Health and Care Services

Richard Fuller Excerpts

Wednesday 3rd July 2013 Commons Chamber

[Mr Dorrell]

I will come on to the impact on pay later. My hon. Friend is right that the challenge antedates the election of this Government and that it increasingly looks beyond this Parliament, as did last week’s public expenditure announcements. There are specific challenges implicit in the Nicholson challenge for the coalition and for the Opposition. To my colleagues in the Conservative party, who sometimes ask why we have a ring fence around the national health service, I simply say, “Understand what you are asking.” We are already strapping ourselves to the mast indefinitely into the future of meeting a rise in demand of 4% per annum without substantial growth in real resources. Looking back, we see that the national health service has delivered a 1% efficiency gain trend rate over its first 60 years, and the national average for the rest of the economy is 2%. We are expecting the health and care system to deliver a 4% efficiency gain. To anyone believing that we are likely to be able to meet demand for health and care to acceptable standards against a background of reduced resources—in other words, more than a 4% efficiency gain year on year—I say, “Do the maths.” That is the challenge to the Conservative party.

[Richard Fuller (Bedford) (Con)]

Will my right hon. Friend give way?

[Mr Dorrell]

Will my hon. Friend forgive me if I complete the challenge so as to be even-handed, as the Chair of a cross-party Committee should be?

Some Labour Members may wish to look for ways to avoid the difficult questions posed by the Nicholson challenge, but we need to remember that if we were to try to meet demand without addressing any of the efficiency questions—to take it to the other extreme—we would need £5 billion a year of new money over and above keeping up with inflation. That is more than 1p on income tax year on year, or 6p on income tax in the lifetime of a Parliament, to meet demand in the health service, unless we address the Nicholson challenge.

The conclusion that the Committee puts to the House is that the Nicholson challenge is unavoidable. Anybody who takes any serious interest in health and care has to address it. Nobody seriously believes that any Government will put up income tax by 6p in the pound in the life of one Parliament simply to fund health and care, and nobody in my party seriously thinks that we can avoid meeting demand for health and care. If we cannot avoid meeting that demand, we have to deliver a 4% efficiency gain out of the service merely to allow it to live within the current real resource available to it. That is the Nicholson challenge, and it is why the Committee—from a cross-party standpoint—has said, from the beginning of this Parliament, that it is the most important challenge facing the health and care system.

[Richard Fuller]

I wish to challenge my right hon. Friend on the 4% efficiency requirement that is, essentially, the 4% increase in demand that we expect. I am a big believer that history is a good guide to the future, and I understand the changes in demography that will push that challenge. How much of the demand comes from a quantum increase in demand and how much from a price increase for the inputs into the health budget?

[Mr Dorrell]

I do not wish to detain the House for the whole of the time available for this debate, but my hon. Friend raises an important question about how that demand is made up. The interesting thing about the drivers of demand—rising expectations, the cost and availability of modern medicine and the implications of an increasingly elderly population—which each new Front-Bench spokesman reveals as a newly discovered truth, is that they were first discovered by Rab Butler when he became Chancellor of the Exchequer in 1951. He set up a commission to ask whether the health service was an insupportable burden. The conclusion reached then, and by every successive Government since, in this and in similar processes in other countries, is that demand can be met, but it requires a serious analysis of the nature of the demand and how resources are used effectively to deliver it.

There is a danger in discussing health and care as if they were purely an economic question, especially for those of us who have been employed in the Treasury—like you, Madam Deputy Speaker, and me. There is a danger of sounding like a Treasury Minister and implying that the economic questions are the only issues in this regard. I need only offer names to the House to demonstrate that economics is not the only issue here—Winterbourne View, Mid Staffordshire and Morecambe Bay. Our system faces huge challenges, not just to do with economics but in respect of the quality of service that is delivered on a daily basis. Put simply, it is not enough just to go on delivering the service as it is now because, too often, it fails. Implicit in the Nicholson challenge is the requirement to face profound quality challenges, as they exist in the system, at the same time as squaring the financial circle I have been describing. In some quarters, it is suggested that that is a counsel of despair—that the circle is unsquareable.

The Committee disagrees, which is why the report states, at paragraph 30:

“At a time when steadily rising demand for health and care services needs to be met within very modest real terms funding increases for the NHS and even tighter resource constraints on social care, the Committee remains convinced that the breadth and quality of services will only be maintained and improved through the full integration of commissioning activity across health and social care.”

In other words, it is the Committee’s cross-party view that it is the integration—the reimagining of what health and care need to look like—that is the answer to the questions posed both by the Nicholson challenge and the quality challenges implicit in the names that I mentioned. It is important to be clear why that is the Committee’s view.

Efficiency, as implicit in the context of the Nicholson challenge, is not just about buying a bit more cleverly or holding down costs. It is about understanding what the demand is that we are trying to meet and putting in place the structures—incidentally, I do not mean the management structures—for the delivery of care that are likely to be able to meet the demands placed on them, not over the last 50 years but over the next 20. It is reimagining and driving a process of change through the health and care system that is the only realistic challenge to the financial and quality challenges that I have articulated.

--- Later in debate ---

[Steve McCabe (Birmingham, Selly Oak) (Lab)]

I recognise that there is almost no prospect of a return to the 4% annual rises in the health economy that we had got used to, and the right hon. Member for Charnwood (Mr Dorrell) explained the impact on income tax of such a move. The Institute for Fiscal Studies reported that to return to that would require a budget freeze on every other Government Department for the foreseeable future, even allowing for significant growth in our economy. We have to recognise that the NHS will have to make do, therefore.

The NHS is currently halfway through finding efficiency savings of more than £16 billion up to 2016. The savings are coming primarily from pay restraint, administrative cuts and reductions in centrally determined payments. In the long run, pay restraint may lead to a shortage of essential staff and, of course, poor pay and conditions is a factor in the poor-quality social and residential care we already see. As my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) pointed out, social services directors say that reductions in payments to care providers are leading to a fall in the quality of the care they are able to commission, and that often leads to a cycle of admissions to hospital.

Although it is politically convenient to scapegoat administrators, even the Minister must recognise that there is a limit to efficiency savings in administration. In these circumstances, the decision to waste so much on a top-down reorganisation now looks a little stupid.

[Richard Fuller]

The hon. Gentleman has raised the issue of low pay in certain sectors. He will know from the evidence of the Select Committee report that 16 of the 42 trusts stated that pay amounts to at least 50% of the total cost pressures. Does he think there is a case throughout the NHS for looking at managing down the pay of the more highly paid, so that those on the bottom can get higher increases?

[Steve McCabe]

There is some merit in looking at that, but when the people at the top end are scarce, we must be careful not to lose them to other countries. That is a challenge.

Today’s announcement about charging foreign nationals was strange in the sense that it seems to undercut existing private providers such as BUPA. I am not quite clear how that will save money. I fear it is the kind of posturing that may well end up costing us money, rather than saving money.

Like others, I welcome the Chancellor’s decision to allocate £3.8 billion to the joint NHS social care budget, but I would like to know an awful lot more about how it will be allocated and spent. In particular, I would like to know how the Minister hopes to measure its impact on medical services such as accident and emergency and hospital beds.

I would like us to have a statement on the proposed pathfinder integrated care pilots, because many of us are curious to know where that is going. It seems to me that there is not an awful lot of point in proclaiming the virtues of pooled budgets unless we know exactly what the Secretary of State thinks he is going to achieve. We have an idea from the Health Committee about where it thinks that might go, and the shadow Secretary of State has sketched a vision, but so far we have had an announcement from the Chancellor about making money available yet we do not have any idea what the Secretary of State hopes to achieve through that measure.

I would like to make one suggestion to the Minister: he should take a look at the home from hospital care service, which I understand operates in several parts of the country, and which was inspired by the work of Geraldine Amos almost 40 years ago now. In Birmingham, that service helps people move from hospital back into their own home and community and, of course, frees up hospital beds. It is quite a limited service in Birmingham at present, as it is currently financed by a grant from Birmingham city council, and I am not sure how much longer that will last, given the pressure on local authority budgets. That is, however, one example of how quite a small amount of money can be used to make quite a big impact in getting people back and settled at home, and trying to stop repeat admissions and bed-blocking. The recent NHS Confederation survey of chairs and chief executives revealed that 50% of respondents believed that the financial pressures have affected waiting times and access in the past 12 months and that 70% believe that waiting times and access will be affected by the continuing financial pressures in the next 12 months. So it is slightly strange that we have heard so little from the Government about how they plan to redesign services so that they are able to unlock more sustainable efficiencies for the future.

Given the answers I have received to some written parliamentary questions, my impression is that far from having a vision for the NHS, Ministers are seeking to evade responsibility for it. I have lost count of the number of written answers I have received advising me to contact this body or that body when I have asked the Minister for basic information and figures. We need a bit more clarity about the Government vision, and local communities and their representatives, including local and national politicians, should be properly engaged in that vision. That is one area where we could all be in it together; we could all be party to some kind of change programme, which would help us to redesign the services and to plan an NHS that will have to operate with fewer resources in future.

My recent experience of trying to obtain straight answers on the future of the NHS walk-in centre at Katie road in my constituency does not fill me with any optimism. Why on earth should clinical commissioning groups be allowed to keep private and secret a report on the future of walk-in centres, given that the report was not even commissioned by them? Why should the local Members of Parliament not be given access to that report? Why on earth set up a body such as HealthWatch if it does not get automatic access to it?

I would really like to know a bit more about that Government vision, and I would be particularly interested to know what they want to do to manage some of the growing pressures to which hon. Members have referred. I would like to know the Government’s policy with regard to the greater prevalence of long-term conditions such as diabetes and dementia. Like the hon. Member for Southport (John Pugh), I think it is hard to see the impact of health and wellbeing boards in that area, not because they are not bringing the right mix of people together, but because their chairmen are currently engaged in a line-by-line review of budgets designed to exclude everything that is not a statutory obligation. It is difficult to see how such bodies will be the ones with vision about long-term conditions when that is the level at which they are currently operating.

The Secretary of State should give a clear commitment to tackling the problem of conflicting incentives in the NHS. Acute trusts are paid for their activity through the tariff, while primary care and community care is paid through block contracts which actually serve as a disincentive to activity. I welcome the news that Monitor and NHS England are to examine this problem, but we need some response to it fairly quickly.

In conclusion, I recognise that we are discussing the estimates made possible by the economic circumstances of the country, but it remains the responsibility of the Secretary of State to provide vision and leadership for the NHS, even in such difficult times.

Thalidomide Trust (Grant)

Richard Fuller Excerpts

Thursday 20th December 2012 Commons Chamber

[Richard Fuller (Bedford) (Con)]

I join other right hon. and hon. Members in praising the dedicated, intelligent and sensitive leadership of the Thalidomide Trust over many years. The news from the Minister will be welcomed by thalidomide survivors throughout the UK, including in my constituency by a friend of mine and his wonderful family. The issue for many thalidomide survivors is the pursuit of an independent everyday life. Will the Minister advise me and the House why the decision was made to have a 10-year grant rather than a lifetime grant, which would have eliminated all uncertainty? I am very interested in the Minister’s comments on that.

[Norman Lamb]

We had a genuine judgment to make. On the one hand, I wanted to provide a good deal of certainty for a lengthy period, but this is a unique group of people. Their health is deteriorating, but we do not yet know what the prognosis is for the rest of their lives. It therefore might have been dangerous to allocate a sum of money for the rest of their lives. For all we know, their needs may grow considerably. It is therefore right to take stock in 10 years’ time and make a judgment on their needs at that stage.

Adult Social Care

Richard Fuller Excerpts

Monday 16th July 2012 Commons Chamber

[Liz Kendall]

I was stating the facts about the care crisis, which have been made clear not by me but by organisations representing older and disabled people, by local councils and by the NHS. It is the Government’s denial of the existence of the care crisis and their insistence that there is enough money in the system that I am seeking to correct.

As I have said, the Government have failed to recognise, let alone tackle, the care crisis, and they have failed to face up to the difficult decisions that we need for the future. Their progress report on funding merely says that the Government support the principles of Andrew Dilnot’s commission on the funding of long-term care and support. They now claim that it is only right for Dilnot’s proposals to be considered as part of the spending review. That was not their view two years ago, when they made a clear promise in their NHS White Paper to legislate on a new legal and financial framework in the current parliamentary Session. Now we have only a draft Bill to reform social care law alone. At best that means that there will be no change in funding before the next general election, and at worst it means no change at all if the Government return to power.

[Richard Fuller (Bedford) (Con)]

Will the hon. Lady give way?

[Liz Kendall]

I want to make a little more progress.

According to yesterday’s edition of The Sunday Telegraph, Andrew Dilnot has said that the delay has left older and disabled people in fear and misery. He expressed serious concern about the possibility that the Government will set the cap at a far higher level than that proposed by his commission—at £75,000 or even £100,000 rather than £35,000. He also said:

“if you go beyond £50,000 it is less effective in giving reassurance to the population and ceases to be a way of helping people with lower levels of assets.”

Instead of making real progress on funding reform, the Government trumpeted proposals for a national deferred payment scheme, providing loans to cover the costs of residential care.

[Liz Kendall]

It was Labour Members who proposed cross-party talks, and it was Government Members who decided unilaterally to publish the progress report on which we had been trying hard to agree. The hon. Lady accuses Opposition Members of not being serious about funding reform. We are, and I will set out what we would like to happen so that those talks can proceed.

The deferred payment schemes that were announced last week already exist in some parts of the country and are currently interest-free, but according to the Government’s plans interest will be charged, which will make loans more expensive than they are now. Many councils remain utterly unclear about how they will find the money to pay for those schemes. As the Local Government Association says,

“Councils are not banks and the implication of this level of debt in an already overstretched system needs urgent attention.”

The truth is that the Government have so far ducked the care challenge, and the reasons for that are clear. First, owing to their disastrous economic policy, they are now borrowing £150 billion more than they originally planned to borrow. The Treasury has pulled the plug, and has kicked long-term care funding into the long grass.

[Richard Fuller]

I thank the hon. Lady for giving way. As she recognises, cross-party consensus is required if we are to solve the social care problem. Care workers—the people who actually provide the care to people—do not get sufficient attention, however. One of the problems they have suffered from over many years is per-minute billing. Does she recognise that our changes to get rid of per-minute billing are worth while, and what impact does she envisage that will have on the provision of care over the long term?

[Liz Kendall]

The hon. Gentleman raises a serious point. I know from shadowing care home assistants in my constituency that commissioning by the minute can cause considerable problems. For instance, it does not allow the staff to meet the individual needs of those who are most desperate for help and support. As I have said, we welcome many of the proposals in the White Paper, but they need to be properly funded, and that is why I am so concerned that the issue of long-term care funding has been kicked into the long grass.

The second reason why the Government have failed on this issue is that the Health Secretary’s obsession with reorganising the NHS has been a disastrous distraction. Two years have been wasted on an unwanted and unnecessary reorganisation, when everyone should have been relentlessly focused on the key challenge of our ageing population: meeting rising demand for care at a time of unprecedented financial pressure.

The third reason is the most fundamental of all. Many Conservative Members have still not grasped the basic principle that we must collectively and universally pool the risks of facing catastrophic care costs, as we do in the NHS, in order to make things better and fairer for us all. A voluntary system that leaves it up to individuals and their families alone will not work. The only way forward is through an effective partnership between individuals and the state.

--- Later in debate ---

[Paul Burstow]

When there is a crude race to the bottom and contracting is by the minute simply to ration access to the service, resulting in a care home provider or home care provider delivering care on a very time-and-task oriented basis, that is totally unacceptable. We know that in places such as Wiltshire, where home care services are organised on an outcomes basis, that is delivering better results for the service users and releasing resources to reinvest in services.

[Richard Fuller]

When I intervened earlier, Mr Deputy Speaker, I forgot to refer hon. Members to my entry in the Register of Members’ Financial Interests as the director of two care companies.

The Minister is absolutely right to say that there is a patchwork of responses from local authorities. I absolutely welcome the end of per minute billing, which is a tremendous step forward, but I draw the Minister’s attention to the comments made by the hon. Member for Stretford and Urmston (Kate Green). She talked about the pressures of meeting the minimum wage and the pressures that local councils are putting providers through. The Government must consider that issue, because there is exploitation in some areas. As businesses and charities try to meet the requirements local councils are putting on them, workers are finding it difficult to achieve a sustainable wage in providing care services.

[Paul Burstow]

My hon. Friend is absolutely right to highlight that issue, which the Low Pay Commission has commented on over a number of years, including before this Government came into office. In our White Paper, we make it very clear that local authorities, as the commissioners of such services, must be mindful of their responsibilities in ensuring that the resources they provide to providers are sufficient to allow them to fulfil their legal obligations.

Contaminated Blood and Blood Products

Richard Fuller Excerpts

Thursday 14th October 2010 Commons Chamber

[Richard Fuller (Bedford) (Con)]

Thank you for allowing me to speak for a couple of minutes, Mr Deputy Speaker. The actions at the root of this debate take us back many years. For many of us—including me—they take us back to a period that stirs great emotions. It was a period when an illness was ignored, when people’s deaths and suffering were marked by stigma, when Governments were in disarray and, too often, in denial and when life-changing mistakes were being made.

Everyone in this House commends the campaigners on this issue for their vigilance and persistence over the years. The debate relates to a judgment between principle and practicality in the operation of our Government, but also to individual lives, such as that of a family that lives in Kempston in my constituency. The issue of principle appears to be accepted and clear to all sides: a group of our own citizens, who had already suffered greatly, have been denied justice for many—too many—years. It is the responsibility of all hon. Members to challenge the Government to bring that period of injustice to a close. If December it is, Minister, then December it must be.

The main practical argument concerns cost, which is wrapped in the real pressures of affordability given the current pressures on the public purse. The written ministerial statement contains welcome indications for those affected by hepatitis, but I urge the Minister to consider the point made by my hon. Friend the Member for Blackpool North and Cleveleys (Paul Maynard) in clearing up other anomalies.

My constituent, Lisa, wrote to me urging me to attend this debate. She stated:

“We must trust in the democratic process to enable us to bring about change”.

It is my honour to represent her today. She wrote movingly about how she lost her husband when he was just 32—her son was just two years old at the time; about the pain as his body struggled in his failing battle with HIV and hepatitis; about the consequential financial pressures of losing her home; and about the sadness of a family life denied but which lives on in her heart and that of her son.

Lord Winston described the issue of contaminated blood as “a disaster”, which is surely the right description. Yesterday, we witnessed on our television screens another country come together to overcome the consequences of another disaster and painstakingly rescue 33 heroes who had suffered entrapment below ground and return them to their loved ones. Too many of the heroes who have fought for justice cannot be here today and cannot be returned to their loved ones. However, many of them are here, and many of the loved ones of those affected by this disaster are present, too.

It is time for the Government to show their mettle and demonstrate their principles, if not their culpability. I wait with anticipation to hear the Minister’s reply and place my trust and that of my constituents in her resolve.

[Mr Deputy Speaker (Mr Lindsay Hoyle)]

I shall move on to the Front-Bench speakers. I have the pleasure of calling Diane Abbott. It has taken since 1987 for her to reach the Front Bench, which is a long time, so we look forward to this experience.