The Long-term Sustainability of the NHS and Adult Social Care

Lord O'Shaughnessy Excerpts

Thursday 26th April 2018 Lords Chamber

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

My Lords, I begin by congratulating all noble Lords on a debate that has been truly epic: in subject matter, in content, in form, in the heroic contributions—not just in this debate but also from those whom we laud in the health and care services—and in length. I am conscious of the need to give a fitting denouément to such a debate, and I hope I will do it justice.

Before dealing with the content of the report and the many excellent questions from noble Lords, I will say four things. First, I thank and congratulate the noble Lord, Lord Patel, and the entire committee on an excellent and far-sighted piece of work. My noble friend Lord Ribeiro called it a landmark. The noble Baroness, Lady Hollins, called it game-changing. It is a very far-sighted piece of work. Indeed, some of the very important recommendations in it—the addition of social care policy back into the department, the commitment to a long-term funding settlement, and a workforce strategy—are not small suggestions, but those have all been taken up by the Government since the publication of the report.

Secondly, I apologise yet again for the unacceptable delay in our response. It was not good enough. I apologise, too, to my noble friend Lord Saatchi for the jargon in it. It is a jargon-ridden industry, as he knows, although I do not think that his quote was a direct quote. I hope not. I would say only that he should have seen the first version.

Thirdly, I reaffirm the commitment of this Government to a world-class NHS free at the point of use, with access based on need. My noble friend called the NHS a remarkable institution, which indeed it is. The noble Baroness, Lady Masham, called it our most important insurance policy. We are also committed to a social care system that provides good-quality care and is based on a fair and mixed model of funding. I think that all noble Lords would agree with those commitments; we know that compassion is not the preserve of one political party or another.

The fourth, and in some ways most important, thing is to express my gratitude and admiration for those who work in the NHS and care services—among the most-loved people in our country, as my noble friend described them. I want to reassure the noble Lord, Lord Kakkar, that these people, who serve us through their lives wherever they were born, will be at the heart of the celebrations for the NHS’s 70th birthday party. I also want to join the noble Baroness, Lady Jolly, and others in paying tribute to the many migrants—150,000, I believe, including the Windrush generation—who make such an important contribution to our national life.

As many noble Lords have pointed out, the NHS and adult social care systems face unprecedented challenges due to the ageing and growing population. These challenges are not unique to this country but common among developed economies. The noble Lord, Lord Warner, described it as tsunami of rising demand. It is worth pointing out, as did the noble Lord, Lord Patel, that the Commonwealth Fund has ranked the NHS as the overall best-performing health system for the second time in a row, but I accept his criticism, which is entirely fair, that we need to do better in achieving world-class outcomes.

I will deal now with the six main chapters in which the report is structured. The first is service transformation. The report says:

“Service transformation is at the heart of securing the long-term future of the health and care systems”—


and we quite agree with that statement. At the heart of the integration of those two systems are, of course, the sustainability and transformation partnerships. I reassure the noble Lord, Lord Willis, and the noble Baroness, Lady Wheeler, that we have not abandoned these plans—quite the opposite. We are investing in them like never before, with more than £2.5 billion of capital. However, I take on board the comment of my noble friend Lord Suri about the importance of engaging with communities in these transformation programmes because, if we do not bring people with us, change will not be supported.

We are also trying to improve integration between the NHS and local authorities in social care through the better care fund, which is now pooling more than £5.5 billion into the provision of integrated care. Bringing those two subjects into departmental policy-making is critical for the future.

Several noble Lords pointed out the panoply of arm’s-length bodies that exist in this space, but I can reassure the noble Lord, Lord Bradley, and others who asked about it that regulatory integration is going on. NHS England and NHS Improvement are working more closely than ever, and our mandate to the NHS and the remit letter to NHS Improvement were published together for the first time ever last month. I also assure noble Lords that we are able to achieve these changes without the need for primary legislation. The noble Baroness, Lady Thornton, the noble Lord, Lord Carter, and my noble friend Lord Prior asked about our commitment to integration. It is absolutely there in our strategy, along with a commitment to more integrated care systems. These are already demonstrating big improvements in the delivery of care in community settings, which is of course not only better for people’s care but more cost-effective.

I also reiterate our commitment to publishing our social care Green Paper by this summer. It will set out our plans to tackle care and support for older people and the challenge of an ageing population, but we are deeply conscious, as the Prime Minister and the Secretary of State have said, that changes to social care and the NHS need to go hand in hand.

The noble Lord, Lord Kakkar, wisely pointed out that consensus is needed not just on funding but on service transformation. It is incumbent on all parties to look to their own political tactics, particularly as we face the local elections next week, and ask honestly whether we are prepared to be part of that consensus. There are clear benefits to be derived from the rationalisation of services. The noble Lord, Lord Rodgers, and the noble Baroness, Lady Wheeler, talked about stroke services, where centralisation has helped. I think that 84% of stroke patients now spend the majority of their hospital stay in a specialist stroke unit, compared to 60% in 2010. There is clearly more to do and I will write to the noble Baroness with more detail on the stroke action panel.

We see fantastic examples of integration happening on the ground. The noble Lord, Lord Turnberg, and the noble Baroness, Lady Walmsley, talked about the work of Sir David Dalton and the Northern Care Alliance, which I have visited in Manchester. I have spent time with David and the alliance truly is a model for integration that we want to push, through the five-year forward view.

Many noble Lords, including the noble Baronesses, Lady Meacher, Lady Finlay, Lady Murphy and Lady Tyler, my noble friend Lady McIntosh, the noble Lord, Lord Rea, and my noble friend Lord Bridgeman all talked about the importance of primary care. The Government completely agree about the importance of good quality and good funding for primary care. Primary care funding is increasing in real terms over the spending review period. There are more nurse training places, as we discuss often in this House, more GP training places and a commitment for 5,000 extra staff in GP surgeries. This Christmas we saw, for the first time, GP services running 8 am till 8 pm seven days a week, to support people during winter. This is all about keeping people out of acute care wherever possible.

My noble friend Lady McIntosh asked in particular about rural coverage. I can tell her that a full review of the Carr-Hill funding formula, which affects allocations for surgeries across the country, will take place shortly. I believe that a review on that will be published next year.

I would like to take a moment to congratulate the noble Lord, Lord Carter, on his exemplary work in improving productivity and reducing variation. He is somewhat of a legend in the service, it has to be said —so much so that he even has a programme named after him. It is impossible to have a meeting without a reference to the Carter programme. I see that the noble Lord is smiling.

There are things such as the getting it right first time and model hospitals programmes, which my noble friend Lord Prior mentioned, and we are now applying some of these technologies to the better use of medicines as well. The noble Lord, Lord Carter, also talked about delayed transfers, as did the noble Lord, Lord Loomba, the noble Baroness, Lady Greengross, and my noble friend Lord Suri. Over what was a difficult winter we saw some improvement in delayed discharge, but we know there are still thousands of people who are medically fit to be discharged and should not be in hospital, and we need to get more of them into a social care setting.

Turning to the workforce, the report states:

“Those who work in the NHS and adult social care are the lifeblood of the organisations they serve”.


We completely agree that these people are the best asset we have. The Secretary of State announced in March a three-year pay deal for those employed under the agenda for change pay contract, which we hope the unions will agree. It will help our plans for retention. We have recently carried out a public consultation on adult social care to gather greater evidence of how we can recruit to that workforce. That has to go hand in glove with recruiting into the NHS.

Following the committee’s report, one of the great achievements has been Health Education England’s draft strategy for a 10-year workforce plan. As the noble Lord, Lord Willis, said, it is probably 25 years overdue, but it is important in that it sets out for the first time the idea, particularly for the lower-skilled workforce, of having a career that spans social care and allied health professions. Bringing together those workforces is surely critical to delivering integrated care.

In order to retain our staff we need to make sure they are treated properly. The statistics about harassment have been mentioned. It is completely unacceptable. The noble Baroness, Lady Watkins, and the noble Lord, Lord Parekh, mentioned it. We are making some changes to try to improve the well-being of staff, including more flexible working, greater support through nursing associates, the new homes for nurses programme and tackling bullying.

As the noble Baroness, Lady Meacher, and my noble friend Lord Sterling pointed out, it is equally important to address the blame culture. We are trying to get away from it through the learning from deaths programme and rapid resolution and redresses processes so that we can create a culture of learning rather than blame from when things go wrong.

There is a chapter in the report on funding. I shall deal with funding in two ways: short-term funding, if you like, and longer-term funding issues. We of course agree with the committee about the need to provide further funding between now and 2020. Noble Lords will know that we have backed the NHS forward view with an extra £10 billion by 2020-21, and the NHS was given additional funds in the Autumn Budget and more in the Spring Budget. We have also announced more than £9.4 billion extra dedicated to social care funding over three years, so we recognise that there has been a short-term need, regardless of what happens in the long term, to put more money into the health service and social care—but I accept the challenge from all noble Lords that a long-term settlement is needed, and I will return to that subject.

The committee’s report says:

“The Government should make it clear that the adoption of innovation and technology, after appropriate appraisal, across the NHS is a priority and it should decide who is ultimately responsible for this overall agenda”.


The noble Lord, Lord Winston, pointed out that many of the most impactful health innovations have come from the United Kingdom, and we agree that the NHS should be investing in and adopting new technologies. As my noble friends Lady Bloomfield, Lady Redfern and Lord Saatchi, said, uptake can be too slow. We are trying to address this through the life sciences industrial strategy and our response to the accelerated access review. We are investing in better digital and data infrastructure through things such as the global digital exemplars as well as providing support directly to SMEs to help them bring their innovations into the system. I now chair a new data strategy board, which is trying to bring our data infrastructure up to date. We plan to launch an NHS app at the end of this year to have more patient-focused digitisation and are creating the first local health and care records, which will provide across every health and care record dataset— believe me, there are a lot—the opportunity to link up data for direct care, which we will then build on through digital innovation hubs to provide that kind of dataset for research purposes. I hear over and over again that this is one of the unique opportunities that the NHS and Britain have because of the way our health and care services are set up.

My noble friend Lord Prior, who knows much more about these issues than I do, asked about the role of the NHS in supporting life sciences. He is quite right to say so. I would choose one example, the world-leading 100,000 Genomes Project. We are genuine world leaders in genomic medicine. It is now moving out of the research realm and this year we are setting up for the first time an NHS genomic medicine service, which is a great example of collaboration between the science base and the NHS. I was glad to hear my noble friend Lady Bloomfield’s personal positive experience of this kind of partnership. However, it is worth saying, possibly in typical fashion, that we have too many programmes in this area that need to be rationalised. I asked my team to have a look at it about six months ago with the Office for Life Sciences, and there are 38 programmes supporting innovation across six agencies, possibly not adding up to the sum of their parts although spending £750 million. I am very focused on making sure that money is spent more rationally and with greater effect.

One of the ways that that will happen, as the noble Lord, Lord Winston, was quite right to highlight, is through the academic health science centres and academic health science networks. We have just recommissioned the academic health science networks. I intend to do the same for the AHSCs as well but I wanted to ensure that they are fully integrated into the innovation review we are carrying out internally. It is deeply important to me that Imperial does well because all my babies were born at the Queen Charlotte’s and Chelsea, which I believe is a stone’s throw away from the noble Lord’s office.

My noble friend Lord Saatchi asked about the commencement of the provisions of his Act. He will know that it is something I am looking into at the moment and am not able to give him the commitments he is looking for. He knows I was not Minister at the time but I can tell him that this is something that is taking my attention, and I will write to him on that topic.

Many noble Lords emphasised, probably more than any topic other than funding, the importance for public health of prevention and patient responsibility. Indeed, the report called for the Government to be clear with the public that access to the NHS involves patient responsibilities as well as patient rights, a point emphasised by the noble Baroness, Lady Walmsley. It is undoubtedly the case that a healthy population is key to the sustainability of the NHS and many noble Lords, including the noble Lords, Lord Ribeiro, Lord Rea and Lord Rennard, have pointed out that tackling obesity is a great challenge. We have launched a childhood obesity plan. One of the major aspects of that, which has been commented on in this House today and on other days, is the impact of reducing sugar in soft drinks as well as a comprehensive sugar reduction programme. I am delighted that we will perhaps be able to relay to the young respondent of the noble Baroness, Lady Walmsley, that this is a preventable disease and we are trying to prevent it. It seems to be working, and there is cause for young people to have hope.

We are going to publish all the data and research that informs our plans, so that it is open for scrutiny. We are committed to considering whether sufficient progress has been made and whether additional policies are needed, whether in the form of advertising bans, statutory regulation or, as my noble friend Lord Ribeiro said, more bariatric surgery. We accept that we need to get a grip on this crisis, and we will take further steps if the ones we have taken so far have not worked.

It is worth addressing public health spending, which noble Lords have mentioned. We know that it came under pressure—there is no hiding that—as we made difficult decisions on coming into government in 2010. However, the 2015 spending review made £16 billion of funding available for local authorities over five years and, as the noble Baroness, Lady Masham, the noble Lord, Lord Rennard, and others have said, it is important that this public health funding, as well as other social care funding, must increasingly focus on keeping people independent in their own homes.

Many noble Lords—the noble Earl, Lord Sandwich, the noble Lord, Lord Rodgers, Lord Bradley and Lord Cotter, and the noble Baronesses, Lady Tyler, Lady Hollins and Lady Thornton—have talked about mental health and parity of esteem. We have legislated for that, of course, but that is not the only way in which we shall achieve our aim. There is increased funding. The mental health investment standard will be compulsory this year for CCGs. We are recruiting more staff and reducing out-of-area placements. We have the first waiting time standards and are extending those to receiving treatment. Making sure that those services join up around the sufferers of mental illness is critical, and we know that the Prime Minister has a deep commitment to that agenda. I accept that we need to do more and to go faster but, unfortunately and sadly, we are starting from a very low base.

The noble Baroness, Lady Finlay, raised the important issue of screening, diagnostics and staffing in radiology and pathology. This is one area where we can use technology. Indeed, the life sciences industrial strategy and sector deal committed us to use AI—another topic of conversation in the Chamber today—to transform radiology and pathology.

My noble friend Lord Farmer rightly highlighted the importance of family breakdown. He has been an ardent proponent of these issues. There is a focus on the role of families in the mental health Green Paper, but I always accept his pressure to do better. My noble friends Lord Colwyn and Lord Ribeiro talked about the importance of dental care and oral health. Actually, access to NHS dentistry is rising and the number of decay-free five year-olds is at its highest level, but I accept that this is something that we need to do more on, and I hope that our sugar reduction plans will help.

The noble Baroness, Lady Masham, my noble friend Lord Ribeiro and the noble Lord, Lord Brooke, talked about alcohol. I think we can take confidence from the benefits of the action taken to reduce smoking, and we are looking carefully at the minimum unit pricing scheme as it is implemented in Scotland, because we accept that there is powerful evidence in its favour.

I say to the noble Lord, Lord Cotter, that I will investigate the hospital closure he mentioned. My noble friends Lady Redfern and Lord Ribeiro asked about the bowel screening programme. The intention is to roll it out from this autumn.

The final section is headed “Towards a lasting political consensus”—leaving the best till last, perhaps. As the noble Lord, Lord Rodgers, reminded us, attempts at national consensus have eluded many Governments since the 1970s. The noble Baroness, Lady Pitkeathley, rightly encourages us to be bold. The Prime Minister is being bold. She recently announced a plan to come forward with a long-term funding settlement for the NHS, so that we can avoid what my noble friends Lady Redfern and Lord Prior called the feast and famine approach. I congratulate my noble friend Lord Prior on his work and that of the noble Lord, Lord Darzi, on the IPPR report published today. The Government have been working with NHS clinicians and experts, of course, but also with stakeholders—users, patients and carers—and I can tell the noble Baroness, Lady Pitkeathley, that my letter to her will be with her on Monday and we will publish our action plan on carers in the coming weeks.

I think the ultimate purpose of the report of the noble Lord, Lord Patel, is to build a political consensus. If there is one area where I share the concern of the noble Lord, Lord Hunt, and the noble Baroness, Lady Thornton, it is about a royal commission. I am not sure we need another one. As the noble Lord, Lord Hunt, said, what we need is leadership and consensus, but I thought we saw perhaps a glimmer of the future approach that the Labour Front Bench might take—I hope it is not true—of not wanting to be part of that consensus. I think the noble Baroness was keen to dispel that impression, and I hope that the Labour Party will join us in this process, but I accept that it needs political leadership from the Government of the day.

I have to deal with the proposal in the paper for an office of health and care responsibility, strongly pushed by the right reverend Prelate the Bishop of Carlisle, the noble Lords, Lord Taverne and Lord Rea, and the noble Baroness, Lady Thornton. The OBR, on which it is modelled, evolved from the Institute for Fiscal Studies, so perhaps the first stage to getting such an idea off the ground is to establish it as an independent health economic body outside government.

On funding and taxation, the noble Lord, Lord Layard, whom I know and admire, made a compelling argument for the benefits of a sophisticated form of hypothecation and the happiness that would come from such action. The noble Lord, Lord Desai, called for a softer version of such an approach.

Many noble Lords talked about what they felt was the willingness of older people—people over retirement age—to contribute, whether via national insurance or forgoing a winter fuel allowance. Many noble Lords used the phrase “intergenerational fairness”. I tell them without, I think, overstepping my brief and getting into Treasury territory, that to someone in this perhaps younger corner of the House that seems quite appealing, and I shall make a very personal case to the Treasury to consider it. I think it is representative of older generations’ willingness to contribute to the financial sustainability of the NHS. It is also important, as the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Desai, said, to make sure that we prepare people for the costs that will inevitably come their way in the social care system, which will continue to have a mixed-funding model.

To touch on Brexit, my noble friend Lord Prior asked about a research participation visa system for skilled workers and about remaining part of the European regulatory environment. I can say that on all those aspects, we have set out our intentions to be part of the research community and the regulatory environment. That is something that we hope to achieve through the negotiations.

To conclude, I thank the noble Lord, Lord Patel, and his committee again for a truly landmark report, which we continue to study hard. Our homework has been sent back to us by the noble Baroness, Lady Thornton, and I think it fair to say that since it was published I hope we have gone at least from a C+ to a B- with the actions we have taken. The Government have committed extra funding to the NHS since last November, but we are in no doubt about the pressures on the system because of the ageing and growing population, as well as the demands for improvements in areas such as mental health. A major review programme is under way through the five-year review, but there is no getting away from the fact that we need to move away from annual top-ups towards a sustainable long-term plan. The Prime Minister, with the support of the Chancellor, will provide a multi-year funding settlement in support of such a plan. Any such plan must turbocharge, as noble Lords have said, progress in spreading the excellence that exists in some parts of the system across the whole health and care service.

Alongside the development of this plan, we will have a new workforce strategy and a Green Paper and then there is social care. Our department and, indeed, No. 10 are particularly clear that the solutions to social care and the NHS must go hand in hand. As the NHS reaches its 70th birthday, this is what the Government are focused on delivering. We know that we can do that only with a broad consensus for change. This report is an excellent contribution to that process, and one that will stand the test of time.