That this House takes note of the long-term sustainability of the NHS to be able to deliver comprehensive, timely and affordable health and social care for all, including options for systems of care and funding.
I see noble Lords leaving. The debate will not be that bad. It has certainly emptied the House.
I am grateful to the noble Lords who are taking part in the debate. I look forward to their speeches, particularly the maiden speech of the noble Baroness, Lady Ramsey of Wall Heath; I wish her well. Several noble Lords—the noble Lords, Lord Stevens of Birmingham and Lord Darzi, the noble Baronesses, Lady Harding and Lady Watkins, and the noble and gallant Lord, Lord Stirrup—would have joined us, but other commitments do not allow them to do so.
I declare my interests. I am a fellow of several medical royal colleges and faculties. Importantly, I worked for 39 years in the NHS in its glory days. My comments will be based on comparing the current state of our healthcare system with 26 other systems that I have looked at. They all have some problems but, compared with more developed systems of universal care in Europe and the Far East, ours is severely strained.
On 26 April 2018, 6 years ago, we debated this exact Motion. There were 50 speakers and the debate lasted nearly seven hours, interrupted by a Statement on artificial intelligence, which mentioned how AI will transform healthcare. Today’s debate may well mirror that debate in 2018. What has happened since then? We have daily media reports of the demise of the NHS as we know it, and lots of suggestions for how to improve things. Public satisfaction with the NHS is at its lowest point; waiting lists are at their highest level; waits at A&E are long and harming patents; and there are huge inequalities in health and poor outcomes—I could go on.
After several reorganisations and reforms, including a seismic one in 2012, the NHS has not found the equilibrium that it needs. But the NHS is still capable of delivering superb primary, community and hospital care. Thousands of hard-working, resourceful and committed front-line professionals are prepared to go the extra mile, despite feeling undervalued. They need to be better supported and valued before they too give up. It is access to care that has become a major problem.
The current state of NHS is not because of some inevitable built-in decay; it is a system failure. It is the result of decades of political short-termism, a lack of long-term planning and an underinvestment in capital infrastructure and technology. The system lacks capacity, with fewer beds and equipment such as CT, MRI and PET scanners, and with a huge workforce shortage compared with other countries. We now have a workforce plan stretching to 2035, with no longer-term funding. We need it to work. I congratulate the Minister for getting 50,000 nurses in place, as the Government hoped to.
A lack of planning means that disease is diagnosed at a later stage, leading to poor outcomes. Modelling suggests that, by 2040, one in five people will be living with a major illness, which is upwards of 9 million people. Nearly 3 million people of working age will not be in work due to ill health. Not investing in health means greater pressure on the budgets of other departments. Anxiety, depression and chronic pain will be the main causes of ill health, which has implications for primary and community care.
My Lords, I declare my interests as chair of Genomics England and Oxford University Innovation and a board member of BioNTech. It is a great pleasure to follow the noble Lord, Lord Patel, who is an eternal champion of the NHS and a great expert in these matters. I am grateful to him for convening today’s important debate.
As time is short, I will focus on the role of genomic technologies in future-proofing the NHS. From Crick, Watson and Franklin discovering the double helix structure to the Human Genome Project, the UK has long been at the forefront of genomic discovery. With the 100,000 Genomes Project we did something quite different—we drove that discovery into the heart of the clinic for patient benefit. Today Genomics England hosts the largest clinical whole-genome dataset in the world. Recruitment of this cohort was complete in 2018 but analysis is still ongoing, increasing the diagnostic yield all the time. In rare diseases this is over 30% and rising, while in some individual conditions, such as cystic renal disease, it is over 60%.
Each of these diagnoses is a life changed. One 10 year-old girl was admitted to intensive care with a life-threatening condition. It turned out that she had been undiagnosed with a rare condition for over 7 years with more than 300 secondary care episodes, costing the NHS over £350,000 to date. It took whole-genome sequencing to uncover a genetic deficiency and provide her and her family with a diagnosis at last, ending her diagnostic odyssey. Moreover, a bone marrow transplant proved curative. From sequencing to treatment in her case cost £70,000, just 20% of her pre-diagnosis healthcare costs. This sounds like an edge case, but rare disease patients have an average of 67 appointments over 75 months before diagnosis. For many patients this diagnostic odyssey is much longer.
My Lords, I am very grateful to the noble Lord, Lord Patel, for opening the debate, and very much welcome my noble friend Lady Ramsey on the occasion of her maiden speech.
The noble Lord, Lord Patel, talked about the NHS being severely constrained, but we know that the NHS can work well. Fourteen years ago, the NHS was in rude health, with new hospitals, new services, and waiting times that had come down dramatically. In 2010, the British Social Attitudes survey reached the highest level of satisfaction ever at over 70%.
What have 14 years of coalition and Conservative Governments brought us? The latest survey, published three weeks ago, recorded the lowest levels of satisfaction since those surveys started in 1983, of 24%. Long waits have become the norm; access to GPs, dentistry and CAMHS services have become very difficult for many people; ambulance waits are outside safety targets, and social care is unreformed. As the noble Lord, Lord Patel, said, we have very poor health outcomes as well. If the NHS is to be sustained, it has to respond to health and care needs very different from those that existed in 1948. There are complex long-term conditions among a growing older population—yet the NHS at the moment seems woefully unprepared or, as the noble Lord, Lord Patel, said, it has not reached an equilibrium.
To turn this around, I agree with the noble Lord, Lord Patel, that we first have to start upstream, with a bolder preventive focus to reduce health inequalities and improve life expectancy. As my noble friend Lord Filkin, the noble Lord, Lord Bethell, and others say in their recent report, Health is Wealth, our nation’s poor health damages lives, communities and our economy. Then major surgery is required of the NHS. Wes Streeting has outlined a decade-long programme of modernisation, with plans to digitise massive amounts of NHS paperwork and to make proper use of the NHS app to give patients real control. What the noble Baroness said about genomics really fits into that model.
My Lords, what a pleasure it is to follow the noble Lord, Lord Hunt of Kings Heath, who like myself is a former NHS manager and who clearly understands the difficulties and nuances of the future challenge of the NHS. I am also thankful to the noble Lord, Lord Patel, for this very timely debate.
The current performance of the NHS worries many and therefore needs to be improved urgently before it can be a stable platform for us to rise to the challenge of the significant technological and demographic changes that will take place if it is to become sustainable. The NHS’s current performance is distressing to say the least, despite the gallant efforts of many staff within the system. People in need of care and treatment are unable to see an appropriate medic or professional, with some waiting up to three years just to get on the NHS dentist list. People are waiting in the back of ambulances outside A&E for hours, while people waiting for a cancer diagnosis are not getting access to timely treatment, which can be life threatening, and people in great pain and agony are waiting far too long for planned operations. The Government have allowed this to happen and now try to placate the public with a list of office-generated statistics and playing catch-up. It is not good enough. People deserve far better than this.
Despite this picture of appalling failure by the Government, this debate makes us think very carefully about the future of our NHS. I am sure that the debate will be framed around two themes: one is how to make the NHS more productive, efficient, and innovative, while the other theme will be the wider context of the demographic, economic and social issues in which the NHS will have to work. The reality is both these themes will have to be addressed for a sustainable NHS.
Time today is limited, so I cannot go into depth about what is required across both themes, but I shall throw these issues in as a starter for 10. The 1948 orthodoxy on which the NHS stands has to be addressed, if we are going to see an NHS that can meet future need. For instance, why do we have a fixed view which is over 70 years old of what a hospital should be? Why are emergency and elective services always in the same building? Is it time to think more laterally about emergency hospitals and elective hubs? The model of primary care needs to be questioned. Why have we had the same model and front door system for over 70 years? This needs significant change, for those who need significant primary care needs due to comorbidities and those who occasionally dip in and out of primary care. Maybe a different type of service delivery is required, as the integrated electronic health record takes hold, with no longer just one model of GP and primary care access.
My Lords, I congratulate my noble friend on his excellent speech introducing this debate. I am very much looking forward to the maiden speech of the noble Baroness, Lady Ramsey of Wall Heath, bringing her great expertise to bear on this issue. I declare an interest, I suppose, as former chief executive of the NHS in England and Permanent Secretary at the Department of Health between 2000 and 2006, when I had the privilege to work with three noble Lords who are taking part in this debate: the noble Lord, Lord Reid of Cardowan, as Secretary of State, and then successively the noble Lords, Lord Hunt of Kings Heath and Lord Warner, in your Lordships’ House.
I want to make three points about the major reforms that are required, and a fourth point on implementation. I shall state them briefly at the beginning, in case I run out of time. The three reforms follow very much from what the noble Lord, Lord Scriven, just said: that we are using a 20th-century model of service delivery for 21st-century issues, and that must change. The second point is that the Government need to create a cross-sector health and care strategy and plans, of which the NHS is part. Thirdly, this needs to be underpinned by changes to professional education—that is fundamental, but it has not yet been mentioned and I want to say something about it. Finally, implementation needs to be based around a shared vision that motivates and involves people, and efforts to build consensus and momentum.
I say in passing that I very much enjoyed the speech of the noble Baroness, Lady Blackwood. It was fantastically important. I also know that the noble Lord, Lord Bethell, and others will be talking about the links between health and prosperity. A healthy workforce and a prosperous country are fundamental.
The first major reform is the need to change the model, with much more focus on primary and community care, support for carers and social care, and action by many people. It cannot be just the same model or a question of more GPs and nurses. Around the country now, we see community health workers doing outreach, the great programme of Growing Health Together in Surrey, and people creating the future. We need to build on those examples of what a new model of primary and community-based care will be.
My Lords, it is a pleasure to follow the noble Lord, Lord Crisp, and I thank the noble Lord, Lord Patel, for providing the opportunity to consider this challenging but vital issue. I look forward to the maiden speech of my colleague, my noble friend Lady Ramsey of Wall Heath.
I shall focus my remarks on care needs, highlighting the crucial interdependence of care and the NHS. I will draw on my experience as a member of this House’s Select Committee on Adult Social Care, so ably and empathetically chaired by my noble friend Lady Andrews, whose report, A “Gloriously Ordinary Life”, was published at the end of 2022.
It is clear to me that, if we are to ensure the long-term ability of the NHS to deliver comprehensive healthcare for all, adult social care is crucial. Fundamental changes to social care funding and provision, in the form of a national long-term plan for adult social care, are a national imperative. We engage with the NHS at all points in our lives, but adult social care is often invisible and off the public agenda until we have a sudden need for it. Yet as our report noted, 10 million of us are affected by it at any one time, either because we receive care and support or because we provide paid or unpaid care. Because we are living longer and with more complex conditions, we are all increasingly likely to be one day included in that number.
Noble Lords will be aware that there is no national government budget for adult social care in England. Services are financed primarily through local authorities, bolstered by large numbers of people who fully or partly fund their own care. As the APPG on Adult Social Care highlights in its recent report Future of Care 5, this piecemeal approach means that social care is particularly vulnerable and will often be the first to lose out when—I say that advisedly—the NHS or local authorities have their budgets cut. The 29% cut in local government funding since 2010 has led to an estimated 12% drop in spending per person on adult social care services.
My Lords, I am most grateful to the noble Baroness for finishing just before five minutes were up, but she has been the only one. The excellent speech of the noble Lord, Lord Patel, finished two minutes before his allotted time. I gently remind all noble Lords to keep to their allotted time of five minutes. I know that the next speaker will keep to it because he is a perfect timekeeper.
My Lords, it is a great privilege to speak after the noble Baroness, Lady Warwick. I thank my good friend, the noble Lord, Lord Patel, for bringing about this important debate. I declare my interests as a research fellow on public health at the Milken Institute School of Public Health and a research fellow on biodefence at King’s College London, and as chairman of Business for Health, a community interest company which advocates for greater involvement in health by businesses.
There have been so many powerful words about the importance of investing in our healthcare system. I saw at first hand the incredible power of our national health system during the pandemic. I love the system and what it does for our society. However, we cannot duck two particularly important problems when debating this key issue.
One is the unbelievably heavy cost to society of our healthcare system. The deputy chair of the NHS, Wol Kolade, whom many will know, put this very bluntly; when he joined the board it was £100 billion a year, and it is now edging towards £200 billion a year. He asks:
“Where the hell is it going to stop?”
That is a pertinent question for this debate. We cannot treat our way into good health. We have to look at the underlying health of the country and at how we prevent disease.
We also have to think about the return on investment of our healthcare system. If we want to sustain it and to have it in a secure financial position, we have to ask whether it is giving a return on investment. We have 2.8 million people who are long-term ill at the moment and half a million extra who have left active employment. The OBR predicts that there is no hope that they will return, and there may well be another half a million on the way out in the next year or so. If the economic and spiritual prosperity of the country is not being underpinned by our healthcare system, we have to wonder whether, as a number of noble Lords have pointed out, we need a bit of a rethink.
My Lords, it is a great pleasure to follow the noble Lord, Lord Bethell, and to congratulate my noble friend Lord Patel on the thoughtful way in which he introduced this important debate. I declare my interests in the register, in particular as chairman of the King’s Fund and as chairman of King’s Health Partners.
My noble friend alluded to the report of your Lordships’ ad hoc Committee on the Long-term Sustainability of the NHS, published in April 2017, to which the Government responded in February 2018. The debate to which he referred extensively covered the questions raised in that report and the Government’s response, but, regrettably, very little has changed since. It must be recognised that we have had the global pandemic, an acute health emergency, and many other challenges, but the reality is that we have not been able to address in any meaningful measure either acute or mid-term challenges in the sustained delivery of health and care in our country, and nor have we even initiated a meaningful approach to its long-term sustainability.
We have heard in this important debate that performance, regrettably, is not where it should be in clinical outcomes. It is well recognised and sought after by all parties in all constituencies that we improve clinical outcomes. They are not as good as modern medicine would predict and could deliver. Operational delivery is poor and its trajectory in the NHS does not appear to be improving. On workforce, we have found it impossible to inspire and motivate healthcare professionals, be they clinicians, nurses or other healthcare professionals, to remain committed to the NHS and be inspired not only to serve but to innovate, undertake research and ensure that the application of that research and innovation is quickly brought to bear for the benefit of patients. More broadly, the research and innovation agenda, which our country has led for so many decades, appears to be falling behind. If that agenda is not at the centre, sustainable healthcare in our country will not be achieved.
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Unfortunately, there is no silver bullet to reduce the growth in people living with major illness in the short to medium term. Diseases that affect millions, such as diabetes, cardiovascular disease, stroke, some cancers and chronic lung disease, are all amenable to either prevention or early detection. The focus needs to change to prevention and health, not just healthcare. We need to move from: “I am ill; I need to get better” to “I don’t want to be unwell”. Countries that have recognised this are seeing the benefits of higher life expectancy, people living more years in good health and being more economically productive. The system needs to change to make primary and community care a central part of our care system.
The current funding of primary care is at 8.4% of the total NHS budget of £192 billion, which is the lowest in eight years, and it employs only 154,000 of the total 1.3 million workforce. This proportion will need a significant increase to at least 20% or more if we are to see improved access to primary care. The traditional system of a single portal of access to healthcare also needs to change. To enable patients to have greater choice of access, community care will need to be staffed by a multidisciplinary team of professionals, including general practitioners.
An explosion in data, generated by patients and the health system, will drive healthcare through screening services’ early detection of markers of disease, such as blood pressure monitoring and hypercholesterolemia, to mention but two. Population and risk-based genomic screening, liquid biopsies, individual health data monitoring and so on will lead to early risk identification and detection of disease. Healthcare will be digitally driven, technologically enabled, personalised and patient-centred. Patients will be involved in planning and managing their own health. The best health systems in the world have strong community care, with a focus on helping people stay well.
From birth to death, health, healthcare and long-term care in old age is a continuum. If any part of it is not functioning, it affects the rest. The lack of a properly funded and organised social care system is having a huge effect on the NHS. We have had 28 years of kicking the can down the road. After seven policy papers, six consultations and four independent reviews, we have a social care system that is means-tested, needs-assessed and underfunded.
There is a lack of a workforce plan for a service that needs 1.5 million staff, with 2 million people still needing care—one-third of whom get no support. With a rise of 20% in working-age adults needing social care, this needs urgent attention. Capacity is getting worse, and public satisfaction with social care is as low as 13%.
Various options have been considered, including free personal care, the Dilnot cap and universal care. The best performing comprehensive system of social care is provided in countries with a long-term care insurance, or which is tax funded, based on the principle of social solidarity. People above a certain salary range pay throughout their lives. Without a solution to the funding of social care, the NHS cannot survive.
I now turn to the key issue of funding the NHS. Funding of the NHS has always been a rollercoaster, despite its link to the performance of the NHS. The planned budget for 2024-25 is £192 billion, an increase in real terms of 0.6% from the 2023-24 settlement but a reduction from 2022-23. According to NHS England, it will provide a spending increase of 0.25%. Over the parliamentary term 2019-20 to 2024-25 the increase has been 3% per year, but from 2010 to 2019 it was 1.4% on average.
Following the famous “expensive breakfast” in 2000—when Prime Minister Tony Blair announced on breakfast television an uncosted commitment that he would bring NHS spending up to the EU average—and the Wanless report, there was a multiyear increase in funding leading to better NHS performance. Waiting lists came down dramatically and health inequalities began to improve.
If the EU average had been maintained in the years that followed, the budget would now be £40 billion higher per year. Lack of capital funding—an average of £2.5 billion per year from 2010 to 2019—has led to poor infrastructure and a lack of equipment; it has not increased. Rising costs have led to calls for funding reform. Social insurance, some element of self-pay and hypothecation have all been suggested. Each has its own problem. Analysis suggests that a single-payer system is most effective in costs and complexity. The public seem to prefer a tax-funded system. What is important is that there is properly costed long-term funding that tracks GDP growth. Also important to note is that while measures of prevention and healthy living may make people live longer in good health, they will not cut costs. If cutting costs is a priority, a different model of care will be needed—but people may not live longer.
In conclusion, a sustainable future for both NHS and social care is possible, and with it a healthier population that leads to increased life expectancy and decreased health inequalities. It needs a long-term funding commitment, including in capital funding, and strong primary and community care with a focus on prevention and health. It needs to be digitally driven, connected and tech enabled, and to have a clear plan with timelines for its introduction. An overcentralised, bureaucratic system will not address the fundamentals of effective healthcare. This may well be the last opportunity for the NHS as we know it and as we want. If not, the public may well seek an alternative that could lead only to a two-tier system of care.
My question, in this election year, is to the Minister and the noble Baroness on the Opposition Front Bench: what plans does each party have to make the NHS sustainable in the long term? What support will the Liberal Democrat Front Bench give to make amends for the part it played in the reforms of the coalition years? I beg to move.
That is why Genomics England was founded—to use the power of genomics to do better. Our aim is to change the fundamentals of healthcare delivery. We want to create a virtuous cycle by making genomics routine in the NHS and supporting frontier genomic research and discovery, and to continually replenish one of the richest genomic datasets in the world. In doing this we will create a return for participants through better diagnostics and therapeutics; a return for the NHS by boosting productivity and efficiency through stratification, screening and early intervention; and a return for the UK by increasing R&D investment and clinical innovation.
Genomics England now enables the NHS to deliver the world’s first nationwide whole-genome sequencing service for more than 190 clinical conditions across rare diseases and cancers. The service has supported more than 90,000 patients since its launch at the end of 2020 and is scaling fast. We ask patients for a specific consent to use their data for research purposes. Over 95% agree, and their data is stored in the National Genomic Research Library to enable cutting-edge research. The findings of that are then driven back into the clinic to improve NHS care. This means that the Genomics England structure is inherently translational by design; the heart of our mission is to drive long-term, sustainable improvements in the care of our participants and in the NHS as a whole.
We see research and clinical results flowing all the time: research at Great Ormond Street for children with blood cancers found that whole-genome sequencing was proven to provide additional information for diagnosis in 81% of cases, it changed the management of condition in 24% in cases, and it reclassified diagnosis in 14% of cases. Meanwhile, baby Oliver in Cambridge was born with a 6-centimetre tumour on his leg. Under the microscope it looked like an infantile fibrosarcoma and the standard testing was inconclusive, but with whole-genome sequencing it was confirmed as a benign myofibroma. This meant that baby Oliver was spared chemotherapy and surgery and is now happy and healthy.
We know that over the next decade data, analytics and genomics will transform healthcare by enabling personalised medicine. This means more effective and tailored treatments, better diagnostics and predicting disease susceptibility so that we can intervene earlier— possibly even preventing disease altogether. Earlier intervention and more targeted treatment not only improve patient outcomes but reduce the huge healthcare costs of ineffective treatments and side-effects. Multimodal genomic data that we are building now have the potential to cut the costs of drug development and improve population health management.
That is why at Genomics England we have launched three programmes designed to push the envelope of genomic medicine further into the clinic. We are diversifying the ancestry of genomes to improve equitable outcomes for patients; validating long-read and multimodal cancer technologies to drive earlier and more accurate diagnostics for cancer patients; and our Generation Study, a newborn screening pilot, is designed to end the diagnostic odyssey where it starts and explore options for supporting genomic-enabled prevention. The potential of genomics is immense, but to fully harness its power we must continue to invest in research, infrastructure and education to realise its full potential and truly make the NHS sustainable.
However, three major changes need to accompany this. First, we need a step change from the current overcentralised and bureaucratic NHS. As Nigel Edwards of the Nuffield Trust has said, we have a culture of checking, assurance, performance management and other manifestations of a controlling and low-trust approach, alongside a system with a very large number of priorities. I do not know whether the Minister is aware how much NHS England’s approach is despised and hated within the health service at the moment. I would suggest that that comes from the approach that Ministers are now taking to NHS England. It comes right from the top.
This has to go with the workforce. We need a fundamental change in how we treat our people working in the NHS. Bullying, problems of recruitment, retention and morale—these are everywhere in our health service. I have been fascinated to read the outcome of a King’s Fund and RCN project entitled Follow Your Compassion, which looked at the experience of 22 newly qualified nurses and midwives. The work that they do is high stakes, with significant and often disproportionate responsibility placed on them almost immediately after qualifying. Life, death and human suffering are everyday encounters, and the work of caregiving is emotionally demanding. But the overwhelming experience of participants was reported as their feeling unprepared, anxious, silenced and exhausted. You can have as many workforce plans as you like but, unless we get to grips with how our people are treated in the health service, you will never really sort the workforce problems out.
Finally, we must invest in leadership and management of the NHS. I remind the House that I am president of the Institute of Health and Social Care Management. Unlike the military and many private organisations and companies, the NHS does almost nothing to select, nurture and develop the next generation of executive leaders. Training and development are often sporadic, which, combined with the lack of a systematic appraisal, makes development and deployment of key talent almost impossible. The Government’s insistence on carving yet more managers out of the system at the moment is having a very damaging impact on their ability to take forward the kind of change that needs to happen.
If we do not sort this out, if we do not change the culture, if we do not put more trust in the NHS locally and if we do not sort out social care, all the other changes that we need to make will come to very little. This Government have now had 14 years; they have had their opportunity—it is time for change.
As technology, robotics, AI and data-driven services become central in predicting, planning and delivering healthcare, appropriate leadership skills at all levels of the NHS will need to be addressed to maximise the potential of these issues, as well as to minimise the risks. Is it time to end the leadership model based predominantly on managing efficient siloed organisations by moving to leaders who are experts in maximising health gain and facilitating community action to bring about complex change?
Societal issues, such as housing, education and the environment will have to be addressed, as the NHS does not work within a vacuum. A population that is ageing with comorbidities, and the balance between the working-age population and the non-working-age population—and, of course, climate change—needs to be addressed. Some key issues that we need to think about across government to support the NHS maximising health gain are supporting people to age with dignity and independence, tackling deep-rooted worklessness, and an absolute laser-sharp determination to narrow the health inequalities, as well as having a long-term and fully understood funding formula for both the NHS and social care.
All this will take long-term, focused action by government and society. I am not sure that the siloed structure of central government can deal with these challenges effectively at present. The approach must be a community health-based model, to maximise healthiness and improve health outcomes.
One simple way of supporting this would be for the Treasury to set up designated funds that can be used in communities and the NHS to invest for health. That would break down the problem of pretending we can move existing NHS budgets, which are mainly sunk, fixed costs, into prevention and reducing health inequalities.
Talking of funds, it is vital, as the noble Lord, Lord Patel, said, that we sort out, once and for all, the social care crisis. The NHS can never be sustainable if, as a nation, we have not dealt with social care funding. After the general election, I think it is the duty of all politicians, from all parties, to sit down and work out a cross-party solution to this difficult problem that has been left for far too long. We need to take a different approach and think about some fundamental questions if we are to have a sustainable NHS.
I turn to the second major reform. I have spoken many times in the House about the African saying, “Health is made at home; hospitals are for repairs”. I have also been pressing the case for quality standards to include healthy homes. The NHS is dealing with many problems that it has not caused, and those need to be addressed at source. There needs to be a government cross-sector health strategy and plan, of which NHS and social care is a part. I suggest that that plan needs to focus on the aim of creating a healthy and health-creating society—and indeed a prosperous society while we are at it. The focus should be not just on dealing with the problems—by tackling such things as air pollution—but on creating the conditions for people to be healthy. Think of Sure Start, for example, which I know many noble Lords will be aware of. Such a plan would create the conditions for people to be healthy. That is why we should be looking at health as being about healthcare and the prevention of disease but also the promotion of the causes of health and creating the conditions.
The third major reform underpinning all this is a need to transform professional education. I am happy to be associated with a radical group of young professionals who are starting to drive this agenda, recognising that they will need different skills for the sort of model I am talking about, as well as retaining the basic science.
The final point is implementation. My experience as chief executive is that I was lucky to arrive at a point when two things had happened. First, the Government of the day brought people together to create a plan; they built energy and hope, and there is not much energy and hope around today. That hope and energy created good will that carried us forward two or three years. That good will lasted a really long time and allowed us to make radical changes, including bringing in the private sector and other things. It is very much harder today, obviously. As was already mentioned by the noble Lord, Lord Hunt, by the end of 2005 waiting lists were below 1 million, with a six-month maximum wait, and there was more improvement to come from then on. It is very much harder today. The NHS is in worse condition, although there is still good care being provided, as the noble Lord, Lord Patel, emphasised. But the Government must do something—whether it is a new Government coming in or this Government continuing—to bring people together around this problem and create a solution that people will buy into.
We must also deal with the presenting problem. We cannot just deal with the long-term. A new Government coming in will have to look at the waiting lists and how to handle that, but they must then pivot to health. Twenty years ago, I believed that we must talk about the issues people were presenting with, such as waiting lists and A&E, and then pivot to a focus on health. We never quite pivoted to health. It is time now to change from talking about healthcare to talking about health, which embraces healthcare but also prevention and the creation of health.
If we are looking at new models and systems of care and funding within the NHS, we have to change short-term emergency funding. Social care needs a long-term funding plan. As our Select Committee highlighted, improving adult social care should be seen not only as an investment in the NHS but in ourselves, as a resilient and caring society. As the quality and consistency of services has suffered, so has the pressure and demand on unpaid carers risen. Estimates suggest that there are more than 6 million unpaid carers in the UK, and the actual figure is likely to be much higher. Estimates of the value of unpaid care provided by family and friends vary between £100 billion and £132 billion a year. That is an extraordinary contribution to the health of this country and it really needs to be seen to be valued. However, as one carer who gave evidence to our report told us:
“Unpaid carers are often not even considered to be a part of the health sector and yet without them the sector would collapse”.
Despite their numbers, carers feel invisible and many are at financial, emotional and physical breaking point. Hearing the lived experiences of those who gave evidence to the Select Committee was sobering, at times even harrowing. Time and again, they told us of being unaware of what help was available, not knowing who to ask or how to access help, or of not being listened to and being put through tick-box exercises that bore no relation to their actual circumstances or needs. Time and again, these carers were falling between the gaps of a broken system, often over many years.
One parent carer told us that, while her daughter was under the age of 18, she had a central point of contact within the NHS, a paediatrician, who could project manage the different strands of specialism her daughter needed. Once she turned 18, all this fell off a cliff. The distinction made between a health need and a social care need means that unpaid carers, often family members, are on their own, battling to get information and help.
In the Select Committee report, we urged the Government to establish a commissioner for care and support who would be able to raise the profile of social care, act as a champion for older adults, disabled people and unpaid carers and accelerate a more accessible adult social care system. Sadly, this recommendation gained no traction with the Government, but, in light of the overwhelming body of evidence on the need to improve adult social care and advocate for those at the heart of adult social care of all ages, can the Minister give us any assurance that this will be revisited?
That is why, alongside the noble Lord, Lord Filkin, and other colleagues, I launched Health is Wealth: A Fast Start for a Covenant for Health. We prioritised five areas of prevention which I believe are achievable and affordable and will yield a massive economic benefit. First, we have to scale up and deliver on our ability to detect and address the risk factors of disease. I am grateful to my noble friend Lady Blackwood for her words on genomics. Secondly, we have to strive for a smoke-free Britain. We should all celebrate this week’s achievement on the smoke-free generation legislation, but there is so much more we can do in the next 10 years to reduce the 5 million people who already smoke. Thirdly, we need to build a much stronger focus on healthy eating, making it affordable for all and helping us reverse the upward trend in obesity. Fourthly, we must focus on the health of our children, ensuring that healthy habits are ingrained from an early age. I emphasise mental health here, in particular the role of the digital world in provoking a mental health challenge for our young people. Finally, we need to ensure that no area is left behind and look at helping those who live in areas with the worst health to live longer. That includes the underlying environment in which they live—the dirty air, the mouldy homes and online and toxic workplaces.
The moral argument for this prevention and upstream focus is very strong, but the economic argument is overwhelming. We cannot keep pouring increasing amounts of money into more hospitals, doctors, nurses and medicines in the hope that we can treat our way out of this problem. We have to address the determinants of health. Can the Minister say what more can be done in this space from a position of ambition for the NHS? We cannot keep scapegoating the NHS for the poor health of our country. We have to look upstream and focus on the determinants of health.
That is not to say that there have not been many important and very well-meaning initiatives over decades to address acute problems and longer-term sustainability issues, but they have not delivered. As a result, we must ask how we are going to reach a position where we can develop a national consensus that brings together diverse political, public and professional constituencies with a common understanding and vision for the future—a consensus that is appropriately motivated and understands that what is proposed is deliverable and remains a deep-seated national commitment across the political divide?
Part of the problem may be that questions, with regard to the medium-term or long-term sustainability of health and care in our country, are projected and considered through the lens of a clinical, a delivery or an innovation problem, rather than looking more holistically at all those issues. Some of them were addressed in the previous NHS long-term plan, but they need to be considered more broadly in the context of our country’s economy and other policies, such as immigration, which need to be co-ordinated with a wider understanding of healthcare delivery needs, if we are to have a sustainable long-term plan.
I follow the fine example of my noble friend Lord Patel and ask the Minister, as well as the noble Baroness, Lady Merron, and the Liberal Benches, what approach are they going to take, for the national interest, to achieve consensus on the needs for delivering our country’s health and care? How will this consensus be delivered? In the debate on the noble Lords’ report in 2018, the idea of a royal commission was dismissed as something that was not politically acceptable and would not deliver in a short enough timeframe. Six years have passed since that debate; maybe something like a commission would have delivered the answer in that period. It is now essential that we develop a clear consensus and have the courage to adopt a long-term plan that addresses the holistic needs beyond the question of clinical care alone.