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National Health Service

Volume 758: debated on Thursday 8 January 2015

Motion to Take Note

Moved by

My Lords, it is a privilege to be able to open this debate on the future of the NHS. It comes at a time when we are gearing up for the election and when it seems entirely possible that the NHS will be of some interest to the electorate. I will try to set the scene with a broad brush and leave it to other noble Lords to focus on various specific aspects.

We are going through a time when the media are full of one NHS disaster after another; with reports of cancelled operations, GPs and A&E departments being overwhelmed and waiting lists rising. We have not been short of media analysis in the past few days. That this is not simply the usual media hype is pretty obvious. We have had a number of careful reports from the Nuffield Trust and the King’s Fund, for example, that make sobering reading, with titles such as Into the Red? The State of the NHS Finances and Is General Practice in Crisis? suggesting that all is not well and that we cannot continue as we are.

The Government have woken up rather belatedly, with a sudden rash of activities. We have had NHS England’s Five Year Forward View, full of interesting aspirations; the Dalton review, with some ideas about how to go about achieving some of them; a number of crisis funding rescue efforts; and the Prime Minister reportedly sending in his pre-election “hit squad” to try to sort things out. However, it is pretty clear that quick fixes are not the answer and that the nature of the difficulties we face requires much longer-term solutions. It is good to hear that my own party is making some realistic proposals that might make a difference.

The causes of the problems are pretty widely understood. A service designed largely around acute hospital care has ignored for too long the needs of people with multiple long-term illnesses, especially those of the growing band of elderly patients whose needs are much better met in the community than in hospitals. This demand is certainly rising. The number of over 80 year-olds is set to double over the next few years and, for example, the number of people on more than three different pills for their multiple illnesses is growing by the day. I dare say that there will hardly be a Member of your Lordships’ House who is not on at least two pills keeping them in the fine trim that we see today, and I fear that I am no exception.

However, it is not only the growing proportion of the elderly and the worrying rise in the number of people with dementia that is causing difficulties; it is also the pressing demand placed on acute services. We can do so much more for patients than we ever could, and the population increasingly expect that they will be given the most effective treatments available. Many of those treatments are now very expensive. Complex scanners and investigations, coupled with the development of designer drugs produced specifically in response to an understanding of the genetic make-up of smaller and smaller subsets of patients, pose severe problems for a service working within rigid financial constraints.

It is in that financial squeeze where the nub of the problem lies. The fact is that the rate of inflation in health service costs is running way ahead of general inflation rates and certainly ahead of the growth in GDP. So every year the gap between demand and the funds available is widening, and this is what is responsible for the idea so often trotted out that the NHS is a “black hole” into which money just disappears. I do not believe that for a moment, and I will explain why shortly.

You might think that a Government would try to keep pace, if not with inflation then at least with the rise in GDP, small though that might be. In fact, the slice of the national cake devoted to health has gone down from about 8.5% when Labour left office in 2010 to 7% now—that is a fall of 17% in our share of the nation’s wealth. Even worse, predictions by the King’s Fund point to a further fall to 6% of GDP by 2021, on the current Government’s projections. That, I suppose, is all part of their plan to reduce overall public expenditure to pre-1940s levels, despite their protestations about a desire to protect the NHS.

It might be asked why these problems seem to have become much more acute in the past few years. After all, we have not all suddenly become older and sicker. The fact is that when Labour left office five years ago we had managed to get rid of waiting lists, patients were seen on the same day by their GP and patient satisfaction levels were high. It is no coincidence that we had appointed some 130,000 more front-line staff to cope with demand. So what has happened that left us with our current difficulties? Certainly, the distractions of the Lansley reforms did not help, with all the redundancies and re-employment of senior managers and the loss of continuity in leadership that followed. As Maynard Keynes said:

“It is not sufficient that the state of affairs which we seek to promote should be better than the state of affairs which preceded it; it must be sufficiently better to make up for the evils of the transition”.

I fear that we are still suffering from the evils of transition.

Then we have had the Nicholson challenge and the so-called efficiency savings of no less than £20 billion over the past five years. Of course anyone working in the service knows that it is always possible to improve efficiency, but now it is clear that the pips are being made to squeak too loudly as we run out of such short-term measures as wage freezes and the like. The inevitable result is that we are failing to keep up. GPs are overwhelmed, waiting times in A&E departments are rising, waiting lists are growing, social service departments are failing to cope and many such departments are now able to deal only with those in most serious need.

So what is to be done? I shall focus on four specific areas: disease prevention by public health measures; bringing hospital and community services much closer together; focusing on some specific aspects of care where we are clearly failing, namely A&E services, general practice and mental illness; and stimulating much more research and innovation where the potential dividends in health and well-being, as well as economically, are considerable. Of course none of these sounds entirely novel, but the fact is that we have failed miserably to achieve them so far. I want to examine why that is the case and what we should do now to ensure that we do not fail again.

First, with regard to prevention with the aim of reducing demand, no one can argue with the need to try to prevent the many illnesses caused by smoking, drinking too much alcohol and eating too much food. That is why I believe that the Government must get on with the plain packaging legislation, for example. We also know that the most effective measure to reduce alcohol consumption is to increase the duty on alcohol. It is pretty clear that whenever the price of alcohol goes above the rise in the general cost of living, the incidence of death from liver disease goes down—and, let’s face it, the increased revenue generated could make a useful contribution to the Exchequer and the NHS. I will leave it to other noble Lords to go into why the Government are reluctant to use this most effective measure, but the problem here is not that these are not vitally important things to be doing—they clearly are—it is the expectation that we will see financial savings from doing them in any reasonable timespan. Any impact on costs will inevitably take time.

Secondly, I turn to the need to see much greater co-operation and collaboration—what we used to call “integration”—between community-based and hospital services. The report from Sir David Dalton provides some very helpful ideas about how this might be achieved. He, of course, has managed to show how it is possible to integrate services extremely successfully in Salford and his report describes a number of other potential models for collaboration that fit in with different local circumstances. Clearly, the removal of the barriers between hospital and community is highly desirable and the idea of pooling health and social care budgets could be a very supportive measure. However, we have to be sure that current competition laws do not get in the way, and even more importantly, we have to be clear that the funds are available to facilitate this transition. It would be naive to believe that it could be done within existing budgets, even though in the longer term that sort of joined-up service will be more efficient, and of course it will suit patients’ needs much better. But in the short to medium term, it will need transitional funding.

The idea behind the Government’s better care fund was to try to bolster community services at the expense of the NHS, which itself is pretty cash-strapped. Robbing Peter to pay Paul is never going to be popular with Peter, and we now have the lowest number of beds per head of population than anywhere in the western world. If we are to see this vitally important change in the way services are delivered, we have to accept that fresh money will have to be found from somewhere.

Thirdly, I turn to three of the biggest challenges facing the NHS at the moment: problems in general practice, gaps in mental health services, and the troubles in A&E departments. The problems in general practice have been well rehearsed. I had a letter from a young general practitioner the other day in which she encapsulated the difficulties she faced. She said she was increasingly exhausted as her workload just seemed to grow and grow. She pointed to the shortages of practice nurses and care workers, the difficulty in recruiting to those posts, the fact that many of her colleagues were retiring early and that general practice was becoming a very unpopular option for young medical graduates. It seems likely that that is the reason why it has proved difficult for the Government to encourage medical schools to get 50% of their graduates into general practice. It is striking, too, that she said that she had to spend up to 50% of her time in administration. What a waste of her valuable time, which could be much better spent in dealing with her patients.

So there is much to do there. We need to recruit and train more support staff, especially practice and district nurses, who are in such short supply; we should bring together bigger groupings of general practices into multipractices or the like so that there are economies of scale; we need to recruit and train more GPs by making the job much more attractive; and we definitely need to reduce the horrendous bureaucratic burden under which they labour. I am afraid that once again your Lordships will have noticed that none of that can be done without some additional funding.

On accident and emergency departments, which have been in the news so much of late, there is this somewhat optimistic view that once we have stopped people smoking, drinking and eating too much and once primary and community care is up to scratch, the pressures on A&E departments will disappear. But that, of course, is some considerable way off and it denies the evidence from everywhere else in the civilised world that there is a universal rise in A&E visits. So, once again, moving the deckchairs here will not solve the problem and it seems inevitable that more funds will be needed to recruit and fill posts, both medical and paramedical, in these desperate departments. We are clearly wasting far too much money on expensive locums when that money should be directed to permanent posts.

Mental illness, despite much rhetoric about parity of esteem between physical and mental illness, remains a Cinderella service. I suspect that other noble Lords will expand on this, but there can be little doubt that more resources are needed there, too.

Finally, I will say a few words about research and innovation in the NHS. The UK has been pretty successful in supporting medical research through both public funds and the research charities—and here I should express my interest as scientific adviser to the Association of Medical Research Charities. Some good things are happening here: for example, with the National Institute for Health Research, under the direction of Dame Sally Davies with the strong support of the noble Earl; the Health Research Authority is streamlining ethical approval; and the MHRA is providing quicker routes for licensing new medicines. However, there are many problems, too, because while we may be good at research, we are too often sluggish in taking up innovations. There are concerns that future funding for NIHR and its invaluable academic health science networks and centres remains uncertain, and there are also worries about the willingness of CCGs to support the Charity Research Support Fund. We are also failing to encourage and support those entering a clinical research career while their conditions of service are being neglected.

A tortuous funding approval process also gets in the way. It may come as some surprise to learn that to get the approval of NHS England for a new medicine to treat a rare disease there are no fewer than eight committees through which it has to go. It has been said that if you want to avoid making a decision, set up a committee. If you want never to make a decision, set up eight committees. That is a case where NHS England needs to look at its own efficiency, and if it is just an example of its committee structures, it has some way to go.

In the pressure for ever more efficiencies, we must avoid being so short-sighted as to leave research and innovation to wither away. The dividends we will lose are just too great. I believe we know what should be done—there is a growing consensus on that. However, it is increasingly clear that without an input of more resources we will not be able to rescue the NHS from this downward spiral. Even Simon Stevens, the chief executive of NHS England, has said as much. The next Government will have to face up to this issue and square with the public about how they intend to protect an NHS and a social service system that is so precious to them and to focus on the sources of the increased funds that are needed. I look forward to the speeches of other noble Lords and to the Minister’s response.

I remind the House that time is very tight, so I ask noble Lords to keep their remarks to six minutes. When the clock shows six, your time is up.

My Lords, I think we are all very grateful to the noble Lord, Lord Turnberg, for initiating this debate. Obviously, it could not be more timely. He may recall that he and I first met when he was president of the Royal College of Physicians and I was a Minister at the Department of Health. Even then, we had the same post-Christmas problems—we may also be taking the same pills, for all I know, but I will not speculate on that.

I will put forward two particularly positive points as we review the situation, which is obviously worrying, and the longer term situation, which the noble Lord wants us to address. The first is that the NHS remains a good and a tried and trusted model for the delivery of healthcare. If you look around the world, it is very difficult to find one that is better as regards value for money and quality—although we know that there are gaps. It is also, as my noble friend Lord Howe pointed out in his Statement yesterday on the winter problems, remarkably flexible when it needs to be. We see that a number of hospital trusts are coping with these sudden increases in demand in a very innovative and sensible way.

The second positive point I will make is that there is wide consensus—although one would not think so in the political debate that is going on—over the way the NHS should evolve. I will concentrate in my short remarks on the Five Year Forward View, which was produced by Simon Stevens, the chief executive of the National Health Service England, in October last year. That has received general support from all sides of politics, and it was both realistic and sensible. However, the conclusions it reached have been underplayed. The central conclusions Simon Stevens points out in his report’s final two paragraphs are that even if funds remain broadly flat in real-terms increases—and in fact, despite what the noble Lord, Lord Turnberg, said, spending on the National Health Service and on health in this country as a whole has more than doubled in real terms since I was a Minister back in 1997—and if the service continues its annual increases in efficiency of 0.8% a year, which is not a huge annual increase, the £30 billion gap which he envisages by 2020 would reduce to £21 billion. If the increase in efficiency was doubled to 1.5% every year—again, not a huge increase—it would reduce that £30 billion gap to £16 billion. If efficiency could be increased to 2% to 3%, which is quite normal in other industries and services, the funding gap would be almost wholly eliminated and we would be able to reach the nirvana of a continuingly progressive and successful health service.

In that context, I make one suggestion to my noble friend Lord Howe. We know that many hospital beds are occupied by people who do not need to be there, who do not need acute care any longer, and who could be in a recovery situation or intermediate care elsewhere. It is the fact that many housing associations and mental health trusts have been lobbying hospital trusts up and down the country, asking to provide intermediate and recovery units for them, so they can transfer patients from acute services into those intermediate or recovery services. I noticed on the BBC last night that a trawl had been done of where the problems were; a spokesman for Addenbrooke’s Hospital in Cambridge said that 20% of its beds were occupied at this moment by people who could be cared for in a recovery unit or in another form of intermediate care. But the housing associations and mental health trusts are finding that, although very often the chairman and CEOs of hospital trusts are glad to have this support, it is simply impossible to get decisions. The noble Lord, Lord Turnberg, pointed out that among other things it is very difficult and slow to get decisions through the bureaucracy of even the trusts themselves, let alone the overall NHS, and this is causing a real problem.

I hope that my noble friend Lord Howe will look at this issue, where there could be an immediate improvement, within a matter of months, in the number of facilities being taken up by people who do not need to be in hospitals. It would save the capital costs, because housing associations would pay for them out of their own capital funds. It would also save current costs, because an NHS bed costs £2,000 a week to maintain. The housing associations tell me that they could do it for less than £1,000 a week, halving the current costs as well as providing capital money for the NHS. So there is an example of where efficiency savings could be made in a very short space of time. We are talking about months or even a year or two.

Simon Stevens’s conclusion, following the final two paragraphs of his report, was that,

“nothing in the analysis above suggests continuing with a comprehensive tax-funded NHS is intrinsically undoable”.

I believe that to be correct and right, but we will achieve that only if the trusts up and down the country stop being just administered and manage the resources, using the funds available to them properly.

My Lords, I congratulate my noble friend on his timely debate, which has become even more relevant in the face of the tsunami of so-called special incidents which are apparently swamping the NHS at the moment. On the face of it, the A&E tsunami is rather unlike the other winter crises that we have experienced. After all, the weather is not particularly severe and we are not experiencing a threat from a new infectious illness, such as SARS, or even a normal seasonal flu epidemic. Indeed, as was rightly asserted in this House yesterday, much of the primary cause of the present situation is government policy—and, specifically, the reduction in social care and the fragmentation of health services to which the noble Lord, Lord Horam, referred.

The only possible political silver lining that I can see is that the Secretary of State Mr Hunt seems to recognise that he is accountable and responsible for what is happening. I was surprised and somewhat relieved to hear him say yesterday in Commons Hansard:

“I take responsibility for everything that happens in the NHS”.—[Official Report, Commons, 7/1/15; col. 277.]

That is in sharp contrast to his attitude last autumn when the Secretary of State received the Five Year Forward View as though it was a rather interesting contribution from an independent think tank. In exasperation in response to that, the shadow Secretary of State, my right honourable friend Andy Burnham, commented:

“I do not know who runs the NHS these days, but I do know that it is certainly not him”.—[Official Report, Commons, 23/10/14; col. 1045.]

He also said that this was a clear illustration,

“of the serious loss of public accountability”,

following the 2012 reorganisation Act.

Those of your Lordships who took part in the long drawn-out proceedings on that Act in this House will remember the battles that we had to retain the central responsibilities of the Secretary of State in the legislation, responsibilities that had after all been there since 1948. We eventually succeeded so that the Act now reads:

“The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England”.

The noble Lord, Lord Mawhinney, a previous Conservative Health Minister, said in our debate that everyone now knew that the,

“Secretary of State is the boss and is held accountable”.—[Official Report, 8/2/12; col. 303.]

I certainly hoped that this meant that in spite of the determination to transform the NHS into a regulated but independent competitive industry, the personal statutory accountability would prevent the most harmful results that we feared from the Act. I was wrong. Now I can only hope that the present damaging crisis may suggest to Ministers that they should exercise greater responsibility and accountability, not just for expenditure but for at least some of the policies proposed in the forward view.

I want to focus in my remarks on paragraph 3 of that report, which says:

“The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health”.

I certainly accept that clarion call; my concern is that the 2012 Act has made it difficult to fulfil. Noble Lords will be aware that public health programmes are often rooted in community-based, sometimes voluntary organisations. These can be very useful, particularly when informal outreach schemes dealing, for example, with problems such as drug or alcohol abuse, can be much more successful than statutory services. but today the competitive reorganisation has led to a hugely expanded pool of non-NHS community providers—a staggering 69% of the new contracts agreed. In my estimation, that must lead to enormous fragmentation and great difficulty in achieving national goals.

In particular, I draw noble Lords’ attention to very real problems in delivering good sexual health and HIV prevention and treatment services under this new system. In recent months, as the noble Lord, Lord Fowler, has just done, we have rightly focused on the Ebola virus, but the latest figures for HIV in this country are a cause for a new concern. In the past 12 months, the numbers of gay men newly diagnosed are the highest since the figures were first collected 20 years ago. During the intervening years, of course, we have developed world-leading clinical care in this complex field and created much-admired prevention programmes, but those are now threatened. Part of the problem is that the public health commissioners in local authorities simply do not have the relevant specialist knowledge and experience. I have learnt, for example, of a particularly stark case in Chester, where the hospital-based specialty services created and led by a very senior consultant are to be replaced by a consortium of GPs. There the Countess Of Chester Hospital put forward a comprehensive tender for an integrated sexual health service led by five consultant doctors costing £2.4 million. This has been rejected in favour of an exclusively GP service with no hospital specialist input, costing £2.8 million. It is very hard to see any financial or clinical logic behind this. I wish it was just one example, but it is not.

I want also to explain my concern about the particularly bad situation in relation to HIV prevention. The Government have now said that the programme for national HIV health education will be cut by a staggering 50% in the next financial year. We cannot afford complacently to allow the prevention and treatment of infectious, dangerous diseases to slip from the effective grasp of a national health service. I fear that that is likely to happen.

Overall, I would like to be optimistic about the future. I agree with many of the ambitions in the Five Year Forward View and respect Simon Stevens, who was a special adviser when I was a Minister in the Department of Health. However, he is far too complacent about the encroachment of independent advisers and the resulting fragmentation of important services. Overall, we must retain the national leadership of the NHS not only through the executive managers but essentially through the Secretary of State. His accountability to Parliament and responsibility for the provision of health services should always be the keystone of the health service.

My Lords, I, too, thank the noble Lord, Lord Turnberg, for giving us the opportunity to discuss these matters today. He, like a number of other noble Lords, is a veteran of such discussions. While I pray in aid documents such as that produced by the Royal Commission on Long-Term Care, the Wanless report, Wanless II, the Darzi report and now the Five Year Forward View by Simon Stevens, he will perhaps agree with me that, over the time that he and I have been Members of this House, the issues facing the National Health Service have not changed but have remained the same. We have had report after report telling us in varying degrees of detail what the shortcomings of the National Health Service are, how it does not integrate with a sufficiently unbroken social care system and what it needs to do to put that right.

My right honourable friends in another place, Norman Lamb and Paul Burstow, have similarly followed those discussions. I am pleased to say that, in their time in government, they have enacted quite a number of the recommendations put forward, not least the return of public health to local government. Back in the time of Derek Wanless, the observation was made that if our tax-funded National Health Service was to endure, it would have to do so in the context of a population that was informed and engaged about its own health, and that the NHS could not tackle that on its own. I hope that any future Government, tempted as they no doubt will be to rearrange the service—let us call it not a top-down reorganisation but a rearrangement—will resist the temptation to take public health back from local government and will leave it where it is, with the health and well-being boards, to give them the chance to build on the work they have done on prevention in the past two years. Some 70% of the health service is now about enabling people to manage long-term conditions.

It occurred to me—particularly in the past week, when we have been inundated with stories about how the NHS is failing to deal with emergencies—that much of the literature on the NHS is directed at how we deal with an ageing population. At the same time, we have rather lost sight of how young people engage with the NHS. The most interesting findings over the past month or so concerning the problems in A&E were not about lots of older people who are no longer being supported by social care turning up inappropriately in accident and emergency units but rather the number of young people who turn to accident and emergency units as opposed to their GPs. That is a very worrying issue to which we should give great thought, because GPs continue to be the linchpin in terms of most people’s ability to manage their own healthcare and their health and well-being in the longer term. If young people are engaging only with A&E on an episodic basis, that will store up problems for the NHS in the longer term.

Finally, one of the most laudable things that has happened in the past two years is the increased attention that this Government have given to mental health, which is supported by the Opposition. We are finally beginning to understand the importance of mental health and the problems that we cause the country in the longer term if we ignore it. Some interesting work has been done by new organisations which have not previously taken any part in our health debate, such as Mumsnet, which has talked for the first time about the incidence of mental health problems in very young people aged under 11. It also talks about the high incidence of perinatal mental health problems beginning to challenge orthodox providers in the National Health Service and the voluntary sector. I sincerely hope that the next Government will continue to work with organisations, perhaps new and emerging voluntary providers, to take a completely fresh look at some of the long-standing problems that we know have challenged the NHS.

We as a party have said that we will aim to increase NHS funding by £8 billion. We will do so on the basis of continuing challenge and reform. It is possible for there to be a 25% reduction in preventable mortality by 2025, but only if we continue to change the way in which the NHS interacts with the population, the voluntary sector and the people who are capable of addressing the problems upstream that present as emergencies to the NHS.

My Lords, I thank the noble Lord, Lord Turnberg, for securing this very timely debate. The National Health Service is so important that it should not become a political football. Patients need accurate, safe healthcare to enable them to get better quickly. If that is not possible, they should have compassionate care. All services need to co-operate and communicate with patients. Integration should be the aim, not working in silos.

I give myself as an example. I had been coughing for months and had an X-ray on 21 November but have never had the result. Having had three antibiotics, I decided to come off the statin that I was taking as I became frustrated with the cough. It seems to have worked. So much of patient care seems to be trial and error.

I take this opportunity to stress some of the difficulties surrounding rural health. Our surgery at Masham is open only every other Saturday for half an hour, for a half day on Thursday and is closed every day between 12.30 pm and 2 pm. The surgery needs to be improved but no one will pay, so my doctor went to Canada.

Next door to the surgery is the Marsden pharmacy, which has a four-inch step with no handrail or ramp, making it inaccessible for people using wheelchairs unless they are super-fit, and for those using walking frames. It is frustrating that this building has just been renovated and disabled peopled, who perhaps need the pharmacy more than most, have not been considered.

On Sunday, I spoke with a member of the Army from Catterick, which has the largest military camp in Europe. I was told that the Catterick Medical Centre has been given a bad report and has to close every day at 3.30 pm, leaving the A&E department at the Friarage Hospital as the only alternative. More military personnel are coming back from Afghanistan and Germany. Therefore, urgent improvements are needed if the future of the NHS is to improve.

I was very pleased to be invited to give the awards to the Yorkshire Ambulance Service last autumn. I found the staff to be dedicated and enthusiastic. In rural areas, where the countryside can be challenging and public transport in some areas is non-existent, the ambulance service can be vital. Without doubt, the Air Ambulance is the most popular charity in north Yorkshire. The impact on the ambulance services in England is very great. There continues to be a year-on-year increase in demand. The major increase has been seen in top-level emergency calls.

There is a worrying situation in that there is a shortage of district nurses, with many having retired or gone off sick. They are so important in helping with ill and disabled people in the community. What plans are there to increase the numbers in the future? I have a cousin married to a registrar surgeon. The surgeon tells me that there is concern about the modern shape of training for surgeons. She tells me that hospitals with poor records should not be training and that sometimes deaneries come round and find poor standards but do nothing about it. She also tells me that the European working time directive has not helped with the training of surgeons. Surgical training should be a priority. I ask the Minister: should we not be aiming for the highest standards of surgery and safety, and stop the worrying increase in negligence claims that is draining the NHS?

I am so pleased to see my colleague, the noble Baroness, Lady Wilkins, back in her place. As president of the Spinal Injuries Association, I ask the Minister to look into the worrying situation where so many excellent doctors and surgeons working in spinal injuries have retired and new young doctors are not coming forward to take their place. Also, the cutting of physiotherapists and occupational therapists is detrimental to rehabilitation. High-lesion tetraplegics on respirators are often kept in intensive care beds in general hospitals because of the lack of beds in spinal units. Therefore, there is a blockage in intensive beds in general hospitals, causing huge problems.

Because of paralysis, the “three Bs”—bowels, bladders and bedsores—become very important to these patients. One of the distressing problems for spinal patients being in general hospitals is the difficulty of having their bowels evacuated, as nurses seem to shun this essential part of care. I hope that in future the NHS will recognise the importance of specialised spinal units with trained specialist staff.

I end by saying that there are many complicated conditions that need to be researched, but of concern is the increase in people with liver disease and hepatitis C. I hope that in future they will get the new, crucial drugs that are available but not yet approved by NICE.

My Lords, I am sorry that we are missing a contribution from the noble Lord, Lord Ribeiro. He is always worth listening to. I hope that being scratched from the debate does not mean that he is unwell.

I thank my noble friend for bringing up this wide but highly topical subject, given the daily headlines about one NHS crisis or another, including today. The issue is also high on the agenda of all parties in the run-up to the election. What is becoming increasingly clear—my noble friend Lord Turnberg referred to this—is that the NHS and social care are underfunded and that this is the main reason for longer waiting times and deteriorating services. To call for greater efficiency in a health service that is recognised internationally as highly cost-effective can only mean staff reductions or lower salaries, and worse care. Some say that this is deliberate to encourage more people to move to private medicine.

I want to focus on prevention, which is highly relevant to today’s pressures, as described in the Five Year Forward View, to which several noble Lords have referred. It is better written than the average document from the Department of Health and freer of jargon and acronyms, although I noticed one or two lapses—for example,

“the need to transition to a more sustainable model of care”.

The report puts prevention of disease high on the agenda in the section headed, “Getting serious about prevention”. This phrase is taken from the health review written by Derek Wanless 14 years ago. At this point, I should declare an interest as trustee of the UK Health Forum, formerly the National Heart Forum, which advised Wanless when he was writing his report. He suggested, as the noble Baroness, Lady Barker, said, “a fully engaged scenario”, in which all sections of society should become aware of the health implications of their activities and products. He warned that unless the country took prevention seriously, we would be faced with a sharply rising burden of avoidable illness. As the Forward View put it,

“that warning has not been heeded—and the NHS is on the hook for the consequences”.

Instead, one in five adults still smokes, a third of people drink too much alcohol or do not take enough exercise and almost two-thirds are overweight or obese. This has had consequences in increasing the flow of costly treatments.

Our expectation of life, however, continues to go up. Part of this is due to the success achieved in reducing cigarette consumption, partly due to the measures introduced by the last Government, including banning tobacco advertising. This Government have also brought in some tobacco control measures but, rather worryingly, they seem to be dragging their feet on the important issue of plain packaging. It is important to get this legislation on to the statute book before the election and to do that it must be laid before Parliament before the end of this month or sooner. I think that the noble Earl is aware of the widespread desire from across the health professions and elsewhere for this to be done. I hope that he will be able to assure the House, perhaps today, that this legislation will reach the statute book before the election. If not, the Government and the Conservative Party will lose even more credibility when they claim to safeguard the nation’s health.

The NHS should also take some credit for the continuing increase in life expectancy, but the increasing incidence and prevalence of avoidable non-communicable disease is a major cause of the heavy pressure that the NHS is now under. One example of this is the avoidable burden that heavy drinking places on A&E departments at weekends. The Government have not taken the first step in reducing alcohol consumption that minimum pricing would provide. There is little doubt that the drinks industry is putting pressure on the Government to avoid this simple measure. It would have most impact on cut-price off-sales, which many young people indulge in, “preloading” to avoid higher bar prices when having a night out. In the past few days, the alcohol health association has said that there should be more information on alcohol products, giving not only the strength but the calories and other health implications.

The Five Year Forward View puts it rather admirably:

“We do not have to accept this rising burden of ill health driven by our lifestyles, patterned by deprivation and other social and economic influences. Public Health England’s new strategy sets out priorities for tackling obesity, smoking and harmful drinking; ensuring that children get the best start in life; and that we reduce the risk of dementia through tackling lifestyle risks, amongst other national health goals ... While the health service certainly can’t do everything that’s needed by itself, it can and should … become a more activist agent of health-related social change”.

My Lords, belatedly all political parties are waking up to the fact that the future of the NHS is top of most people’s agendas in this country, which is why it is going to be prominent in all manifestos for the coming election. The country is also recognising that not only is the population getting older, needier and more disabled but disabled people like me are living longer than we probably would have done some time ago. Boys and young men with Duchenne muscular dystrophy only 15 years ago were dying in their teens, yet today, thanks largely to night-time ventilation, they are living into their 30s and 40s.

The lessons in the field of rare neuromuscular conditions—the field that I know best—are clear. Money spent wisely now by commissioners on access to specialist support and better care in the community for people with these conditions will save a significant sum later in unplanned emergency hospital admissions. That was the finding of a 2011 audit by Professor Michael Hanna of the National Hospital for Neurology and Neurosurgery in Queen Square, yet it appears that commissioners are not prepared to invest in this way to save in the future. I count myself lucky that I live in the capital, near a centre of excellence in this field, but there are significant gaps around the country in specialist care. The ideal is the development of managed clinical neuromuscular networks that bring together consultants, physiotherapists and family care advisers. An example is the one in the south-west, which co-ordinates service provision and the sharing of skills and expertise.

I now turn to research, which was a hugely important but largely unrecognised part of the Health and Social Care Act: the Act places a duty on the NHS, for the first time in statute, to promote research. A future NHS must do more to promote research and ensure that the UK has the clinical trials infrastructure to attract investment from pharmaceutical companies wishing to conduct trials. That was mentioned also by the noble Lord, Lord Turnberg. With the right support, the UK could become a world leader in this field—for example, through support for patient registries and databases for rare diseases. At present, the Muscular Dystrophy Campaign funds the NorthStar database and the national neuromuscular database, but this arrangement does not guarantee long-term security. Does my noble friend agree that if the NHS is to promote research, it should provide support to databases and registries for rare diseases?

I now turn briefly to funding for new treatments. The NHS will face an increasing challenge to deliver innovative but high-cost treatments with advances in genetic medicine. Will increased competition for funds mean that treatments for rare diseases lose out? To avoid that situation, will the Government introduce a ring-fenced fund for rare disease drugs, as has been done in Scotland?

That brings me to my last point, which is that the NHS must have a clear and transparent means of approving new treatments. I am sorry to say that the experience of the Duchenne treatment Translarna does not bode well, with one of the final stages of the process being held up. I know that my noble friend’s colleague, the Minister for Life Sciences, has been closely involved in helping to find a solution. Will my noble friend encourage his colleague to redouble his efforts to help steer through an interim solution that would allow patients access to this drug, which is available in Europe, by April of this year? It is effective only in boys who can still walk. There are many parents who watch in despair while the days pass, knowing that without a drug such as Translarna eventually their young sons will take their last steps.

My Lords, my interests are in the House of Lords register but I should declare that I am executive director of Cumberlege Connections and of Cumberlege Eden & Partners.

I, too, congratulate the noble Lord, Lord Turnberg, on initiating this debate. He is a truly remarkable man and is probably one of the most qualified and experienced of your Lordships when it comes to analysing the health service, as was evidenced today in his remarkable speech. I did not agree with it all, but it was remarkable. If one looks further, it is really interesting and fascinating to read his book, Forks in the Road. Does not that title really sum up the views of the nation? The NHS is hugely valued. We are at one in wanting to ensure its future. We are journeying on the same road, but there are many choices to be made on the way.

The ethic is inalienable. Whether we are rich, poor, young, old, black or white, we want a service that is largely funded by the taxpayer. I say largely because successive Governments, including the Labour Party when it was in government, have largely eroded the ethic by stealth—introducing prescription charges and other charges. The general public do not want to produce a credit card for services rendered but they are ambivalent as to who provides the service. If the service is compassionate, kind, professional, efficient and provides value for money, albeit that it is provided independently, the public are largely satisfied.

I endorse the views of my noble friend Lord Horam. Worldwide the NHS is recognised as a winner. We have been ranked as the top health system in the world by the Commonwealth Fund. We also know that when it comes to asking the British what makes them proud to be British, the NHS is top of the list, before the Armed Forces and even the Royal Family. We also know that there is always room for improvement. Lest we get complacent, we only have to think of North Staffordshire, Winterbourne View and so on.

The noble Lord rightly highlighted the challenges that we face and they are beyond dispute, but we should not ignore the progress that we have made. At a time of austerity, we have increased the NHS budget by £12.7 billion. “Not enough”, is the cry but it will never be enough. In the past five years, the number of clinical staff has increased by 12,500, and 850,000 more operations are being delivered each year compared with 2010. The number of patients looked after in mixed-sex wards is down by 98%, which is a subject I know is very close to the heart of the noble Baroness, Lady Jay, from when she was in opposition and when she was in government. Listening to her speech today, I was deeply worried when she quoted the shadow Health Minister as saying that he did not understand how the current system works. I respectfully suggest that he looks at pages 88 and 89 of the book by the noble Lord, Lord Turnberg, which clearly sets that out in a diagram.

Looking at the next five years, as has been said, NHS England’s priority is to engineer a radical upgrade in prevention and public health. It goes on to say that the NHS will,

“back hard-hitting national action on obesity, smoking, alcohol and other … health risks”,

which I welcome. I share the view of my noble friend Lady Barker that we should stay with the health and well-being boards, and not be tempted for another reorganisation.

In Britain, we attempt to run a fair society, a society which protects citizens from abuse by those unwilling to respect others. We have cracked down on drunken or reckless drivers and on faulty cars. People who abuse our roads are prosecuted and our roads are safer for it. The problems of the NHS are in some measure due to people abusing the system. Resources are spent on dealing with drunks, time-wasters and drug misusers, leaving the system in danger of being overwhelmed so that those in real need are deprived of life-saving treatment. The NHS constitution is very strong on rules for staff but is ineffective and weak when dealing with users. The contrast with drivers who have to learn and adhere to the law is very stark.

Looking to the future, we have to introduce rules to protect and enhance the treatment of people who are ill. Without known rules, any organisation, including this House, can descend into chaos. With a strong economy, we can afford to pay for its use but we should not fund its abuse. Does my noble friend agree?

My Lords, I, too, congratulate the noble Lord, Lord Turnberg, on the way in which he introduced this debate. It has been a civilised and, in many respects, expert debate. I am worried that I may lower the tone because I want to make a couple of more political comments. However, I shall try to do so in a civilised way.

The basic reason I wanted to speak in this debate is that I fear for the future of the National Health Service given the implications of the emerging Conservative approach to public finance in the next Parliament. I do not in any way doubt the sincerity of Members opposite—my friend the noble Lord, Lord Horam, the noble Baroness, Lady Cumberlege, who has just spoken, and the Minister—the Secretary of State for Health or the Prime Minister, or their commitment to the principle of the National Health Service. However, I doubt the sustainability of that commitment given the approach to public finance set out in the pre-Budget report at the beginning of December, particularly the prioritisation of tax cuts when resources become available and the intention to reduce by the end of the next Parliament the share of public expenditure in GDP to 35%.

The Government have done their best in this Parliament, in their way—I congratulate them on that—to maintain NHS spending in real terms, which, given the financial pressures on the country, was a good thing to do. That has worked for a while. The previous Government increased spending on the NHS a great deal. There were productivity gains to be made from that increase in spending and we have continued to see outcomes improving in the present Parliament.

However, the strains are now beginning to show. We know that, because of the increase in population, NHS spending per head is falling. Simon Stevens’s five-year analysis—I confess to being an admirer and friend, having worked with him—is brilliant. It demonstrates that there is a large potential funding gap unless, as the noble Lord, Lord Horam, pointed out, it can be closed by a more rapid rate of efficiency gain. With respect to the noble Lord, that will be difficult to achieve in a highly labour-intensive service. It is not like private sector manufacturing. This is a highly labour-intensive activity and 3% efficiency gains will be very difficult to achieve. So we will need additional investment.

As to what will happen to the rest of the public sector under this public spending outlook in the next few years, we will see severe austerity in welfare and public services, as set out in the pre-Budget report; more strain on poor families; a continuation of inadequate supply of social housing; weaker children’s services unable to protect children at risk; a narrower school curriculum because schools cannot afford to teach more broadly; and local authorities unable to meet the needs of all but very needy people in adult social care.

What will be the consequence of all this? Every academic and expert in public health tells us that if there is an increase in poverty, ignorance, bad housing and social neglect, what we will get is more pressure and problems for the National Health Service. On a holistic view of public spending, the Government’s plans are flawed and we need a more sustainable position. So I congratulate my party on at least indicating what it will do in the first year of the next Parliament in terms of extra spending and how it will be paid for.

Finally, we need cross-party debate and consensus on a long-term funding model for the NHS. I firmly support Frank Field’s ideas for a broadly based hypothecated tax that would take the funding issue out of politics and enable managers in the NHS to plan ahead for a more efficient service.

My Lords, I join in thanking the noble Lord, Lord Turnberg, for securing this important debate, and in so doing I declare my own interests as professor of surgery at University College London, consultant surgeon at University College London Hospitals NHS Foundation Trust, and chairman of University College London Partners, our academic health science centre and network.

It is striking that in 1948, some 48% of the population failed to reach the age of 65. Recently it was calculated that only 18% of the population would fail to do so. That is a remarkable manifestation of how important universal access to free healthcare has been in securing the health prospects of our fellow citizens. It is also striking that by 2025, it is estimated that 18 million of our fellow citizens will be living with a long-term chronic condition. With an ageing population and all that chronic disease, it is inevitable that there will be increasing demands on the facilities and resources available for the provision of healthcare. Indeed, we have seen in recent weeks increasing demands being made on accident and emergency services. The Nuffield Trust recently published a report which estimates that by 2022, if the current changes in demographics with an ageing population and the present growth in demand is maintained on a similar trajectory, we will need to provide 6.2 million extra bed days a year, which equates to some 17,000 extra hospital beds, the equivalent of 22 new 800-bed hospitals. It is therefore important that the noble Lord has tabled this debate about the future of the NHS because we must ask how we will address this increase in demand.

We have also heard that it is not only about an increase in demand. Quite rightly, it is about an increase in expectation. That is because in the United Kingdom we pride ourselves on having invested substantially in a strong science and research base and in biomedical research. Much of that investment is taxpayer-funded, and it is therefore absolutely right that our fellow citizens expect to see the benefits of that research applied to improvements in healthcare and the provision of better long-term prospects for a healthy life long into old age.

The noble Baroness, Lady Cumberlege, mentioned the recent US Commonwealth Fund report grading 11 different healthcare systems. Ten healthcare systems from around the world are compared to the United States system, and once again, for 2013, the NHS ranks number one for the quality of care—that is, the efficiency of care, the safety of care, patient-centred care and the co-ordination of care. Interestingly, however, we rank 10th out of the 11 nations in providing healthy lives for our citizens. So there is more to do to deliver effective healthcare and, in this regard, as has been noted in the debate, it is important to pay attention to the NHS England Five Year Forward View. Quite clearly, the funding models described in that Five Year Forward View expect some degree of efficiency gain further to the substantial gains that have been achieved during the lifetime of this Parliament. What assessment have Her Majesty’s Government made of how much of that additional gain in efficiency will be derived through the application of innovative therapies and interventions as well as innovative models for the delivery of care?

In this regard, it is particularly important to take note of the announcement made yesterday by NHS England of the national Innovation Accelerator programme and of the appointment of the new national director of new models of care. In this regard, I emphasise my declaration of interest as chairman of UCL Partners, as UCL Partners is the host for the national Innovation Accelerator programme, which is being supported by NHS England and the Health Foundation.

There is no doubt that innovation plays, and has played in recent years, an important role in the delivery of healthcare. What assessment has been made of the emphasis on the adoption of innovation, for instance the approach towards telemedicine? What progress has been made in providing telemedicine solutions to the management of chronic long-term conditions for the 3 million people living with long-term conditions that it is anticipated would be covered through these new strategies by 2017?

In addition, of course, there has been great emphasis on the whole area of personalised medicine, and the announcement of the 100,000 genome mapping programme. Again, I wonder whether the noble Earl could comment on how much progress has been made in that regard. How much progress also has been made in respect of the UK Biobank and the development of a national health and informatics strategy combining data from all of those to provide a very strong basis for improving health outcomes and driving improved healthcare for our fellow citizens?

The challenge for improved workforce planning will also need to be addressed. As part of changes introduced in the Health and Social Care Act 2012, Health Education England was to take an important role in ensuring that local needs for the provision of healthcare—understanding the local needs of local populations—would better drive workforce planning. Is the noble Earl content that that journey has begun and that Health Education England is able to perform in that way?

Finally, great emphasis was put on the need to develop clinical leadership. In this regard, I wonder what assessment has been made of the NHS Leadership Academy and when we might see the report of the noble Lord, Lord Rose of Monewden, and his assessment of how leadership in the NHS might be improved to ensure a greater chance of our achieving the goals that we all share.

My Lords, I thank my noble friend Lord Turnberg for securing this debate. I want to concentrate on the future of the spinal cord injuries unit. I declare an interest, having been spinal cord injured at university in the 1960s. Last year, I returned to the national spinal injuries centre at Stoke Mandeville Hospital to do four months of unsolicited in-patient research, having broken both my legs. The scene is depressing. I found that the speciality in which we led the world is pinched and demoralised. The result is a pointless waste of NHS money as well as of precious lives. Even in this sorry state, the relief to have been found a bed there after 10 days in a general hospital was overwhelming. I cannot thank the noble Earl and my noble friends enough for all their appeals to secure me that bed. Such help should not be necessary, but I will be undyingly grateful.

It is tragic that the demand for the spinal injury service far outstrips the supply, yet bed numbers have been and continue to be cut, leaving newly injured people in district general hospitals. Twelve spinal beds at Stoke have been changed to general use since September 2013 and, despite continual assurances, have still not been returned. Nationally, as of 6 January, 151 newly injured people that we know of are being treated in general hospitals by non-specialist staff, at the risk of developing complications such as urinary tract infections, pressure sores and psychological difficulties. The most vulnerable patients are those high-level tetraplegics who need ventilation to assist with their breathing. Currently, 19 ventilated patients are waiting to be admitted to specialist care, with an average waiting time of six weeks. Their intensive care beds cost around £1,500 per night, 50% more than a ventilated bed in a spinal unit.

Delayed discharges badly frustrate the optimal use of spinal units. The situation at the Salisbury Odstock spinal unit is not unusual. One patient has been awaiting discharge for more than two years, and another for more than a year. They are occupying spinal beds that cost £500 to £600 a night. We know that the drastic cuts to social care and the appalling lack of accessible housing have caused bed-blocking but, as I found, so has the intransigence of the CCGs. To protect their own budgets, CCGs refuse to accept the spinal centres’ advice and insist on their own assessments when the patient is almost ready for discharge. A completely unnecessary delay then ensues in organising care packages and essential equipment. In some parts of the country the local CCG will not even take the unit’s advice on providing the appropriate wheelchair. Instead, a patient has to be transported, with an escort, to their local wheelchair centre, with all the costs that that involves. As a result, there are considerable delays and in some cases rehabilitated patients have even been discharged home on stretchers to wait for a wheelchair at home—what a waste.

The situation with delayed discharges has now reached such a critical level that the All-Party Group on Spinal Cord Injury is about to conduct an inquiry into the causes and to make recommendations. I ask the Minister, first, to support that inquiry and, secondly, who now is in a position to be able to do something about this? The spinal centres have no power to compel the CCGs to address these issues; neither, it appears, does NHS England.

NHS England directly finances spinal injury as a specialism but the money is not ring-fenced. The centres will tell you that up to half their budget is absorbed by their host trust before it reaches them. Would it not be better if the NHS funding went direct to the spinal centre, which could then pay the host hospital for the services it uses?

Underlying all these issues is a general downgrading of spinal cord injury as a specialism in its own right, which must have Ludwig Guttmann turning in his grave. Currently there are consultant vacancies right across the service due to the lack of suitable candidates. Sadly, once we aligned our specialist medical training with Europe, spinal cord injury became part of the medical specialism of rehabilitation rather than a specialism in its own right. There appears to be no clear mechanism to ensure sufficient numbers of spinal consultants or adequate nursing staff and therapists to meet the need. Is anything being done to change this?

At Stoke Mandeville the trust has merged the spinal unit into a specialised services directorate along with haematology, pathology, sexual health and miscellaneous others. As a result, the spinal unit is managed by senior managers who have no knowledge or experience of working with spinal cord injury. I found that the staff feel neither valued nor supported. As a result, key staff have left, with the loss of their invaluable specialist knowledge, skills and expertise. When we have such a shortage of staff, surely it is vital to retain the ones we have.

Finally, whichever party wins the general election, will the new Government recognise that our world leadership role in this area of specialist medicine is now being sacrificed because the management of the service is driven by concern with local issues? Will they develop a strategic vision once again to keep the UK in the forefront of the care, treatment and rehabilitation of people with spinal cord injuries?

My Lords, it is a pleasure to follow the noble Baroness. How good it is to have her back among us. She is a testimony to the care that she has received. It is good for her to remind us of some of the problems that are faced by those who have to undergo spinal surgery.

I begin my remarks by referring to the noble Lord, Lord Liddle, because he ended with a plea for consensus and for taking the NHS out of party politics, and I endorse that entirely. He also made clear how important and central funding is. That is the issue.

Let us remind ourselves that the health service is, in effect, via Beveridge, the product of a grand coalition. Whether we will ever have a grand coalition like that again, I do not know; I certainly hope that we will never have the war that created it. However, it may be that the strange results in June could make that an infinitely preferable solution to the SNP holding the balance of power—but I must not digress because I wish to say that we are not serving the interests of the country or the health service by bandying about words such as “privatisation” and “weaponisation”. We have to focus on the service, what it needs and the funding it needs, and there has to be—I have said this many times in this House and in another place—a plurality of funding.

When I entered the other place in 1970, I did not have a single constituent with an artificial hip or an artificial knee, let alone a transplanted heart. By the time I left, 40 years later, the situation was very different. When I first entered the other place, I used to write a letter to every 18 year-old coming of age, and I used to write a letter to every 80 year-old, because it was quite an achievement in those days to reach the age of 80. I could not have done that in 2010. That is really the underlying problem. We are living longer, we have far better medical techniques, drugs and cures, and we are still relying on a single funding base.

I would like to see a commission set up after the election—Frank Field would be an ideal chairman—to look at funding and to rule nothing out. We have charges at the moment for prescriptions for certain people. Many GPs of my acquaintance say that it would cut down the absent rate—people who do not turn up for their appointments—if we charged for them. We could have a charge for those who are in hospital if they are in full-time employment. I quite like the Field idea of a hypothecated tax. We could have £1 on every bottle of alcohol and 50p on every packet of cigarettes devoted specifically, absolutely and totally to the NHS. We could have a system, as other countries do, of obligatory insurance. I am not particularly commending any individual one of these remedies, but I am saying that there are many alternatives.

The noble Lord, Lord Turnberg, who introduced this debate very splendidly, made the point that there has to be—he did not use the words—a plurality of funding, and there does. We should have a commission under a respected figure—and I believe that it would be entirely right that that respected figure should come from the left of the political spectrum. I do not believe that the Labour Party can for a moment claim entire credit for the National Health Service—of course it cannot—and I am proud of what Conservative Governments have done, but it was brought into being under a Labour Government and I see no reason why a respected figure whom we could all trust could not chair such a body, which would be broadly representative, to look at these alternatives, ruling absolutely nothing out.

Another thing that we should look at is what treatments are properly available under the National Health Service. If somebody is smashed up in a car crash, of course plastic surgery should be available on the NHS without any charge—but should a man or woman be allowed to change their shape through plastic surgery on the NHS? No. We have to look at a whole range of things, and we have to say what is appropriate for a world-class National Health Service to deliver to all people and how we contribute best to it.

After all, we all do contribute to it through our taxes—those of us who pay taxes, and the vast majority of us do. If there are additional charges here or there, and if there is a hypothecated tax such as Mr Field has recommended and the noble Lord, Lord Liddle, has endorsed, that is fine, but let us get this out of the petty party-political arena. Health is of supreme importance to all of us. There is no politician in any party who is not sincerely dedicated to the health of the people—of course there is not. Let us accept, as the noble Lord, Lord Liddle, said, the absolute integrity and sincerity of those on all sides of the political spectrum. Let us say that funding is the fundamental issue and let us try to get a consensual answer to the problems to which I have alluded.

My Lords, it is a great pleasure to follow the noble Lord, because he has taken the discussion in the direction that I wanted to take it. I start by saying that the NHS is a miracle; it has a great staff. It works by consensus, but, as Lord Bauer, who was here some years ago, used to say, the more we are similar, the more we exaggerate our differences. The differences that we have over the NHS are actually very small, but it pays us politically to exaggerate how large they are. For as long as I have lived here and taken part in debates on the NHS, it has always been in crisis. I do not remember a single debate in which everybody said, “Isn’t it great? Things are fine. Everybody is happy. Nurses’ and GPs’ morale is no longer shattered”. It never works like that. We can live with this miracle only by being dissatisfied with it constantly.

There will always be the cliff-hanger idea that there is not enough money. There is absolutely no way of having enough money in a zero-price service which will not generate excess demand. That is not even elementary economics. If you do not know it, you should not be allowed even to enter a course of economics.

But we have still managed. We have managed to finance the NHS by and large from a single source of funds—although there are peripheral aspects. One problem will be—and this is not a matter of who wins the next election—that there will no longer be the kind of money there was. As I have said in other contexts, we are about to enter a low-growth period for the next 10 or 15 years, and the good times are over. They are not going to come back—this is nothing to do with me, nothing to do with the Labour Party and nothing to do with the Conservative Party—so we will have to think of smart ways of meeting the needs that we will have. Not only is the NHS a zero-price service but the types of demand that it faces are proliferating. People are not only living longer but they want a better quality of life, a better shape and things like that—and then we have to address new problems, for example in mental health.

Let me concentrate on one big lacuna that I see in the system. The system does not ask consumers to do enough. We provide them with a zero-price service, but, in return, the consumer does nothing. The consumer is not asked to look after his or her health, to cultivate good habits of not drinking too much or not smoking too much, or whatever it is. The consumer expects, upon presenting himself or herself, to be treated. In any zero-price industry and with any zero-price commodity, if you are not going to allocate resources by price, there has to be something else to ration, and the rationing that we use is time. Waiting time is one rationing device that we use. As we have seen from recent coverage of the A&E crisis, people feel that if they are asked to wait for hours, it is the end of the world. They should have gone to their GP, as the noble Baroness, Lady Barker, said, but going to their GP is too much of a hassle, so they suddenly present themselves at the cheap option, A&E. But if you have to wait, you should accept the price because you did not invest the time in going to your GP. You think this is cheaper? It is not. You have to pay in extra time.

One thing I have advocated off and on is that patients ought to be made aware of how much things cost. They should not be charged but they should be made aware of the shadow price of the things they get, especially the things they waste. If they do not turn up for an appointment, they should be told what it costs. For a long time, I have advocated that we should give each person a shadow budget per head of NHS spend—perhaps £1,500 or 1,500 points. Every time you go to a GP or anywhere, you have a little Oyster card and it deducts so many points from that amount. You do not have to pay but you will be made aware at the end of the year by getting an account of how you spent your 1,500 points.

People ought to be made aware that these things have different prices. If we can make them at all aware of this, it might change their behaviour. We will need not only more productivity but better behaviour from consumers. We will all have to economise. We cannot let the consumer out of the need to economise to get a better health service. I do not have time to say much more than that, but I hope that if we can change behaviour with shadow pricing in the National Health Service, we will have taken a great step forward.

My Lords, I, too, commend the noble Lord, Lord Turnberg, for securing this important and timely debate. Like other noble Lords, I also come to the debate as a long-term user of the NHS, but one who fears for its future as I see the most tried and trusted institution disappearing almost daily in terms of its ethics, values and what it stood for.

In 2006, the current Prime Minister told us that the NHS would be safe in his hands. He promised that there would be no more pointless, top-down, disruptive reorganisation and that changes would be driven by the wishes and needs of NHS professionals and patients. As a matter of fact, this Prime Minister has presided over the biggest, most costly and I would say pointless reorganisation in the entire history of the NHS. Patients and professionals alike have personally experienced the results of this destructive reorganisation which the majority neither wanted nor needed. No Conservative or Liberal Democrat manifesto contained any mention of this approach, nor was it mentioned in the coalition agreement.

Last October, the CQC report described some A&E departments and maternity units as so short of doctors and nurses that they posed a danger to patients. NHS staff are leaving the profession feeling undervalued, underpaid, overworked and not consulted. The result of this mass exodus means that last year the NHS spent £1.3 billion on agency and contract staff.

Let’s face it. This has been one of the worst weeks in the history of the NHS. Day after day we have heard that one health authority after another is unable to cope with patient numbers, with waiting times increasing, operations postponed, staff demoralised, ambulance services under pressure and many operating below mandatory levels. People are urged to use A&E departments for genuine emergencies only, yet many have been unable to get a GP appointment. As a nation, we are of course living longer. The official statistics show that over the course of the past few years more than 700,000 elderly people have blocked hospital beds because a care home or a support home could not be found to accommodate them.

Throughout the world, the NHS has been admired and even envied for its record in providing healthcare to people when they need it most—publicly owned, publicly funded, publicly respected and publicly accountable. However, the NHS is becoming unrecognisable. I am not alone in fearing for its future. The British people want an NHS dedicated to making a difference rather than a profit; a service which belongs to the people and which is not for sale. I want the workers to be properly represented in the decision-making process, properly remunerated and consulted about how the service is run and delivered.

I, for one, look forward to the British people having the opportunity to rescue the National Health Service and hand it back to those who need it, those who use it and those who care for it.

My Lords, I congratulate the noble Lord, Lord Turnberg, on securing this debate. My first point is that we may have differences, but the National Health Service is basically safe in the hands of all the parties represented in this Chamber. We disagree about how we do it, but we do not disagree about the fundamental aim: to provide a health service free at the point of demand. I was very interested in what the noble Lord, Lord Desai, said. I have known him since I was at the LSE many years ago. The points that he made about a zero-price service are absolutely spot on.

I am interested, even pleased, to hear that we are top of the world rankings. I am also surprised, having had experience for 35 years of the Belgian and French health service, that we have outranked them, because that has not been my personal experience with those two health services. None the less, I will believe it: the survey is obviously right.

Why do I speak today? When I was at the LSE 45 years ago, I wrote my dissertation on out-of-hours GP services. Although my career moved me to a distinctly different area, that is a subject that has continued to interest me. Today, I want to speak particularly about the problems—note that I say “problems”, because I think that the word “crisis” should be used sparingly—facing the out-of-hours medical service. First, many people do not find the out-of-hours medical service easy to access. That is in part caused by the lack of GP cover. The previous Government negotiated a GP contract which, I am told, gives the average GP the highest pay and the lowest hours in the European Union.

Evidence suggests that about 30% of patients who self-present at A&E would be better advised if they had called NHS 111 first. However, using A&E may be preferable, particularly for young working people, to trying to get an appointment with a GP. Some young and generally healthy migrant workers do not understand our medical system and do not register, so recourse to A&E is a natural consequence of unexpected illness. The out-of-hours service which exists to provide medical cover when doctors are not on duty is not widely understood.

In Cambridge, where I live, we remember Dr Ubani, the doctor with imperfect English who, after a full week’s work, flew in from Germany to do a session of weekend cover and killed a patient through overprescription. Few people are, however, aware of the considerable steps taken to prevent such a tragedy recurring.

Doctors’ surgeries are, for much of the time, dark and closed. A&E services have the lights on and, whatever the figures say, you will be seen swiftly if there is a life-threatening condition. If not, frankly, there is an option of settling down with a book and waiting one’s turn. This is not necessarily an unwelcome scenario, especially if the alternative is taking time off work, sometimes from a zero-hours contract, to see a GP.

We also know that the present system of dealing with calls through the 111 service can lead to additional referrals to A&E. The 111 service is staffed by trained advisers but their training is in operating the system, not in medicine. The system has a fail-safe and evidence would seem to suggest that this can lead to more referrals. However, imagine the outcry if the system allowed discretion without knowledge. We would soon have an outcry, and rightly so, if there were unnecessary deaths.

Finally, there is considerable evidence that in nursing homes and for other carers of the elderly the first manifestation of a medical issue will lead to the calling of an ambulance. This has rightly followed a lot of inquiries about failings in homes but, as a consequence, it adds to the pressure.

It will be evident from what I have said that a stronger and earlier medical input is a crucial part of dealing with this problem. I would like the Minister to look into the following suggestions and, in due course, come back with a response. First, in Cambridgeshire the clinical commissioning group is in the process of establishing a joint emergency team that will provide integrated care covering community and hospital care, for a fixed price per person per year. This project, which begins on 1 April, will provide a round-the-clock emergency service that will work alongside ambulances and out-of-hours GPs. Will the Minister take a close look at this initiative with a view to promoting its use elsewhere? I notice that it is mentioned in the report.

Secondly, I ask that consideration be given to integrating the 111 and out-of-hours service. Thirdly, I suggest that the introduction of a GP input into the A&E front of house or reception areas could deal quickly and effectively with some of the less serious cases. Finally, I ask the Minister to continue to look at ways to extend the hours that GP services are available. We are no longer in an economy nor do we follow lifestyles where a visit to the doctor is easy to fit in. We need to build an element of consumer choice into the provision of medicine.

I have lived partially in Belgium for the last 35 years. It has a fully socialised medical system, not a private system, but the patient can shop around. There is patient power there at GP level, much more than in the United Kingdom. Maybe this is another European practice that is worth studying with a reference to importing more patient power into the National Health Service.

My Lords, I, too, congratulate my noble friend on securing this debate at such an appropriate time. I share his analysis, particularly around what I see as the decline in the effectiveness of general practice. However, I want to focus on just two strategic issues: the Five Year Forward View and the funding issues; and the problem of social care and the role of local government.

First, on the forward view, everybody should be extremely grateful to Simon Stevens for the leadership that he has shown in bringing forward this document and securing such a large measure of agreement for many of the ideas in it. I very much support his approach of pointing people in a direction of travel but without what I would regard as an overcentralised, detailed game plan or a further reorganisation. The emphasis on local solutions is a big step forward but I want to draw attention to the key funding assumptions underpinning the forward view vision.

The document acknowledges what many of us have been saying for some time: that the NHS faces a £30 billion funding gap by the end of the decade. It says clearly that this can be closed only by a combination of reducing demand, increasing NHS efficiency and more generous “staged funding increases”, in its words. That is absolutely right, but whether you close that gap depends a great deal on what combination of those assumptions actually takes place. You need everything to work in order to close the funding gap entirely.

Underpinning all that is a set of assumptions about the efficiency gains that we have talked a bit about today. Under this vision, the NHS is required to achieve an annual efficiency gain of at least 2%, possibly even 3%, for five years on the trot. Its long-run performance is 0.8%, rising recently to about 1.5%, with a big chunk of that 1.5% being achieved by pay restraint—not a card that you can keep on playing year after year. Some would say, “The assumptions on efficiency in this document are heroic, Minister”. As someone who has been in this field a long time, I have to say that I cannot see the NHS sustaining that level of efficiency gain over a five-year period.

My second point concerns one of the provisos that the Five Year Forward View assumes will actually take place—that is, and this is the document’s term, “sustaining social care”. The reality is that the huge reduction in adult social care funding over the past five years has been a disaster for the NHS. The hospital “bed-blocking” that we so glibly talk about today is in large part a direct result of the draconian cuts in social care funding over that period, which, as the Dilnot commission’s report pointed out in 2011, was in any case underfunded in relation to demography even before the 2010 election. Here I should declare my interest as a member of that committee.

The continuing tightening of the eligibility criteria for social care has produced an extremely efficient pipeline of frail, elderly people for A&E departments, many of whom then seamlessly become acute hospital bed-blockers. The Better Care Fund is a belated attempt to stop the situation getting worse, but it does little to repair the damage already done and has itself been criticised for its highly bureaucratic approach by one of the Government’s own Ministers, Mr Francis Maude. I have real concerns that unless something is done to tackle the continuing shrinking of the resources for adult social care, the NHS can only get into a worse set of troubles, and many of its patients will receive a poorer service. Acute hospital medical wards are about the last place you want to leave frail elderly people who are confused.

I close by drawing attention to the issue of local government. Successive Governments have neglected local government; too often they have seen it as the problem rather than part of the solution. I hope that my party will pay attention to this problem. Attention needs to be given to the excellent report for the Labour Party by Sir John Oldham’s independent committee on treating the whole person and integrating care, and not seeing medicine as a collection of professionals attending to various body parts of the individual. Unless we can actually get real about funding and about repairing the damage done to adult social care funding and services, we are not going to make much progress in sustaining our NHS.

My Lords, I, too, thank my noble friend Lord Turnberg for securing this debate; almost every other speaker has referred to the appropriateness of its timing. I declare an interest as the chairman of Milton Keynes Hospital NHS Foundation Trust, as I will refer to it considerably.

This debate is about the future of the NHS. I was fortunate as the chairman of Milton Keynes Hospital NHS Foundation Trust to meet a group of young students who have just started their medical training at Milton Keynes Hospital through a partnership that we have just sealed with the University of Buckingham. They were bright, enthusiastic and committed people who are looking forward to their future and, I suggest, to the future of the NHS.

It perhaps seems appropriate to look back, as other noble Lords have done, at where we are now and what we are learning from where we are, alongside debating and sharing what future this magnificent service can have—a service of which we are proud and which offers care from cradle to grave. My noble friend Lord Turnberg referred to medical and technological interventions and developments, as did other noble Lords in their speeches. As other speakers have said, although these have clearly made a huge difference to people’s lives—and we welcome that—I do not think that any of us realises the strain that has fallen on the hospitals as a result, in particular on acute hospitals that provide these services.

I will share things that I know happen in my hospital and elsewhere. It is now almost taken for granted that, if a baby is delivered at 22 weeks, it will survive and flourish, which is an admirable thing to achieve. However, to do that, the service required from the NHS is huge as regards the care that that baby needs—in some instances it involves one-to-one specific nursing requirements. The same applies, as other noble Lords have said, at the opposite end of the service. Milton Keynes is a community that includes people of all ages, from the very young to the very old, so it has the same problems as many other hospitals. The interventions and developments that we have had in treating cancer and other medications for improving health, to which noble Lords have referred, have made immense improvements and breakthroughs in people’s lives. However, I am not sure that, as the noble Lord, Lord Desai, rightly said, although in very different terms, we—patients, communities or any of us—understand just what the effect of that is. We all welcome the improvements made in our lives—any of us would want our relations to have all that—but the implications for an acute trust of funding and service provision are extensive.

Over the last few weeks and even days, my trust, like many others, has been seeing very poorly patients, mostly old men and women, brought in with chest pains, breathing difficulties and even with pneumonia, and others are heading that way. We, like other hospitals, have dedicated staff, from consultants and nurses to healthcare assistants and, importantly, porters, who are often not mentioned but who make the wheels of the organisation move—porters moving trolleys in and out of A&E can make a big difference to the facility that we have to look after patients, and that support is absolutely crucial, particularly at this time. The staff have a huddle every morning or at every shift change and look at what is going on. If you come in, morning after morning, and find that not a single bed is available for anyone who comes through your doors that day, that is a big challenge to start the day with. However, every member of staff works in high spirits and with complete dedication. They care—as I think we all do—about the type of service that they are going to give. They worry, as we all do, when the stress goes on for as long as it has, that they are not able to give the care that they want each and every patient to have who goes through their hands.

The reasons for that are multiple and we have discussed many of them today in this debate. I will pick up on one thing that my noble friend Lord Warner just talked about, which is our relationship with local authorities. As my noble friend Lord Warner and other noble Lords said, many of the bed-blockers—it is a most unfortunate phrase; these are wonderful people who have had interesting and dedicated lives—are there because there is nowhere else for them to go. The ability of local authorities to purchase places in nursing homes and care homes, not just in Milton Keynes but elsewhere, has been reduced because of the cuts, so there is nowhere for people to go.

In addition—and I shall say this quickly, because I am running out of time—what has accelerated the process and caused the overwhelming concern over the past few days is that we have just experienced what in hospital terms is called a “double weekend”. Christmas Day was on Thursday, Boxing Day was on Friday and there followed Saturday and Sunday. The consequences are that we already have challenged services but we also have consultants and nurses who are not working over those days, which means that we cannot provide the usual service.

The Front Bench is getting anxious that I am not finishing in time, so I will finish there. All that I would seriously ask on behalf of my staff in the hospital is that we should not have massive change. Please let us not have a whole new look at what we are doing, with someone coming out with something entirely different. Everybody is weary with that, so let us just look at what we have and make sure that we can make it work better.

My Lords, I thank the House for allowing me to speak briefly in the gap. In the debate led by the noble Lord, Lord Kakkar, in November, on health and innovation, I described a piece of health innovation that I am leading in Tower Hamlets, bringing a health centre, a school, housing and a whole range of enterprise projects together in an integrated health and education project. Professor Brian Cox and I are embedding a science summer school in this project, focused on how Britain becomes the best place in the world to do science. It has taken us seven years to create the health centre; we have lived through three different Governments. I have to thank the noble Earl, Lord Howe, for helping us to resolve this issue; it is very good news indeed.

What lessons have we learnt from a real project on the ground over the past seven years? My first point is that we need consistency. The message and the people constantly change. Secondly, there needs to be accountability. No one seems able to take a decision; there are layers and layers of approval processes, requiring business case after business case, then point one comes in—I refer to my point about consistency—and you are back to square one.

Thirdly, we need clarity. To the outside world, the NHS is the NHS is the NHS. Unfortunately, within the NHS there are so many silos that only the NHS can understand and which all have to have their say, and they all have different approval mechanisms. Then, because of the accountability processes, nobody can take a decision, so it becomes a game of “We will agree if they will agree”, with no one willing to make a final call.

Fourthly, there must be local empowerment. The centre has to make all the decisions but it is the people on the ground at a local level who should be leading. Locally, things are either done to you from the centre or not done at all.

Fifthly, there needs to be partnership and trust. We are not all the evil private sector, all out to screw the NHS. Partnership can achieve so much and has done so to date. The NHS has got to learn to trust and work with others, and it may just find that it can benefit enormously. The best local authorities have made real progress here, but the NHS by and large has not. Our project is bringing large amounts of money, which are coming from outside the NHS budget, into health initiatives on a housing estate. That is what partnership does.

Sixthly, on primary care premises development, the Secretary of State is continually talking about moving to a more preventive and proactive approach, and he is right to do so. To do this, you need to do all that I have mentioned above. However, NHS estates have been given a very narrow, financially driven brief. They need fresh instruction and leadership with a specific brief to foster partnership and opportunities for GP practice developments that will then deliver a preventive and cost-effective, proactive approach. They need to be the solution, not the problem—because not despite.

Most importantly, it must be about patients, patients, patients. Some parts of the NHS seem to have forgotten all about that.

My Lords, as this is a general debate on the NHS, I remind the House of my interests as a consultant trainer with Cumberlege Connections and president of GS1. As I am going to raise the Cancer Drugs Fund, I also declare that a relative of mine, Joe Wildy, is an employee in the government affairs department of Sanofi.

I, too, congratulate my noble friend Lord Turnberg on securing the debate and on the quality and breadth of his opening speech. It is clearly timely; never has the health and social care system been under so much pressure.

As many noble Lords have suggested, this pressure can only grow with technological and medical advances, and the sheer fact that the number of those aged over 80 will double by 2037. Implicit in the Motion of the noble Lord, Lord Turnberg, is the question of whether a comprehensive service is still feasible and affordable. I have no doubt that it is but nor do I doubt the scale of the change that the NHS must effect to ensure that sustainability. I have identified seven key areas of change. First, we have to undo the damage caused by the Government’s 2012 Act without undergoing a huge restructuring, as my noble friend Lady Wall said. Secondly, we have to ensure a sustainable funding regime for the NHS and social care. Thirdly, we have to integrate health, mental health and social care. Fourthly, we have to invest in and re-energise primary care. Fifthly, we need a much more assertive public health programme. Sixthly, we need more personalised care and innovation and, seventhly, we have to invest in and support a workforce to help us transform services.

It is a truth universally acknowledged that the 2012 Act has been pretty much a disaster. Despite all the protestations of Ministers, a huge amount of money has been spent and services have been fragmented, and too much energy is spent by all the players simply trying to keep the new system’s head above water. At a time of real crisis in emergency services, it is palpably clear that no one is in charge locally or nationally. My noble friends Lady Jay and Lady Wilkins, and the noble Lord, Lord Mawson, identified the buck-passing of responsibility between a mishmash of clinical commissioning groups, commissioning support units, local area teams and health and well-being boards, which are all quite unable to show the required leadership.

It is the same at national level. Ministers, the Department of Health, NHS England, the NHS Trust Development Authority, Monitor and the CQC vie with each other, often conflict and certainly provide no clear leadership. No wonder the National Audit Office commented in November that it is not at all clear where responsibility for strategic change lies. Quite! It is not surprising that performance is problematic. The Government inherited an NHS that was meeting the then 98% four-hour A&E target. They reduced that to 95% but hospital A&Es have missed that target for 76 weeks, with many hospitals in the last two weeks declaring major incidents. It is clear that the service is under extreme pressure.

On resources, never has the NHS had to cope with a flat-line budget—which is essentially what it is—for such a long time in its history. The recent NAO report on the financial sustainability of the NHS makes for sober reading, as does NHS England’s Five Year Forward View. My noble friend Lord Liddle pointed out that the Chancellor’s intention to reduce public expenditure to 35% of GDP by the end of the Parliament means that the actual resources going to the NHS will be bleak indeed.

I want to ask the noble Earl about an aspect of the immediate funding problem, which concerns the Cancer Drugs Fund. In August last year, the Government announced additional funds for the CDF to ensure that as many people as possible could access these pioneering, life-enhancing drugs. However, I understand that six months later NHS England is poised to remove that access for unknown thousands of patients. What is the Government’s policy on the CDF?

I ask the noble Earl yet again about the money now being paid back by the pharmaceutical industry to underpin the cost of certain drugs, subject to a modest inflation figure every year. Where is this money being spent? Why is it not being spent on new medicines and new treatments, where surely it ought to go? Is it a fact that NHS England does not accept the agreement that the department reached, and that is why it is not playing ball in ensuring that the money is invested where surely it ought to be invested?

On funding, my party has committed itself to a £2.5 billion Time to Care fund. We also want to remove some of the wasteful costs of the current restructuring. However, we should listen to my noble friend Lord Warner on the gap identified by NHS England. The fact is that the 3% efficiency target is formidable, or heroic, as he said. We will have to tackle this one way or another.

We also have to tackle the integration of physical health, mental health and social services. We need personal care plans and a single point of contact. We can see the current problems, which my noble friend Lady Wall identified. We see the fruits of a lack of integration. First, adult care has been impossibly squeezed. This has forced frail older people to rely on the NHS as the provider of last resort. It also means much less support for people when they are ready for discharge from hospital. Delays then happen, with longer lengths of stay. That is the problem we face. Without a properly resourced social care system, and without integration, we are not going to be able to move away from it.

Then there is primary care. Is it any wonder that A&Es throughout the country—recently the Great Western trust in the south-west, the Walsall trust in the Midlands and the Royal Surrey County Hospital in Guildford—are having to warn patients to stay away? It is no wonder when people find it so difficult to see their GP. In the east Midlands, the CCG in Erewash reported that one in five patients had to wait a week for a doctor’s appointment. Barnsley Hospital in South Yorkshire recently surveyed patients, many of whom complained about difficulties in getting a local GP appointment. This has to be tackled. I remind the Minister that whatever one says about the contract, the fact is that this was not a problem in 2010, even though the period between 1997 and 2010 had seen a steady increase in the number of patients coming through the door.

Investment in primary care has definitely fallen behind, and a workforce crisis is emerging. One good start would be for the Secretary of State to desist from his thoughtless attacks on GPs. We have pledged to use part of our £2.5 billion Time to Care fund to recruit more GPs, but we need to do much more to bring GPs into the core of the system. I remind the noble Earl, Lord Howe, that when Andrew Lansley proposed the 2012 reforms, he said that the reason was that, “GPs spend all the money and we want to give them the levers because that will effect change”. However, the huge gap in the system is that clinical commissioning groups seem to have no impact whatever on the performance and behaviour of GPs. I thought that that was the whole purpose of delegating budgets to CCGs. The reason, of course, is that the contract is held with NHS England, which has been quite unable to impact on the performance of GPs.

My noble friend Lord Rea talked about public health. I certainly agree with him and NHS England on its five-year plan. It says that we need a radical upgrade in prevention and public health. It says that it will back hard-hitting national action on obesity, smoking, alcohol and other major health risks. That is very welcome. The question I would ask the noble Earl, Lord Howe, is whether the Government will let NHS England do that—because I have to say that the Government’s record on public health has been very disappointing indeed.

There is one other area that I have time to mention: the adoption of innovation in the National Health Service. The noble Earl knows that he and I share the concern about the slowness of the NHS to adopt new treatments and new medicines. Surely, given our fantastic life sciences, and the strength of our pharma and medical devices industries, we have to find a way to encourage the NHS to move to adoption much more quickly than heretofore. I certainly hope that in his winding-up speech he can say a little more about how we are going to do that.

My Lords, I start by congratulating the noble Lord, Lord Turnberg, on securing this debate and thanking those noble Lords who have contributed to it.

As noble Lords will know, having covered the health portfolio continuously since 1997, I still find myself continuously in awe of the NHS and the principles that underpin it, as well as of the people within our health service who live out these principles, not least at the moment.

The NHS is currently facing challenges that it has never faced before. Even though the Government have protected the NHS with real-terms funding increases, we do not underestimate how challenging it has been to continue to deliver high-quality care in the current climate. Demand for healthcare is rising and changing as the population ages and different diseases come to the fore. We are faced with an ageing population, as has been said, and one where increasing numbers of people are living with multiple chronic conditions. The big issues that the NHS must deal with now, such as dementia and lifestyle conditions such as obesity, cannot be addressed by the traditional model of a healthcare system which is focused on the acute sector.

I want to spend most of my speech considering the future of the NHS following the recent publication of the Five Year Forward View. This document, which was published jointly by NHS England and five other arm’s-length bodies, sets out a vision for how our health system will evolve over the next five years. It is a vision which the Government share. The Secretary of State and I have previously set out the four pillars of our response, which are worth recapping.

The first pillar is to ensure that we have an economy that is able to pay for the growing costs of our NHS and social care system. A strong NHS needs a strong economy. The success of our economy means that we were able to provide additional funding in the Autumn Statement, including £1.7 billion to support and modernise the delivery of front-line care, and £1 billion of funding over four years for investment in new primary care infrastructure. In all, NHS funding will be about £3 billion more next year compared with this year, and all that extra funding will be baselined for future years.

The NHS itself contributes to that strong economy in a number of ways, and we want to help it to develop its role. It is helping people with mental health conditions to get back to work by offering talking therapies to 100,000 more people every year than four years ago. The NHS can also attract jobs to the UK by playing a pivotal role in our emerging life sciences industries. In the past three years, we have attracted £3.5 billion of investment and 11,000 jobs. This Government have set out our ambition to be the first country in the world to decode 100,000 research-ready whole genomes.

The second pillar of our plan is to change the models of care to be more suited for an ageing population. As I said earlier, we need to accommodate growing numbers of vulnerable older people who need support to live better at home with long-term conditions such as dementia, diabetes and arthritis. To do that, we need a greater focus on prevention, which will help people to stay healthy and not allow illnesses to deteriorate to the point where they need expensive hospital treatment.

This Government have already made good progress in improving out-of-hospital care. Last year, all those aged 75 and over were given a named GP responsible for their care—something that was abolished by the previous Government. From April, everyone will have a named GP. Already 3.5 million people benefit from our introduction of evening and weekend GP appointments, which will progressively become available to the whole population by 2020. The better care fund is integrating the health and social care systems to provide joined-up care for our most vulnerable patients. Alongside that, the Government have legislated, for the first time ever, on parity of esteem between physical and mental health.

However, I recognise that there is more to do. NHS England has already invited applications from local areas for the £200 million of funding which has been made available to pilot the new models of care set out in the Five Year Forward View. To deliver these new models, we will need to support the new clinical commissioning groups in taking responsibility, with their local partners, for the entire health and care needs of people in their area.

A strong economy and a focus on prevention are the first two pillars of our plan. The third pillar is to be much better at embracing innovation and eliminating waste. Previously, the NHS has often been too slow to adopt and spread innovation. Sometimes this has been because the people buying healthcare have not had the information to see how much smart purchasing can contain costs. From this year, CCGs will have access to improved financial information, including per-patient costings. The best way to encourage investment in innovation is a stable financial environment. Following the next spending review, local authorities and CCGs will receive multi-year budgets. The NHS also needs to be better at controlling costs in areas such as procurement and agency staff as well as reducing litigation and other costs associated with poor care. We are working with NHS England and partner organisations to agree the level of savings in each area, which will allow more resources to be directed to patient care.

The final pillar of our plan is to continue to develop a culture of care in all parts of the NHS. We have made good progress since the Francis report. We have introduced a greater focus on patient care. There are 5,000 more nurses on our wards and 4.2 million NHS patients have been asked, for the first time, if they would recommend to others the care they received. We plan to go further over the next few months. We will set out how we will improve training and safety for new doctors and nurses, launch a national campaign to reduce sepsis, and, responding to recommendations made in the follow-up Francis report, tackle issues of whistleblowing and the ability to speak out easily about poor care.

Noble Lords have raised a number of other important issues in this debate. I shall endeavour to respond to as many as I have time to do. First, I shall talk about funding, a subject covered very thoughtfully by the noble Lord, Lord Turnberg, my noble friends Lord Horam and Lord Cormack, and the noble Lord, Lord Liddle, among others. The Five Year Forward View argued that a combination of growing demand and no further efficiencies would bring about a funding gap for the NHS of nearly £30 billion by 2020-21 against a flat real baseline. A 2% efficiency growth, rising to 3% over time, produces a remaining gap of £8 billion. But if the NHS can achieve 3% efficiency gains, the remaining challenge would reduce to around £4.4 billion in 2020-21. I will talk about the scope for efficiencies in a moment, but this is broadly the same real-terms funding increase that the Government have committed to the NHS over this Parliament.

The funding announced in the Autumn Statement fully delivers the investment required to make the Five Year Forward View a reality in 2015-16 and provides funding to start delivering the changes required by the Five Year Forward View to deliver a sustainable NHS in future years. As I have said, this new funding will be baselined for future years. As has happened over this Parliament, real increases in funding will be required to complete this transformation and ensure a sustainable NHS in the future but the NHS will also be required to make significant efficiencies. Of course, I cannot go further than that at the moment because the detailed funding package for 2016-17 onwards will be announced at the next spending review, whichever party is in government. It is worth pointing out that all the £1.5 billion of investment in NHS front-line patient care in 2015, stemming from the Autumn Statement, will go to improving local NHS services and will help the NHS to meet rising demand. On top of that, we are introducing a £200 million transformation fund. The fund will kick-start the work needed to develop new ways of caring for patients which do a better job of joining up GPs, community services and hospitals.

In part of her speech, the noble Baroness, Lady Jay, focused on competition. I am sure she will remember that greater competition in the NHS was introduced through deliberate policies from 2003, such as the independent sector treatment centres and choice of any willing provider. Rules were put in place in 2007 to manage this competition. We as a government continued that approach of managed competition, overseen, however, by an expert health regulator in the shape of Monitor. I would just say that this has hardly led to a giant expansion of private provision. Commissioner spending on healthcare from private sector providers equates to about 6.1% of total NHS revenue expenditure, which is only 1.2% more of the NHS budget than in 2010. Much of the increase is accounted for by social enterprises and charities, which I know the party opposite supports.

The key here is that it is not politicians who take these commissioning decisions but clinicians. As the noble Baroness conceded, there has not been a change in the Secretary of State’s core duty. He is responsible for promoting a comprehensive health service. This remains consistent with the wording of the original 1946 Act. At the same time, what the Act also did was right. The Health and Social Care Act puts clinicians in charge of decision-making about patients rather than politicians or administrators. That involves a strengthening of local accountability and decision-making through clinical commissioning groups and local health and well-being boards. Local authorities are once again responsible for public health, as my noble friend Lady Barker reminded us. We have also restored a culture of care to the health service so that doctors are primarily accountable to their patients, not top-down- targets or bureaucrats. I simply say to the noble Baroness, Lady Jay, and the noble Lords, Lord Morris and Lord Hunt, that any future Government would reverse those measures at their peril.

The noble Lord, Lord Turnberg, said that the NHS should become a much more preventive service and we fully agree with that. Action is needed to address the common risk factors for the big killer diseases. To give one example, the NHS health check provides an opportunity to review an individual’s health against some of the risk factors that he listed. Last year, more people than ever before received a free NHS health check. Since it was introduced, 7.5 million offers have been made and more than 3.7 million NHS health checks have been received, offering a real opportunity to reduce avoidable deaths and disability and to tackle health inequalities.

My noble friend Lord Balfe spoke about GPs and, in particular, GP access. We are introducing a number of measures to ensure that people who need to see a GP do so at a time to suit them. We have invested through the Prime Minister’s Challenge Fund £50 million this year to help more than 1,100 practices to develop new ways of improving GP access. We have committed to invest another £100 million into the scheme next year and we will extend seven-day opening to every patient in the country by 2020. From January, practices will also be allowed to register people outside their local area, making it easier for hard-working people to register near their place of work or somewhere else that is convenient to them. Despite a decrease in head count, there has been a 1.2% increase in full-time equivalent GPs since 2012 and the number of practice nurses and other practice staff has also grown, representing in total a real capacity increase.

The noble Lord, Lord Rea, focused on alcohol, an important issue. We are committed to reducing alcohol-related harm and have already banned alcohol sales below the level of duty plus VAT, meaning that it will no longer be legal to sell a can of ordinary lager for less than around 40p. Alcohol consumption per head has fallen, I am pleased to say, in recent years. Reduced affordability of alcohol, influenced by tax rises up to 2013, has been a factor in this. Alcohol minimum unit pricing is still being considered as a possible way forward but no decision has been taken.

The noble Baronesses, Lady Masham and Lady Wilkins, turned our attention to spinal injury services. The NHS England spinal cord injuries service specification clearly sets out what providers must have in place to offer evidence-based safe and effective services. It sets a core requirement that each specialised SCI centre can demonstrate that it has a minimum of 20 beds dedicated exclusively for the treatment and rehabilitation of SCI patients. The overall bed complement for England is being reviewed through a demand and capacity project led by the Spinal Cord Injury Clinical Reference Group. That group aims to produce a report in 2015-16.

The noble Baroness, Lady Wilkins, argued for a strategic view of spinal injury services. As she knows, NHS England commissions specialised rehabilitation services as defined by the service specification, which sets out what providers must have in place to offer safe and effective specialised rehabilitation services. The clinical reference group is currently completing a review of those services. It will involve establishing nationally what the current demand is for rehabilitation services, which must be the first point of reference.

My noble friend Lord Horam spoke about bed blocking and asked whether some of the delayed discharges could be resolved by discharge to mental health trusts or housing associations, and whether local areas could do more than they are doing. I would simply say to him that these things have to be dealt with locally; we cannot hope to do it centrally. The Health and Social Care Act 2012 gives local clinicians more power and responsibility to develop the right solutions for their local areas. Hospital trusts are already forming effective partnerships to ensure that patients get the support they need to be discharged from hospital quickly, and I can tell him that NHS England and others are supporting them to do this.

My noble friend Lady Barker focused part of her speech on mental health. I fully agree with her that public services should reflect the importance of mental health, putting it on a par with physical health, as we have argued so often. Parity of esteem between mental and physical health is now enshrined in legislation. For the first time, we have introduced waiting time standards for mental health, ensuring that NHS England and local partners properly prioritise access to mental health services, and we have made mental health part of the new national measure of well-being so that it is more likely to be taken into account when government departments are developing and implementing policy.

The noble Lord, Lord Kakkar, in his wide-ranging speech, covered a number of key issues. I turn first to efficiency savings. There is no doubt that the NHS needs to be better at controlling costs in areas such as the procurement of medicines and clinical equipment, and indeed non-clinical equipment, energy and fuel, agency staff, the collection of fees from international visitors, and reducing litigation and other costs associated with poor care. Gains can also be made in ways of working, such as by getting paramedic teams to treat more patients at home rather than bringing them to hospital; creating more regional centres of excellence for specialist treatments such as stroke and heart disease; bringing more services out of hospital and into the community by, for instance, having specialist consultants in GP surgeries; offering more patients better access to GPs, including evening and weekend appointments and Skype consultations; and joining up health and social care services such as through the Better Care Fund. Working with NHS England, the department has announced plans in all these areas. We will agree the precise level of savings to be achieved through consultation with NHS partner organisations over the next six months. That will lead to a compact signed up to by the department, its arm’s-length bodies and local NHS organisations with agreed plans to eliminate waste, thus allowing more resources to be directed to patient care.

The noble Lord, Lord Hunt, asked me about the cancer drugs fund. Of course, the policy behind this is to give patients access to the drugs they need, but I would qualify that by saying that those drugs need to be clinically effective. That is the reason why NHS England is doing the sifting process that is currently in train. The payments from industry that he referred to were never going to be hypothecated; they form part of NHS England’s general budget. Having said that, NHS England does have the freedom to apply the money as it sees fit, whether that is for drugs, radiotherapy, or indeed any other investment that it deems to be clinically effective.

Moving back to the noble Lord, Lord Kakkar, who asked me about innovation, the appropriate use of technology-enabled care services such as telehealth and telecare can support patients in managing their long-term conditions more effectively and enable people with social care needs to live independently for longer. We are making progress in this area, and I will be happy to bring him up to date by letter on that. As regards the new NHS Innovation Accelerator programme announced yesterday, I agree with him that that is very good news. It invites leading healthcare pioneers from around the world to bring their tried and tested innovations to the NHS. Again, I can expand on that by letter.

Where are we with the personalised medicine agenda, informatics and the UK Biobank? I can say to him, as I can to my noble friend Lady Thomas, that we are determined to make Britain the best place in the world to discover and develop 21st century medicines. By harnessing the UK’s unique strengths in research, the NHS, medical charities and a vibrant life sciences cluster of innovative companies, we are sure that we can accelerate access to new treatments and attract major new investment and growth.

I will need to leave the other questions to the letter that I have promised to send round to all noble Lords who have spoken. However, suffice it to say for now that in recognising that the NHS faces some definite challenges as we strive to increase both the efficiency and quality of care, we also have a clear plan for how we are going to tackle this. The progress that we want to make will only be made possible by people: those who work in the NHS and those who rely on it. We need to free people up to make decisions about the NHS, creating models of care that suit local needs while upholding a world-class standard. I am confident that we can do that together.

My Lords, I thank all noble Lords for their wide-ranging and well informed contributions. I have learnt a lot. I clearly cannot comment on every noble Lord’s contribution, but I particularly wanted to say how pleased I was to hear from the noble Baroness, Lady Wilkins, who is back in her place and in fine voice.

Clearly, we were never going to solve all the problems of the NHS today, but I believe that this debate has been a useful contribution as we ease our way into the next election. The next Government will have to level with the public, who are very supportive of the NHS, and grapple with the issue of how we might cope with the conundrum of paying for a service that becomes more complex as every day goes by.

Of course we should become more efficient, but I am reminded that Aneurin Bevan, when the NHS began, thought that as we cured and prevented more diseases the service would get cheaper. However, every year it seems to have got more expensive, and as we cure one disease, another disease pops up. It is an unfortunate fact that the mortality rate among humans is almost 100%—exactly 100%. On that happy note, once again I thank all noble Lords for their contributions and look forward to the next Government’s actions as a result.

Motion agreed.