My Lords, I refer the House to my membership of the GMC council. I was privileged to lead a debate 25 years ago in your Lordships’ House to celebrate the 50th anniversary of the NHS. My noble friends Lord Brooke and Lady Pitkeathley spoke in that debate, and I am delighted that they are speaking today—they are great survivors.
In 1997, the Labour Government inherited an NHS in crisis, with low morale and long waiting times. I was privileged as a Minister to contribute to a complete revival of the service’s fortunes. I pay tribute to my colleagues, to the right reverend Prelate the Bishop of London, who played a pivotal role as Chief Nursing Officer, and to my noble friend Lord Prentis, who took up the post of general secretary of UNISON at a very important time in the turnaround in the service’s fortunes.
The NHS plan of 2000 was a programme of huge vision: 100 new hospitals built; major investment in the workforce and an agenda for change; new services such as NHS Direct and walk-in centres; maximum 18-week waits for elective treatments; maximum four-hour waits for A&E; patients were actually able to see their GP. In 2010, the British Social Attitudes survey showed satisfaction with the NHS at over 70%, the highest rate it has ever recorded. Today, satisfaction has plummeted to 29%—the lowest figure ever recorded. The main reasons for this dramatic drop are waiting times for GPs and hospitals, staff shortages and lack of government spending.
How did the coalition and then the Conservative Governments throw away such a brilliant inheritance? The evidence is very clear: austerity was to blame, based on a small-state ideology and introduced just as the economy was recovering to a 2.2% growth rate in 2010. Growth was killed off by the coalition Government, who devastated public investment. The huge social cost of this self-imposed harm is plain to see. By 2020, poverty in working families had reached a record high. Life expectancy increases stalled for the first time in this country in 100 years. In 1952, the UK had the seventh-highest life expectancy at birth in the world. OECD data shows that, by 2020, it had fallen to 36th.
Austerity targeted local government the worst. It had a huge impact on adult social care and, today, has left half a million people waiting just for an assessment, let alone any support. We now have the prospect of the Home Office wanting to restrict care workers coming from abroad by increasing the salary requirement and restricting dependants. The obvious solution—to pay care staff more—is not viable because, as Juliet Samuel wrote in the Timesthis morning, the same Government are the care sector’s main customer and will not pay up. You could not make it up.
The NHS has been through the longest financial squeeze in its history. Its annual growth from 1948 to 2019-20 was 3.6%, but under the coalition Government dropped to a miserly 1.1%. Any increased funding that came post Covid has been eroded in real terms due to high inflation, resulting in a very stretched NHS. It is no wonder waiting lists are now a record 7.8 million people. In 2022-23, only 56% of those attending A&E were admitted, transferred or discharged within four hours, compared to 98% in 2010.
My Lords, following the splendid introductory speech by the noble Lord, Lord Hunt, which ended with a quotation from Nye Bevan, I will make a little historical contribution to this important debate, if I may. Other speakers will be dealing with the present and looking forward to the future; I hope a historian may be forgiven for looking back to the origins of the NHS, the 75th anniversary of which we are celebrating.
Cinemagoers in the 1940s learned much about public affairs from the widely admired Pathé News, which was shown before the main film. In March 1944, audiences who saw that month’s Pathé News heard the following words from the Minister of Health about the formation of a National Health Service:
“Whatever your income, if you want to use this service—nobody is going to try to make you unless you want to—there will be no charge for treatment. The National Health Service will include family doctors who you choose for yourselves and who will attend you in your own homes when this is necessary”.
The clipped, kindly, authoritative voice continued:
“It will cover any medicines you may need, specialist advice and, of course, hospital treatment, whatever the illness, special care for mothers and children and a lot of other things besides. In fact, every kind of advice and treatment you may need … We are out to improve the health of every family and the whole nation. If we cut out the money worries which illness brings, then there would be no reason to put off getting advice and treatment”.
That is how the nation heard that it could look forward to the provision of comprehensive health services, free at the point of use, from which it was to benefit so profoundly in the years that lay ahead.
The voice from which it heard about these radical reform plans was that of Sir Henry Willink, the Conservative Health Minister in Churchill’s wartime coalition. It fell to Willink to work out how to achieve this promised transformation of healthcare in Britain. He set about the task in a spirit of consensus, telling Pathé News viewers:
My Lords, I congratulate the noble Lord, Lord Hunt of Kings Heath, on his excellent introductory speech. He hit all the nails very firmly on the head.
As the NHS reaches its 75th year, it is a very different and much larger beast than when it started out. The challenges are not just greater but different. On the upside, to a great extent we have conquered infectious diseases through vaccination and sanitation. Because of the success of medical science, our population is ageing, leading to greater demand for healthcare. On the other hand, we have a high level of health inequality and poverty, and a food system that does not provide a healthy diet for many people. Preventable diseases are now the greatest cause of illness and death. In 1948, people walked everywhere; many did manual labour, so obesity was rare; they ate seasonally and cooked their meals at home, and ultra-processed foods did not exist. But the air was not necessarily cleaner, because we burned coal to heat our homes. Today, we lead a very different life.
So, post-Covid, the NHS has five major challenges. There is the state of social care, causing too many people to enter hospital and stay there for too long. Linked to that, there is a crisis in ambulance service response times and A&E waiting times, causing excess deaths and harm. Many diseases, including cancer, are being diagnosed far later than they could be, leading to poor outcomes. Long waiting lists for urgent and elective care are leading to damage to the economy as people cannot work while they wait. There is too little preventive work to help people lead healthier lives.
The Government’s response is a focus on increasing the front-line workforce while ignoring the poor communication and system planning in the service. While we certainly need to train and retain more health professionals, especially in deprived areas, they are not the only people the workforce plan should be focusing on. We need system planners and communications experts. The money available for the NHS to tackle these problems is not infinite, which means we need greater productivity.
My Lords, I congratulate my noble friend Lord Hunt on securing this debate and on outlining not just current problems but potential ways forward, which is what we should be concentrating on. This is an important debate, because few issues are more significant for us as individuals and indeed as society. Our individual and collective health and well-being very much depend upon a robust NHS. The figures my noble friend gave, including the 7.8 million on the waiting list, showed very clearly that we do not have that today, I am afraid.
Time is always limited in these debates, and there are certainly many aspects of the current state of the NHS that warrant mentioning—alas, far too many to mention. However, unusually, I want to start by mentioning some of the briefings we have probably all received in the last few days since this debate was announced. I was particularly struck by the briefing paper from the Association of Directors of Adult Social Services. It highlighted that in August, more than 470,000 people were waiting for a care and support assessment to begin, up 8% on March of this year. It highlighted the almost universal view that increased pressures on the NHS will put even more pressure on adult social care—a significant and growing problem.
We also had an interesting paper from a well-known opticians, pointing out that greater use of the glaucoma referral system, with optometrists working with the NHS, can significantly benefit patients and the whole of the NHS service; a similar situation arises with audiology services. The Royal College of Psychiatrists told us in its detailed paper about the contribution that early support hubs can make. The Bowel Cancer UK group gave us striking figures that nine in 10 people will survive bowel cancer if diagnosed early, but only four out of 10 are actually being diagnosed early. The most significant point about all these examples is that they highlight issues that are not simply about asking for more funds. They are pointing out and giving examples of how early invention can not only benefit patients and individuals but reduce long-term costs.
My Lords, I too thank my noble friend Lord Hunt for introducing this debate in his typically tub-thumping and inspiring manner.
I owe my life to the NHS—quite literally. Without the NHS’s resources and the commitment and skill of those who work in it, I would not be standing here making yet another speech on health in your Lordships’ House to join the many I have made since I became a Member at same time as my noble friend. It is no exaggeration to say that it causes me emotional distress to hear the phrases that people are now using about our beloved NHS—“The NHS is not what it was”, or, “You can’t rely on the NHS now”—or to see friends in my village spending their life savings on paying for surgery in the private sector because they are no longer able to tolerate the pain in their knee, or cope with being off work for a year or even two because they cannot get their hip done. That is what 7 million on the waiting list means.
I will not repeat what other noble Lords have said about the length of the waiting lists. They must be fixed, but we cannot fix them without fixing what causes them. Is it any wonder that you have to wait at the front door of the hospital when you have a traffic jam at the back? The NHS and social care are inextricably bound together—how many times have we said that in your Lordships’ House—yet we are no nearer to solving the problem than we were 25 years ago. In fact, it has only got worse. As we know, people are living longer with more comorbidities. We should rejoice in that because it is an NHS success story, but, as we know, local authority budgets, which have been so constricted for so many years, are unable to provide the services we need. The problems in social care are just the same as they have always been: not enough money, too little integration and fragmented services. That is what a previous Prime Minister promised to fix. As my noble friend said, “That went well, didn’t it?”
My Lords, I welcome the opportunity to have this debate and thank the noble Lord, Lord Hunt, for having secured it. We are so very lucky to live in a country that has a health service, and we should celebrate the NHS on its 75th anniversary. I pay great tribute to the many dedicated doctors, nurses and health professionals who have worked in the NHS over the past 75 years, many of whom really are true heroes.
However, we are having this debate at a difficult time, as we have heard, with the NHS facing unprecedented challenges and the fallout of the pandemic still significantly impacting the system. There is also, perhaps, a generational change of attitude. I do not think we have ever before had doctors and nurses going on strike. On top of that, a number of very difficult situations have come to light, with maternity scandals, as we have heard, in hospitals such as Shrewsbury and Telford, Nottingham, Mid and South Essex, Morecambe Bay and East Kent—to name some of them—revealing huge failings in safety, as well as the realisation that hundreds of avoidable deaths occur in our hospitals. No longer can we say that the UK has the best survival rates for many cancers. All this paints a picture that the NHS is somewhat in crisis. As we have heard, a recent IPSOS survey noted that public satisfaction with the running of the NHS as a whole is at its lowest level for 25 years.
Time is short in this debate and it is such a huge subject, so I thought I would concentrate my remarks on the GP system and primary care. We had the most wonderful system, but since the early 2000s this too seems to have dramatically declined, starting with the change to the GP contracts. The British Social Attitudes survey found that the proportion of patients who were satisfied with GP services, in particular, has plummeted from 68% to 38% since 2019, with people often struggling to get the care that they need. Anecdotally, we consistently hear about the crisis of patients not being able to access their doctors. Many GP practices have taken on the system of triaging patients, but if you are really feeling unwell, you do not feel like fighting with the receptionist to see a doctor—the result being that people give up and go straight to A&E, which naturally has a knock-on effect on waiting times there and on the ambulance service, which cannot discharge its patients.
My Lords, 2023 is the year we celebrate 75 years of our National Health Service, and what is crystal clear, above anything, is the continuing strength of people’s attachment to our NHS. The vast majority of people—nine out of 10—believe that the NHS should remain free at the point of delivery, while eight out of 10 continue to believe that the NHS should be funded through taxation. This support extends across all political parties, across leave and remain voters, and across all age groups—and for me, personally. Twenty years ago, like millions before and after me, our NHS saved my life, and for that I will always be grateful. The health service is still there for all of us, 75 years on, from cradle to grave.
How did it come to be that the waiting list for treatment will exceed 8 million by December 2024? How did it come to be that the number of patients waiting for treatment and suffering real harm could double in three years to 7,900? We need to look no further than the recent OECD Health at a Glance 2023 report, whose international comparisons showed that the UK has among the lowest average growth in per capita health expenditure. We need look no further than the Care Quality Commission’s own works warning of the dangers of longer waits and reduced access, especially in maternity, ambulance and mental health, as already referred to.
We need look no further than this House’s own investigation earlier this year. The report was called Emergency Healthcare: a National Emergency. Emergency healthcare is facing a crisis. To quote from our report:
“Patients are delayed at every stage of trying to access emergency healthcare … Stories of ambulances being stuck outside of hospitals”,
which is “posing an unacceptable risk”. The impact on the workforce, according to the same report, is that there are
My Lords, I am grateful to my noble friend Lord Hunt of Kings Heath for his—as expected—truly amazing speech. He is a man with great experience of the health service, both before he came into this House and, in particular, while he was serving here as a Minister. He is a man of great value; he is one of the few politicians around who resigned on principle on an issue. He resigned over Iraq. I was one of those who was on the wrong side and I admire him greatly for the work he has done and what he continues to do.
As he mentioned—as did the Baroness, Lady Pitkeathley—I also spoke on this way back in 2003. I also spoke in 2018, when we were celebrating 70 years. What particularly interested me then was that the standing of the NHS in the eyes of the public was very high. I thought it was a great opportunity for us to try to take this jewel. The NHS is something which binds us together. As the previous speaker just said, it is important that we go back to that and find ways in which the public attitude, as it presently stands, is reversed.
I suggested in 2018 that we ought to think about creating a national charity for people to participate in and leave gifts in their wills to, and so on. The Government said no, because some trusts already have their charities and that would undermine them. Well, some trusts do have them and they are very successful, but, if you examine it, you will find that the ones getting great amounts of money are in wealthy areas. In the dispossessed areas, where we have the worst health and growing rates of ill health, you will find that charities either do not exist or, if they do, not much money is going in. I would be prepared to put something in my will—not for Chelsea and Westminster, which I am close to, but for the NHS. The money would then be redirected to the areas of poverty where we need to be making the greatest changes.
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What has the Government’s response been to all this? First, we had the costly disaster of the Health and Social Care Act 2102, which enforced a wasteful market on all clinical services, disrupted collaboration and the integration of services, and cost millions of pounds. Earlier this week, the Minister was here bringing in a regulation to get rid of the whole wretched thing. We also had a former Prime Minister’s pledge on 40 new hospitals, which was exposed as a deceit early on. Even the current Prime Minister some time ago, in one of his many pledges, promised to cut NHS waiting lists, but that has been downgraded because NHS leaders have been told to prioritise controlling costs. Up and down the country, the NHS is stopping schemes to cut waiting times because it cannot get the funds; for instance, for new equipment to increase productivity.
The NHS has faced two major periods of crisis in its history. The first was in the early 1990s and the second is now. The common cause is a long period of Conservative government. We fixed it last time and we can do it again, but it will be tough. As Paul Johnson from the IFS commented after the Autumn Statement,
“a combination of high spending on debt interest, low growth, and the demands of an ageing population mean that there is little scope to increase spending on hard-pressed public services … growth is the only way out of this”.
But this Government’s dismal performance offers little hope of that. Interest rates are set to remain high according to the Governor of the Bank of England who, two days ago, said that the UK economy’s potential to grow is
“lower than it has been in much of my working life”.
How do we go forward from here? We need a Government who will drive through a huge modernisation programme. Inescapably, funding will have to keep pace with demography and technical advances, but we also clearly need to get the most out of every pound we spend.
Data from the Office for National Statistics reveals that more working-age people are self-reporting long-term health conditions, with 36% saying that they have at least one. The case for investing health resources to get those people back to work is convincing and ought to appeal to the Treasury. Wes Streeting has suggested that we also need cultural change which gives local services much greater freedom to reform and to try new and different ways of providing healthcare while embracing the latest technology. This is really important: productivity will not be improved by beating a big stick so, please, we do not need any restructuring, crony contracts, wasted payments on management consultants, rip-off outsourcing or agency bills—all characteristic of the current Government’s approach.
The NHS needs to plan with multiyear revenue settlements, and it needs investment in capital. We are years behind other countries in investing in capital. The result, as the NHS Confederation reported this week, is a less productive service, still hampered by
“Victorian estates, too few diagnostic machines and outdated IT systems”.
We need system reform. Primary care is overstretched, with too many patients ending up inappropriately in A&E. Planned treatments get cancelled as a result. Patients’ conditions deteriorate and hospitals then find it difficult to discharge them, owing to pressures on adult social and community care. Add in mental health demands and it is no wonder the system is falling over, but we need a whole-system solution to deal with that problem.
Ministers are fond of talking about integration but, for patients, the experience of seamless care between primary, secondary, tertiary and social care is a distant dream. We also need to take advantage of our fantastic science base, and our pharma and medical technology sectors. The problem is that investment in R&D and clinical trials has dipped. We must get that back and ensure that the NHS adopts the innovations being made in this country to get the advantage to patients and improve productivity. This is key to what we have to do in the future.
Our workforce is all important. The Institute for Government was absolutely right in arguing that an improved approach to setting pay, workforce planning and enhancing working conditions would help to reset the relationship with our staff and start to resolve recruitment and retention problems. We will have to pay particular attention to the lowest-paid staff and try to align social care staff more to NHS terms and conditions.
We know that there is a huge demand for healthcare professionals globally. It is very unlikely that countries’ demands will totally be met, so we have to look at the smart use of AI and technology to liberate clinicians from the clunky and frustrating IT systems found littered across the NHS.
We need a stronger preventative process to reduce health inequalities and improve life expectancy. We need social care to be given a fundamental boost. Do your Lordships remember that Prime Minister Johnson promised to fix social care? That went well. As a minimum, every vulnerable person should expect an assessment and some form of care and support. In the long term, we have to end the lottery of care which leaves many people who are above the means-tested level none the less struggling hugely to pay care home fees.
Primary care also needs a reset. I commend Sir John Oldham who, under the last Labour Government, did fantastic work in helping GPs to improve their effectiveness. Primary care has to become a place again where GPs want to work and where if patients want direct access to their GP, they can get it.
There must be no delay in bringing legislation to reform the Mental Health Act 1983. The failure of the Government to bring the Bill before us because it is not a measure that would show a gap between them and us is deplorable. That Bill has consensus support and was produced by an expert. We know the way forward, but it has been delayed yet again. I commend a report, A Mentally Healthier Nation, which was recently signed by dozens of organisations with an interest in mental health. It sets out a fantastic programme for better prevention, quality and support.
Finally, I will mention the people who I represented for a lot of my earlier life, when I did proper jobs—NHS managers and leaders. If we are serious about an improvement agenda, can we stop disparaging those people? Can we stop false economies by restricting the number we invest in and start to invest properly in their training, support and development? Amanda Pritchard, the chief executive of NHS England, gave evidence to the Health and Social Care Select Committee only a couple of weeks ago in which she talked about the patchiness of giving those crucial people the kind of support they need to do the jobs that need to be done.
I am grateful to so many noble Lords for taking part in our debate. I am convinced that, with drive and determination, we can turn the NHS around. Wes Streeting has described his reform programme as having three aims: hospital to community, analogue to digital, and sickness to prevention. They sound about right to me. Despite the Government’s dismal record, austerity funding and attacks from the right, the NHS’s founding principles—being comprehensive, free at the point of use and tax-funded—remain in place.
In ending, I think it is appropriate to give the last word to Nye Bevan, founder of the NHS. He said:
“The NHS will last as long as there’s folk with faith left to fight for it”.
There are plenty of people prepared to do that. I beg to move.
“It is not a cut and dried scheme. These proposals are for discussion in Parliament, and we want them talked about by everyone concerned, and you, everyone in this audience, are very much concerned”.
The nearer the scheme came to fruition, the more concerned the British Medical Association grew about the effect it would have on their members’ private practice. Willink made a number of concessions to the BMA, agreeing that doctors would not, as had originally been envisaged, be grouped as salaried employees into health centres under local authority control. This concession had far-reaching results, which the Labour Party had to accept when it found itself in charge of the legislation that created the NHS after 1945.
Today, Sir Henry Willink is almost entirely forgotten, his contribution to building our National Health Service unsung. Willink was a calm, modest, intellectual figure, later master of a Cambridge college, who had no taste for rough party politics, totally unlike the brilliant, flamboyant, combative Nye Bevan, who denounced the Tories as “lower than vermin” when the NHS was officially launched in July 1948. By the way, younger elements in the Conservative Party responded by forming Vermin Clubs, with little membership badges featuring ugly creatures. Miss Margaret Roberts, later Mrs Margaret Thatcher, had quite a collection of these badges.
Since Bevan carried the legislation through Parliament, it would be absurd to question his central role. But neither he nor the Labour Party deserve to monopolise the credit for the building of the NHS. Bevan’s biographer, Dr John Campbell, refers to
“the long and cumulative process by which the Service came into existence in 1948 … There can be no doubt that some form of National Health Service would have come into being after 1945 whoever had won the General Election”.
The Tories, who made a firm commitment to finish Willink’s work in their 1945 manifesto, made a cardinal political error as Bevan’s great NHS Bill was going through the Commons: Willink moved a hostile amendment, opposing the nationalisation of all hospitals, voluntary and municipal. This enabled Labour, in the rough and tumble of party politics, to portray the Conservatives as opposed in principle to the NHS, which was of course totally untrue.
Perhaps on the 75th anniversary of the NHS this year, it might be appropriate to remember Henry Willink as well as Nye Bevan. Willink stood for consensus; Bevan for conflict. Could it be that, over the last 75 years, the NHS would have benefited from a little more of Willink’s consensus and a little less of Bevan’s party strife? Would progress have been easier to achieve if politicians of all parties had worked together, in full partnership with health professionals, in that spirit of national unity, embodied in Churchill’s wartime coalition, from which our NHS emanates?
I will make just one point about the provision of health services today. I do so with sadness, disappointment and a little anger. In the debate on the King’s Speech, alongside the noble Baroness, Lady Donaghy, I drew the attention of the House to the compelling case that the Royal Osteoporosis Society, supported by parliamentarians of all parties, had made for government funding of fracture liaison services. A commitment appeared to have been given in this House in a ministerial reply to a debate on these services in September. It contained the following words:
“We are proposing to announce, in the forthcoming Autumn Statement, a package of prioritised measures to expand the provision of fracture liaison services and improve their current quality”.—[Official Report, 14/9/23; col. GC 241.]
The Autumn Statement last week contained no such announcement. Commenting on the U-turn, my noble friend Lord Black of Brentwood, who introduced September’s debate but cannot be in his place today, deplored the Government’s unwillingness to make what is, in reality, a tiny investment of some £27 million per annum in fracture liaison services. This callous decision will blight the lives of tens of thousands of people with pain and disability and put many people at risk of premature death. This was a deplorable position indeed in the year of the 75th anniversary of our NHS.
Nobel laureate Paul Krugman said:
“Productivity isn’t everything, but in the long run, it is almost everything”.
A crude definition of productivity is the ratio of inputs to outputs. Some think this is all about individuals working harder, but NHS staff are all already working extremely hard. It is not about working harder but working smarter. It is about improving outcomes. It is also not just about national initiatives. There is bound to be poor buy-in for national initiatives when staff on the ground often have a better idea of what could be done better. That is not to say there is no room for national initiatives, but they do not need to be designed by McKinsey.
There are problems with measuring real productivity in the NHS: how to adjust for the mix and quality of outputs and recognising the difference between outputs and outcomes. The NHS produces a wide variety of outputs. GP appointments are not the same as hip replacements, but the service has quite sophisticated statistical ways of dealing with this. It is harder to adjust for quality. Doing two knee replacements rather than one looks productive, but not if the second was needed only because the first was botched; and especially, as in the case of a lady I know, if the patient has to see the consultant three times before he will accept that there is something wrong. Then we must ask, is the outcome better as a result of the NHS having done something? The lesson here is that it is productive to listen to patients. Unfortunately, the NHS has cut back on patient-reported outcome measures, which are a valuable way to assess outcomes. My first question to the Minister is: are there plans to reinstate or replace PROMs?
A recent internal paper about productivity said that NHSE is
“very good at generating ideas”
for efficiency initiatives but does not have clear processes to evaluate them. It added:
“The overall volume of initiatives means it is very likely that the system is overwhelmed, which means that initiatives are not as effective as they could be. Moreover, a lot of the initiatives we are taking forward lack the buy-in from front-line staff that is needed to make changes stick”.
The system and infrastructures that support waiting list management include IT and tools for proactive patient tracking, as well as the processes that staff follow to efficiently and accurately co-ordinate pathways for patients on waiting lists. Millions of hours of clinicians’ time are wasted due to inadequate IT systems. A recent BMA report found that four in five doctors believe that improving IT infrastructure and digital technology would help to tackle backlogs. Can the Minister therefore say whether systems analysts and IT and AI specialists are included in the workforce plan, as well as medical professionals? We did not just win the Battle of Britain using pilots.
Sadly, there are too many examples of the skills of our health professionals being wasted because of inefficient systems planning and poor communications. A recent example concerns former BBC journalist Rory Cellan-Jones, who suffered a broken elbow and facial bruising following a fall. He spent two unnecessary days in hospital and calculated that 90% of the staff time spent on his case could have been avoided with better planning and communications. It was eight days after his accident before he received appropriate treatment. It was not just a question of communication between staff, but communication with him. He says in his blog:
“Getting information about one’s treatment seems like an obstacle race where the system is always one step ahead. … But communication between medical staff within and between hospitals also appears hopelessly inadequate, with the gulf between doctors and nurses particularly acute. I also sense that, in some cases, new computer systems are slowing not speeding information through the system. On Saturday morning, as we waited in the surgical assessment unit, four nurses gathered around a computer screen while a fifth explained … all the steps needed to check-in a patient and get them into a bed. It took about 20 minutes and appeared to be akin to mastering some complex video game”.
It also took four hours to get the paperwork for his discharge.
My Lords, I have experienced a similar situation and it grieves me to see our skilled professionals not being used in the most cost-effective way. What are the Government planning to do about this?
All of those examples and that theme link up with what we were told by Universities UK, which has outlined the problems we are seeing with applications from students for positions in critical areas of nursing and the whole range of medical specialties. Even if we did get the increase in the number of students, we are also short of clinical academics and people to do the teaching to get the placements they need in our hospitals. This area is particularly critical to the way forward. Although the Government sometimes boast about increasing student numbers, there is still a very long way to go before we recover from the cuts made from 2010. That is one of the reasons why we are in such a serious situation.
I want also to mention one other issue that particularly alarms me. In October, just a month ago, the Care Quality Commission rated 65% of maternity services in England as inadequate or requiring improvement. Its report says, having inspected 73% of all maternity units:
“The overarching picture is one of a service and staff under huge pressure”.
Despite the efforts of staff, who are often praised because of their efforts by people on the receiving end, many women are still not receiving the safe, high-quality care they deserve. The CQC went on to say that this was particularly a problem for ethnic-minority women, for whom the service was particularly poor. Its overall assessment was that we have a deteriorating position in maternity services. All of us who have children know that the moment a child is born is one of the most important times of your life. It really is alarming that, in 2023, 75 years after the establishment of the health service, which was partly formed to improve maternity services, we have that situation.
I must just mention a related issue from my local area. Last week, it was reported that no babies have been born in Kirklees for around 18 months. Kirklees is one of the largest metropolitan council areas, covering Huddersfield, Dewsbury, Batley and lots of other smaller towns, yet there are no facilities for childbirth there. The units in Huddersfield and Dewsbury have been closed. Just imagine being a pregnant woman going into childbirth and having to travel potentially for an hour in those circumstances. The reason given is staffing issues. There are plans for the future, but in some cases it will take nearly two years before that service becomes available.
I have the figures for the increasing number of doctors, midwives and consultants under a Labour Government, but I end by echoing what my noble friend said: we fixed it last time; we are going to have to fix it again.
I know that the Minister, when he comes to reply, will give us statistics on how much more money this Government have put in, but it is spent on the wrong thing: on hospitals instead of primary, community and social care, which are the services that keep people out of hospital. As the Association of Directors of Adult Social Services reminded us:
“National policy and investment has predominantly focused on addressing issues relating to discharge from hospital”—
there we go with hospitals dominating again. Consequently, people are sicker and have a higher level of need, so more resources are needed. ADASS says that we can fix this system only
“by shifting policy and investment towards early intervention and prevention”.
Hurrah for that, but preventive work—the stuff that keeps people out of hospital—is always the Cinderella when money is being dished out because it is long-term policy.
I have just had the privilege of chairing a special inquiry into integration between community and primary care services. Our report will be published shortly, and I hope it will not only give a useful insight into what the problems are due to a lack of integration are but draw conclusions about how they could be addressed.
Our focus on hospitals as the embodiment of the NHS blinds us to the other services, which are much more important to the patient and much more effective in sorting out the waiting list problem. Primary and community care services are what most people have contact with in the NHS. If we are really serious about improving NHS performance, then that should be our focus. Your community physiotherapist can prevent the need for a knee replacement, and your community occupational therapist can prevent the fall that results in hospital admission. I hope the Minister will assure the House that the Government understand the great importance of prevention in tackling any problems in the NHS.
I will mention two more elements in the NHS that we ignore at our peril when it comes to performance. The first is the voluntary and community sector, which provides so many services that contribute to good health, both mental and physical: the plethora of disease-specific organisations, support groups and information services, which are vital and make such an important contribution in healthcare, as we saw during the pandemic, that are now under threat because of a lack of funding from local authorities and pressure on their volunteers. Only one-third of directors of adult social services were able to invest in community and voluntary services.
Secondly, your Lordships would expect me to flag up the vital contribution of families to health care—those millions of unpaid carers. I quote from the State of Caring 2023 report from Carers UK on carers’ health and well-being. The report shows that
“carers’ mental and physical health is getting worse, and for some it’s at rock bottom”.
It says that
“42% of carers said they needed more support from the NHS or healthcare professionals, and …better recognition from the NHS of their needs as a carer”.
The report also says:
“35% of carers said they were waiting for specialist treatment or assessment, either for themselves or the person they care for”,
and that they were therefore worried about their ability to go on providing that vital amount of care. One carer, talking about the challenges with their mental health, said:
“I know I could ask for counselling, which I’ve had several times over the years through my GP and other organisations. But the waiting lists are very long”—
too long for me.
The Government’s vision should be that we have an NHS which is the most carer-friendly health service in the world, both for the unpaid carers and for the one in three staff who work in the NHS and are juggling caring responsibilities themselves. I hope that when the Minister replies, he will reiterate the Government’s commitment to having a clear and deliverable strategic approach to improving carers’ health and well-being, and the structures which enable carers to get the support that they so much need.
It is clear that GPs too are feeling under pressure. A report published by the Health Foundation charity paints a picture of high stress and low satisfaction with workload. Just one in four UK GPs are satisfied with the time they are able to spend with their patients and appointment times are among the shortest of 11 countries surveyed. I gather that the average doctor now has to deal with 41 to 50 patients a day. When asked, GPs feel that the right number is somewhere around 30, maximum, and this situation is leading to burnout. Only one in four GPs in England is now working full time; most work three days or fewer each week. A third of GPs are considering leaving within five years, with the Royal College of GPs claiming that it is “no longer feasible” to be just a GP, despite an average salary of over £100,000 a year.
Many doctors now do not know their patients. Talking to older GPs, I learned that the job satisfaction came from knowing whole families and caring for them throughout their lives. While not knowing your doctor may not be a problem for the young and healthy, if those with small children or the elderly know their GP that makes it much easier for the GP to treat them, without having to read through all their notes each time, thus cutting their time down. I have cited in previous debates the Norwegian study published in the British Journal of General Practice, which clearly demonstrated the benefits and stated that it can be lifesaving to be treated by a doctor who knows you.
Yet in the UK, GP practices are becoming bigger and the relationship between doctors and patients less constant. While patients over 75 in the UK are given a named GP, it would appear that some doctors interpret this as just having to look at patient records. I understand that patients who wish to be seen urgently cannot always see the same GP that day, but how can a doctor deliver appropriate and responsible care to a patient without ever meeting them?
What can we do, going forward? I believe we need to redesign the whole system so that it works for doctors and health professionals, and, most importantly, for patients. Training more GPs is one easy answer. I know that there was an increase of 25% in funded medical school places in the three years up to 2020, but clearly we need more. We must cut down the number of patients who doctors are being asked to see each day. We must make it advantageous for doctors to work in a practice, rather than being a locum. Smaller practices used to work better. Most importantly, we need to encourage doctors to know their patients again; this will lead to better outcomes, as shown by the Norwegian study, and help ease pressure on the whole system.
However, we need to do more to encourage people to take responsibility for their own health. Prevention is key: good diet and exercise are vital; health checks are important and should go on until an older age. We should also include mobility checks, as people who cannot exercise will put on weight, leading to diabetes, heart problems et cetera. That would help to prevent hip and knee problems. We need to encourage practice nurses to deal with more conditions and get qualified pharmacists to be able to give a wider selection of medication without a prescription. Community nurses are such an asset, and we need to ensure that doctors work closely with them. Those dealing with patients on the phone need to be trained to be kind and caring.
Mental health takes up more and more time. Are there better ways of dealing with this, rather than endless medication? Should we encourage people with certain conditions not to go first to their GP? For example, could those with back pain go first to an osteopath or a physio or a sports therapist, who can often sort them out? Good IT can really help with the whole system.
We must make sure that primary healthcare works better for patients, as well as being a job that is once again enjoyed and valued by doctors. This is so important, as, if we can once again restore good primary healthcare, that will ease the whole health system.
“significant challenges, including shortages, low job satisfaction and retention rates, and poor health”.
Ambulance staff were described as “overwhelmed … fatigued and depleted”. Our NHS is under unprecedented strain and our own House of Lords report drew attention to the 133,000 vacant posts in the NHS and the 91,000 vacancies in acute social care.
Anyone who uses NHS services knows that they are only as good as the staff who are treating them. These are workers who were on the front line during the long months of the Covid crisis. Many left—exhausted and shell-shocked by what they went through. If our NHS is struggling with the huge gaps in staffing and is struggling to motivate those who remain, our NHS will always struggle to deliver the quality of care that it wants to.
However, there is some good news on the horizon. The NHSLong Term Workforce Plan has finally, after many years, been published. Much of the plan is positive, particularly the focus on boosting the use of apprenticeships. But even this plan was massively delayed. Now, the challenge of providing a thriving and sustainable NHS workforce for the future has become even greater.
The biggest problem with the plan, as with so much of healthcare policy, is a continuing failure to provide any solution to the deteriorating situation in social care. The state of social care is appalling, with the number of vacancies now reaching 152,000 in England alone. It is a service kept alive by the use of migrant labourers, who legally can be paid 20% less than the existing workforce. There is now growing evidence of widespread exploitation of migrant staff in the social care sector. There is growing evidence of care workers from overseas having money deducted from their wages to cover dubious fees, facing demands to repay thousands of pounds when they try to move jobs and being forced to pay extortionate rents for sub-standard accommodation. It is an adult social care service that is not fit for purpose and is causing gridlock at the interface with the National Health Service.
As the Government have prevaricated and delayed, so the sector has moved further into crisis. There are questions that must be answered. We have a long-term workforce plan for the NHS, but why is there no corresponding social care strategy? We have a successful NHS social partnership forum, but why is there not one for adult social care? Why are the Government willing to participate in the NHS forum but stand aloof—conspicuous by their absence—from a social care forum?
What is needed more than anything is ambition and a proper overhaul of the adult social care system. In short, we need the introduction of the national care service that we on this side of the House are calling for. The vision that led to the creation of our NHS is as valid today as it was in 1948. Today, it treats 1.3 million people per day. It is productive, despite little investment in capital works. It gives value for money, but, as demand increases, so do the pressures. Innovation is vital—that goes without saying—but so is the NHS long-term workforce plan. NHS England believes it could mean an extra 60,000 doctors, 170,000 nurses and 71,000 more allied health professionals by 2036.
Such a transformation will be achieved only if the Government of the day have the ambition to see the plan as their priority and provide the resources needed. The vision that underpinned our NHS has stood the test of time. We have all benefited from the courage of those involved in 1948. It is our duty now to ensure that our NHS continues to evolve so that it is there for future generations. Like everybody, I would like to quote from Aneurin Bevan. My favourite quote has nothing at all to do with the NHS, but Nye Bevan said this, and I have always used it as a way forward: “If you walk down the middle of the road, you get run over”.
If we look at what is happening, as my noble friend Lord Hunt pointed out, we are starting to see for the first time in near history that life expectancy is halting and going in the other direction. If you live in Westminster, your life expectancy is going to be of the order of 86 years, but if you are in Manchester it is down to 77 or 78—and this is happening against a background of general decline in many areas of the health service.
I hope the Minister might still give some thought to the idea that we should try to find ways of having far greater involvement of the public. The charity approach was one idea. When Alan Milburn was Secretary of State, he tried to find ways to get more people involved. They even explored the idea of shares in the NHS, so that people were making a personal commitment to it. I still believe there is merit in going back to some of those issues.
Covid has of course made a difference, and we should not deny that—the Minister will, without a doubt, labour this point in defending the state we are in. When we came into power in 1997, the health service was in a mess and, as was said, it is in a mess again. We have to find our way forward. Care in particular has to be addressed, and we have a plan there, but I believe that the way forward will be to try to involve more people in building a base for revising our approach to it. I appeal to the Minister: the Government made promises in 2019 but have not delivered on anything, so would they be prepared to consider working closely with the new Government, if Labour comes to power, to try to take care out of the Punch and Judy that we have had so much in the past—to come together and to shift care away from political disputes between the parties? I hope the Lib Dems might be willing to give their support to that entirely different approach to care, because it is so desperately needed.
I wonder why this review of Covid is going on until 2026. How much money will be spent on it before it is completed? Would it not be better spent on trying to address some of our current problems in the health service? With Covid, some underlying causes needed addressing. The first was age—and care is the way we start to address that properly. The second was the underlying cause of weight: 50% of the deaths attributed were attached, for a variety of reasons, to people being overweight. The Government have a number of proposals for change, but have fallen well short. They made a grave mistake in winding up Public Health England—at least it was seen as a focal point for campaigning, and it was coming out with strategies that were noticed. We have completely lost focus on where we go in campaigning on obesity, and I hope that, when my party comes to power, it will address that more than it has been addressed in the past. The third area that was identified in the Covid review was the disproportionate number of people of colour who suffered badly. As was mentioned, a recent report says that people of colour are still gravely disadvantaged in health terms compared with the white population. We need to find new policies to address that difficulty and to turn it around so that people start to feel that they are a better part of the community than they are now.
My appeal overall is to try to take certain areas where we are failing to make progress out of the Punch and Judy of politics, to develop new relationships that would move us forward on issues that we have all had policies on for years but have not made progress on. I hope the Minister spends some time, in responding, on the need to get the public more involved than they have been and to get some unity of purpose between the parties in the areas where we have still not made any movement but should have.