Baroness Brinton (LD)
My Lords, I thank the noble Baroness, Lady Blackwood—the predecessor of the noble Lord, Lord Bethell—and the honourable Edward Argar for the helpful meeting we had just before Recess to discuss the Bill. I also extend my thanks to the noble Baroness, Lady Blackwood, for her services as Health Minister to this House. She will be sorely missed. I congratulate the noble Lord on continuing in this role.
I echo the thanks that other noble Lords have expressed to all the organisations which have sent us excellent briefings. Given that this is a Bill of one and a half pages, we have received probably a few telephone directories’—if they still existed—worth of briefings. It has been fascinating to hear the debate in your Lordships’ House today and to hear the same themes again and again from all sides of the House.
The Liberal Democrats will not oppose the Bill, although, we believe that, along with many others, it is not the panacea to health and social care that both the Prime Minister and Matt Hancock have been leading people to believe. I point out that the Bill does not seem to take account of any Barnett consequentials or social inequality issues, as has been raised by noble Lords. I hope that the Minister will be able to reassure the House that if there is extra funding for England, that should also be reflected in the devolved countries. There really needs to be a redistribution in terms of need as well. We absolutely understand that that has gone badly wrong in recent years.
Other noble Lords have already given a great deal of evidence on the current financial crises faced by different parts of the NHS, but it is worth briefly reiterating some of the headlines. We have heard that the revenue will increase from £120 billion in this financial year to £127 billion for the year we are about to start, and then increase further to £148.5 billion in 2023-24. Last year, NHS England’s long-term plan set out how it will deliver services over the next decade. I think I probably was not alone, when I read that plan last year, in thinking, “My goodness, they certainly know to squeeze every last penny out of the NHS to try to deliver those services.” We see what is happening at the moment with the pressures on the NHS. It is struggling—for the very good reason that this funding is not enough.
Others have argued that there is no need for this Bill at all as there is no need to enshrine NHS funding in law as an item separate from the Budget. That Theresa May and then Boris Johnson have felt that this was necessary speaks more, frankly, about the lack of public trust in the Government to deliver what many people believe that the NHS needs to survive. It is their beloved NHS and they want it to survive.
As others have said, the elephant in the room in this Bill is the lack of any clarity about the funding of social care. Most experts and non-experts alike recognise that some of the most severe pressures on the NHS are because of the total crisis in social care funding, brought about by severe, sustained and repeated cuts in the revenue grants to local authorities.
The Bill provides an average increase of only 3.4% year -on-year in funding. As other noble Lords have mentioned, the King’s Fund and many others who have written to noble Lords have said that the NHS needs a minimum of 4% per annum to restore the NHS key performance measures and to start to take account of demographic change, which will impact more on the health service and social care than perhaps any other part of public spending.
It was interesting listening to the noble Baroness, Lady Penn, and I will gently chide her, as she has chided her own side, by reminding her about it being the largest cash settlement in the NHS’s history. Full Fact, an independent organisation, found that, while that is correct in cash terms, after inflation the rise is £20.5 billion, which was exceeded by a £24 billion real-terms increase between 2004-05 and 2009-10. Therefore, the comments from the Labour Benches today are absolutely on the money—it is about the money. If people believe that is more money but then discover that there is not, they will become very angry very quickly.
Therefore, the question for the Government is: will the increase in funding that they are putting into law bring about the changes that our NHS and social care system needs? I use that phrase repeatedly because the department decided to extend its name to the Department of Health and Social Care—despite the fact that the crisis in social care is because all the funding is in a different department and is not only not accessible but regarded in a completely different way.
A&E waiting times continue to increase. We have already heard that achievement of the four-hour standard target dropped to below 80% for the first time since the target was introduced. Is that what is behind the Government’s discussions about abandoning some of the health targets? We explored that in the debate introduced by the noble Lord, Lord Hunt, a couple of weeks ago. I remain concerned that losing some of those targets and identifying new things that are not targets but something else will change the focus of work. There is a place for performance targets in the public sector. They should not change things for the bad, and I believe that they have changed them for the good. If these and other targets are being missed, that demonstrates that there is a problem in the NHS, not a problem with the targets.
Workforce problems persist across the NHS, with one in 11 vacancies being unfilled. The noble Baroness, Lady Finlay, reminded us of the health implications of social inequalities, especially poverty. At Second Reading in another place, the Secretary of State talked about the priorities for the new funding: more GP appointments; new cancer screening and faster diagnosis; prevention, detection and treatment of cardiovascular disease; and investment in innovative technologies, such as genomics and artificial intelligence. Many noble Lords who have spoken today have touched on most of those points. However, if something is not a priority and the money provided for it is not sufficient, we have to worry. The priorities say nothing about mental health, social care or public health.
In recent days, we have heard from a number of organisations that have pointed to the problems with each of the privileged priority areas marked for special treatment, so even they think that what is being provided is not enough. We have heard from noble Lords that in order to deliver more GP appointments, we need more GPs. However, it takes time to train them and at the moment the problem is that they cannot be recruited. They are training as doctors then going elsewhere. It is almost like the discussions that we had four or five years ago about the reasons people could not be attracted into A&E work in hospitals. It was because it was perceived to be a difficult place to work, and primary care is now facing that too. We also need better clinical support services, including community nurses, especially on overnight shifts—a point that I will come back to in a moment—to support GP services.
Noble Lords have discussed the fundamental problem of recruitment and retention of doctors, including GPs, especially with the history of funding hospitals and secondary care over and above primary care. We all know that this will take a decade to resolve. However, it has been made significantly worse because EU and other national doctors are leaving primary care due to the hostile environment. They feel that they are no longer welcome to work in the United Kingdom. Salary bands alone will not make the UK an attractive place to work, so this Government will have to do considerably more to encourage recruitment from abroad. We will need that if we are to at least temporarily stop the problems that we have at the moment.
On cancer services, Cancer Research UK has pointed out that
“no allowances are made within this for the growing cost of staff required to run the NHS.”
How do we think cancer services are going to be run? It says:
“This is a significant oversight, and as pressure piles up on existing overworked NHS staff, patients are being let down.”
Much of what it says is echoed by those who work in cardiovascular services, and we should also be clear about what is needed to help social care survive. I thank the noble Lord, Lord Low, for his comments on that, and I am particularly grateful for the briefing from the MS Society. It reminds us that local authority funding has not kept pace with demographic pressures. For adult social care it is not just a not-inflation cost; it is cutting services off at the knees. Although the additional £1.5 billion promised at the recent spending round for 2021 is useful, experts believe that that is the minimum needed to keep the social care system going.
Looking ahead, there is a large funding gap to improve the system on a sustainable basis. Last year, as has been mentioned, the House of Lords Economic Affairs Committee estimated that improving care quality and addressing unmet need alone would require £8.1 billion in 2021. There is a big difference between £1.5 billion and just over £8 billion. The MS Society puts it in very human terms: one in three people living with multiple sclerosis is not getting the support they need to complete essential daily activities such as washing, dressing, eating or moving around the house safely.
It is worth remembering that the NHS Long Term Plan clearly states:
“Both the wellbeing of older people and pressures on the NHS are also linked to how well social care is functioning. When agreeing the NHS’ funding settlement the government therefore committed to ensure that adult social care funding is such that it does not impose any additional pressure on the NHS over the coming five years.”
Does the Minister believe that the amount allocated to adult social care is sufficient to avoid a negative impact on NHS constitutional standards? Does he believe that the amount allocated to adult social care is sufficient for local authorities to meet their duties as set out in the Care Act 2014? Given that we are told that the Treasury has asked all departments to prepare for 5% cuts, can the Minister confirm that the local authority grant for the next four years will have not only zero cuts but large and sustained growth for social care, public health and other parts of local authority budgets that impact on the health of the nation?
Investments in genomics and artificial intelligence—and other research, as we have heard from the noble Lord, Lord Willis—are important because we must constantly improve our health system and use technology and research to maintain much of our leading edge, not just in research but in treatment techniques.
It is disappointing not to see mental health services as a priority. How the Government can talk about parity of esteem without funding it seems somewhat astonishing. Sir Norman Lamb and the Liberal Democrats in coalition persuaded the Conservatives that we should talk about parity of esteem for mental health. Will the Minister tell us what that equates to in money terms? I will not repeat the arguments made by many noble Lords during this debate about the problems with CCGs cooking the books. There is no other phrase for it: they cook the books. If they can get a tick for delivering on mental health, and yet we know that the money is being diverted, that is a lacuna in the system and it needs to be plugged swiftly. What extra funding will the Government provide for mental health services and how will they insist that CCGs deliver it and are accountable, not just in some annual report but as the year progresses, to make sure that it is spent on mental health services?
I turn to another area that CCGs have been working on: services for children with serious medical conditions. CCGs have cut the support and care required for these children over the last two years to the point at which there are virtually no medical respite care centres left for children on ventilators who require PEGs for feeding. Actually, they have also cut community nursing services at weekends and overnight. It does not affect just children; they also serve people with cancer and other illnesses. If you have a feeding tube that comes out in the night, the only thing you can do is go to A&E. That is ridiculous. Sending someone to A&E, particularly if they are in a home, costs far more than having a regular night-service system of community health services; but CCGs can do it, so they do.
I have a long list—but I will not go through it because time will not let me—of the other services that need to be considered. I have made the point about children; others are musculoskeletal services, occupational therapy and physiotherapy. They are all struggling because they are not seen as a priority.
I began by talking about the lack of trust in the Government to fund the NHS at a level that would deliver real and sustained growth in services. On the Lib Dem Benches in both Houses, we will hold the Government to two comments made by Matt Hancock at Second Reading. First, he said:
“The legislation explicitly states that the Bill establishes a floor, not a ceiling, for how much we spend on … the day-to-day running costs of the NHS.”—[Official Report, Commons, 27/1/20; col. 564.]
Later he said:
“I can guarantee that the mental health funding will be ring-fenced.”—[Official Report, Commons 27/1/20; col. 568.]
We stand at a crossroads in NHS funding. The Bill starts to make provision for increased funding but is by no means enough to provide the growth needed to bring services back to previous levels; nor does it take account of demographic change. All of this is without any of the other pressures that noble Lords have described—what happens if we have a further coronavirus problem?—and obviously the Bill does not tackle the issues in social care, public health and other key services. If these are not funded urgently and properly, the Bill will be nothing more than a temporary sticking plaster on an arterial bleed. I look forward to the Minister’s response.