable consequence of a very difficult situation, and seeking to make political capital out of an administrative oversight does not seem at all proportionate to the situation.

This is an extremely exciting Bill we have before us. I very much look forward to debating it in this Chamber. I am extremely grateful to the noble Baronesses, Lady Brinton and Lady Thornton, for their questions.

[The Deputy Speaker (Lord Bates) (Con)]

My Lords, we now come to the 20 minutes allocated for Back-Bench questions. I ask that questions and answers be brief so that I can call a maximum number of the 16 speakers who have asked to ask questions in response to this Statement.

19:30

[Baroness Watkins of Tavistock (CB) [V]]

My Lords, I declare my interests as outlined in the register and broadly welcome this paper. I particularly applaud the removal of the need for competitive tendering and the introduction of the discharge to assess model, which I and many other professionals have long advocated. However, could the Minister explain why such extensive powers are planned for the Secretary of State prior to the reforms of social care coming before Parliament? Why can they not come concurrently? He has partly just explained that, but it would be much better if we waited and did the two things together. Section 5.153 of the White Paper is designed to widen the scope of Section 60 of the Health Act 1999 to provide further powers enabling the Secretary of State to

“make a large number of changes to the professional regulatory landscape through secondary legislation.”

I seek assurance that there will be ample opportunity to debate this latter issue during the passage of the Bill.

[Lord Bethell (Con)]

I am extremely grateful to the noble Baroness, Lady Watkins, for her generous remarks on competitive tendering and discharge to assess. These are examples of where we have listened to stakeholders and those in the NHS who have called for changes. In terms of the powers given to the Secretary of State and the link with social care, it is worth remembering that this Bill is a stepping stone towards other changes. Changes to social care funding can take place largely without any legislative change; they can be introduced by secondary legislation. Changes to the funding model in social care are a matter for a very large engagement process that will include other parties, as the Prime Minister has outlined, and will include very considerable engagement with stakeholders.

In the meantime, we are seeking to correct an overreach in the seclusion and mandation of the NHS to give the Secretary of State the kinds of powers that are reasonable in a parliamentary democracy in the governance of such a large and important national institution. Those powers are to be used with restraint and a degree of circumscription, but they rebalance the political geography of the NHS to give it full accountability. As such, they give the kind of authority the Secretary of State needs to institute the kinds of social care reforms I know the noble Baroness, Lady Watkins, is interested in.

[Baroness Neville-Rolfe (Con) [V]]

While the costs of reorganisation are certain, the expected benefits may or may not be realised. The fate of the Lansley reforms is a lesson for us all. The country will judge the performance of the NHS over the coming decade in the light of this truth. Will the Minister specify objectives against which the new reforms can be assessed?

[Lord Bethell (Con)]

My Lords, the objectives outlined in the White Paper are reasonably clear. The four headline objectives are to make it easier for different people in the system to join up to find ways to address complex issues, to remove unnecessary bureaucracy, to empower local leaders to make the best decisions for the populations they serve and to facilitate a range of other improvements held back by existing legislation.

This is a large Bill with a very large number of measures. It is not, and does not pretend to be, unified by a single thought or held together by an ideology or motivation of any particular philosophy. It is the application of a very large number of recommendations that have come out of a huge engagement with the NHS family, patients and other stakeholders. As such, it is a pragmatic, thoughtful and restrained approach to an important piece of legislative housekeeping of this much-loved healthcare institution.

[Baroness Pitkeathley (Lab) [V]]

My Lords, I share the concerns of my noble friend Lady Thornton about these proposals, but I take issue tonight with one particular assertion in the Statement that health and social care are

“part of the same ecosystem.”—[Official Report, Commons, 11/2/21; col. 506.]

As far as patients are concerned, this has never been the case as healthcare is free at the point of use whereas social care is and always has been charged for. In a debate in your Lordships’ House on 28 January, to which the Minister replied, virtually every speaker from all sides of the House said that this is the anomaly which must be addressed. Will the Minister add to his previous remarks about money and charging issues and assure the House that the Government will address this issue in the long-promised reforms of social care and recognise that warm words about integration and collaboration are simply not enough?

[Lord Bethell (Con)]

The noble Baroness is right that there are distinctive qualities to social care and medical care, but the lived experience of most patients and residents is that those living in social care are very often heavy consumers of the NHS. As far as most of them are concerned, the support and treatment they are given needs to be much more closely linked. For instance, it is a strange anomaly that many living in residential social care have a completely different budget and sometimes completely different staff providing their medical treatment and their care treatment. This is not a functional distinction that we are seeking to overturn; what we are seeking is to get those teams of people and the decisions made about the care of individuals working much more closely together. We are not seeking to introduce a revolution in the funding of social care, and the financing of social care by local authorities and private individuals will continue, but we would like to see the distinction between social care and NHS medical care become more seamless, more joined up and, therefore, more effective.

[Lord Kakkar (CB) [V]]

My Lords, I draw attention to my registered interests. The justification for any reorganisation of the health and care system must be to improve patient and population outcomes. The current system, which has been unable to deliver the benefits of integrated care, is heavily regulated on the basis of distinct institutional boundaries and care settings. How do Her Majesty’s Government propose to address the regulatory impediment to the successful delivery of integrated care as part of the proposed reorganisation?

[Lord Bethell (Con)]

My Lords, the noble Lord is entirely right that the regulation of both clinical care and social care is critical and key not only to good performance by both sectors but to the way in which they work together. That is why we will look at the CQC and its role in social care regulation. We will seek to enhance the way in which the CQC can look deeply into social care to set higher standards and to ensure that, when it comes to integrated care, social care is stepping up to the challenge as best it can.

[Lord Grade of Yarmouth (Con) [V]]

My Lords, the front line of social and community care—indeed the whole of the NHS—begins with local pharmacies, which, as the Government well know, are in dire financial straits, closing down at a rate of four or five every week. I ask my noble friend the Minister: is it the Government’s policy to wait until these vital community services have all gone bankrupt before they act?

[Lord Bethell (Con)]

My Lords, I start by paying an enormous tribute to the 11,251 community pharmacies for the work they do day in, day out, and in particular their contribution to the vaccine rollout. I remind my noble friend that £370 million has been made available by the Government in increased advance payments to support community pharmacies with cash-flow pressures caused by the pandemic. The community pharmacy contractual framework—the five-year deal—commits £2.5 billion annually to the sector. Non-monetary support has also been provided in recent months, such as the removal of some administrative tasks, flexibility in opening hours, support through the pharmacy quality scheme, and the delayed introduction of new services. I am afraid I do not quite recognise the figures my noble friend cited on the closure of pharmacies, but if he would like to write to me, I would be very glad to look into them more closely.

[Lord Brooke of Alverthorpe (Lab) [V]]

My Lords, the White Paper refers to the NHS problems with obesity. I make no apology for introducing this topic, because obesity is one of the major underlying causes of Covid deaths, but it is rarely raised in the direct communication between the Prime Minister and Professor Whitty and the population in the No. 10 conferences. As World Obesity Day approaches on 4 March, will the Minister speak to the Prime Minister or Professor Whitty and see if we could have this fundamental topic raised as an indicator that this is where cost savings can be achieved and we can get better health, if we work on it?

[Lord Bethell (Con)]

The noble Lord is entirely right: obesity is not only a major issue, it is specifically cited in the Bill, where we have clear measures to try to address it. I do not need to raise it with the Prime Minister or the CMO because they both take it incredibly seriously. The Prime Minister has spoken movingly about his own challenge when he caught Covid—the five stone by which he feels he was overweight, the impact that had on his life chances, and how close to death he came because of obesity when he went into hospital. That was a metaphor for the whole country, and that is why we have launched a major obesity strategy in respect of marketing and advertising. It is why we remain committed to the obesity strategy, and more measures will be rolled out during the course of the year. I am extremely grateful to the noble Lord for reminding me about World Obesity Day on 4 March, which we will be marking very seriously with a publicity campaign.

[Lord Scriven (LD) [V]]

My Lords, nearly 75% of NHS expenditure goes on hospital and ambulatory care. Will the Minister explain how the proposed reforms will, in reality, lead to the redirecting of significant hospital sunk costs into ill health prevention and improving population health outcomes, as implied in the White Paper?

[Lord Bethell (Con)]

My Lords, we are putting considerable resources into hospital rebuilding, with 40 hospitals being built over the course of the Parliament; that is a major investment programme. The investment in population health comes out of different budgets. We are looking at how we will use ICSs to bring population health and responsibility for the outcomes of popular age and health metrics much more closely to GPs and hospitals. This oversight needs to be corrected, and it is one of the primary objectives of this Bill.

[Lord Naseby (Con) [V]]

My Lords, speaking as the husband of a former full-time GP, I ask whether the Minister is aware that neither general practice nor community care are meeting patients’ needs today and they require a total review. Also, is it fully understood by government that there is insufficient capacity in our current hospitals and that we need to build more? Having said that, I say that the vaccination programme is brilliant—and I place on record my sincere thanks, from the bottom of my heart, to the NHS staff at Bedford Hospital for saving my wife’s life.

[Lord Bethell (Con)]

I will indeed share my noble friend’s tribute to the vaccination programme and to Bedford Hospital for saving Lady Naseby’s life, for which we are all enormously grateful. However, I would probably leave his company on his remarks on GPs; they are extremely effective in the service they provide to their local communities. The patient satisfaction surveys do not support his contention that there is a massive gap there.

We are committing to building new hospitals in order to expand our capacity, but the essence of the measures in this Bill is more about prevention, population health and supporting better outcomes for the kind of public health measures around things such as obesity that ensure that people do not have to spend their time in hospital when they feel ill and, instead, have an early-stage intervention.

[Lord Curry of Kirkharle (CB) [V]]

My Lords, my interests are recorded in the register. This White Paper and proposed Bill are extremely welcome and long overdue, and I very much support the direction of travel. I have been curious and interested to read that reducing unnecessary bureaucracy in the process of change is a key plank of the White Paper. I am interested in how the Minister expects this to be achieved; as a former chair of the Better Regulation Executive, I know how difficult this is. Will there by some form of oversight to ensure that this does take place, and some way of monitoring that fact as well?

[Lord Bethell (Con)]

My Lords, the noble Lord makes a very wise observation. The challenge of reducing bureaucracy has confounded many Ministers in the past, and I would not want to suggest in any way that this is an easy challenge. However, it is our belief that, by getting those involved in primary, secondary and social care, and in public health, working more closely together in integrated care systems, with a culture of collaboration and clearer accountability for the outcomes of the populations in their areas, we can reduce the friction of paperwork, duplication and oversight that has cost the health system dearly, and can build a more effective way of providing healthcare services for individual populations.

[Baroness Armstrong of Hill Top (Lab) [V]]

My Lords, much of the laudable ambition of this White Paper is in the integration of the two sectors, but the truth is that you cannot have integration of health and social care without parity of esteem. With a social care system that the Government themselves have called dysfunctional, we know, certainly from all the evidence of Covid, that there is no such equality between the two structures. The legislation to implement this White Paper—I fear the Minister has it ready, considering the number of times he has talked about a Bill tonight—should not come before the desperately needed reform of social care.

The Secretary of State voted for the Lansley reforms more than 20 times in the Commons and they are what he now wants to undo. Unless this integration becomes a real possibility through dealing with social care first, this will look and feel like a vanity project for the Secretary of State. I therefore ask the Minister to assure us that we will know what will happen in social care before he brings a Bill on structural change of the National Health Service to this Chamber.

[Lord Bethell (Con)]

My Lords, I agree with the noble Baroness that there is a challenge around parity of status. The pandemic has vividly brought alive the challenging circumstances of those who work and live in social care. It is a tremendous tribute to the British people that they have given the lives of the elderly and the vulnerable such a high priority by putting the life of the country on hold to protect the health of the vulnerable and elderly, and that they have thought carefully and thoughtfully about those who live in either residential or domiciliary social care, for instance. It has brought alive for the whole nation the circumstances of those who live in social care.

I have heard loud and clear those in this House who have made the case for those who work in social care, often in low-paid roles but with a huge amount of responsibility and a massive task ahead of them, to receive better training, have clearer career paths, and, as the noble Baroness rightly points out, have a higher status. However, I do not agree with her that the sequence should be financial reform followed by structural reform. With this Bill, we are trying to put in the correct structural circumstances for social care so that it has parity with the NHS and a collaborative jigsaw fit with those in clinical and public health roles. Therefore, when the financial reforms are put in place, they will be done most effectively and with the largest impact.

[The Deputy Speaker (Lord Bates) (Con)]

My Lords, I am afraid that the time allowed for Back-Bench questions has now expired, with apologies to the noble Lord, Lord Vaizey, and the noble Baronesses, Lady Barker, Lady Stuart, Lady Donaghy and Lady Jolly, that I was not able to call them.

House adjourned at 7.52 pm.