NHS: General Medical Practitioners

Lord Warner Excerpts

Monday 20th November 2023 Lords Chamber

Asked by

[Lord Warner]

To ask His Majesty’s Government what was the net change in the number of NHS general medical practitioners (GPs) in England, after taking account of resignations and additional recruits, in the past three years; and how much improvement in the retention of GPs they are planning to make as a result of the NHS Long Term Plan published on 30 June.

[Lord Evans of Rainow (Con)]

My Lords, as of September 2023 there are 2,025 more full-time equivalent doctors in general practice than in September 2020. We are working with NHS England to increase the general practice workforce. This includes measures to boost recruitment, address why doctors leave the profession and encourage them to return to practice. Last year, a record 4,000 doctors accepted a GP training place. The long-term workforce plan has committed to increasing this to 6,000 by 2031-32.

[Lord Warner (CB)]

I suppose I should thank the Minister for that rather optimistic reply, but is he aware that the number of patients has increased by 20% since 2015 while the number of GPs has actually declined? I can tell him that 464 GP partners were lost last year and that a quarter of GPs work only part-time. A recent survey by the Royal College of General Practitioners revealed that 57% of GPs are now saying they will not be in general practice in five years. Can the Minister explain how the new long-term workforce plan will get us anywhere near the number of 6,000 that he mentioned, when the plan expects a retention figure that will expand the number of GPs by only 700 by 2036-37?

[Noble Lords]

Too long!

--- Later in debate ---

[Lord Warner (CB)]

I am coming to the conclusion. Are we not in a situation where NHS England and the Department of Health and Social Care have failed and we need some new thinking to sort out the problems of GPs?

[Lord Evans of Rainow (Con)]

My Lords, I take this opportunity to congratulate the noble Lord on the work he did as a Labour Government Minister between 2003 and 2007. I am grateful for his question. We are incredibly grateful to GPs and their staff, whose hard work ensured that more than 32.6 million appointments were carried out until September 2023, more than two-thirds of which were face to face. On 30 June, NHS England published the NHS Long Term Workforce Plan. The plan sets out the steps that the NHS and its partners need to take to deliver the NHS workforce, including GPs, that meets the changing needs of the population over the next 15 years. We are working with NHS England to increase the general practice workforce in England. This includes measures to boost recruitment, to address the reasons why doctors leave the profession and to encourage them to return to practice. NHS England has made a number of retention schemes available to boost the general practice workforce.

Sue Gray Report

Lord Warner Excerpts

Monday 31st January 2022 Lords Chamber

[Baroness Evans of Bowes Park (Con)]

I am sure there will be a lot of discussions around this issue.

[Lord Warner (CB)]

My Lords, could the noble Baroness say a little more about the setting up of a new regime in No. 10? Will Parliament be involved in any way in the selection and approval of the Permanent Secretary to head the Prime Minister’s office?

[Baroness Evans of Bowes Park (Con)]

As I said to the noble Lord, Lord Butler, I am afraid that some of these questions are jumping ahead. What I can say is what I have already said: that the Prime Minister has said he will create an office of the Prime Minister, with a Permanent Secretary. He has also said that “in the coming days”, he will say more about the steps being taken

“to improve the No. 10 operation and the work of the Cabinet Office, to strengthen Cabinet Government, and to improve the … connection between No. 10 and Parliament.”

I am afraid I cannot go further than that.

Health and Care Bill

Lord Warner Excerpts

Lords Hansard - Part 2 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Lord Lansley (Con)]

My Lords, I shall intervene relatively briefly. The noble Lord, Lord Hunt, quite rightly said that this is a significant departure from the intentions of the 2012 legislation. The 2021 Act, among other things, created the body that is now NHS England and gave it independence. None of that independence was intended to mean, nor has proven to, that it was not responsive to even the day-to-day wishes of a Secretary of State, as I am sure the noble Lord, Lord Stevens, would verify. What it did put in statute was that, if the Secretary of State wants to set something as an objective of NHS England, they put it in the mandate. If the Secretary of State requires a change to those objectives, they publish a revision to the mandate.

Going beyond it is, I think, the product of circumstances where we had a Secretary of State who was encountering an emergency and thought he could press lots of buttons and things would happen, but pressed some and they did not. I think, even in his experience, that was more outside NHS England than inside it— I may be wrong, but that was certainly my impression. The point is that the Secretary of State did not even realise what powers he had in an emergency; they are all there and he was not required to change the mandate, because it was an emergency. In a public health emergency, none of this, strictly speaking, is within the same bounds.

Ministers have quite rightly said that this is the Bill the NHS asked for. But Clause 39 is not the clause that the NHS asked for; it is the opposite of what it is asking for. There are many practical issues. The noble Lord, Lord Hunt, is right; if it appears, including to the senior people and bright youngsters, that power is going to shift from NHS England back to the Department of Health and Social Care, they will go and work in the department. One of the things I was most pleased about was that some of the brightest and best, including civil servants in the department who I knew well, went to work in NHS England, because they thought, “This is a great future.” That is terrific, because one of the problems was that NHS managers were being imported into the Department of Health, rather than bright policymakers going to the NHS. The NHS is too important an institution for it not to have the best possible policymakers under its own purview.

The noble Lord, Lord Hunt, and the noble Baronesses, Lady Thornton and Lady Walmsley, have done a sterling job in trying to mitigate a general power of direction for the Secretary of State. Frankly, I have not heard a case for it, it is contrary to where we are and where we need to go, and the simplest thing is to simply take Clause 39 out of the Bill.

[Lord Warner (CB)]

My Lords, it is a delight to follow the noble Lords, Lord Lansley and Lord Hunt, on this set of amendments, with which I totally agree. I want to dilate for a few moments on the realpolitik of being a Minister in the great, august organisation called the Department of Health and Social Care. I can say some things that the noble Lord, Lord Lansley, as a former elected Minister, possibly cannot.

When I ceased to be a Parliamentary Secretary and was promoted to work with the big boys and girls as a Minister of State, and had to deal with issues such as reconfiguration, poor performance and so forth, I became used to regularly meeting elected MPs who wanted to tell me about the errors of their ways in decisions that had been taken in the public interest. There was a steady flow of them, which, if I may say, tended to get bigger the nearer you got to an election. If people wanted to go through the archives, I would refer them to the history of Lewisham Hospital and of Chase Farm Hospital, to name but two.

Very often in these situations, it is not about closing a whole hospital but about re-engineering—we will come to some of this in the next group. I give the example of stroke services in London. It is re-engineering a particular set of services, which the local MP is then put up for trying to ensure that change does not happen. That is where you need to help Ministers do the right thing, when it is in the public interest to make changes. The amendments from the noble Lord, Lord Hunt, help Ministers do the right thing.

The point the noble Lord, Lord Lansley, made is absolutely valid. In many of these circumstances, it becomes very difficult if you are an elected Minister—as distinct from an appointed Minister, who does not have to face the electorate—to resist some of the local pressures to avoid change which would be disadvantageous to a local hospital. For those realpolitik reasons, I think the noble Lord, Lord Hunt, is on the right track and we should support the amendments.

[Baroness Walmsley (LD)]

My Lords, I support the noble Lord, Lord Lansley. Clauses 39 and 64 give the widest possible powers of intervention to the Secretary of State and even the power to delegate that power to someone else. The noble Lord, Lord Hunt, and other noble Lords clearly believe that the Government are going too far, hence the large number of amendments in this and the next group.

I believe that the Clause 39 powers could justifiably be used only in the case of some cataclysmic failure of the NHS. There are four questions to ask. Is it possible that the Secretary of State would ever need these powers of intervention at an operational level, given that he already has the mandate? Does the Secretary of State have any other powers which could be used prior to this atomic bomb of a power? Has the NHS survived well enough over the last 10 years without the Secretary of State having such powers? Does Clause 39 upset the balance between the Secretary of State and the autonomy of NHS England? I think the answers are no, yes, yes and yes—your Lordships can work it out.

The Health and Social Care Act 2012 removed the Secretary of State from this sort of meddling. I thought at the time that it might also avoid him or her taking the blame for failure, but that was just me being cynical and there has actually been no failure of political accountability over the last 10 years. The ninth report of the House of Lords Constitution Committee refers to this issue. It notes that, in 2011, it

“raised concerns that that Bill could erode ministerial responsibility due to the proposed duty on the Secretary of State to promote autonomy for persons exercising functions in relation to the health service. What is now section 5 of the Health and Social Care Act 2012 was amended, such that the Secretary of State instead must have regard to the desirability of securing autonomy. This helps ensure a balance between enabling those providing health care services to deliver services in a manner that they consider appropriate, whilst ensuring ministerial responsibility.”

The Constitution Committee believes that, in combination with Clause 64, the powers taken for the Secretary of State by Clause 39 would undermine that autonomy and upset the balance. They also risk

“undermining accountability by making it more difficult to understand which body is responsible for a particular function of the NHS.”

The fact is that the Secretary of State already has the power to change the mandate of NHS England—as the noble Lord, Lord Lansley, pointed out—to adjust its funding or to bring political pressure upon it to behave in certain ways, without the need for the powers in this clause. Indeed, I think it would be very unwise to use these powers, and he or she will certainly get the blame if it all goes pear-shaped. The Bill, as has already been pointed out in some detail by noble Lords, the DPRRC and the Constitution Committee, gives the Government considerable regulatory and guidance powers, about half of which allow no parliamentary scrutiny at all. Does that not give the Secretary of State enough ability to ensure things are done in the way the Government wish? The Secretary of State already wants to be Henry VIII; does he also want to be King Herod?

--- Later in debate ---

[Lord Lansley (Con)]

Let me give my noble friend one simple example of how this could shift decision-making from NHS bodies to the Secretary of State. We discussed previously, in an earlier group, the availability of in vitro fertilisation services. There will be pressure on the Secretary of State to issue a direction that the NICE recommended availability of in vitro fertilisation services should be provided. By what means is the Secretary of State going to say, “No, I can’t issue such a direction”? It is entirely within his power to do so. The pressures will all be on the Secretary of State to issue directions to do things that the NHS locally may choose or choose not to do. The power will shift. Is he aware of what he is wishing for?

[Lord Warner (CB)]

Before the Minister answers that question, could I add another? We have had 10 years’ experience of NHS England under three chief executives and a number of different chairmen. Can the Minister give any examples of where the powers the noble Lord, Lord Lansley, gave the Secretary of State have been inadequate for them to give direction to NHS England?

[Lord Kamall (Con)]

The Secretary of State cannot issue a direction to CCGs or ICBs on any of this using this power. We have been clear that direction cannot be given in relation to drugs, medicines or on treatments that NICE has recommended or issued guidance on. I gave the example of where we want this guidance—with the draft guidelines published for ICBs. The Secretary of State would be able to intervene and ask to see that guidance—

Health and Care Bill

Lord Warner Excerpts

Lords Hansard - Part 2 & Committee stage
Tuesday 11th January 2022 Lords Chamber

[Baroness Young of Old Scone (Lab)]

My Lords, I support Amendment 60 in the name of my noble friend Lady Thornton on the need for ICBs to share innovations and good practice widely, in the spirit of collaboration. The NHS has for many years been rather poor at sharing and adopting innovations compared with, for example, local government, where several effective networks exist for the sharing of good practice and there is a real culture of such sharing.

The Science and Technology Committee, under the chairmanship of the noble Lord, Lord Patel, reporting on its inquiry into the life sciences, found that the NHS ought to be a unique opportunity for the spread of innovation across the system—that is what the “N” in NHS is all about—but that it was a long way from realising that aspiration. The evidence from NHS England’s director of innovation was lacklustre in the extreme, and progress from NHS Improvement was slow. The Select Committee report said that the current structure of the NHS “stifles innovation”.

When I was chief executive of Diabetes UK, I discovered how even getting innovations and improvements that would save the NHS substantial money was like pulling teeth. In frustration, I wrote to the then Chancellor—slightly tongue in cheek—to tell him how to save a billion quid by implementing the best practice patient pathways for diabetes patients. I am still waiting for a response.

In an effort to see how other countries’ health systems handled improvement and innovation in diabetes care, I went to Canada and the USA, and came to the conclusion that collaborative health systems such as Canada’s were better at sharing and then adopting improvement and innovation than competitive ones like the United States. My noble friend Lady Thornton’s amendment is highly necessary and sets the tone for a collaborative rather than a competitive approach, which should be at the heart of the NHS for the future.

[Lord Warner (CB)]

My Lords, I will say a few words about specialised services on the basis of a committee that I chaired about five or six years ago at those services’ request. It followed the demise of strategic health authorities under the 2012 Act. The one thing that this committee demonstrated very clearly was that population was significant and that, if you ignored population, you were not likely to get good outcomes. There was no magic figure on population but it was of a size common in the territories of most of the SHAs. That is not to say that the SHAs did a crackingly good job, but they were the organisations with the size of population necessary for good commissioning of many of these specialised services.

The trouble was—and it is the same trouble mentioned by the noble Lords, Lord Lansley and Lord Sharkey—that if you have a regional system, by definition you give it some degree of control over its priorities. It follows almost as night follows day that different regions will take different views about the significance of specialised services in their particular region. We have struggled with this issue for many decades and not found it easy to come up with a solution.

You can go the whole hog and put it on NHS England, but that poses the problems that the noble Lord, Lord Sharkey, honestly owned up to: many of the people with these conditions are getting a range of services outside that specialised commissioning service. I came to the conclusion that you have to have something that is of the size of, or of a similar size to, the former SHAs, but you do need a role at the centre trying to ensure a level of consistency of approach in those larger areas. I think we are still fumbling our way towards the right mix of that and I cannot see that we will be able to put in this legislation a definitive answer to that particular set of conundrums.

While I am on my feet, I shall speak to Amendment 215, to which I have added my name. To some extent, I reinforce the seriousness of the situation that Ministers and the public face with the enormous backlog of patients awaiting treatment that the noble Baroness, Lady Wheeler, drew attention to. I refer the Committee’s attention to the excellent report by the National Audit Office published about six weeks ago. This report made it absolutely clear that in September 2021 there were nearly 6 million people on the waiting list for elective care and that one-third of these people had been waiting longer than the waiting standard of 18 weeks. Some 300,000 rather unlucky people had been waiting in pain and discomfort for more than a year. The NAO made it clear that even before Covid-19, many parts of the NHS were not meeting the waiting time standard and that about one in five cancer patients was not meeting the waiting standard for urgent referrals by GPs—that is a pre-Covid situation that has simply got worse as time has progressed.

I recognise that the Government have promised to provide an additional £8 billion between 2022-23 and 2024-25, some of which they expect the NHS to use to increase elective capacity by 2024-25 by 10% more than its pre-pandemic plans. I have to say, as a former Minister responsible for reducing waiting times and implementing the original 18-week maximum wait, that Ministers need to realise that announcing the extra money is the easy bit; putting in place a system for ensuring that the NHS leviathan actually uses the money for its intended purpose and can demonstrate delivery of the promised outcome is an entirely different matter. It took the Blair-Brown Governments from late 2004 to early 2008 to deliver the 18-week maximum wait and the cancer targets, using a lot of different tools in the ministerial toolbox.

There is not one simple solution to delivering these changes. The regimes that were implemented by those two Governments used a lot of extra money; a relentless, transparent measurement; and a great deal of clinical and political management pressure. They used expanded patient choice, so that patients could drive change, and I have to say to the noble Lord, Lord Davies of Brixton, that they also used the private healthcare system to increase diagnostic and surgical capacity by about 10% to 12%, but they did so at NHS prices. So, there is not a single solution; there are a lot of solutions that have to be applied and measured.

A critical factor in this is keeping everybody honest through transparent information about how progress is being made. If that is lacking, you are probably doomed to fail. The strength of Amendment 215 is that it puts in place a system for regular reporting of progress being made—or not being made, in some cases. It is important, as my own experience has shown, to know which parts of the country are doing well and which are not doing so well, so you can actually ensure that some action is taken on the slowest ships, as they say, in the convoy.

It should come as no surprise from what I have said that I strongly support Amendments 6 and 19 and do not support Amendment 21. I recognise, as we were discussing earlier this afternoon—time flies; I mean this evening—the whole issue of health outcomes and outcomes frameworks. Those are very important. However, at the end of the day, you cannot secure good outcomes without speedy access to clinical services. You do not get them. Waiting times of the length we currently have can lead only to poor outcomes. We must put in place systems that measure the progress being made in driving these waiting lists down. Given the seriousness of the situation, we need something about this in primary legislation to ensure that people across the country and the NHS are moving in the same direction in driving waiting times down.

[Lord Bethell (Con)]

My Lords, I want to say a brief word in support of the amendment on innovation in the name of the noble Baroness, Lady Thornton.

Having just been the Minister for Innovation, I can tell noble Lords that they could fill their entire diary travelling the country and seeing fantastic innovation in the NHS up and down the country. Noble Lords could fill their Zoom calls speaking to countries around the world that look to the NHS for some of the best innovation and partner with it on innovative programmes. However, that innovation is often extremely isolated and rarely spread evenly across the whole country. In fact, I often thought that my job title should have been not Minister for Innovation but Minister for Adoption because my role should have been to take the best that the NHS does and spread it across the country more evenly. That is the objective of the Government’s health policy at the moment: to see a much more even spread of best practice right across the country.

Although we cannot legislate for culture, we can give signals to the system about what we think is important. I therefore think that the noble Baroness, Lady Thornton, is on to something in suggesting this amendment. It should be given careful thought by the Minister.