My Lords, I am pleased to open the debate today. I thank the Minister and all noble Lords who have their names down to speak and look forward very much to their contributions. This debate takes place at a time when the whole NHS is under immense pressure, with media headlines such as “NHS in crisis”, “End of general practice as we know it” and “Will we have an NHS in the future?”, to quote a few. The focus of today’s debate is primary and community care—the backbone of our health service—how its performance affects patient outcomes, and whether there is a need to reform the primary care service.
Primary care has been the bedrock of the NHS since its inception in 1948. It has been revered by patients and has delivered huge health improvements. When Nigel Lawson—now the noble Lord, Lord Lawson of Blaby—said that the NHS was a national religion, it was because of patients’ love of its primary care services. The two professional groups worshipped by the people were the general practitioners and nurses in primary and community care, not the brilliant obstetricians, colorectal surgeons, palliative care doctors and—I say on behalf of the noble Baroness, Lady Murphy, who had to withdraw because of cataract surgery yesterday—not even the psychiatrists. Primary care is now in a different place. It is still the bedrock of the service, but the foundations are shaky, even crumbling. Unless fixed, the whole system will collapse.
What is primary and community care? It is the first point of contact for healthcare and is provided mainly by GPs, but also increasingly by nurses, dentists, optometrists, pharmacists and many other allied health and care providers, including physiotherapists, mental health nurses, care co-ordinators and, in the community, health visitors, specialist nurses, midwives and end-of-life carers. The system is about caring for people rather than treating specific diseases. A system designed to work as an integrated team, with the patient as its centre and focus, has now been broken through incoherent policies, being starved of resources, and a lack of attention to the need in primary care to develop a technologically driven healthcare system and the infrastructure and professionals needed for an efficient and effective system to run.
My Lords, I thank the noble Lord, Lord Patel, for bringing about this important debate. As ever, he has a canny nose for the timing of these things and he is absolutely spot on. I know from my time in office that the pressures on primary and community care are intense and I agree that we need an urgent rethink. That is why I will put my name to any forthcoming proposal from the noble Lord to the Liaison Committee for a Select Committee on primary and community care.
The NHS has experienced long waits in hospital care before, which are extremely distressing, but it has never faced such a grave challenge in general practice—and as we know, general practice is the bedrock of the NHS. This is the right moment for noble Lords to distil complex recommendations for primary and community care into succinct, wise counsel for the Government to consider. I will share a few thoughts on how that might work. First, primary and community care is the first point of contact with the care system for the public. When we consider the remit of this Select Committee, we must remember that for many people this is not a GP. It is likely a website, an app, a school nurse, a community hospital or a pharmacist.
Secondly, there is definitely a workforce crisis—briefings from the Royal College of GPs, the Royal College of Nurses, the King’s Fund and others make that very clear, and I am grateful for their persuasive statistics—but the crisis in primary and community care is not just a workforce crisis that can be answered through solving recruitment, retention, workload and the GP contract, although those are extremely important challenges. Anyone who listened to the Minister’s answer yesterday to the OPQ about GP training will be clear that there is no massive new wave of GPs set to save the day. As the noble Lord rightly pointed out, only one in four GPs are currently working full-time, and training numbers are going sideways, so we should assume that there will be fewer GPs rather than relying on imaginary regiments of doctors riding to the rescue. Rather than deluding ourselves, we should make our plans accordingly.
My Lords, it is a great pleasure to follow the noble Lord and to thank the noble Lord, Lord Patel, for his speech. I fully echo his desire to see a special Select Committee created; I hope that the Liaison Committee members present will take note of that.
The noble Lord said that primary care is the bedrock of our health service, and I agree. If it does not function effectively, the whole healthcare system suffers, and it is clearly suffering greatly at the moment. It is not just workforce shortages or the crumbling estate. A recent Civitas report made for sober reading. It ranked the performance of the UK healthcare system with that of 18 comparable countries and, lamentably, it placed the UK second to bottom across a series of major healthcare outcomes, including life expectancy and survival rates from cancer, strokes and heart attacks. Recently, the Health Foundation has drawn attention to the UK having an astonishingly low number of MRI machines and CT scanners: fewer per person, according to the OECD, than any other developed country. That is besides having fewer doctors and nurses than our north European neighbours and very poor uptake of new medicines.
We see England’s hospitals being caught in a vice. On the one hand, the race to work through the enormous backlog of care means an unceasing stream of new patients into fewer beds. On the other hand, a decade of flatlining, at best, funds for social care means that even when treatment is concluded, thousands of patients remain in hospital beds waiting for follow-up care. Emergency departments have no beds to send new arrivals to the wards, patients with urgent needs wait for hours on end, ambulances cannot hand over patients, and are stuck in a queue outside A&E. We have to see the inadequacies of primary care in this much wider context.
The pandemic has accelerated the move to online booking and phone consultations with general practitioners. That has made care quicker and easier for many people, and we should not ignore that. On the other hand, it has led to many other patients facing enormous difficulties in getting face-to-face access to their general practitioner. The NHS England stat last October which showed that over 15% of practices recorded less than 20% of their GP appointments being held face-to-face is very worrying indeed. Last month, Pulse magazine reported that 1.5 million patients had lost their GP in the last eight years after the closure of almost 500 practices. Recruitment issues were part of the problem but we should not ignore the issue of workload, inadequate premises and sheer morale issues.
12:34 pm
Baroness Masham of Ilton (CB)
My Lords, I thank my noble friend Lord Patel for this necessary debate, and I declare an interest. In November 1981, I was given an honorary fellowship award by the Royal College of General Practitioners, and I have been and am a user of the NHS, being a high-lesion paraplegic. I ask the Minister: how is the NHS going to be improved without an adequate workforce?
We have a growing elderly population, with many complex conditions, who need treating. I am absolutely perplexed that many well-qualified students with many A and A* exam results, and who would like to study medicine, are being turned away by universities because the universities do not have an adequate number of places or because they are too expensive to train. This seems ludicrous when there is such a shortage of GPs and specialist consultants. This is a frustrating situation. What can the Government do to rectify it? Should we not try to be self-sufficient for the future years by training our enthusiastic young people, not training just half of what we need? We must invest in our future.
I bring to the notice of your Lordships and the Minister the situation of sick notes. It seems to be a difficulty for small businesses when an employee goes off sick and keeps getting repeat sick notes. Because of confidentiality, an employer cannot get advice from the GP. Are these repeat sick notes being given over the telephone, and for how long can they keep coming? Since the coronavirus epidemic, many GPs prefer telephone calls to face-to-face visits to surgeries. Small businesses need advice, as they have to put in staff to cover the absent staff who are off sick. At this difficult time, it may be the last straw which breaks the camel’s back.
Bed-blocking is well known and seems to be getting worse. This is not the fault of patients but it is very serious. Ambulances are being held up by multiple patients needing beds and waiting to get entrance to hospital. One of the main problems is that many elderly people have serious falls and cannot leave hospital until there is a care package in place at home so that it is safe for their return, otherwise they will be back in hospital. There is a desperate need for carers and a community team of physiotherapists, occupational therapists and speech therapists for patients who need to be safe at home. This does not come cheap. More funds are needed in both home care and hospital. It is no good robbing Peter to pay Paul; we need both.
My noble friend Lord Patel is asking for a House of Lords Committee on this important matter. It cannot wait: something should be in place before winter sets in. Whatever is set up needs to start the moment Parliament returns in October.
My Lords, it is a great privilege to follow those four opening speeches. However, I knew that I was getting myself into quite unnecessary trouble by putting my name down for this debate. Having had no internal experience of the National Health Service, I cannot follow the catalogue of problems which we have so far heard.
I start by declaring an interest: I am in receipt of community care. I will not go into detail, but I was in hospital two or three times and the NHS picked up that this would probably lead to the need for aftercare. Lo and behold, community care appeared. It has been very interesting and extremely helpful, but it raises two matters.
First, there was no explanation for why this was happening; it just happened. There has been no explanation which might lead one to understand the objectives or the value of the work, and possibly even the value for money of the work, being done in what is undoubtedly an endeavour to ensure independence—an endeavour for which I am very grateful.
The second matter that has arisen is that I cannot any longer understand whether there is a borderline—and if there is, where it is—between primary care and what might loosely be called hospital-based care. Because of my short stays, two hospitals have picked me up and are determined to monitor all sorts of aspects of what they found during their investigations. A lot of that work is what I would describe as primary care. I will not go into details, as that is not the point of such a presentation, but, for example, skin trouble, which has been persistent and different and has apparently quite complicated causes, seems to have moved away from primary care.
The other aspect of these experiences means that, for various reasons, I have not been able to create any personal relationship with a general practitioner. I have been responsible for some of the changes that have led to that, but so has the medical centre, where the people change quite rapidly.
My Lords, I am grateful to the noble Lord, Lord Patel, for leading this debate and, beyond that, for the leadership that he provides to this House on all matters health related. Although he used the words community care to refer to community care health services, I know that he will forgive me if I slip over into the other bits of community care, which are so vital when we consider healthcare and which work in collaboration with primary care.
Patients and carers must be the focus of this debate, because improving outcomes for them is what primary and community care services are all about. But I must put in a word of warning here on behalf of those patients and carers: if you ask a typical patient or carer to define primary or community care, they would struggle, as the noble Viscount so ably and vitally reminded us. I must say it is a pleasure to see him with us, not at all past his sell-by date. A typical patient simply does not know the difference and why should they? They refer to “my doctor”, “the hospital” or “the carers who come in to see my mother”. They do not know about different streams, different types of training or regulation; they are puzzled only by why test results take so long to reach their GP, why some care is free and other care has to be paid for.
I have lost track of how many friends and neighbours I have advised should be in receipt of NHS continuing care funding for their elderly parent, when they have immediately been advised to seek a place in a private and very expensive nursing home, without any reference to possible alternatives. What puzzles patients and carers most of all is the lack of communication and integration between services. “Why on earth do they not talk to each other?” they say. “Why do I have to tell my story all over again to every new person I see? Why did my GP not know that I was being discharged from hospital?” Every time I speak to a patient or carer, I find myself at a loss to explain why these things happen.
My Lords, I join other noble Lords in thanking my noble friend Lord Patel for the very thoughtful way in which he introduced this important debate. In so doing, I remind noble Lords of my own interests. In particular, I am chairman of the King’s Fund and King’s Health Partners.
In opening this debate, my noble friend described—and many other noble Lords added to his description—the substantial challenges that the NHS faces in general and in particular in primary and community care. So far in the debate, there has been a consensus and recognition that failure to address those challenges will ultimately lead to the NHS, in general, becoming totally unsustainable. We see the manifestations of this every day in the crisis to ensure that patients in an acute situation can be delivered to hospital through the ambulance service; in the substantial waits and, quite frankly, clinically unsafe environment that now represents many accident and emergency departments; in the tremendous pressures demonstrated in the acute management of patients in medical, surgical and other disciplines in our hospitals; and, most importantly, in the failure to discharge patients from hospital back into the community. The result of all that is an NHS that is considered, regrettably, now to be failing in many aspects. That failure is attended by an increasing loss of confidence among our fellow citizens.
I strongly support my noble friend Lord Patel’s proposal to establish an ad hoc Select Committee of your Lordships’ House to examine in more detail the challenges and opportunities for reform in primary and community care. In proceeding along that line and in having identified the many challenges faced, the issue is to understand how we might address them. To do that, first, we must deal with a major problem, which is the discordant perception and expectation among some important groups, with regard to what should be delivered by primary and community care services in the NHS. The expectations are those of politicians, of the public, and of health and care professionals. Those expectations are starting to differ widely when we look at the reality of what can be provided through a model of primary and community care established at the birth of the NHS.
My Lords, it is a pleasure to follow the informative and thoughtful speech of the noble Lord, Lord Kakkar. I too thank the noble Lord, Lord Patel, for securing what is a very timely debate, given the new Health Secretary’s pledge to put patients first, and the opportunity to talk about how community-based care can improve patient outcomes.
I declare my interest as director and controlling shareholder of the Family Hubs Network Ltd, which advocates for family hubs and advises local authorities on how to establish them. Family hubs are well-placed to deliver a broad range of paediatric physical and mental health services that are more accessible for families. The noble Lord, Lord Hunt of Kings Heath, mentioned accessibility. That accessibility, and the integration of health with other family support in a non-stigmatising and parent-educating environment, has the potential to transform outcomes. Paediatric health needs that are psychosocial and practical require a whole-family approach. Moreover, delivering them in hospital settings a couple of bus rides away from where people live makes it far less likely that children will attend.
Watson and Forshaw’s study found that a third of all paediatric hospital appointments were missed over a six-month period. Even more concerningly, a third of those children who were “not brought in” by their parents were known to social services and therefore likely to come from families already struggling greatly with the basics of child-rearing. Distance from home contributes to the social gradient in health and perpetuates the inverse care law that those with the greatest healthcare needs have the poorest access to that care.
Accessibility matters greatly if services are to be delivered for the convenience of hard-pressed parents and their children, rather than the system. I welcome family hubs’ inclusion in the statutory guidance for the preparation of integrated care strategies. These are described as
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Primary care is the setting for 90% of patient contacts, involving some 26 million patients a month. Huge increases in demand are putting pressure on the whole system and leading to long waits in general practice, emergency care and planned care. These pressures have created the biggest single fall in public satisfaction with the NHS in decades. A recent survey suggests 68% of patients do not feel they will receive timely treatment if they fall ill, 50% think it is harder to get a GP appointment and 40% think the service has deteriorated. With general practice under immense pressure, recent data from the GP Patient Survey and the British Social Attitudes survey suggest two-thirds of people are dissatisfied with service provision, with the quality of care received perceived to be an issue.
If the problems in general practice and its performance are not resolved, it will lead to the demise of general practice as we know it and, in turn, the collapse of the whole system of primary care and the wider healthcare system. We will see a repeat in general practice of what has happened in dentistry, where 90% of NHS dentists are not accepting any new adult patients.
Putting aside the rhetoric, GP numbers are declining, despite higher numbers in training. Recruitment and retention are poor. More GPs are retiring early, with pressures of work, bureaucracy and pension rules cited as reasons. Reports of nearly 57% of GPs working three days a week or less and increasing numbers doing only private work—approximately 1,500 at the most recent count—are a worry. The service may become more privately driven.
Contracts and the independent status of general practitioners dominate all discussions related to primary care. The small-business model of GP contracts is still favoured by professional organisations, but a House of Lords report suggested that model is not fit for purpose. A recent Policy Exchange report, At Your Service, advocates a universal shift to a fully salaried model over time as part of wider reforms in primary care. More and more younger general practitioners are choosing to be salaried.
Of course, no change in service delivery can occur without general practitioners being part of it and, importantly, playing a leading role. General practice can and should provide that leadership, but at the same time recognise that strong leaders remain strong and gain respect by at times letting go of some strongly held values, such as their gatekeeper role or even their responsibility for minor contractual issues. I am sure GP professional organisations are aware of this: my conversations with them suggest that they are not averse to change, but wish to be involved in any policy developments. The workforce issues are not confined to general practitioners. Similar problems exist with nursing, health visitors and community care professionals, all of whom are a crucial part of an effective system of primary care.
Of course, there have been efforts to try to improve the system and deliver patient care. The establishment of primary care networks, starting in 2019, is one key example. While the majority of general practices belong to them, not all do. Success at delivering service at scale in primary care—that is the important point—by PCNs has been variable, and now the BMA is threatening to withdraw its support, with lack of resources and contractual issues given as the reasons for doing so. Some other measures undertaken to improve service are the recently established diagnostic hubs and the recent involvement of pharmacists in blood pressure monitoring.
I was impressed that the voluminous briefings we have all received all cry out for a need for change in primary care that delivers three things: workforce, infrastructure and technology, including IT. Various recent reports have come up with suggestions for improving the primary care system: the report Fit for the Future: A Vision for General Practice, produced by the Royal College of General Practitioners; the At Your Service report I mentioned from Policy Exchange; and the Fuller Stocktake report by Dr Claire Fuller, an eminent general practitioner, which was commissioned by NHS England. All of these reports have suggestions for an integrated system that delivers primary care at scale. In commenting on some of the reports, the King’s Fund has suggested that tinkering with “more of the same” will not produce results. Reforms need to be driven from the bottom up, by the people who do the work.
Undoubtably, we need a primary care service that delivers at scale, is fully integrated with other parts of the health and care system and, above all, is responsive to patient needs and delivers better patient outcomes and health improvement. So what is the way forward? My personal view, which I hope noble Lords would support, is that first and foremost we need political recognition that an effective primary care system is a prerequisite to a sustainable NHS. To this end, proposals for change to make future primary care fit for purpose have to be led by the Secretary of State for Health and Social Care. The words from the Prime Minister and the Secretary of State hitherto are encouraging and I hope they will be followed by some actions.
On the other hand, this House has an opportunity to play an important role by setting up a special Select Committee to report on the future of primary and community care, identifying possible barriers and solutions that could make important contributions to making primary and community care fit for purpose and fit for the future. I hope this gets support from noble Lords.
As for questions for the Minister, I have only one: is there a recognition by the Government that primary care is now in intensive care? None of the piecemeal reforms, mostly of process, will work. Strong, bold leadership is needed to bring about the system change it needs. Otherwise, it will die, and with it the NHS. I beg to move.
Thirdly, we should not over-romanticise relational-based care when the role of the GP is evolving as quickly as that of the bank manager or the priest, and when many patients never ever visit the practice. We got through much of the pandemic with most practices shut, after all. People have extraordinarily diverse needs, from the long-term sick who certainly need regular clinical, face-to-face care to those at the other end of the scale, the occasionally sick or injured who might need a more transactional relationship. We must avoid lazy generalities, and we need a modern service that is flexible enough to meet different needs. That is why I would like any Select Committee studying primary and social care to look at four issues in particular.
The first is the importance of prevention. Too much traditional thinking around primary and community care assumes that patients turn up with symptoms and are guided by the GP on to some care pathway. These days, though, by the time patients have symptoms, it is often too late for the best treatment. This system-wide focus on late-stage acute medicine is costing the country a fortune in hard expenses and opportunity costs: expensive procedures, long recovery times, falling longevity, falling workforce productivity, and hefty social care and welfare bills. It is a huge price to pay. Primary and social care should play a much more proactive role in achieving “domain one” of the NHS outcomes frame- work, which is preventing people dying prematurely.
Secondly, technologies to “transform” healthcare are at our fingertips. I saw the power of digital transformation in primary care from my experience during the pandemic, with virtual wards, testing, the vaccine rollout, surveillance through the REACT survey, the prompt delivery of antivirals, and so on. We should study how primary and community care put digital first and become the foundational layer for scaling digital healthcare through the NHS. This approach is outlined in the persuasive policy paper from Policy Exchange that the noble Lord, Lord Patel, mentioned, At Your Service, by Dr Sean Phillips, Robert Ede, and Dr David Landau. They rightly argue that there is much to do to enhance the existing infrastructure and clarify the legal regulation of data. That is why I am interested in their recommendation for a digital health and care Bill, and in a “smart” first contact navigation programme—an “NHS Gateway”—that can deliver a more personalised “front door” to the NHS. We also need to address the use and sharing of data in primary care for management, clinical and research uses, with suitable resources allocated for this absolutely invaluable work.
Thirdly, I support the recommendation by Dr Rebecca Rosen at the Nuffield Trust for embedding more non-medical clinicians—such as pharmacists and dieticians—into primary care, an approach that worked well for us in the pandemic. There are lots of great examples already in primary care of working differently, from community health worker models in Westminster to the Healthier Fleetwood approach. The question that arises from these experiments is: how do we make innovation in primary care the norm rather than the exception?
Lastly, I will say a word about diagnostics. The pandemic demonstrated the value of consumer diagnostics, attached to digital reporting and used at home or on the high street. These tools engage people with their own healthcare, improve personal responsibility and relieve the pressure on overburdened healthcare systems. It makes no financial or clinical sense that people book a hospital or GP appointment for often extremely simple procedures such as swabs, serology, and faecal and blood pressure tests. During the pandemic, the Lighthouse Lab processed 150 million PCR non-NHS test samples, lateral flow tests were shipped at up to 4 million a day at their peak, and over 2 million blood samples were taken at home by finger prick and posted to labs to maintain the ONS infection study. I give a loud cheer to our new diagnostic hubs, but I fear that on diagnostics we are going back to the old-fashioned, cottage-industry-based pathology mindset rather than embracing the opportunity presented by the consumer diagnostic revolution.
Let us not fight the last war or try to recreate Dr Finlay. This Select Committee must examine the opportunities presented by this crisis for moving away from cumbersome paternalistic models towards a data and diagnostic-empowered citizen patient. That is what a Beveridge 2.0 could look like. That is the way to grow the economy and protect our people.
The noble Lord, Lord Patel, mentioned Dr Claire Fuller’s very interesting report to the NHS England CEO. She concluded that patient satisfaction with access to general practice is at an all-time low and described the 8 am Monday scramble for appointments as synonymous with huge patient frustrations. She said:
“left as it is, primary care … will become unsustainable in a relatively short period of time.”
We have all had evidence from the Royal College of GPs, which says that despite a government agreement to an increase of 6,000 in GPs, the number of fully qualified full-time equivalents has actually fallen by 1,622 between September 2015 and 2021. I mention again that I do not understand how the Government could have reduced the number of medical training places to 7,500 this year, following two years of there being about 10,500. It is amazing and extraordinary that the Government could have allowed that to happen. I had better declare my interest as a GMC member in that regard. The Health Foundation predicts that the shortage of GPs is set to become worse. It thinks that the current 4,200 shortfall will rise to more than 10,000 by the end of this decade.
Noble Lords have mentioned the recommendations of the Royal College of GPs: a new recruitment campaign, freeing up bureaucracy and investing in new technology—and I very much agree with the noble Lord, Lord Bethell, on that. But that is really not sufficient to tackle the fundamental issues we face. Noble Lords may be aware of a recent report by your Lordships’ Public Services Committee which looked at public service workforce issues generally. The stark conclusion is that every part of the public sector has targets for recruitment and none of them will be met. There is a lack of realism in accepting that and starting to do the work that needs to be done when faced with these acute problems. Again, I agree with the noble Lord, Lord Bethell, on that.
We need a realistic conversation about what we can expect primary care to do in future. Most of the evidence we have received says basically that we need more GPs but assumes that we carry on with the same 1948 model of primary care. That is not sustainable at all. We must be realistic and start talking about why that can no longer be the way we go forward.
Dr Fuller’s report to the NHS CEO was interesting. She argued for the streaming of services, with access to care for people who get ill but use health services only infrequently, and a distinction between their needs and those of people who are chronically ill and need care, to know their GP and access to multidisciplinary support. That is the start of thinking more fundamentally about primary care in future.
We must ask ourselves about the role of gatekeeper. People are wedded to the idea of the GP as gatekeeper—or, let us be truthful, as rationer of services. But when we look at outcome figures for, say, cancer, we must ask whether the lack of direct access to specialist care is one of the reasons that our outcomes are so poor. I do not know whether that is true or not, but we certainly need to ask the question.
How can we increase GPs’ job satisfaction? We must do something to give them the confidence to carry on in primary care in a way in which they get job satisfaction. We have many overseas doctors coming to work in the hospital sector. Can we change some of the rules and understandings in primary care to enable them to work there as well?
Finally, is the organisational model fit for purpose? We know that many GPs no longer aspire to partnership. What ought to take the place of that? If we are moving to a salaried service, partly in the employ of private-sector providers, how can we ensure that those GPs are getting the support, professional leadership and confidence to wish to stay in the sector in future?
I look forward to the Minister’s response. We do not need a lot of statistics, which, frankly, is not the answer to the fundamental issues we face. If ever we needed a special Select Committee, this is it.
I end by saying that dentistry in the NHS is in crisis. Something must be done to save many people from agony and frustration. Dentistry has not caught up after the Covid epidemic. I have every sympathy with anyone who has toothache from an abscess, having had one myself last week. The conclusion is that reform of the dysfunctional NHS dental contract is now a matter of urgency. A reformed service will not work if there is no workforce left by the time it is finally introduced.
When thinking about these experiences and about what I do not understand about the National Health Service and how it is organised and run, I am very thankful for what has happened in the delivery of my medical services; I have every reason to be grateful. There have been glitches along the way—a rare side effect, which affects only 1% of the population, but that just proves that I am an awkward person, as so many people are. I am truly grateful for the way in which the NHS has dealt with the various problems that I have had—and here I am, past my sell-by date.
When thinking about that, I reflect on my two grandfathers. They were both medical men, and they were both involved in the negotiations which led up to the Aneurin Bevan health service Acts. If they were with us today, they simply would not understand what is going on. The changes have been so radical—in society, in the behaviour and reaction of people in society, in the medical profession, and in the technology that has come over the past 74 years—that they would not understand what is going on and why it is going on in the way that it is. This leads me to think that we must be coming to a need to discuss, rethink and maybe alter the Aneurin Bevan settlement.
There have been so many efforts over that time, and yet we have heard the catalogue of the first four speeches of this debate. It is clear that something is amiss and that we need to think about this very big organisation, with its huge difficulties. The gearing in such a large organisation and the importance of that fact that, when medical services are delivered, it is very personal—they are essentially between two people; you and some medical practitioner who has been through a long training and has the knowledge—means that it will either work as it should or will run into troubles.
In thinking about where we are, I hope that the first thing that we will consider very carefully is the relationship between the political sector—this is a nationally provided service, funded from taxation and free at the point of delivery—and the medical profession. There is no natural fit between politics and medicine. There was not at the beginning of the health service, and indeed there were compromises made at that time which we still live with. In starting a discussion, we must go back to fundamentals, and we certainly need the medical profession to stand up and be counted on how it sees the way in which the delivery of medical services should be shifted. What is the borderline between primary care and secondary or hospital-based care? What are the fundamental questions which must be asked and answered if we are to go forward?
It is not as though they are new problems or that we do not know how to solve them. We know about integration, shared budgets, joint training initiatives, more realistic funding and better workforce support. We had great hopes when the integration White Paper was published earlier this year: it promised shared planning and delivery for health and social care and making access easier. But there was little to explain how a joined-up system would be managed, be accountable to the public and balance what is delivered locally with national standards and entitlements. That is another cause of bewilderment among patients: “Why does my sister in Devon or Doncaster get something that I have been told I can’t have where I live?”
I must turn to the disaster area of social care, because you cannot focus on any problems in the NHS without fixing social care. I was amazed, as many of your Lordships would have been, to hear the outgoing Prime Minister claim, on Tuesday, that he had fixed it. You could have fooled me or anyone else who works in the system. Why are ambulances in short supply and taking longer to reach those in need? It is obvious: they are queuing at hospitals because there are no beds to move people into from A&E. One in seven hospital beds is now occupied by a patient who is fit to be discharged but cannot be, because there is nowhere for them to go, because of chronic underfunding in the system. With such long-term shortages in the workforce, even those who have a care home place may be neglected, while unpaid carers carry even more burdens, as I have reminded your Lordships on all too many occasions.
I was grateful that the Minister was able to secure a concession for carers in the recent Health and Care Act, enabling them to be consulted at the point of discharge. However, all too often, local services to support them are sparse or non-existent. The charitable sector, which is often the main source of support, is also under severe pressure.
One reason is Brexit—so many former employees were from the European Union—while another is poor wages and another is lack of respect for the social care professions, which are always seen as the poor relation when compared with health services. The Minister referred to that in his Answer to a Question earlier.
The new Prime Minister said that she will stop the health and social care levy, which was meant to fund, first, backlogs in the NHS and, secondly, social care. Will she now give all that money to social care? If so, how much will it be and how many constraints will be placed on how it is used?
The lack of attention to and funding of preventive services is a constant problem, as the noble Lord, Lord Bethell, reminded us. Small amounts of money spent early in a patient journey can head off many problems, but too often we wait for a crisis, which requires far more resources and has poorer outcomes anyway. GPs can be vital in identifying such early-intervention opportunities, but are often denied the opportunity to do so. We must remember too that the cost of living crisis will only make problems of access worse and there will be more demand because of cold homes and inadequate diets.
Many have mentioned problems with primary care and the supply of GPs. The reason there are so many patients who walk into A&E is often the difficulty they experience getting a GP appointment. I know this is a major problem in many areas, but I must put in a word for some GP practices, such as my own, which provide services way beyond those we expect and attempt to support their communities with services and initiatives for the homeless, the lonely and those with mental health problems.
I turn to the reforms needed. We need more progress on integration, taking note of some of the local initiatives, which are fine examples, and not being constrained by the “not invented here” syndrome, which is a problem for many people who work in the health service. We must also face up to the workforce crisis. The Public Services Committee, on which I serve, has been mentioned, and it showed that no recruitment targets are being met. It was a great pity that the Government did not accept the amendments for regular reviews of the workforce put forward by the noble Baroness, Lady Cumberlege, when the Health and Care Act was going through. To address shortages, Governments, regulators and employers must succeed in retaining existing professionals and recruiting and training additional ones. This may mean that they have to challenge conventions about education and training and be far more flexible in how we deploy that workforce. How many times have I heard calls in this House for integrated training across health and social care, but has any real progress been made?
Being more flexible about patient need requires some professions to give up their protected status and to recognise that a nurse, physiotherapist, pharmacist or healthcare assistant can meet patient needs as well as or—dare I say it?—even better than a doctor. It is a pity that radical reforms of the regulation of the health professions have never been tackled, in spite of many promises.
The new Prime Minister said that the NHS will be a strong focus for her Administration. She will always find those who work in health and care committed, dedicated and willing to embrace change. What they ask for in return is honesty about the problems they face and recognition of their devoted service.
That model, having at its heart family doctors well versed with the needs of their patients in broadly small communities in small practice settings, was fine some 70 years ago, but the demographic changes in our country, and the nature of chronic diseases that now attend so many citizens, which have a profound impact on their quality of life and their need to avail themselves of health services, are quite different from 70 years ago.
In addition to that, advances in medical and clinical practice provide important opportunities to impact on many of these conditions, but those advances require changes in the way we deliver care, pathways of care and an important emerging recognition that the hospital cannot be the place where the majority of patients with chronic conditions are managed. They must be managed in the community. Indeed, many must be managed in their home. That requires a different approach to understanding how professionals in primary care and community care settings need to be trained and the skill sets required. It also requires a confidence in understanding that what clinicians might have done previously should be done by other professionals.
Therefore, a professional workforce must be developed, with a recognition that skill sets will have to be developed differentially and that those who might previously not have been involved in delivering direct care—more specialist nurses, community nurses and practitioners—will now need to be encouraged and developed to do so. It also requires the adoption of innovation and technology to ensure that this care can be delivered safely in the community. Patients and their relatives need to be confident that they can understand and have confidence in the digital and technological solutions provided in their own homes and in community hubs and community settings.
Regrettably, none of this seems to be being addressed cohesively, so we rightly welcomed the opportunity provided in the most recent Health and Care Bill for the development of more broadly integrated community care settings and integrated care partnerships and boards to supervise the delivery of that care and bring different elements of the healthcare system together. But we need to go far beyond that. The Minister will be aware that in the debates on that Bill, which he so ably took through your Lordships’ House, there were suggestions, which we have heard from other noble Lords, regarding ensuring that workforce planning, a better understanding of the methodology used in planning, and the parameters considered in terms of demographic change, emerging technologies, advances in our understanding of pathophysiology and the capacity to deliver care should be included in very sophisticated workforce planning that will help us understand not only the number of healthcare professionals required but their potential disposition by way of discipline and specialty, and the capacity, with emerging understanding, knowledge and technology, to train different groups of healthcare professionals so that, as we have heard, they can work more cohesively together as a team, delivering so much more of the care in the community and at home so that patients never need to come to the hospital.
Indeed, other European countries have been able to achieve these ambitions. They have much lower levels of bed occupancy in their acute hospitals. Therefore, they see no particular anxiety about times such as winter, when acute admissions will inevitably increase. We have failed to achieve that. This failure is now taking us to a place where the system will, as I said, become entirely unsustainable.
In closing, I urge Her Majesty’s Government to have the courage to start addressing the problems we face and to start establishing a narrative and communication to bring together professionals, politicians, the public and patients to help understand and develop a consensus around the very important, serious and far-reaching decisions that now need to be taken to ensure that we strengthen primary and community care with new models; to ensure that those models are properly co-ordinated with the changes that need to occur in secondary and tertiary care; and, attending all that, to ensure that we have appropriate workforce planning across those different environments and care settings, attended by a proper review of the regulatory framework in which those professionals will deliver care and a better understanding of how we will ensure proper adoption of innovation through funding innovation streams beyond the recurrent funding for day-to-day delivery of care.
“a way of joining up locally and bringing existing family services together to improve access, connections between families, professionals, services, and providers, and putting relationships at the heart of family support. The Family hub model brings together services for families with children of all ages (0-19) or up to 25 with special educational needs and disabilities … with a ‘Start for Life offer’ at its core.”
Otherwise, access was not prioritised in this guidance, but it should be.
A provider of healthcare services in one county, contracted to provide similar services in two integrated care systems and in two very different ways, told me:
“In one ICS, our contract to deliver children’s community health provision gives us the autonomy to deliver in the community and close to people’s homes. Where we can, we deliver this in Family Hubs so we can provide education for the parents, early help and appropriate expertise. We provide allergy, continence, perinatal mental health, speech and language and other support, all of which prevents unnecessary attendances in GP practices and A&E. However, in another ICS where we are sub-contracted by an acute hospital, we are required to deliver the same services from a hospital setting. The parent and patient experience differs significantly from one that is educated, empowered and supported to one that is the recipient of a treatment.”
Moving on to how health is described in the DfE’s Family Hubs and Start for Life Programme Guide, the lens always seems to be the very early years. Reference is made, for instance, to
“a clinical setting such as a maternity hub”,
mental health is couched in terms of helping families receive appropriate support for their parent-infant relationship and the specific conditions mentioned, such as neonatal necrotising enterocolitis, infer babies’ health needs. This is an important start, and the Department of Health and Social Care is, at this point, mainly interested in family hubs as the place where start for life services can be delivered, but their potential is so much greater than that, as my earlier example made clear.
Can my noble friend the Minister let me know what encouragement DHSC is giving to the wider provision of health in family hubs? I ask because, at present, the Family Hubs Network and others have found a distinct lack of awareness of their potential to ease the load on health providers. Health professionals tell us that paediatricians at local hospitals still do not know about family hubs, but need to. They often see families with well-established problems, such as obesity and incontinence, which are best treated closer to home with regular contact with early-help practitioners in family hubs. Social prescribers and therefore local GPs, even in areas where there are flagship family hubs, are similarly unaware.
Hubs are also a better place to take on the non-health problems which consume so much of GPs time. In 2015, Citizens Advice’s report, A Very General Practice, itemised how much time GPs spend on various non-health issues and found, unsurprisingly, that 80% of GPs said that such demands cut into their time for meeting patients’ health needs. Citizens Advice called for non-health demands to be met in ways that free up GPs to focus on patients’ health, particularly where they require specialist knowledge. The top three non-health issues that patients raise during consultations could and should be part of the family hub offering: 92% of patients mentioned personal relationship problems, 77% problems with housing and 76% problems with work or unemployment. Only one-third of GPs felt they were advising patients adequately.
Family hubs already join up services, including housing and employment coaching, from a wide range of government departments. DWP runs reducing parental conflict programmes in family hubs, where it is easier and less stigmatising to access relationship support, particularly for low-income families. Similarly, the MoJ’s pilot family hub in Bournemouth links with the family court and enables separating parents to get help earlier, and avoid costly and adversarial court processes.
Last week, the Children’s Commissioner’s Family Review said that every government department should bring forward family-strengthening policies, led strongly from the top. Family hubs should be the key delivery sites for them and expand their remit, for example, to include better support when parents make child maintenance claims, measures to tackle rural loneliness and disadvantage and intergenerational opportunities. A Cabinet-level Minister needs to co-ordinate these across government, backed by the new Prime Minister. Liz Truss pioneered this in government when she commissioned my review into the importance of prisoners’ family ties to prevent re-offending and intergenerational crime. She has also promised to look at family taxation, so I am expecting great things from her.
The Children’s Commissioner also said how important family stability is for children and parents. Profound mental and physical health ramifications flow from family breakdown. In a major study of more than 43,000 children, clinicians said that family relationships problems are the most common reason children and young people access mental health services. Resolving them often requires a whole-family integrated approach that it would be better for the health service to deliver in family hubs rather than secondary or primary care settings, which necessarily individualise conditions. Reform to make this a mainstream, default approach, where appropriate, is urgently needed for better patient outcomes, but it requires leadership from government to divert the NHS away from its well-worn tracks. Will the Minister kindly arrange a meeting for us to discuss this further with his new boss?