NHS Long Term Plan

Motion to Take Note

Moved by

To move that this House takes note of the NHS Long Term Plan, published on 7 January, and the case for a fully funded, comprehensive and integrated health and care system which implements parity of esteem, preventative health and standards set out in the NHS Constitution.

My Lords, in opening this debate I declare my interests, particularly those relating to health, as listed in the register. The NHS gives extraordinary care to people in the United Kingdom. It enjoys huge popularity. Yet it is struggling. Austerity has taken its toll. We have seen a deterioration in services and the key access targets have not been met for many a month. Add in increased rationing of treatments, cuts to public health funding, inadequate mental health services and disinvestment in social care and it is hardly surprising that the NHS faces unprecedented pressure. This is what makes the NHS plan so important and why it is important we debate it today to try to turn this around.

I can say at once that much in the plan is welcome: the expansion of primary and community care; the drive for integrated care; the emphasis on clinical services for young people; and the identification of clinical services for cancer and cardiovascular disease, for example, where outcomes in this country lag behind many comparable countries. Welcome too is the acknowledgement of the role of carers, which appears a number of times in the plan. Particularly ambitious is the aim to transform services, using technology to provide many more online interventions and reduce patient visits to out-patient clinics by up to a third. The plan also hints at further centralisation of hospital services for major trauma, stroke and other critical illnesses, again to improve patient outcomes.

So the plan’s overall thrust is welcome as far as I am concerned, but my worry is that the Government have not learned from previous efforts to transform and integrate services. For a start, the plan is almost entirely focused on the National Health Service. It is a great pity that it was published in advance of the Green Paper on adult social care. It also shows scant recognition of the crucial role of local government, particularly in the current crisis in social care, yet the intended integration of health and care simply cannot happen without local authorities being full partners and some kind of long-term funding settlement for social care.

Similar challenges await the NHS, it seems. The plan promises increased investment in primary and community care, but where will it come from when acute hospital services are at full stretch and demand for services will inevitably grow? Although the plan is a sensible statement of intent, the question is: where is the beef to make it happen?

I start with funding. It is no surprise that the NHS is under funding pressure. A growing proportion of the population is aged 65 or over. We already have 2.9 million people with long-term multiple conditions. This is bound to grow over the next 10 to 20 years. It is always hoped that new technology will reduce costs, but the experience of health so far is that it tends to increase costs. If we add that to the current deficits among providers, the demographic challenge and the additional commitments given in the plan, there is a big bill to pay.

My Lords, it is an honour to be given the opportunity to follow the typically penetrating speech of the noble Lord, Lord Hunt. I congratulate him on securing the debate today and thank him for giving this House the opportunity to celebrate the historic investment that the Conservative Government are making in the NHS—I am sure that was his motivation—while giving us the chance to debate how that funding ought to be spent. Constructing a three-minute speech is probably a good discipline for us all, so I will focus my comments today on two issues which are of great significance: integration and innovation.

On integration, the structural centrepiece of the long-term plan is the joining up of healthcare delivery in combined authorities called integrated care systems. This marks a significant departure from 30 years of Conservative and Labour health reform, which had previously focused on creating competition within layers in the healthcare system—primary, secondary and so on. My belief, which I think is reflected in the long-term plan, is that this approach has run its course, not least because it increasingly goes against the grain of the healthcare needs of our people. The median patient is now older, has more complex needs and co-morbidities, and constantly moves between different bits of the NHS to receive their care, so having a vertically integrated healthcare system makes perfect sense.

However, I have two questions for my noble friend that flow from this approach, which as I said is the right one. First, achieving this goal may need primary legislation. Is this something that the Government are prepared to do? If they are, and given the support for integration on the Opposition Benches, the question is whether the Opposition would be prepared to back the Government. Secondly, one concern that has been expressed about these ICSs is that they could create again unaccountable local monopolies. How will the Government counter that risk?

My Lords, I too congratulate the noble Lord, Lord Hunt, on his speech. I will focus on obesity and my colleagues will focus on other areas.

Chapter 3 of the plan proposes improvements in cancer, cardiovascular disease, stroke, diabetes, respiratory disease and mental health. But the disease of obesity is often the root cause of these and is one of the top-five risk factors for premature death. Obesity services are mentioned in chapter 2, but the problem is that there is no recognition that obesity is a disease, the prevention and treatment of which is vital to avoiding a wide range of other diseases. Bringing professionals of many disciplines together to work on this in primary care settings is essential to success. This is not all down to the NHS. Local authorities have a big role to play, along with CCGs. However, because of their progressive underfunding, many have had to withdraw services. From 2016 to 2017, the percentage of CCGs reported as commissioning tier 3 services went down from over 68% to 57%.

I was pleased to read that the NHS will provide more access to weight management services in primary care for people with a diagnosis of type 2 diabetes or hypertension with a BMI of 30-plus. But do you have to wait until you get sick to access these services? I was also pleased that the NHS has noticed the remarkable success of the GP Dr Unwin, who got hundreds of his type 2 diabetic patients into remission through low-calorie and low-carbohydrate diets, and is now going to run a pilot scheme of its own. However, professionals working in the field are clear that obesity is not just a lifestyle choice which can easily be reversed by exercising more or eating less—it is much more complex than that. Will the NHS follow the proven cost-effective model of the Fakenham weight management service, which uses a multi-disciplinary team to give personalised tier 3 services to suitable patients? They provide specialist nurses, dieticians, exercise professionals, consultant endocrinologists, psychotherapies and pharmacotherapy, and can refer some for bariatric surgery, which is also very cost-effective.

My Lords, I am grateful to my noble friend Lord Hunt of Kings Heath for initiating this debate. Reading the National Health Service long-term plan is like being invited to a party without any food or drink: no money or plan for social care, no budget for training and educating the workforce, no indication of how local authorities will be able to afford their share of responsibility, and no budget announcement for public health. The National Audit Office has said that the crisis in social care, the state of finances in the NHS and the record staff shortages and waiting lists mean that the £20 billion announced by the Government as part of the 10-year plan could be wasted.

I will concentrate on health inequalities. When the Black report on health inequalities was published in 1980, it had a profound effect on me. It was published on the August bank holiday, and the newly elected Conservative Government rejected it. Thanks to Penguin Books, which published it in 1982, it had a wider audience and a huge impact on health inequalities. Yet here we are again. If you are woman living in Kensington and Chelsea or Camden, you are likely to live 7.4 years longer than a woman living in Manchester or Blackpool. A man living in East Dorset is likely to live 9.5 years longer than a man living in Manchester or Blackpool. The Chief Medical Officer’s annual report indicates that,

“a child born in the most deprived areas would have 18 fewer years in good health than one born in the most affluent areas”.

Infant mortality, working poverty and cuts in benefits are on the increase, with the virtual disappearance of local authority support services, including children’s centres and smoking cessation classes. The geographical variation of working-age individuals on incapacity benefit is also stark: a 13% claimant rate in Blackpool; 8% in the south-west of Scotland, south Wales and the north-east of England and Merseyside; and below 4% in most of the south of England. The brutal closure of primary industries in the 1980s made these variations worse.

My Lords, I too am grateful to the noble Lord, Lord Hunt of Kings Heath, for giving us this opportunity. I pay tribute to the fact that the plan focuses on autism. I declare my interest in the register as a vice-president of the National Autistic Society. The focus on the need to reduce diagnosis waiting times for autistic children and young people is very welcome. Please do not forget the adults in the community who have yet to receive a diagnosis; they are some of the most complex cases for professionals to address accurately.

The need to reduce the number of autistic in-patients in mental health hospitals is something that this House has debated on many occasions, and which I know is a very real problem for many families around the country. The improvement in understanding the needs of people with learning disabilities and autism within the NHS generally has improved, but there is still much to be done. There is also the issue of increasing investment in crisis support: sometimes we deny people small amounts of support and they end up in crisis. That is one of the most expensive ways to address people.

The long-term plan contains a commitment to piloting a new annual health check for autistic people. That is welcome, but I must say to my noble friend on the Front Bench that it is very important that that is done by doctors and professionals who have a good understanding of autism. If parity of esteem is to mean anything, it must be more than just checking blood pressures and weighing people. Checking the mental health of people on the autistic spectrum is probably almost more important than just checking them physically.

In order to do that, it is important that the GP knows who to call. For many years, the National Autistic Society and others, including the Royal College of General Practitioners, have been calling for improved recording of autism in GP registers, so that GPs know more about the needs of their autistic patients. If we do not have a register, and if GPs do not log who their autistic patients are—even if they do not see them very often—will they know who to call for annual check-ups? It is really important that the need to create a database of who is on the autistic spectrum and where they are is included. That requirement is missing from the report. I hope my noble friend will address that; perhaps she will get back to me and put a letter in the Library of the House. The database has been requested for many years.

My Lords, as president of the Spinal Injuries Association, I join others who have spoken about the seriousness of the NHS and social care workforce. The British Medical Association says that the NHS needs a “robust workforce plan”, including additional resources for training, which is missing from the long-term plan. The Royal College of Nursing says that if the Government do not take appropriate action, NHS England will be unable to improve cancer treatment, mental health and care for more patients at home, as outlined in the plan.

Spinal cord injury is a devastating, long-term condition which leads to complete or partial loss of movement and feeling, loss of sexual function and double incontinence. Access to specialised health services is essential to spinal cord-injured people’s rehabilitation, ongoing physical and mental health, and ability to live independently.

Spinal cord injury centres across the country are increasingly experiencing bed closures, as capacity is sought by their host hospital trusts to meet winter pressures affecting other services. As a result of these closures, it is increasingly difficult for spinal cord-injured people to access specialist healthcare and receive essential treatment for their condition. Without these closures, it has been found that the spinal injuries service needs 54 extra beds to make it viable.

I join Age UK in warning that the number of care vacancies will rise unless the Government take action to allow EU staff to continue to work in the UK. It is said that there are around 110,000 job vacancies in care in England and that around 104,000 care jobs are held by EU nationals. Age UK has said:

“The social care workforce is already struggling but if after a UK withdrawal we shut the door on staff from the EU we’ll make a bad situation even worse”.

The Government should recognise this and allow EU nationals to continue to come and work as paid carers. Coming from Yorkshire, I can say that the latest figures show that almost 4,000 EU nationals are working in adult social care in Yorkshire and Humber.

There are few greater risks to long-term global health than the increasing resistance of many infections to antibiotics. I hope that we will work with other countries across the world to develop new antibiotics and overcome the dreaded killer of antimicrobial resistance.

My Lords, I congratulate my noble friend Lord Hunt on a brilliant speech. I strongly agree with him that the long-term plan is heavy on admirable aspirations but short on implementation in at least three areas: public health, social care and the workforce—I shall focus on just public health and the workforce.

In public health, everyone agrees that our biggest challenges are smoking, obesity, alcohol and air pollution. It is interesting that three out of these four are due to what we do with our mouths—someone said that the most dangerous organ in the body is the mouth, and that is even without talking. However, the brain is more dangerous because all these challenges are due to behaviour and personal choice, and if we are to make a difference we have to influence behaviour.

We cannot place all that responsibility under the public health banner alone. Valuable publicity campaigns against smoking and obesity have been led by the Cancer Research campaign. If we are to reduce calorie and sugar intake, it will depend on the actions of the whole of government to persuade the food industry, possibly by legislation, to make a difference. If we look at how we might reduce alcohol consumption, we see that the best way is by increasing duty on alcohol. There is a close relationship between the rate of taxation and alcohol-related diseases: the higher the tax, the lower the rate of liver disease. If we want to change behaviour, it is the responsibility of the whole of government and not just public health in isolation.

However, there is one vital area of public health that clearly needs support, and that is its role in the control and prevention of infectious diseases. It is Public Health England that detects and controls outbreaks of communicable diseases, nips them in the bud and prevents them by vaccination programmes. Will the Minister please take that on board? I am afraid that I should reveal my own bias, as many moons ago I was chairman of the Public Health Laboratory Service.

Now what about workforce, where the plan is silent? With 100,000 staff vacancies, mostly nurses, filling that gap is an enormous challenge. The suggestion that we should increase our efforts to recruit nurses from overseas will only go so far, so we must do better at recruiting and retaining UK nurses. We can do things. The first is to fish in the waters of nursing associates and nursing assistants. A large number of them are desperate to be given the opportunity of a career structure that will put them on a ladder leading to a full nurse qualification. We should make nurse associate posts more attractive by offering them the prospect of career progression. We should do much more to attract back into the profession the many nurses who have retired for one reason or another. We do not make nearly enough use of this resource. Will the Government answer that?

My Lords, I too congratulate the noble Lord, Lord Hunt, on securing this debate. Like him, I think that there is a lot to welcome in the long-term plan, particularly the commitments to increased investments in mental health, primary care and community care, as well as the emphasis on prevention and health inequalities.

However, there is also much to worry about—mainly things about which the plan is silent. The NHS does not operate in isolation, and I am concerned—like many other noble Lords—that many of the laudable aims of the plan are being directly undermined by cuts elsewhere to public health and social care budgets. For example, the plan’s commitment to a more concerted and systematic approach to reducing health inequalities is welcome, but it comes at a time when public health funding has been reduced in real terms by some £700 million in five years, according to the LGA. So my first question to the Minister is simple: do the Government plan to reverse these cuts to public health?

Adult social care is facing a £3.6 billion funding gap by 2025. With such a focus on prevention in the plan, it simply does not make sense to underfund social care. In fact, according to the National Audit Office, one-fifth of emergency admissions to hospitals are for existing conditions that community or good social care could manage. Unless we invest sustainably in social care and public health, the funding in the plan will not be well used. Given the vital role social care will play in the success or failure of the plan, it is a great shame that the Green Paper was not published alongside it. Could the Minister give a firm commitment on when the social care Green Paper will be published?

While proper funding is vital, services cannot operate if we do not have the workforce to run them—a point that has already been clearly made this afternoon. The National Audit Office has warned that the NHS will not be able to use its new funding optimally, precisely because of staff shortages. This is a particularly pressing issue for adult mental health services, where more than 20,000 mental health positions in England are currently vacant. These positions are simply not being filled fast enough. According to the charity Mind, mental health trusts employed more than 179,000 staff in August 2017. A year on, this figure had risen by only 1,500—nothing like the additional 21,000 mental health practitioners the Government themselves said were needed to treat the additional 1 million people by 2021. Could the Minister give a date for when the NHS workforce plan will be published?