Ageing: Public Services and Demographic Change Committee Report

Lord Crisp Excerpts

Thursday 17th October 2013 Lords Chamber

[Lord Crisp (CB)]

My Lords, this is an excellent report. I very much agree with the recommendations and with the disappointment of the noble Lord, Lord Filkin, at the Government’s response. I add that I am not a member of the committee that produced the report. I also agree with many noble Lords who said that this issue cannot be avoided or just left to muddle through. I congratulate the committee on not letting it go, and on continuing life after its committee proceedings.

I speak as a former permanent secretary of the Department of Health and chief executive of the NHS, and declare that I work in health, although globally, not in the UK. This is, of course, a global issue, as the noble Lord, Lord Livingston, said in his excellent maiden speech. I agree with the analysis that the committee has made of the problem. Very simply, we are using a 20th century model of health and social care to deal with 21st century problems of health and social care. It does not work, and we see that every day in the newspapers and will continue to see it in the newspapers, in our A&E departments, in the number of elderly people who are stuck in hospital—and in everything that we all know.

As noble Lords have said, and as the report says, we still do not have a clear strategic vision for the future of health and social care, and that is fundamental. I will mention two areas where the report could go even further—and I hope that the Government will. There is a lot of agreement, as has been said already in the House, about the nature of the problem. People are all aware that we need a much more community-based system that is much more focused on prevention. We also seem to accept a lot of the implications of that, which will involve bringing together health and social care much more closely, closing some acute hospitals, and investing in technology and in the community. However, agreement falls apart when we get to some of the detail, and the issues of winners and losers. Because we do not have a strategic vision that spells out all the implications, we have too many initiatives that are piecemeal and that often tackle symptoms rather than causes. Camilla Cavendish’s review of healthcare assistants, which was mentioned in the government response, is a good case in point. It was a good review, but it would have been even better if it had been in the context of a genuine, strategic vision for the workforce. Healthcare assistants do not operate in a vacuum.

This is the biggest failure at the moment. The biggest factor to take into account is the workforce. I do not think that it is mentioned in the report or in the Government’s response. I may have got that wrong, but clearly it is not in any of the headlines. Of course, the workforce never is. If you are going to have radical change in the service that is provided, you will have to have radical change in the workforce, as well. I will give some radical examples, although I am not necessarily advocating them. Are we going to be talking about having far fewer specialist doctors and more generalists? Are we talking about nurses doing many more of the things that doctors do now, and other people doing things that nurses have done in the past? We need graduate nurses, but do all nurses need to be graduates? What about the links between health and social care and the workforce? How radical are we going to be in taking this on? I am a member of the Lancet commission on the future of professional education. That has produced some radical notions about the role of senior professionals and team leaders as agents of change who are constantly searching for quality and cost improvements. Are we going to be that radical?

Of course, this is the biggest cost in the NHS; around two-thirds of the cost is in the workforce. In Africa, where I work, we have long recognised that the scarcest commodity is not money but skilled health-worker time. Do we in the UK use skilled health-worker time to best effect? Do we always make sure that people are working, as the Americans say, at the top of their licence, as opposed to doing things that other people in the system can do? This is not just about getting rid of paperwork for professionals; it is about making much more radical changes.

While Africa leads the way in changing health roles globally, the UK leads the way in developed countries—for example, with the expanded role of nurse prescribers and of nurses more generally. As I said, this is the highest cost, which is one reason why it is the most difficult area to tackle, and why people never tackle it. I understand the political traps of taking on the doctors or nurses to make some of these changes, and I understand that it would create winners and losers. However, it is not good enough to leave this to the local level. First, they cannot do it; you cannot make the changes necessary at local level. The headquarters has the responsibility of ensuring the capacity and capability of an organisation, and it is not doing so at all at the moment. Of course, this need not be top-down; it should be developed with practitioners and people at local level. However, as many people have said, the Government have a responsibility to ensure that there is an appropriate framework here for the future. Of course, if it is not sorted out, we will not see change.

My point is that this is not just about economic costs. The other question that needs to be looked at alongside it is: who will give the care? I will take 30 seconds more to refer to the fact that this is not just about professionals. We must not slip into the lazy assumption that the NHS is like a commercial insurance system, and that patients are simply customers. Care is not given just by professionals but by many carers. It is given by neighbours and voluntary organisations; it is given in a wide range of different ways. The NHS and social care form a social system rather than an insurance system. There are roles for carers, patients and families, and we need to redefine those as well. People can do more for themselves. We see examples in other countries of people doing much more in the way of monitoring. We see them delivering dialysis for themselves. Of course, these examples also produce improvements in quality and in cost.

In conclusion, I would be very interested to hear what both the Government and the Opposition say about the challenges that the report sets them in setting out the position for the future and a long-term vision. I will also ask the Minister a specific point, as a first step towards that. Does he accept that a changed, new NHS of the type described here will require a new, radically different workforce strategy, with changed roles for doctors and nurses, and changes in professional education? If he says that that is the responsibility of NHS England, as I suspect he will, will he then ensure from the Government that NHS England, in developing its strategy, will take proper account of the 60% of the NHS budget and of the changes that need to be made there as well as elsewhere?