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Economy: Health and Social Care

Volume 709: debated on Thursday 26 March 2009

Question for Short Debate

Tabled By

To ask Her Majesty’s Government what research has been conducted into the impact of economic crises on demand for health and social care services; and what steps they are taking as a consequence.

I thank noble Lords who have agreed to take part in my debate. I am delighted that quality has triumphed over quantity today.

In February a fast-food chain announced that it was going to create 6,000 jobs. I am not sure if that is a green shoot or a sign of depression. In the same week, my Liberal Democrat colleagues on Leeds City Council announced that they were going to have to cut 300 jobs. When they were cross-examined on the radio, they explained that the reason was that a number of their funding streams had been cut and their income was down, in part because people could not afford to use and pay for their services, including swimming pools. Those two facts were in my mind when I constructed the precise Question that I have put on the Order Paper today.

Academics, voluntary organisations, commentators, service users and staff are all starting to talk about what the prospects are for health and social care funding during the recession, and it is evident from two recent announcements from the Government that they are thinking about it too. The decision to roll forward the funding for the Improving Access to Psychological Therapies programme and additional funding for voluntary organisations that provide information and advice, particularly advice about money, show that this is on the Government’s mind.

My intention today is to stimulate a much wider and deeper debate because it is evident that the effects of this recession will be extensive and long-lasting. When one starts to study the history of previous recessions one is immediately struck by how little evidence there is on the impact of prolonged economic downturns on health and the strategies that different Governments have taken to mitigate the effects. Certainly in past recessions, health was not the prime preoccupation. According to the Wall Street Journal, almost the only US companies to fare consistently well during the Great Depression were purveyors of the “cheap vices” of cigarettes, cigars, tobacco, sugar and confectionery, fats and oils. Their stocks apparently gained between 1.6 and 7.5 per cent a year between 1930 and 1933. Sweets and smokes and fried foods were the solace in hard times. Alcohol is not high in the list perhaps because Prohibition was under way in the US.

Most of the research on the effects of recession concentrates on how poor economic conditions might influence healthcare provision in various countries. Writing recently in the British Medical Journal, Professor Dorling, professor of human geography at Sheffield University, said that it has been shown in previous recessions in the UK, in the 1980s and 1990s, that people in work recover from illness faster and mortality rates for men doubled when they were made redundant. Professor Richard Wilkinson, emeritus professor of social epidemiology at the University of Nottingham medical school, also noted that the mere threat of unemployment and its twin evil of homelessness damaged health. He observed:

“It seems to be to do with stress, which has numerous physiological consequences on the cardiovascular system and the immune system. Sometimes people liken it to rapid ageing”.

There is little specific research on the link between economic recession and increased alcohol and drug abuse. Studies in countries such as Finland show a weak correlation. However, we already know that people in poor communities tend to be hit harder by recessions. These are the communities where those activities are already prevalent. There is a bit of research on health inequalities but it focuses mostly on geographical gaps. In Japan, which had a 10-year economic recession, a big study was done which showed that, in relative terms, people on middle to higher incomes deteriorated more in terms of self-rated health reporting than did those on lower incomes. However, people on lower incomes already experience more extensive poor health. That is an important finding for the Government to consider when they think about where to prioritise their interventions.

As noble Lords will know, in November 2008 Rethink, the mental health charity, provided a briefing to the Cabinet Office and the Department of Health which summarised the available research on links between different risk factors for mental illness in times of recession. The research showed that housing repossession and long-term arrears are linked to higher levels of stress and anxiety; there is a strong link between job loss and symptoms of psychological disorder; and there is evidence that economic recession leads to high usage of psychiatric services, although it also mentioned some caveats and said there are pre-existing conditions in the population which cannot all be attributed to recession.

Mental health is affected very quickly in a recession. Rethink did a survey in October 2008 and found an increased number of referrals and admissions to mental health services. It interviewed 2,000 people and their most pressing concern was the prospect of home repossession. Rethink commissioned a literature survey to go alongside that poll, and the evidence was that mental health admissions went up during the last recession. That poses an interesting question. During a recession, many people experience illness for the first time, and they may present to mental health services when they are in an acute state of distress. The NHS and mental health services have a challenge to make their services more accessible in new and more creative ways to people who have not previously had any contact with them.

I want to talk a little about NHS and social care funding, because this time around we are in a unique situation. The health service was given a very generous settlement last year. The budget rose by 5.5 per cent and it will do so again next year. It has had five years of record rises but that will change in 2010. Alan Maynard, professor of health economics at York, put it memorably when he said:

“After seven years of plenty the NHS faces seven years of want as the gross distortions in the economy are corrected. As a consequence the NHS is under intense pressure to recognise the problem and increase productivity by squeezing more … out of available resources”.

Similarly, the NHS Confederation noted more recently that it is as yet unclear what the impact of the recession will be on the NHS as an employer. However, the efficiency target of 3 per cent is likely to increase in 2010-11.

Managing efficiency is an ongoing expectation in the NHS but no organisation can continue indefinitely to provide more outputs with fewer resources. If money is to become tighter, priorities will need to be set for allocating that money. The NHS Confederation, with an eye to the future, has said that it may now be time to have an expert working group to explore productivity in the NHS and to look at efficiency savings. That group should have a look not just at the NHS as it is at the moment but at international comparators. I suggest that that is a good approach and I wonder whether the Minister might want to consider it. It is important, not least because one of the other things that we know from history is that the toughest times for public expenditure are when an economy is recovering and borrowing has to be paid back.

One other concern in the health service is that, when looking at what to do in a time of recession, politicians and NHS managers tend to look at what is discretionary in the NHS. They conclude that things such as hospitals, A&E units and ambulances have to be funded but that softer things, such as mental health services, community services and public health are fair game. Will the Government, in their forward thinking and forward planning, consider the importance of community services and public health, not least because they are the most effective services at preventive work and they are the ones that tend to be able to reach people long before those people find themselves in crisis?

I want to say a word on the voluntary sector, which I have to mention. The Charity Commission recently reported that donations to voluntary agencies had dropped by 50 per cent since the economic downturn. We already know that every £1 spent on advice, information and advocacy services in the voluntary sector saves £15 elsewhere in service provision, and that service provision includes the NHS. I know that the Government made a grant of £15 million to the agencies which offer money advice, and they were right to do so: when Citizens Advice was getting more name checks than Robert Peston—and deservedly so—it had to have further support. However, there are other advice agencies—those dealing with older people and children—and they, too, need help through this period.

Local authorities have echoed that. When they were surveyed by the Local Government Association back in January, they foresaw increased demand for welfare advice services; they saw that as critical to the ways in which their communities could be resilient in times of recession.

Older people tend to get left out of many of the discussions about recession because they are not economically active. Older people are not benefiting from the money which has been put into mental health because they do not come under that regime, yet thousands of them are extremely anxious about their pensions and income and they, too, need help.

I have one final technical point. Under a system at the moment, older people are allowed to defer selling their house in order to pay for care costs. It is called the system of deferred payments and means that their house is sold after they die to meet their bills. It is a discretionary power of local authorities to let older people do that. My former colleagues in Age Concern are finding that a lot of local authorities are not offering deferred payments to older people. I understand as well as anybody that local authorities are having funding problems at this time, but are the Government able to look at this and offer some assistance to local authorities to enable them to exercise this discretion so that older people who are already facing the trauma of going into a care home are not subjected to further anxiety?

The future is going to be difficult. It will be necessary for there to be greater productivity within health and social care services. Liberal Democrats believe that much productivity and efficiency will be gained by giving local people the opportunity to find new and creative ways of working. Health and social care have enjoyed a boom. It would be tragic if there were to be a bust, and I hope that the Government will enable local people making local decisions to come up with some innovative ways of spending what resources there are on public services in future.

I congratulate the noble Baroness on stimulating this debate and on her excellent and very interesting speech. I should like to focus on mental health, where the impact of the recession is going to be the most severe. As has already been said, all the research confirms that mental illness increases in recessions. This affects not only adults but their children. We had a debate in this House eight days ago on the provision of psychological support to adults and the way in which the Government are improving this in response to the recession. So today I want to concentrate on the needs of children, which have been neglected up to this point.

There are two official surveys of mental well-being, one following the other. They show that 10 per cent of children aged five to 15 suffer from diagnosable mental problems requiring specialist help, but that only a quarter of these children have received any specialist help in the past year. That is obviously unacceptable. It is far too difficult for children to get access to services. The threshold—the bar—is just too high. In fact, most people believe that the threshold has been raised in recent years rather than lowered, as one would have hoped. Unless something is done, this is likely to get worse over the next few years as needs increase due to the depression.

Very interesting analyses of these surveys done by Robert Goodman and others at the Institute of Psychiatry show tremendously clearly the force of impact on a child of the parent being depressed. That is why I am raising this point; the impact of the recession on parents will be transmitted to and felt by hundreds of thousands of children in this country.

Let me just give some further evidence that we are not currently up to scratch. The national service framework for the treatment of people suffering from mental health problems, published in 2004, specifies the number of care staff that a tier 3 CAMHS service should have per head of population. By CAMHS, of course, I mean Child and Adolescent Mental Health Services and by tier 3 I mean the specialist multi-disciplinary teams that exist in every PCT area as the main form of specialist provision.

The standards are there in the national service framework, but in 2006-07 the actual provision of staff in the teams was only two-thirds of that specified in the framework. So we have a long way to go if we are to deliver adequate capacity to meet the needs of our children. If we are serious about Every Child Matters, that is what we have to do, which is why the CAMHS review that was recently completed and submitted to the two departments recommended that the Government should assess training capacity and, if necessary, fund training centres to ensure adequate capacity. To push that forward, a number of us have joined together to make a proposal for what that increase in training capacity should be. Our proposal is that, over the next five years, the number of child therapists should be increased by training 1,000 more therapists over that five-year period, which means 200 a year. The extra 1,000 can be compared with the existing number of clinical psychologists and other therapists currently employed within CAMHS, which is 2,500. So we are talking about a serious but not at all unmanageable increase. That is the minimum needed, and I hope that this proposal or something like it can be included in the department’s proposals for the upcoming Comprehensive Spending Review. This is a good moment to bring that issue to a head, so we have the recession and the CSR together, giving us an opportunity to deal with the problem.

What is the cost? The cost of the proposal is not great. To train those people and employ them when trained would cost an extra £28 million a year in the third year of the Comprehensive Spending Review. If we add in two other things that are necessary, the full proposal would cost £35 million, which includes some top-up training in assessment for some existing therapists, which is very important, and more money for research on child treatments, which is also extremely important.

That brings me to my other main point, which is about the quality of CAMHS rather than the capacity. Again, the CAMHS stresses the need to upgrade the quality so that the NICE guidelines and evidence-based policies are what the service delivers. We have many services that are mainly evidence-based, but we have many that are not, although the NICE guidelines cover most cases that arise and which come to the service. On the evidence, the therapies recommended by NICE will, in most cases, give high rates of success. However, the fact is—and I think that most people recognise this—the guidelines are frequently ignored by many working in CAMHS services. We have survey evidence that confirms that.

Can we find a mechanism in the very decentralised NHS that we now have that could upgrade the services and get them to implement the NICE guidelines? In the Government’s plans now being implemented for adult psychological therapy services, we have a mechanism from which we can learn and achieve similar results in CAMHS. I shall say briefly how the adult programme of improved access to psychological therapies—or IAPT—is working. It started last year. I declare an interest because I am a member of the programme management board. It works as follows: first, IAPT funds the training and subsequent employment of thousands of new therapists, but, secondly, it states that these therapists can only do their placements in services which are agreed to be following the NICE guidelines. So there is a process whereby PCTs have a financial interest as well as a service interest in satisfying the NICE guidelines in what they are offering to their local populations and thereby being fit to host trainees. It is a rather self-reinforcing mechanism and a rolling programme whereby each year more PCTs are approved. With regard to adults, there has been a rush of PCTs wanting to be approved. Only a smallish number were approved in the first year and the programme is being rolled out. By the end of the programme all PCTs will have sought and obtained approval as regards implementing NICE guidelines.

The same procedure would work well within the framework of CAMHS, although CAMHS services are much better developed than the local psychological therapy services were for adults before IAPT began. There is no question that children’s services are being built de novo, but it is a matter of how to upgrade the existing service. What is needed is a small national CAMHS development team working through SHAs to upgrade standards through PCTs that can come up with and establish proposals that claim to carry out the NICE guidelines. I have focused on one group only but their needs will be very severe; those needs already are and will become more severe. They are of course the group on which our future depends. So I hope that the Minister can take these proposals to her colleagues and ensure that some radical proposal of this kind is adopted and promoted within the department through the CSR.

What is shocking to any of us who are concerned about mental health is how, if a child or an adult has a physical problem that needs specialist help, although there used to be a waiting time, we more or less assume that they will get that specialist help. That can be assumed to be going on as a result of the data there is on patients. Only a quarter of patients with mental problems are getting help. In many cases children are taken to or go to a GP, who cannot even consider referring them because the doctor knows that they will not be accepted. Sometimes, if they are referred, the situation is almost worse because there is just an assessment and the child is sent back because there is no capacity to treat them. That is not OK.

Returning to what the noble Baroness, Lady Barker, said, these services are not optional. They are provided on exactly the same footing as cardiology or anything else. There is a duty to carry out the NICE guidelines and the services are nowhere near achieving it. That must be a top priority for the NHS in moving forward. The situation has to improve and I hope that the Minister can assure us that it will.

I thank the noble Baroness, Lady Barker, for initiating this debate and for her interesting and instructive contribution.

The effect of the economic crisis on the NHS is that there will be immense pressure on the availability of resources for the health services, as the noble Baroness has already mentioned. This reminds me of another financial crisis in the NHS some years ago, when a chief finance officer told me to see 22 per cent fewer patients because he wanted to save £5 million in six months. I asked him how he had arrived at 22 per cent—why not 20 or 25 per cent?—and he said he thought it was about right. I said that I needed a sheet of paper with the figures worked out because, I had to explain to him, as 75 per cent of the budget went on salaries, there was only one way to save £5 million in six months: by removing 500 people from the payroll. He immediately said, “But that would cut patient activity”. I said, “But that’s what you were asking me to do”.

In the end, he was forced to make the savings in the way that we suggested. It was easily done: there were 200 vacancies every month, and every vacancy was carefully scrutinised to determine whether any patient would suffer if the vacancy remained. That really concentrates the mind. It did the trick, and we had no sackings or redundancies—which, as a Scot, appealed to me immensely. Incidentally, the salary of this chief finance officer was proportional to the number of people in his department, so why would he want to reduce their number? There are no mysteries, only mysterious people.

Here we are at crisis point again, but on an unprecedented scale. As has been mentioned, the budget rose this year by 5.5 per cent and is set to do the same next year. Experts are suggesting that it may rise by only 1 per cent in 2010, which may well result in a fall in funding once inflation is taken into account. As mentioned earlier, the most humane way—in, I stress, my personal opinion—to cope with this crisis is to make all PCTs impose a close scrutiny on all vacancies, asking the question, “If this vacancy remains unfilled, will any patient suffer?”. If the answer is no, the vacancy should remain unfilled, thus avoiding sacking or redundancy. That policy should have been started six months ago when the financial crisis became obvious, but the Government seem a wee bit hesitant to do it before the general election.

In past financial crises, hospitals have saved money by curtailing regular maintenance of their buildings. That is a tempting short-term expedient, but in the long term the total amount that has to be spent to catch up on sorting out the maintenance is greatly in excess of what it would have been if regular maintenance had been carried out every year. I hope that the Government will strongly discourage this expensive short-term measure.

So much for the future. What about the present? I can best illustrate that with a case history. I am not in the business of exaggerated scare stories. I think it was a former Minister of Health who said that a bed pan cannot fall off a shelf in an NHS hospital without the whole country hearing about it. The following case history, however, illustrates a real longstanding problem that has now got completely out of hand and must be solved once and for all.

The patient, Mrs B, was involved in a road traffic accident on a Wednesday several weeks ago. This resulted in a severe laceration to her calf, requiring admission to the accident and emergency department of a large teaching hospital. The nursing, as usual, was superb, but the management was a scandalous disgrace. As she needed surgery for her laceration, she was starved all day in preparation for a general anaesthetic and surgery. She waited all day, and in the evening was told that the operation had been cancelled. Having been starved all day, she was very hungry and dehydrated, so she asked for some food. She was told it had all been cleared away but eventually got a box of sandwiches. The following day was Thursday and exactly the same thing happened. The following day was Friday, and the same thing happened again—she was starved all day, dehydrated, frustrated, angry and kept in bed with all the attendant risks, including thrombosis.

Saturday was the fourth day. She went to theatre but the wound was found to need a skin graft and so the operation had to be postponed for another two days. On the sixth day, the operation was completed. As this ordeal unfolded, she began to wonder why she had been treated like this: what had she done to deserve it? As so often happens, she concluded that it was her fault because she was 81—a very active 81. I must emphasise that these repeated cancellations were not for clinical reasons to do with the patient; there was no effective attempt to assess clinical priority.

Prime Minister Thatcher used to say, “Don’t bring me problems, bring me solutions”. The solution to this problem is to have the most experienced person there make a management decision to interrupt any suitable theatre used in the five or six operating lists and say, “Excuse me, but at the end of this operation will you please go and have tea because we need to do a 40-minute operation. Just 40 minutes, that is all, to do an emergency operation”. That could have been done on any of those days.

A few weeks after this episode, a doctor fell downstairs at home and lacerated her scalp. Her husband is a surgeon and they discussed what to do. If they went to the nearby hospital, she would probably be starved all day and who knows when the operation would be carried out. So they decided on a DIY job. The surgeon excluded any other injuries, cleaned the wound and, because he had no anaesthetic or sutures to stitch the wound, he twisted a tuft of hair on one side of the wound, twisted a tuft of hair on the other side of the wound and then tied them in a neat surgical reef knot, bringing the wound together satisfactorily. This took five minutes, which they thought was preferable to the five days suffered by their friend Mrs B.

Will the Minister take steps to ensure that it is clearly understood that in every appropriate hospital there must be one person whose duty it is to ensure that repeated cancellations such as those suffered by Mrs B never ever occur again?

I am grateful to the noble Baroness for the opportunity to debate these important matters.

As noble Lords have mentioned, the current economic crisis is a source of hardship and anxiety for many families and businesses. For many people of working age, work and security are central to their health and well-being. Income shocks, lack of job security, unemployment and problem debt can contribute to an increased likelihood of depression and other health problems. Indeed, data from the health service for England show that being unemployed is associated with a reduction in health status roughly equivalent to that associated with being a smoker and, as was so eloquently described by the noble Baroness, Lady Barker, we know that this will increase the demand for some health services during the forthcoming period.

For several reasons, the NHS is in a good position to support people through the present times. First, NHS finances are now in a stable, sustained position thanks to significant investment and careful management. Annual expenditure on the NHS will soon exceed £100 billion per year, compared with £35 billion when we came to office in 1997. We have turned round some of our historic deficits, which will allow us to be flexible in responding to some of the fluctuations in demand for healthcare while maintaining sufficient funds to invest in new services.

We are very much aware that every pound spent on the NHS is from taxpayers, so value for money is critically important at this time, as the noble Lord, Lord McColl, mentioned. Nationally and locally, we need to be vigilant against waste and endeavour to ensure that all funding is used effectively.

We have secured costs in two of the areas of heaviest NHS expenditure—in drugs and pay. The 2009 Pharmaceutical Price Regulation Scheme provides stability in the price of branded drugs for the next five years. The deal allows a price cut of 3.9 per cent in the first year, followed by a further cut of 1.9 per cent and the introduction of generic substitution, enabling a pharmacist to dispense a generic drug against a branded prescription, giving fairer prices and value for money to the taxpayer.

On NHS pay, as noble Lords will be aware, we agreed a three-year pay deal for the 1.1 million staff covered by the agenda for change pay system. It runs until 31 March 2011 and will give certainty to staff and employers.

Through our reforms, we have tackled waiting lists, improved access and raised standards of care. As my noble friend Lord Darzi set out in his report, High Quality Care for All, we are now in a position to emphasise local innovation and action to meet local needs and raise quality. Clinicians and managers are free to respond to fluctuations in local demand for services without having to respond to any new national targets.

It is the responsibility of primary care trusts to understand and plan for change as demands change locally. World Class Commissioning is supporting PCTs to develop their capabilities to assess need, identify strategic priorities and prioritise investment to respond to the healthcare needs of their local populations.

We are very much aware of concern about the effects of the downturn on social care, particularly pressures on care home costs. We are continuing to work closely with local authorities and private providers to ensure that they are able to meet their statutory responsibilities and protect the welfare of care home residents. As noble Lords, and particularly the noble Baroness, are aware, we have been consulting extensively on a Green Paper, which will put forward proposals on how care and support can be funded and delivered in the future.

The noble Baroness will be aware that the department issued guidance to local authorities, circular LADH 2093, which includes guidance on deferred payments. We expect councils to offer deferred payments in appropriate cases. In our view, if local authority policy is never to offer payments, that is likely to be unlawful and would be taken to the courts. However, I undertake to take back the noble Baroness’s question about this issue, because I think that we need to look at the guidance again against her specific point about the downturn and the problems in the housing market. I want to make sure that the guidance does the job that it was intended to do.

The NHS is the largest employer in the country and so makes a key contribution to the economy. It has many jobs which would be suitable for the newly or long-term unemployed, and we are committed to helping to maximise those opportunities. We are working with NHS Employers, Skills for Health, Jobcentre Plus—my noble friend Lord McKenzie is here—NHS organisations and others to develop a co-ordinated strategy. We announced on 23 February that we are going faster, starting with an additional 5,000 apprenticeships across health and social care in the next year.

The noble Lord, Lord McColl, and the noble Baroness, Lady Barker, asked what would happen to funding in the recession. My right honourable friend the Secretary of State told the Health Select Committee on 11 March:

“We have looked at what happened in previous recessions, in the 1990s and the 1980s and we have looked at how government responded to those recessions and we are not going down that same route”,

which, in fact, is the route suggested by the noble Lord, Lord McColl. He continued:

“What happened in the 1980s and the 1990s, waiting lists grew longer—they just stopped operating and stuck them on to longer waiting lists; restricted the flow of new drugs on to the market and got rid of staff. We are not going to do that … When I said in the 1990s and the 1980s that the way the Health Service dealt with this is by getting rid of staff … [it] was because the government then chose to deal with [the recession] by cutting public services”.

We know that it will be tough, but it is doable. The way to deal with a recession is not to get rid of staff, restrict drugs or expand waiting times but to look remorselessly for internal savings, excluding from the very important developments in patient care—I again echo the noble Lord.

The issue of mental health was raised by my noble friend Lord Layard and the noble Baroness, Lady Barker. We know that we have an important role to play in protecting the mental health of people who lose their jobs so that they are in good health and can return to work when the economic situation improves. Since 2001-02, investment in mental health has increased by 45 per cent in real terms. We are expanding the availability of psychological therapies, aiming to train 3,600 extra therapists and treat 900,000 more people in three years. On 8 March, the Secretary of State for Health announced an additional £13 million in 2009-10 for a package of measures to help people who are experiencing distress, depression and anxiety associated with the downturn. This will fund a faster rollout of talking therapy services linked with employment support and health advisers on a dedicated NHS Direct phone line, trained to spot people who might be experiencing depression because of the economic problems.

On CAMHS, I am aware of my noble friend’s keen interest in and support for the Improving Access to Psychological Therapies programme. I am very grateful to him for sending me the improvement of tier 3 CAMHS, drawing on the IAPT experience, which he has also sent to my noble friend Lord Darzi and other Health Ministers. We are aware that my noble friend’s opinion is that we should not have pilots in this area but should just roll out the whole programme. He will appreciate that the evidence needs to include not only the possible benefits of taking action in this area but evidence on what form intervention should take. I know that Health Ministers are taking a keen interest in these developments. They have asked for my noble friend to be kept informed.

I can advise my noble friend that officials in the department are currently looking at what evidence is needed to support a bid in the 2010 Comprehensive Spending Review in this area. The successful bid would provide funding for three years—2011-12 and 2013-14.

My noble friend makes a very good point about the levers to improve the quality of CAMHS. I undertake to take that away and feed it back to the appropriate parts of the department.

The noble Baroness spoke about public health. I agree with her that we should not lose the progress that has been made in that direction. In difficult times, many people turn to things which are bad for their health. As the noble Baroness said, several studies have shown that the overall consumption of alcohol and tobacco could increase. We know that individuals who become unemployed may well increase their consumption of high-fat cheap foods and so on. Because of this, we are continuing to give a high priority to our public health campaigns to reduce smoking and harmful drinking, improve sexual health and promote healthy eating.

The noble Baroness also raised the issue of the third sector. The Government are committed to supporting the third sector through this difficult period. We have contributed significant financial resources to the delivery of the cross-government action plan. As the noble Baroness said, the £15.5 million community resilience fund contributes a significant amount to provide grant funding to small and medium providers in local areas that are most affected by the downturn.

As with all these things, the question is about delivery on the ground. We all need to keep a watchful eye to make sure that the decisions we take at a national level to provide funding result in that funding getting to where it is needed—to local providers of services. That could not only save jobs but ensure that services remain intact through the downturn. I have a large commitment to and interest in this, and we need to make sure that it happens. Those of us who are in contact with the third sector need to listen carefully throughout this period.

These are indeed difficult times. We know that the downturn is likely to increase pressure on health services, but we think that the NHS is in good shape to respond financially. The noble Baroness’s suggestion about discussing how we move forward deserves consideration, and again I undertake to feed it back. I do not know the answer to the question about how much consultation has taken place on that specific matter.

Since the NHS Plan of 2000, our health reforms have taken the long view. We will not jeopardise our vision and the nation’s health by taking short-term, knee-jerk risks with the momentum of reform, whatever the economic climate. The downturn will pose challenges for the NHS, as for any other organisation, but we think that we are in a robust position to meet them. I thank the noble Baroness and other noble Lords for their participation in this important debate.

Will the Minister follow my request for every hospital that admits emergencies to have someone responsible for ensuring that the kind of thing that I described does not happen? This is a common problem, I am afraid.

I beg the noble Lord’s pardon. I actually wrote a note to myself saying, “Lord McColl again points to the need for further efforts to be made in these directions in the delivery of services”. That is a very valid point, and I shall of course ensure that it gets fed back.

Sitting suspended.