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National Health Service

Volume 768: debated on Thursday 14 January 2016

Motion to Take Note

Moved by

That this House takes note of the ability of the National Health Service to meet present and future demands.

My Lords, I am extremely grateful for the opportunity to open this debate and delighted that so many noble Lords have agreed to speak. I very much look forward to the maiden speech of the noble Baroness, Lady Watkins of Tavistock. I am only sorry that speakers have only three minutes to express their views.

It seems entirely possible that one or two noble Lords might draw attention to the parlous state of funding of the NHS. They may even echo Matthew Parris when he wrote:

“Our health service is heading, if not for the rocks, then for the sandbank of chronically sub-optimal performance and monthly threats of insolvency”.

It is tempting to say that this cannot go on. But of course it always does, because of the people in it—the nurses, the doctors, the physios, the porters and so on—who work their socks off to do their very best, despite the lack of resources. They regard it as a privilege to work in a service that aims to care for people and their ills, as indeed did I during most of my working life. When the NHS works well, there is nothing quite like it and the public know that. But when staff morale is at a low ebb, as it certainly now is, and when we have a Secretary of State who seems quick to lay blame but is quite incapable of showing the least sign of appreciation of the staff, then that impacts directly on patient care.

I would not want to be ungrateful for the bit of light relief provided by the Chancellor in the recent spending review, even though that was partly achieved by robbing the budgets for public health, education and NICE. It is hard not to feel, as do the Health Foundation and the Nuffield Council, that this is just another emergency bailout—a temporary fix—when the basic underfunding continues apace as the NHS tries to cope with an ever increasing demand. Having said all that, I hope that I do not disappoint the Minister if I say that I will not be taking that line, at least not yet. What I want to do is to lay out what would be an ideal system for providing total care for the population in the community and in hospital. None of what I say will be entirely foreign or original. Perhaps you know what they say about originality: it is the art of concealing your sources. My sources will be obvious.

The ideal service would have to be completely joined up, with social services, general practice and hospital care integrated. That is so often talked about but rarely achieved because it requires the integration of management and, often, the budget. The silos of primary and secondary care would disappear as GPs were able to work as a team across the divide, in and out of hospital, perhaps even under the same management. This may be a pipe dream, and many—perhaps most—GPs would object, but enough may see the advantages, especially now when they are under such unsustainable pressure that so many are thinking of giving up. Health visitors and district nurses, as well as social workers, could be employed by the hospital so that they could be completely integrated. They would be able to see their patients in hospital as easily as in general practice and the community, without this delaying referral system we have set up.

We had a debate before Christmas about the problems of the care home sector. A number of significant private providers are threatening to go out of business with the potential loss of a large number of care home beds. Currently, about one-third of acute hospital beds are already occupied by patients who would be better cared for in the community. Even more pressure may be put on those beds as care homes are lost.

Would it not be much better if hospital trusts opened their own care homes? A bed in their care homes would cost them about half what a hospital bed costs them, and the trusts would save money and beds—a no-brainer, you might think. Your Lordships may ask where these care homes might come from, but most trusts have obsolete stock that could be rescued, and what about the homes that private providers may vacate? It would need a little capital, but the potential rewards are enormous.

What about those isolated mental health services? At the moment they are far from providing the equity of esteem with physical illness services that everyone talks about. Would they not stand a better chance if they were more joined up with other health services?

There are two other elements in this brave new world that I should touch on briefly. First, why do patients who need to be checked up from time to time by their consultant always have to spend hours travelling to and from the hospital and waiting to be seen? Consultants and patients have telephones, for heaven’s sake. We could do much more if we could get round the tariff system that rewards hospital trusts for out-patient visits but not for telephone calls. The noble Lord, Lord Prior, and I have discussed this before. We are making nowhere near enough use of IT, the internet, remote monitoring devices built into vests and so on. Patients deserve much better.

The other area I should briefly mention is medical research. I should express my interest here as scientific adviser to the Association of Medical Research Charities, which puts around £1.3 billion a year into research. Research should underpin our integrated NHS, and we must take advantage of our excellent basic research capacity and link it with our unrivalled access to the whole NHS population. It is worth remembering that about 50% of our increasing lifespan is the result of advances gained from research.

I suspect that noble Lords will have noticed that much of the full integration I have described requires local authorities and hospital trusts to agree to a single management system and, where possible, a merged budget. That is something that has eluded successive Governments for ever, it seems. What about the idea of patients being given their own personal budgets, which could ease the transition? Perhaps the Minister could say where we have got to with that.

It is not difficult to see why there is resistance. Social services and GPs are reluctant because they see their precious limited resources being used to prop up the hospitals, while the hospitals have historically seen themselves as providers of acute care and only reluctantly as having a responsibility to the community. It does not help when both are financially squeezed. So is it an impossible dream? It seems to me that we do now have an opportunity to go some way along that route, with increasing recognition by all parties that they cannot go on as they are. It will be difficult, but I did not just dream up these ideas.

We have had excellent example of good practice around the country in Torbay and a number of other places for ever, it seems. But most of my ideas have emanated from Salford Royal Hospital, where David Dalton, its chief executive, has already set up much of this integration and has agreement for more. Here I must admit to some pride in speaking about that hospital, because it is where I spent most of my working life as a professor and consultant. It used to be called Hope Hospital, and has obviously taken advantage of my leaving to do great things.

The hospital trust has been employing its own health visitors for some time. It even has two general practices in its employ, one providing out-of-hours services and the other with responsibility for looking after all the residents of care homes in Salford—both in addition to their normal practice.

Incidentally, all 49 of the other general practices in Salford are linked into the hospital’s electronic case records system. The hospital is now virtually paperless, and GPs and hospital staff have access to all the clinical information about their patients wherever they are. From April this year, agreement has been reached between the trust and the local authority that adult social care, including domiciliary and residential care, will come under the trust’s management with a merged budget—remarkable. Perhaps equally exciting is the fact that the mental health trust will in April be contracted through the new single integrated care organisation, a chance to see much better cohesion between mental and other services.

Salford Royal no longer sees itself as simply a hospital but as part of the community for which it provides for the health and care of all of Salford’s 250,000 residents. All those remarkable developments have been possible only because of inspired leadership in both the trust and the local authority, and it has taken many years of patient negotiation between them, and much legwork with the GPs. Salford is of course a nice, circumscribed, if deprived city which sees itself as progressive, and it has the big advantage of having just one CCG.

None of that has required another health Bill to reorganise or, as Ray Tallis has put it, to redisorganise the service. I have lived through no fewer than eight NHS Bills during my 16 years in this House; that is one every two years, and we certainly do not need any more. I have spoken about the Salford experience because that is what I know best, and it may well not be replicable everywhere else, but Sir David Dalton’s report for the Government of a year ago presented a series of different ways in which closer integration has been able to occur. It does not have to be the hospital trust that manages the budget. It could, for example, be some form of unified joint management system. Much more important is inspired and inspiring leadership—not available everywhere, I fear. It has been that leadership that has produced the essential elements of team-working together, with all members feeling appreciated for doing a good job. That is something that the Government could take to heart.

We have heard about the 25 so-called integration pioneers that NHS England talked about last year. Can the Minister update us on them, and on the pilot schemes in east London announced recently? Then there is the much heralded devolution of budget to Greater Manchester, of which Salford is of course an important part. That is clearly the route that the Government want to take, but therein lies the rub. First, in devolving responsibility, the Government get themselves off the hook if things go wrong. That is what devolution means.

Secondly, merging two inadequate budgets by itself may improve efficiency but is unlikely to be sufficient. It would be a huge blow to the Government’s devolution agenda if Greater Manchester failed for lack of funds. It would mean a big step back for the integration that we desperately need and would put off anyone else thinking of taking the same route. It is inevitable that money must come into it, and, to their credit, the Government have recognised that and have now agreed to provide transitional funding for Greater Manchester of £450 million over four years—just over £100 million a year. Whether that will be sufficient remains to be seen, but it is undoubtedly helpful and should be welcomed.

Although it is good to know that the Government are aware of the need for some temporary funding, there remains the more serious, longer term sustainability of the NHS and, in particular, social care. Almost everyone recognises that the UK spends one of the smallest proportions of GDP on health of almost all European countries: about 6.5% of GDP, compared to an average within the EU of about 9% or 10%. Social service funding is even worse off. All of that is in the face of increasing demand from an ageing population and a frightening increase in the number of patients with dementia. Almost every day we read in the papers of yet another failure or crisis.

We can become more efficient, and I have tried to indicate one way that we might be able to do just that, but short-term injections will not be the solution. We must find a way to provide a more sustainable level of funding to bring our services up to the standards of our neighbours in Europe. It is true, as Mark Britnell describes in his book, In Search of the Perfect Health System, that nowhere in the world has a perfect system, and many Governments struggle. But that is no excuse for starving our own service and having to accept an increasingly inadequate level of health and social care. If we are to gain the advantages of integration that we can clearly see in a few places, we must have the sustainable resources to do it. Of course, there is a separate debate to be had about how we fund our health services, which is something for cross-party discussions, royal commissions and so on, and I do not want to get into it today, although I suspect that other noble Lords may do so.

Meanwhile, the Government must get into the habit of valuing their staff and not blaming them; they must try to show that they are supporting and not confronting nurses and doctors all the time. I am sorry to end, as I started, by decrying the low level of government funding and criticising their attitude to NHS staff, but I do so only against the background I described of what it is possible to achieve by an efficient system of integration. Mark Britnell in his book finds that the most important reason why people are proud to be British is the NHS. Its fairness and accessibility to everyone, regardless of ability to pay is a precious resource, and we must not let it fail.

My Lords, I did not agree with everything that the noble Lord said, but I congratulate him on how he set out the pressures that the health service faces and will face in future. As he forecast, it is for reasons like that that I advocate a royal commission to examine the future financial—and I emphasise financial—requirements of the health service and propose ways in which that demand can be met. My proposal has absolutely nothing to do with the current industrial dispute. Indeed, I suspect that the BMA would not be a natural supporter of such an independent investigation. Basically, I want a commission to investigate how we can continue to afford a National Health Service providing care irrespective of income, which is what everyone in all parties wants, while recognising the financial challenges of an ageing population and the extra cost involved in medical advance. At the same time, we must recognise that public spending on health should not crowd out all other areas. I also want to see good education, a strong police service and—if noble Lords are interested, we are debating this subject next Thursday at about the same time—better prisons. If this is not an intrusion into private grief, I want a strong defence policy as well.

It is against that background that I would set out four requirements for a royal commission. First, it should be absolutely independent; it should be neither a political body nor an insider body. Secondly, it should look at how we finance the health service, otherwise there is absolutely no point. What we want are the best ideas on financing a service that we all value, irrespective of party, and we should re-examine old policies—for example, policies such as prescription charges, which mean at the moment that 90% of prescriptions are prescribed free. Thirdly, a royal commission should look at all the options; it should certainly examine experience, particularly in other countries of Europe, but it should investigate the potential of a health tax—a ring-fenced contribution to the costs of healthcare, which would have the advantage of connecting the taxpayer much more closely to the cost of the health service that they finance.

Fourthly, and lastly—and personally I regard this as crucial—a royal commission should investigate the long-term savings and benefit of better public health. Both Governments have failed here. The national health basically remains a sickness service, not because that is what Health Ministers want but because that is what the Treasury allows. The Treasury will try to provide resources for treating the casualties, but it is very reluctant to invest in preventing those casualties. It says that you cannot show that it will work, when the evidence is clear that prevention policies can and do work, not least in the 1986 AIDS campaign, which reduced not only HIV but all other sexual diseases at the same time. Even worse than this general failure is the fact that the Treasury has now chosen public health as the one area in the whole of the health field where spending is to be reduced, which is an entirely retrograde step.

There is a vast amount to do, and what we do now has implications for years to come. I believe that a royal commission has the potential to provide a proper base on which to face the financial challenges and to win public support.

My Lords, I am indebted to my noble friend Lord Turnberg not only for securing this debate but for his long-term contribution to health debates and the development of health policy in your Lordships’ House. Like him and many noble Lords speaking today, I am greatly committed to the NHS. In fact, I owe my life to it. No price can ever be put on that, and no acknowledgment is enough.

Many statistics will be traded here today but I am not going to engage in that. I shall focus on the wording of the debate so far as future demands are concerned and offer my thoughts on what the NHS needs in order to be the institution we know, love and admire into the next century.

In my view, there are two essentials. First, to have a viable health service you have to have a social care service which works. We are all familiar with the reasons why the post-war settlement set up different systems of care: men died at 66—one year after retirement—and women at 68 or 69, so you did not need much social care in those days. Now, with our ageing population, the contrast between a health service free at the point of use and a social care system which is means-tested and publicly funded only for those with heavy needs results in a lottery, so the type of ailment you have will determine the financial support you get to cope with its effects. There is no equity. Moreover, efficiency is hampered by a lack of integration in organisation as health and social care are separately commissioned. Look at the 3,000 hospital beds today occupied by people fit to leave but stuck there because funding or assessment has not been resolved. The economic cost of this is huge but to it must be added the cost of the human misery caused by this situation.

We simply must move to a single, ring-fenced budget for health and social care which is commissioned in one place and within which entitlements are understood. We hear constantly that health and social care are becoming better integrated. In the 18 years I have been in your Lordships’ House, I have lost track of the number of times I have heard that assurance from Ministers on all sides of the political divide, but progress is piecemeal at best. We have to hope that somewhere, sometime and soon we will have a Government with enough vision and courage to disregard the five-year focus of any Government and propose a proper reassessment of the post-war settlement to reflect the current and future needs of our ageing nation. It can be done with vision and commitment, as my noble friend has shown us in Salford.

The second thing the health service needs—here I echo the noble Lord, Lord Fowler—is to focus not so much on curing illnesses but on the prevention of illnesses. Statistics are legion about the illnesses which are debilitating to the individual and expensive to the NHS, and the obvious way of tackling them is to prevent them arising in the first place—for instance, diabetes, so associated with obesity; strokes, so associated with high blood pressure; and lung diseases, so associated with smoking and lack of exercise. Yet time and again we hear that nowadays prevention programmes run statutorily or by the voluntary sector are being cut because they are long-term investments and may not pay off, so to speak, for as much as 10 or even 20 years, so they make easy targets. Does the Minister agree that this is short-sighted? We are at a point where only far-sighted, perhaps controversial, but courageous actions will preserve for the long term our much-loved and much-admired NHS.

My Lords, I, too, thank the noble Lord, Lord Turnberg, for securing this important debate. I also want to thank all the people who work in the NHS at the moment. We need to recognise that much of it works very well, despite the pressures which I am sure we will focus on during this debate.

My starting point is that the world is changing. With the demographic time bomb, a large increase in the older population and the conditions associated with that, comorbidities and the changes in the technology delivering medical services, our NHS is facing perhaps the biggest challenge of its time. That is before we even start to look at the financial allocation.

I, too, want to focus on public health. There are concerns about the £200 million in-year cuts which are impacting on the ability to help the public prevent their own need to call on the health service.

I congratulate the noble Lord, Lord Fowler, on the fantastic AIDS campaign. We need a public campaign on how to use the health service now. The number of people who bypass the GP and go straight to A&E, despite what has been done on this subject, is still appalling. Talk to any emergency doctors and they will tell you that there are plenty of people who they should not be seeing there.

The noble Lord is not the only person asking for a commission; my colleague Norman Lamb in another place has also said that we should have one on the entirety of health and social care, for all the reasons that noble Lords have mentioned. We have been talking for years about full integration, and I shall come on in a moment to an example of where I see one particular small project working very well.

Our NHS faces a much bigger crisis, and that is staffing—both nurses and doctors. Not only are we exporting a large number of them—over 5,000 doctors applied for certificates to work abroad, and many of them have gone—but I am not sure whether noble Lords are aware that UK doctors make up only 63.5% of doctors currently registered in the UK. That means that over one-third of our doctors have been foreign-trained. Some 91,000 of our nurses at the moment have trained abroad—that is, one in seven. It is an enormous number. We may have separate debates on how we do not train enough and how 10,000 nursing places have been lost. We have been thinking on a very short-term basis about medical education over the past five years, specifically since the removal of the SHAs. It is vital that we start to plan longer-term. Hiring doctors from abroad may work in the short term but often causes problems in their own areas and countries. While some trusts work closely with other countries—such as the West Hertforshire trust, which works with nursing schools in the Philippines—that is not universal.

My final point is about good integration. Hertfordshire is launching the Sloppy Slipper Swap this month, funded by the county council and the CCG. Some 4,000 people in Hertfordshire have trips and end up in hospital. Most of those are at home and are caused by poor footwear, so it is great to see a fully integrated campaign run by the libraries to ensure that people have access to education and a free pair of slippers, as well as advice about winter warmth. That is the sort of project that we need to see replicated throughout the country.

My Lords, I thank the noble Lord, Lord Turnberg, for this extremely important debate. I declare an interest as chair of the Centre for Ageing Better, a new What Works Centre that does what it says. I will focus on the implications for the NHS of an older population and I shall seek to look 10 years forward, as I think it is essential that we do so in order to address this question.

The starting point is that we are living longer, and this is a cause for enormous celebration and thanks. There are people in this Chamber and in our society who are alive now who would not have been without the changes and successes of medical science. So we should address this as a fantastic opportunity to consider how we benefit from longer lives, rather than seeing it as a disastrous crisis.

Nevertheless, we have to face up to the scale of change and challenge. The ONS tells us that in 10 years’ time there will be 40% more people aged 85-plus. We know what that implies for the NHS in terms of demand and cost. We know that it means many more people with long-term conditions—there are some estimates in Ready for Ageing? if noble Lords want illustrations—and we know from the five-year forward plan that long-term conditions drive 70% of NHS costs. So one way or another there will be a major increase in the proportion of GDP that we spend on health and social care over the next 10 years. Wanless estimated about 11% of GDP; the King’s Fund report by Barker estimated about 12%. Those give us the scale of increases in GDP spending that we are likely to make by one means or another.

What should we do? I agree with the noble Lord, Lord Fowler; it is not the model that is wrong. The model of the NHS is fundamentally equitable and relatively efficient and low-cost compared to others. The question is essentially: how do we fund an NHS and a social care system to address this?

Prevention is critical; it has been talked of, so I will say only two sentences on it. Wanless said in 2002 that unless we address prevention we will hit a crisis; the NHS Five Year Forward View said that we have now hit that crisis because we failed to address prevention properly. At present there is no ambition, plan, leadership or social debate about how we will make the major shifts in personal attitudes and behaviours that will avoid self-inflicted damage and cost to individuals and the public purse later on. Many lives are poorer because of that, so we have to address it, and although it will be slow to make change, it is fundamental to success.

In conclusion, on how we as a society pay for between 11% and 12% of our GDP on health and social care to benefit from longer lives, the question is clearly how we do it in a way that is fair to all people. We need to recognise that many of today’s pensioners are better off than ever. Pensioner poverty has been largely eradicated, and pensioners have a very privileged tax and benefit status—I celebrate that personally. However, in truth the question is: what is the political agreement with the public? Is it essentially, “We will protect you in a privileged tax and benefit position” or “We will commit as a society and as politicians to protect the quality of health and social care that you will need in an equitable way in our society so that you will benefit from your longer lives”?

My Lords, I join noble Lords in thanking the noble Lord, Lord Turnberg, for this debate and I look forward to the maiden speech from the noble Baroness, Lady Watkins. With regard to debates, I put on record that it would be very useful for this House in particular each year in the late autumn to debate the draft mandate that the Government give to NHS England. That is the primary basis upon which the accountability through the Secretary of State to Parliament should be exercised. It was not debated here or in the other place, and it should have been.

I am very proud that, as my party’s spokesman over nearly 10 years, we made unambiguous and absolute our commitment to the values and constitution of the NHS, as my noble friend Lord Fowler equally made clear, and that we made a commitment to increase the budget of the NHS in real terms. Frankly, in the last Parliament it was 0.5% in real terms on average per year; the long-term average has been something over 4% in real terms per year, so the pressure on NHS budgets is unambiguous.

I agree with the noble Lord, Lord Turnberg, that the only reason that in 2014 the Commonwealth Fund could say that we had the best healthcare system among leading economies was because NHS staff deliver a superb service with modest resources. Over the last five years, they continued to deliver substantial efficiencies; in doing that they met the so-called Nicholson challenge of delivering £20 billion. We did it in part not least because—my noble friend the Minister and his colleagues hid this away on 21 July last year—the reform process cost £1.4 billion but delivered £6.9 billion of direct savings during the course of the last Parliament.

However, we need to do more in the future. Time does not permit me to do more than list the things we need to do. We need an NHS digital infrastructure that is user led and that delivers what the Wanless report called for but which did not happen. We need a preventive system. In the creation of Public Health England, the responsibilities of local authorities and the public health strategy in the White Paper of 2010-11 there is a strategy, but it needs to be funded, as my noble friend said, and as Wanless recommended, it needs to be delivered. On commissions, Wanless is a cautionary tale. To agree that a large amount of money should be available for the NHS does not necessarily deliver the preconditions for the success of that service in using that money effectively. We also need new models of care—integrated and personalised care—and better procurement, on which I look forward to hearing from the noble Lord, Lord Carter of Coles. We need the Dilnot report on social care to be implemented, as we heard in the debate before Christmas. Not least, we need tariffs for the acute sector to be realistic, even if challenging in terms of quality and efficient care.

Finally, we need a long-term future for the NHS, and I am not just referring to the next £20 billion of efficiencies over the next five years. There needs to be an understanding that, while there is a requirement to continue to be efficient, there is light at the end of the tunnel and that when we get to 2020 and beyond, the NHS budget, having gone down from 7.8% to probably 7.1% of GDP, does not go down any further and prove unrealistic in relation to rising demand. From that point onwards, for the subsequent five years, NHS England can then build a vision around a commitment to a sustained level of NHS funding relative to the income and wealth of this country.

My Lords, in my three minutes I will concentrate on one section of the NHS Five Year Forward View, published 18 months ago, headed “Getting serious about prevention”. It makes the point that we are reaping the consequences of failure to prevent chronic diseases that would be largely avoidable if only suitable changes in behaviour could be made. The former Chief Medical Officer exhorted people to change their so-called “lifestyles” and live more healthy lives—I think we know the list.

The five-year view does not emphasise sufficiently that these diseases are all strongly related to social conditions. As Sir Michael Marmot has shown, there is a gradient in both mental and physical health through all socioeconomic groups from the top to the bottom. Health education messages to change behaviour are, however, less effective in the lower part of the spectrum. Poverty and inadequate housing may make it more difficult to give up harmful habits such as smoking, drinking or comfort eating, which can give momentary relief from economic and social pressures. Changing behaviour where it matters most is therefore the most difficult; powerful underlying pressures, some from the tobacco industry and parts of the food industry, are pulling in the opposite direction.

Professor David Gordon and his colleagues at Bristol University have drawn up an alternative list of desirable health behaviours to those advocated by the CMO. They take a rather different approach, which goes like this: “1. Don’t be poor. If you can, stop; if you can’t, try not to be poor for long. 2. Don’t live in a deprived area. If you do, move. 3. Don’t work in a low-paid, stressful manual job. 4. Don’t live in damp, low-quality housing”. There are six others, which I am afraid time precludes me from listing.

Those suggestions all have a direct bearing on health and longevity, but they lie outside the remit of the NHS and are mostly the responsibility of local authorities and other departments of state. If they were adequately funded, a great load could be lifted from the NHS, which at present is carrying a burden for which it is not really designed. I suggest that the continuing financial crisis of the NHS will not be solved until it is properly funded and other departments of state whose responsibilities have a bearing on health are enabled to carry their full share of maintaining the nation’s health and well-being.

My Lords, I add my thanks to the noble Lord, Lord Turnberg, for putting this debate on the table. In dealing with this question, I consulted the army of doctors, specialists and carers who enable me to be here today and to function. I asked them, as well as my colleagues in the department of health economics where I used to work, what kind of solutions they thought would deal with the problems that we face.

The general response was the suggestion that is already on the table—that you cannot have good health without having good preventive care at the very beginning, without having good food at schools, without having timetable slots for gym sessions and exercises, or without enabling the next generation to grow up healthy. The problem with the NHS is that people like me are now surviving and are costing a great deal. I am constantly in a variety of hospitals, being pumped and tested and put together. We are expensive—but I hope that we render some services.

On the other hand, what is absolutely required, more than care, is preventive measures. Also, my colleagues from health economics pointed out to me that, in terms of state funding, the NHS has been improving faster than the input to it, year after year since 2010. Essentially, efficiency is increasing; unfortunately, the burden that is put on that efficiency is increasing faster.

We cannot deal with that by looking at the National Health Service simply in terms of health and medication. We absolutely need to prevent people rushing to the NHS because their GPs are overstretched and they cannot get easy access to them—calling an ambulance ensures that they do get access to the NHS, whereas getting themselves to the GP is often costly and time-consuming and involves a great deal of waiting. So what is needed is to enable patients to have better access to GPs.

I do not think that that is served by having round-the-clock services in hospitals. I had dinner with a group of GPs last night. Many of them said to me, “It doesn’t matter whether you get your toenail removed on a Monday or a Saturday”. Hospitals perform a great many functions that do not need to be provided on a seven-day basis. We need to be able to separate what needs doing now, how we do it, and, particularly, how we secure the next generation’s health.

My Lords, I am very grateful for the opportunity to speak in this debate. Much of what I was going to say has been said and I do not intend to repeat it. I have surveyed some of the National Health Service foundation trusts in my diocese and there are common threads, both of opportunity and concern: financial, operational and clinical. Yet it ought to be said that some of the administrations of these health services are doing heroic work at a time of enormous complexity and constraint. Again, as has been said about the need to raise morale among staff, we should at least thank and congratulate those who are making the system work despite the challenges.

As demands rise, constraints are harder to deal with. I will throw into this that questions around PFI will have to be addressed at some point because of the deficits that some of our trusts are facing. One obvious issue here is that collaboration across key organisations at a system or place level is made difficult when each is bound by an independent regulatory regime and independent internal governance arrangements.

The relationship between health and social care was raised earlier. Social care is means tested. If you want to shift people out of acute beds in hospitals and into social care, there has to be a smoother route for doing it; obstacles should be handled or dismantled.

Finally, in relation to questions about the future, I will raise the question of chaplaincy—not as a bit of special pleading but because chaplaincy recognises the holistic nature of the care of people. In a debate such as this, we very easily talk about money, finance constraints and administration systems, but looking at the whole needs of people, so that they cease to be just medical cases or numbers or bed throughput, will be increasingly important.

My Lords, I hope that the right reverend Prelate the Bishop of Leeds will forgive me for my intemperance. Normally, I do not interfere with the bishops, except when I am playing chess. I also apologise, if I may, to the Minister, the noble Lord, Lord Prior. I feel very deeply about what I am going to say, and it will be uncomfortable. I want to assure him of my respect for him and my recognition of his commitment to the National Health Service. However, what I have to say is important.

According to independent international observation, we have the best National Health Service in the world, often funded at a lower level than almost any other equivalent in Europe. However, I am not sure that it can remain so after the 2012 Act, which of course was introduced by the noble Lord, Lord Lansley, whose idea it was.

The one thing that makes our National Health Service as good as it is, is the quality of academic medicine and research that goes on in our universities. Jeremy Farrar has pointed out that the reason he became such a good doctor is that he did research. In spite of the ludicrous boasts that we are doing more research in the NHS and that every patient will be part of research, sadly, this is really not happening. As Professor Geraint Rees, the notable neuroscientist at UCL has said, the culture of the NHS has become increasingly inflexible and actively hostile to clinical academic training. Why do I say that? It is because it is inflexible in allowing research-oriented doctors to move to different regions to get experience. The system makes it difficult for research-oriented doctors to return to clinical training, and the career that I had would now be impossible. Doctors wanting to do research find it extremely difficult to persuade seniors and managers that they should spend time doing this, and the current problems doctors face are a shocking example of what is happening.

The fact is that research takes time: it takes time to read, to reflect, to discuss, to think, to write, to publish and to talk to patients to explain why the research is so important. I see prospective medical students in schools all over the country and they show one thing: they cannot get into a university to do medicine unless they demonstrate their altruism and an understanding that they will need to be ethical, their commitment to justice, and the notion that they are going to have to be extremely diligent. As you see, they go through medical school with all those principles—the notion of justice, public service and, above all, diligence—drummed into them at every stage in every university.

But what have the Government done? I congratulate the current Secretary of State on one thing. He has certainly united the most diligent, altruistic, committed, intelligent and well-trained workforce in the country; they have gone on strike almost unanimously. The fact is that the attitudes that are being pushed on to the doctors are, ultimately, extraordinarily destructive, and the Government have a major responsibility for that. The future of our NHS is imperilled by this change of attitudes.

My Lords, these are challenging times for the population’s health and the healthcare system, for reasons already set out very clearly in today’s debate. What some commentators have called a near existential crisis of the social care sector has brought some services close to breaking point.

The much-heralded greater efficiency and productivity improvements in the NHS, very important as they are, are being pushed to their limits and will not close the projected £30 billion funding gap. At best, they are like sticking a plaster on a health and care system that needs major surgery. As we heard the noble Lord, Lord Turnberg, set out so eloquently, for a sustainable and long-term approach we need to set up a totally new model of integrated health and social care.

We all know that the NHS is not only a public good but a top public priority. The Government have acknowledged this priority in the recent spending review, and the commitment to an £8 billion increase in NHS funding by 2020 is very much welcomed. But frankly, that is only going to stabilise NHS services in the short term, and a lot of it will be taken up with addressing the growing deficit facing NHS trusts and foundation trusts. Critically, it will not, in my judgment, allow the implementation of the seven-day services requirement nor the much-needed investment in new care models.

We also need to understand where this £8 billion is coming from. Cuts to other parts of the Department of Health budget will clearly have knock-on implications for the NHS. So it is of real concern that other health spending, such as public health, education and training, and capital, is expected to fall by more than £3 billion. My key point today is that it is critical that the additional money does not come at the expense of funding for mental health or, indeed, social care. The coalition Government pledged a transformation in mental health services with almost a £1 billion investment, something that the Prime Minister made much of in a carefully packaged re-announcement earlier in the week. While this investment is hugely welcome, it still does not properly address the fundamental disparity between the ways in which physical and mental healthcare are funded and delivered.

The NHS England five-year forward plan had many good things to say about new and more joined-up models of care. These models are fundamentally about abolishing long-standing boundaries between GPs and hospitals, between physical and mental health and between the health and social care sectors. There is so much more to do as well joining up the community services, prevention and public health.

As has already been mentioned by my noble friend Lady Brinton, my right honourable friend Norman Lamb has recently proposed the creation of a cross-party commission on the future of the healthcare system. I strongly support this. The work needs to explore the various tax and fiscal options as part of the solution to the funding gap—something, frankly, which politicians of all stripes have long shied away from. I hope the Government will welcome this initiative.

My Lords, I thank the noble Lord, Lord Turnberg, for tabling this debate, in which it is a great honour as a Member of this House to make my maiden speech.

My career started in 1973 as a nursing student in close proximity to this House at Westminster hospital where, on a more personal note, I was fortunate to meet my husband, a surgeon. I thank him for his support and encouragement in embracing my appointment to this House. Although I do not mean to be controversial today, I can assure your Lordships that this is difficult for me, having extensively argued the merits of investment in nursing versus medicine, surgery versus mental health, and acute care versus community care throughout the 40 years’ experience I have as a nurse and regular practice with a surgeon at home. In turn, this led me to a deputy vice chancellor role at Plymouth University, with responsibility for student affairs, including a range of health programmes. I have more recently been involved in chairing academy schools, working as a non-executive director in the NHS and the Aster Housing Group. I also undertake charitable work in drug treatment centres and in the care of older people.

I thank noble Lords on all sides of the House for the warm welcome that has been extended to me since my arrival and all the staff of the House for the assistance they have given me. I also thank my two supporters—my noble friend Lady Emerton and the noble Lord, Lord Kestenbaum—and my mentor, my noble friend Lord Patel, who tells me that he is watching this from India.

The vision for the NHS is for a modern, efficient and sustainable NHS where care and compassion matter. It has been argued that an integrated approach could both improve the quality of care for patients and improve productivity. Numerous studies have shown that an increase in the number of registered nurses in hospital and community settings is associated with clear benefits for patient mortality rates and other key metrics. Patient outcomes are enhanced if care is co-ordinated and, where necessary, delivered by registered nurses. If hospital admissions are to be reduced, rapid assessment in patients’ own homes from a range of healthcare professionals is vital. Yet are we doing enough to ensure that we are training sufficient numbers of healthcare professionals to achieve and sustain integrated care as outlined in our strategy?

In the early 1980s, as a “nursing officer for change”, I worked in a large mental hospital where over 1,000 beds were closed and replaced with community-based services. The key to the largely successful project was that all clinical staff were provided with further education and development to prepare them for the changes in their role. Community care is now the norm for those who have mental health and learning disability challenges, and most care is successfully delivered in a range of health and social care settings. I would argue that we are not so successful in providing acute healthcare intervention in people’s own homes, as evidenced by increasing admission rates to hospital, yet other countries successfully provide more care in the community. We hardly have an ideal situation at the moment.

Key to successful community care for people with the most acute medical problems and long-term conditions is the number and kind of nurses that are available to work in a range of settings, yet we know that we have an international shortage of qualified nurses which is estimated to be at least 20,000 in the UK alone, resulting in increased agency staff costs and, perhaps more important, reduced continuity of care. Happily, the number of nursing places in universities is set to rise this year, but for the next three years we will have the lowest output of registered nurses because of previous short-term cuts. The noble Lord, Lord Willis of Knaresborough, has indicated that we need to put training at the very heart of the NHS agenda, and that lifelong learning is essential. If we want a thriving healthcare structure, we must ensure that we have a workforce that is provided by the voluntary, social enterprise and independent sectors as well as the NHS. We need to recruit, train and retain care assistants, who provide support for individuals in their homes working with registered nurses.

In a recent letter to the Times, the noble Lord, Lord Hunt of Kings Heath, concluded that the NHS is currently remarkably robust considering the level of investment. I agree, yet as others have said today, funding remains relatively stable in real terms and the only way to resource the future is to redesign our service to meet future challenges. Nursing is pivotal to this. In the current situation, the role and complexity of nursing is poorly understood, especially the role of the registered nurse with a degree. I can assure noble Lords that degree-level nurses are not too posh to wash, but can do so only if they have enough time to do it with care and compassion, as well as overseeing others who can deliver care well. The Guardian recently suggested that NHS leadership is ailing, but pointed to the Florence Nightingale leadership scholarships as an area of good practice. We must provide more opportunities for leadership development to ensure a supply of competent leaders who are able to respond to changing demand and lead the redesign of services for a sustainable NHS.

I have argued that registered nurses are pivotal to greater NHS productivity. This will require valuing and investing in the profession not only in terms of education and opportunity but by demonstrating for tomorrow’s care workers kindness and compassion in employment terms, so that this, in turn, is reflected in the care they give not only to us in this House but to society at large in the four countries of the United Kingdom.

My Lords, it is my great privilege to welcome the noble Baroness, Lady Watkins of Tavistock, to the House and to extend warm congratulations to her on her most excellent maiden speech. It is an indication of the expertise that we can look forward to in her future contributions.

I thank the noble Lord, Lord Turnberg, for the opportunity to debate this important topic, which is to see how the NHS can be turned from a national sickness service back into a national health service. The rapid development of scientific knowledge, the growth of technology and research into the etiology of disease have led to valuable treatments for many conditions, and continue to do so, but at the same time the concentration on public health that was a priority at the inception of the NHS—preventing disease and promoting the health and well-being of the population—has decreased, although it remains a very important ingredient. Highly technical treatments and shorter hospitalisation now are appropriate but, because of the lack of community support, hospital beds become blocked.

As a retired nurse with 62 years’ experience, I am aware that the intent has always been to preserve the place of public health, but it has been overshadowed by the more exciting treatment side. The well-being of patients remains a requirement for nurses in the nurses’ code of conduct. A few lines refer to the fact that well-being in public health and care standards should be included in the syllabus of the nursing degree.

The NHS constitution also includes well-being as a responsibility of all staff. However, it is recognised within the Five Year Forward View that public health remains in urgent need of revival. That is for several reasons, the most important being the health of the population and the cost-effectiveness of a healthier population. Recently, Simon Stevens said that we cannot put more on the overstretched NHS staff. Healthcare professionals are the key to the future of the National Health Service. Unless they take a lead in promoting health and prevention of disease, nobody else will have the knowledge or the skills to take that forward. I do not refer just to doctors and nurses but to social services and all charitable contributors.

There is an in-built resistance to breaking down professional and organisational barriers but we must have the right leadership—leadership has been mentioned several times this morning—to take forward the health service so that it is not only a sickness service. It should be possible to influence and persuade lateral thinking and bring the holistic culture to health. It should start with the promotion of health, the prevention of disease, the treatment of disease and the well-being of the population, which should provide an evidence-based and cost-effective service.

The idea of the royal commission is good but, my goodness, a royal commission takes a long time. This is an urgent need and perhaps we may ask the Minister for a full debate on public health quickly.

Perhaps I may remind the House that this is a time-limited debate. Although most speeches have finished when three minutes is still showing on the clock, speeches have reached their permitted limit when three minutes first shows on the clock.

My Lords, the wording of our debate in part says,

“the ability of the National Health Service to meet present … demands”.

I think we all agree that when it meets present demands, it does so in an exemplary way. The problem is that it does not meet all demands and the failure to meet demands is increasing. I picked four important points at random and was interested that, at least in part, they overlap those inadequacies to which the noble Lord, Lord Turnberg, drew attention.

There is very little integration between health and social services. We are sad about that at the community level but is it realistic to expect that to happen if, at the government level, there is not integration between health and social services? Perhaps the time has come to reverse the decision to separate them that was made some years ago. Thousands of people urgently need hospital treatment who cannot get it because beds are blocked by frail, elderly, blameless people who cannot otherwise be cared for. That is a failure in demand.

All around us, GP surgeries are closing, some of them permanently. I think 20 closed permanently in the county of Northamptonshire just last year. No one knows how many are being shut on a short-term basis because we cannot get the GPs to keep them open. It is a failure of demand when two or three weeks elapse before you can see your GP and when your chances of dying are 16% greater if you happen to be admitted to hospital over the weekend.

One of the problems with the NHS is that it is embedded in politics. That is not a new phenomenon: it was true when I was on the Front Bench doing my thing 25 years ago; it remains the case. Any chance to change the structure for the future has to deal with that political problem. Maybe a royal commission is the way forward, or something smaller, independent, with public consultation could lead the way. I can think of no place better than your Lordships’ House, which is full of expertise, common sense and vision, to lead the way to make it possible to engage the politicians who now lead us, on both sides of the House, to look at the possibility of a better future.

My Lords, I, too, thank my noble friend Lord Turnberg for securing this important and timely debate, and join in the welcome of the noble Baroness, Lady Watkins of Tavistock. It is good that we have another nurse in this House. In my memory it is the first time in some 16 years that we have had three nurses speak in quick succession in a debate. If anyone with any influence out there is listening, we need even more nurses in this place.

It goes without saying that unless we have a highly skilled and well-educated nurse force there are implications for the future of the health service. But now, without any consultation whatever with the Royal College of Nursing, the Royal College of Midwives or UNISON, we are hit with the Chancellor’s CSR announcement. It is the same sort of attitude that my noble friend Lord Winston referred to so far as the medical profession is concerned. There was no reference whatever to the nursing and midwifery professions about the changes to the pattern and funding of nurse education. That announcement has come out of the blue and provides that, from 2017, student nurses, midwives and others will have to pay their university tuition fees and that, at the same time, their bursaries will be scrapped. Thus will end free education for nurses and midwives. The justification is to allow more applicants to get into university—to allow more to get past the so-called cap on places. Listening to the Chancellor’s announcement, you would have thought that the dreaded cap was nothing whatever to do with the Treasury and the restrictions on funding for university places for student health professionals.

There are few, if any, graduate professions as ill rewarded as nursing, so I am not sure how the Chancellor thinks that his plans can work if potential nursing students are to be faced with what for many will be career-long indebtedness of perhaps up to £50,000, to be paid back immediately on qualification from a miserable starting salary of about £21,000. Quite clearly the Chancellor and the Department of Health have been seduced by the Council of Deans of Health and Universities UK because the whole plan seems to be more about income for universities and, at the same time, savings for the Government than it ever has to do with workforce planning and the alleged possibility of more university places.

In a Written Answer to me the Government admitted that they do not collect data on how many student nurses leave university because of financial reasons, yet they now pray in aid the fact that there will be more money available from loans, as if the bursary system was a primary retention problem. To look at the figures, if the present percentages at universities are replicated, then many of the 10,000 so-called extra places will go to increasing numbers of midwifery and other health profession students. It will leave probably 6,000 extra places for nurses—2,000 per annum. Unless my maths is badly wrong, we will potentially have some 22,000 nursing students per year. That is the better part of nearly 3,000 fewer places than we had under Tony Blair’s Government of some 10 years ago. As with so much, we had the numbers right then, and we need to get back to that Labour figure if we are serious about tackling nurse staffing in the NHS.

Very close to home, a member of my family who has a number of degrees, is a skilled practice educator and teaches at university from time to time was until very recently still paid as a staff nurse. That is not a reward for 30 years’ continuous practice and education that will encourage nurses to take on a huge debt to come into our profession. With the greatest respect to the Minister, for whom I have the highest regard, we have either to start to pay nurses properly for their duties and responsibilities or else we have to do a quick U-turn if we are to get more students into university. We have to look carefully at what we are doing here and we have to work with those who represent the nursing and midwifery professions, which at the moment the Government have manifestly failed to do.

My Lords, this is a very important debate and I wish there were more time for it to be conducted. I thank the noble Lord who initiated it. However, we are living in a fairyland in which we are talking about further improvements in the NHS, most notably a 24/7 service, at a time when the existing structure is under the most desperate threat. As we all know, another £200 million is to be cut from preventive measures but no one has so far mentioned the £22 billion of savings that the NHS is supposed to find through productivity agreements over the next five years. The ideal that we all share of bringing together social care and the NHS is largely vitiated by the Treasury’s inclination to continually cut local authority spending at a time when we are talking about improvements in, for example, preventive measures. That shows we are still denying the harsh facts in front of us.

It will be a great advance if we can even keep the NHS together for another couple of years. The noble Lord, Lord Winston, rightly said that it is being preserved at present through the extraordinary dedication and commitment of its badly paid staff, whose work is inadequately recognised. We owe them a great deal for keeping the NHS going but we simply cannot continue to think that we do not have to address the central issue of steady, consistent and adequate funding. We are nowhere near doing that.

In listening to the comments of the noble Lord, Lord Fowler, I remembered the very detailed study of the Barker commission published in October 2014, which was drawn up with the aid of the King’s Fund but has still not been discussed in this House or anywhere. It proposed that spending on health and social care should reach a figure of between 11% to 12% of GDP by 2025. We are still not discussing that proposal and still pretending that it does not exist. The noble Lord, Lord Fowler, rightly mentioned two difficulties. First, can a royal commission provide an adequate response within a year, or even less, because it is crucial that it does? Secondly, it is absolutely essential that any measures adopted are supported by all parties. We have to have an all-party response for which we all bear responsibility and we must not invent new ways to spend money that we do not have. If I may say so, in the noble Lord, Lord Prior, we have the kind of person who can go to the Treasury and say, “It is no good taking away with one hand what you give with the other because that simply leads to extreme frustration and even to desperation”.

We need a royal commission that conducts its business much more rapidly than is usually the case. We also need to debate the Barker report. However, we must recognise that, more than anything else, we need sustainable, steady and consistent funding, including funding drawn from taxation, because without that we will not be able to save the NHS.

My Lords, except to congratulate the noble Baroness, Lady Watkins of Tavistock, on her excellent maiden speech, our restricted time means that I will skip the usual niceties and nuances and concentrate on the absence of a credible funding system.

We are in the middle of a decade when we expect the NHS to cope with substantially increased demand and service expectations on an annual budget increase of roughly 1% a year in real terms for 10 years. Before this decade, successive Governments provided the NHS with a real-terms annual increase averaging 3% to 4%. It is virtually impossible, I suggest, to retain a good-quality labour force, meet rising demands, improve quality, and redesign service delivery on a 1% annual real-terms increase for a whole decade, ending up with 7% of GDP, roughly, being spent on our NHS.

By 2020, the combined health and care system will face a funding gap, I would suggest, of some £35 billion a year, with the 2015 spending review closing that gap, on the most favourable interpretation, by about £10 billion. The rest of the money comes from our old friends: pay restraint, new ways of working, and better productivity. I accept that the NHS could use its existing resources much better but, even if the NHS delivered all the proposals of the noble Lord, Lord Carter of Coles—a very big “if”—it would not close the funding gap. The 2015 spending review totally fails to deliver a credible funding strategy and actually makes a bad situation worse by failing to provide any kind of viable funding system for publicly funded adult social care or public health. The NHS and social care are confronted not with a managerial or professional failure but with a failure by politicians across the political spectrum to engage with the public on how we fund a sustainable, integrated health and social care system over the longer term.

To have good-quality and readily accessible health and care services, largely free at the point of clinical need, the public have to be helped to understand that they must pay for them, whether through more taxation, some form of co-payment, or a combination of the two. To get to grips with this rather politically unpalatable truth, we need an authoritative, independent inquiry that will work quickly to examine the possible options for new funding streams to provide some buoyancy and future-proofing. The Front Benches in both Houses need to get behind the ideas of either the noble Lord, Lord Fowler, or the Liberal Democrats, outlined by Norman Lamb in his 10-minute rule Bill. We need to start acting now to future-proof the NHS’s funding.

My Lords, I congratulate my noble friend Lord Turnberg on obtaining this timely and wide-ranging debate. I declare my health interests as shown in the register. I will concentrate my short contribution on mental health, which I believe has never been higher on the public’s agenda.

The NHS currently spends only about 13% of its budget on mental health treatment and support, including GP time, prescriptions and secondary mental health services. However, evidence from prevalence surveys shows that only 25% of people, including children, with common mental health problems receive any treatment. There has been a great deal of talk in recent years of parity of esteem between physical and mental health and I welcome recent announcements of additional funding for mental health services, but the funding gap is still huge.

The King’s Fund and the Centre for Mental Health identified that a third of people with long-term physical conditions—4.6 million people in England—have a co-morbid mental health problem, most commonly depression and anxiety. The cost of care for this group is 45% extra and more still for those with multiple conditions. This adds up to an additional cost of £10 billion nationally each year. The extra costs are for a variety of reasons, including poorer self-care and condition management. This can increase the cost of prescriptions, cause or lengthen the hospital admissions and dramatically increase both morbidity and mortality.

At least £1 billion more is spent on the cost of staff mental health in the NHS, at least half of which is likely to be hidden, as staff present at work but may be struggling to do their jobs as well as they would wish. A significant part of the £14 billion cost of untreated mental health care could be saved while offering better healthcare. For example, liaison psychiatry in acute hospitals has been found to save £3 to £4 for every £1 invested, cutting costs by an average of £5 million per hospital.

Crucially, earlier intervention is vital in all areas of mental health care. There is clear evidence that investing in perinatal mental health care, parenting programmes to help families to manage children’s behaviour, treating childhood depression, anxiety and conduct disorder, promoting mental health in schools and early intervention in psychosis all generate savings far in excess of their costs.

I hope that the Government will also invest in liaison and diversion services and that the Treasury will shortly approve the business case for mainstream funding of these services. Huge savings can be made here in the criminal justice system and the health service. By investing wisely in mental health support, the NHS may be better able to sustain itself. Reaching out to people with physical conditions and symptoms whose mental health needs are unmet will improve health at a lower cost. I hope that such integrated proposals will be pursued by the devolution of health and social care in Greater Manchester, building on the work of Salford that my noble friend Lord Turnberg so well described.

My Lords, I am glad to congratulate the noble Baroness, Lady Watkins, on her maiden speech. Due to the pressure on time, I want to focus on one very small area, which has been alluded to by various noble Lords but which I want to develop a little. It is the pressing and vital need to reboot the concept of a social contract, which lay at the heart of the national health system as envisaged by Beveridge and which balanced rights and responsibilities, not least against the background of living in a time when people have increasingly emphasised rights and perhaps downplayed the sense of duty and responsibility.

In 2013, PricewaterhouseCoopers produced a report on the 65th anniversary of the NHS, which identified two key factors that would be essential for the future of the NHS. One of them was the extent to which people took personal responsibility for their own health and care, and that of their families. Then last year, when the independent research published by the Commonwealth Foundation revealed the UK’s health system to be at the top of the league among nations in the developed world, the one area where we did not score highly was in the prevention of illness. That report highlighted the particular problem of large numbers of people in this country with unhealthy lifestyles.

It is deeply concerning that so many illnesses are caused by addictions to alcohol and smoking, while we have the highest rate of child and adult obesity in Europe. Estimates of their cost vary but just those three areas could well be costing as much as £17 billion per annum. To address these issues requires a deep cultural change across our nation, along with a renewed emphasis on personal responsibility for our health and for exercise, for people of all ages. But of course these sorts of changes are some of the hardest to make. The need for a new social contract between citizens and the NHS is urgent, with a much greater emphasis on what we need to do in response to what the NHS provides. Indeed, this message needs to be reinforced every time anyone comes in contact with the NHS.

While laws and taxation have a contributory factor, we need to create a climate which celebrates health and people taking responsibility for it, for them and their families. There is a great deal of evidence that one of the most powerful factors in bringing about such behavioural change is the influence of peer groups. We need to work consistently with health campaigns, sports and leisure clubs, statutory and voluntary youth and children’s groups, schools, colleges, churches and everybody from the Mothers’ Union to the WI and the University of the Third Age to think how we can celebrate the need for personal responsibility. It needs to be undertaken over the long term; we are talking in terms of decades. If we are to see significant change then the evidence of the campaign to reduce smoking, which has halved since the 1970s, shows that it can be done but will take time and consistency.

My Lords, I declare my interest as a now fully retired dental surgeon with over 40 years’ experience and a fellow of the British Dental Association.

All too often when we speak about our health system, oral health is conspicuously absent from the debate, and this morning is no exception so far. Both the Government and Opposition seem united in seeing a more integrated approach to delivering health and social care services as the key to ensuring the future sustainability of the NHS. It is essential that dentistry is factored in and included in any wider health strategies, and that the interplay between oral health and general health, and dentistry budgets and other NHS budgets, features in any discussions on healthcare provision.

An excellent report published by the Faculty of Dental Surgery reveals how much further we need to go in our fight against tooth decay. A third of five year-olds in England are still suffering from caries, and within that group the average child has at least three teeth affected. It is simply shocking that in this day and age tooth decay—an entirely preventable condition—continues to be the most common cause of hospital admissions among five to nine year-olds, with 500 primary school-age children requiring hospital treatment every week. This not only causes the children and their parents unnecessary stress and pain but is also a complete waste of NHS resources, costing the taxpayer over £30 million a year.

A fifth of five year-olds eligible for school meals have severe or extensive tooth decay, compared with just one in 10 among those from more privileged backgrounds. The situation is particularly alarming considering that approximately 90% of dental problems are preventable and the damage they cause is cumulative and costly. We must also raise awareness of the risks of tooth decay, especially of the impact of sugar consumption on children’s teeth. I fully agree with the BDA that no option should be left off the table in the efforts to end Britain’s addiction to sugar. Possible measures range from lowering the recommended daily allowance, through action on marketing and labelling, to possible sales taxes.

I also urge the Minister to consider investing in a national oral health programme to drive improvements in children’s oral health in England, following and learning from the success of such programmes in Scotland and Wales. I once again urge the Government to consider the overwhelming worldwide scientific evidence which clearly points to fluoridation being a safe and effective way to fight caries and narrow the significant inequalities in children’s oral health across the country, and to encourage local authorities that do not yet use this resource to introduce water fluoridation schemes.Noble Lords will all agree with me that a shift in focus from treatment to prevention is crucial if we are to ensure the NHS will be able to face the challenges of the future. This statement is as true in the area of dentistry as it is elsewhere in our health system.

My time is up. I was going to say a few things about oral cancer and the importance of the dental team in the new tobacco control strategy, and was going to bring your Lordships good news of a dental treatment that does not involve drilling.

My Lords, I thank my noble friend Lord Turnberg for securing this debate and declare my interest as an engineer and chairman of the Warwick Manufacturing Group at the University of Warwick. I also run the Institute of Digital Healthcare jointly with the medical school.

Two years ago, I was treated for pneumonia at the Queen Elizabeth Hospital Birmingham, a fantastic new hospital led by an outstanding former nurse, Dame Julie Moore. The care I received was immaculate, and I understood then why the NHS is sometimes called our other national religion. However, I see it as our national science. After all, it is the subject of many experiments and is constantly being tested.

One current test is higher care standards, which requires more medical staff on wards. As a result, agency staff costs have soared. Monitor expects the bill to be over £4 billion this year, blaming a fundamental mismatch between supply and demand for medical staff. A lot of companies have made very good profit exploiting this, and it is rather ironic that Ministers are now proposing a cap on rising bills as the answer. The truth is that, whether in energy or agencies, price caps are a short-term fix. The solution is to increase supply.

Several medical schools, including Warwick, offer four-year medical degrees for graduate entrants. Such graduates do very well both academically and in their career. Warwick graduates are currently second only to Cambridge medics in gaining specialty training places. Shorter courses also mean qualified students can contribute to the NHS earlier. Four-year graduate entry degrees broaden access, attract quality applicants and give faster returns on public spending. It would be ludicrous to close such programmes. Yet medical schools could be forced to do so, as EU legislation demands that medical qualification takes five years. Currently, the fifth year for graduate entrants is the first-year foundation programme. During this time, graduates are provisionally supervised under the GMC before full registration as an independent practitioner is granted.

However, after the Greenaway review, the Government proposed merging degree graduation and full registration. This would unintentionally make four-year courses impossible, as removing the year under provisional registration would leave graduate entry courses short of the EU demand for five years’ training. To resolve this, graduate entrants could continue to do their first foundation year under provisional registration, and I understand the GMC may favour such a solution. We must innovate to attract outstanding medical students, then get them working as soon as we can. To achieve this, I urge the Government to pledge that future graduate entrants will retain the option of a four-year medical degree.

My Lords, I also thank the noble Lord, Lord Turnberg, for this important debate. I have my own recent family reasons for having the deepest gratitude to wonderful NHS staff, who deploy life-saving skills. I also have a niece who is a junior doctor.

However, I want to concentrate on diabetes. There is huge potential—it is a no-brainer—to spend more wisely. Four million people live with diabetes, and they cost the NHS £10 billion a year—£1 million an hour—which is 1/10th of its budget. The total cost to individuals and society is £24 billion and rising fast. My particular focus is on those who are insulin-injecting, predominantly with type 1 diabetes. I have some, albeit second-hand, experience of this, having been with my husband for the 40-odd years since he was diagnosed. The NHS has never included me or learnt from me; for example, when it comes to coping with hypos. I should mention that my husband already has access to the technology I will refer to, that he is chairman of a health trust and that he was, for several years, chairman of the UK branch of the Juvenile Diabetes Research Foundation.

NHS England’s Five Year Forward View last summer referred to diabetes only as a preventable illness resulting from,

“the nation’s waistline … piling on the pounds”.

This completely ignored and insulted those with type 1, whose diabetes is not caused by obesity. As well as the integration of services, I urge an “invest to save” approach to both research and care. Around 400,000 people have type 1 and although they account for only one in 10 of those with diabetes, they consume, on some estimates, half of the £10 billion that diabetes costs the NHS annually. As much as 80% of the cost of treating people with type 1 is spent on avoidable complications. Two reports from the National Audit Office, and one from the Public Accounts Committee of the other place—a second is in progress—have been scathing about NHS care failures.

How do you invest to save? First, you do it in research. The glittering prize is a cure. JDRF and the researchers it funds do excellent work, but the UK Government spend only £6.5 million a year—10p per head of population—on diabetes research, backed up of course by crucial EU funding that Brexit could put at risk. This spending is puny and inexplicable.

Secondly, you invest to save in devices for self-management. The key to keeping type 1 diabetics well and avoiding debilitating and expensive complications of organ damage is good blood glucose control through self-management. Insulin pumps and continuous glucose monitors have proven benefits in the management of type 1 diabetes, and NICE guidance attests to their cost-effectiveness. Testing without finger pricks now exists, and NICE needs to look positively at this. Yet only 7% of people with type 1 in the UK have a pump, compared to 15% in Germany and 40% in the US. Only 1% or 2%, mostly self-funded, have a CGM.

I conclude by saying that spending to save on diabetes is an easy win; there is no excuse not to do it.

My Lords, there are some excellent specialist units doing exceptionally high-quality work with good leadership and splendid teams of skilled staff which are world-class, and patients are grateful for their correct diagnoses and care, but there are also hospitals which have inadequate equipment, lack of staff and leadership and poor morale. Patients are often misdiagnosed and have a poor standard of care, causing concern and lifelong problems. There should always be good communication, honesty and transparency. Patients should feel safe and have faith in those people looking after them.

The big question is how this can be achieved across the country when demands are growing and we have to rely so much on staff from other countries. It is refreshing when one finds keen, enthusiastic doctors who love their job. The present situation with dissatisfied junior doctors is very concerning. A satisfactory solution must be found.

Patients who have had an operation and are in need of rest and recuperation should not be subject to a noisy and stressful environment. They need a well-organised, peaceful ward with a responsible sister in charge, so many people say, “Bring back matron”. Many people across the UK are anxious about the money spent on agency staff, who cost a monumental amount of funds and may not have the necessary commitment. This situation is milking the NHS.

It is vital that infection control is treated as a priority in the NHS. It will come to the fore as antimicrobial resistance comes to dominate acute hospital care. The UK had the global lead in infection control, appointing the first specialist infection control nurses. If they suffer cuts, it will be a disaster.

Worldwide, the lives of billions of people are affected by zoonosis, diseases transmitted from animals to humans. This is an immense public health problem. Bush meat, which is meat that comes from wild animals captured in developing regions of the world such as Africa, was the origin of HIV and Ebola. Thousands of tonnes of bush meat are coming into the UK each year. It is illegal to bring bush meat into the United States of America; it is very strict. Should we not do likewise? One never knows what dreadful diseases are around the corner.

My Lords, I, too, thank my noble friend Lord Turnberg for securing this debate and congratulate the noble Baroness, Lady Watkins, on her excellent maiden speech. I also declare my interests as being those on the register.

We have heard that the public value the NHS so greatly, and we know from the Commonwealth Fund studies that we rank very highly in healthcare systems in the world, yet something is clearly wrong. We need to address the question of funding, but in this brief speech I should like to focus much more on what we need to do now in the short term to equip the Minister to go back to have those necessary arguments with the Treasury to secure the correct level of funding.

The interesting thing is that we have a great system. Somebody said the other day that we have done everything right once. What we have failed to do is build on the great experience that we have built up in a number of areas. If we look at quality or use of resources, we see unwarranted variances right across the system. The noble Lord, Lord Lansley, asked about procurement. The fact is that in some hospitals we are sometimes paying double and using twice as many staff to get the same outcomes. We need to work on a national system which delivers consistency, not only in quality through the CQC but in the new arrangements that are being put in place through the NHS improvement agency, to make sure that everyone is doing the same thing right. We have not learnt from the great achievements that we have in many places in the system.

The second area is one on which many people have spoken: the whole question of the right care in the right place, the flow through the hospitals—people call it workflow in industrial situations and increasingly in healthcare. One big thing that has emerged from the speeches of other noble Lords is the whole question of discharge from acute hospitals. There are 130,000 acute hospital places in England, and probably 10% of them are blocked, so 13,000 beds are being used inappropriately.

The third point is collaboration. Others have talked about integrated care. Salford is a wonderful example. Northumbria proves what we can do: integrated acute, community and social care. We know how to do all this; we do not need to look to consultants to tell us. The NHS knows that what we have to do is organise to deliver it. Critical to that will be the 1.4 million people who work in the NHS. I think it is equalled only by the Chinese army and Indian railways in size of workforce—and possibly Walmart. I suggest that the other three have a high degree of leadership. We probably need to get away from leadership by bullying to leadership by leadership, so that the system can actually deliver.

I repeat that we need to equip the noble Lord, Lord Prior, to go back with those right arguments. Those of your Lordships who read the Guardian on Monday may have noted Matthew D’Ancona’s little piece. I end with this quotation:

“The custodian of the NHS”—

we are all custodians, I suggest—

“who truly seeks to safeguard its future must fight for internal efficiency, restless reform and the changing needs of patients, as well as for extra cash”.

My Lords, this debate is about present and future demand and how we best manage it. In doing so, we need to include all rare disease, not just the big killers. Individual rare diseases may not kill many, but collectively they are a significant part of the disease burden.

Mesothelioma is such a disease. In the recent mesothelioma debate, the Government confirmed that 60,000 are expected to die from that terrible disease over the next 10 years. An international comparison by the Eurocare group shows that the UK survival rate at one year is 36%. Sweden’s is 46%. In other words, one in 10 patients more dies here than in Sweden, or 6,000 lives over the next 10 years. The disease is identical and the treatments identical. This is therefore a matter of care quality management.

We see this pattern across cancer. The British Journal of Cancer published the latest international performance assessment. Here is a sample of the one-year survival rates for 2005 to 2009. In lung: Sweden 41%, England 31%. In colon: Sweden 82%, England 73%. In ovarian, Sweden 79%, England 64%. This sounds remarkably like the England football team’s latest performance against Sweden. Perhaps, as in football, we should turn to Sweden for management advice.

Sweden has driven improvements in its service not by chucking more money at the problem but in the way it manages the service. Hospital quality is published at a granular level, not some meaningless general level. Patients with a specific disease know which hospitals to avoid. Some of your Lordships will recall the Colchester cancer scandal. What did not come out in the media at the time is that the East of England Cancer Registry foresaw such an issue many years before in research showing that smaller centres had worse outcomes than larger ones. They may still do, but who is to know without the data?

Yesterday I tabled a number of Written Questions for the Minister on the data that the Minister already has in the National Cancer Intelligence Network in Public Health England, which could help patients to get better care if it was published, such as cancer-specific hospital performance data. I am sure that the Minister would agree that these are important issues, and that the reasons they are not being published should be investigated. Once these investigations have happened, will the Minister agree to meet me—I would be grateful if the Minister could reply on this point in his wind-up—to see how these results could be put into the public domain? I believe that these figures are an important component in seeing improvements in cancer care.

My Lords, I thank my noble friend Lord Turnberg for initiating this debate and congratulate the noble Baroness, Lady Watkins, on her wonderful maiden speech.

It is quite a while since I have spoken on health or social care matters, but I am fearful for the future. The ingredients of broken promises on social care funding, inadequate funding of the National Health Service, increasing demand and creeping privatisation mean that the pressure cooker may one day explode. The Government seek to avoid blame by making doctors and nurses subsidise our health provision, and finding a scapegoat in local government for the failures of social care. Student nurses are paying for their own training and working for nothing in the NHS for half their time; their pay has been capped and they are paying for their lodgings; safe staffing ratios have been scrapped; and nurses are doing even more outside work for the privilege of working up to 70 hours a week. That does not create a positive climate for the future.

The Government need to take a step back on the junior doctors dispute, which has been badly handled. The overwhelming vote of 98% on a 76% turnout is not just a problem for the Government; it places an enormous responsibility on the doctors’ leaders, because any settlement is going to look like a comparatively poor deal. It is important to allow ACAS to get on with its job. I read a very moving letter in the paper from the father of a junior doctor, who said of his son:

“He regularly works weekends and nights, and spends much of his ‘free’ time adjusting his sleep patterns. He almost always works between one and three hours extra daily because of understaffing … His social life is almost nonexistent due to exhaustion and antisocial hours”.

All that is on a basic pay of £28,000 a year, and he is paying for his own insurance fees as well as very expensive examinations.

Finally, the recent hasty announcement to devolve health budgets to five London boroughs is not genuine devolution. It is more like being persuaded into a life raft only to find the substantial figure of Boris Johnson jumping in at the last minute. Apparently, he is going to oversee the process—clearly, part of the “Keep Boris Busy” campaign. The massive funding gap for social care will be slightly narrowed at the expense of healthcare, and the London boroughs will take the flak. These piecemeal experiments will lead to more complex structures, more contracting out and huge dividends for management consultants, who will hope to increase their £600 million a year income. The losers will be patients and the elderly. I really am fearful for the future of the NHS.

My Lords, the National Health Service is facing its most serious financial crisis since its birth. The Health Foundation estimates that there will be a £6 billion funding gap by 2020, which I suspect is likely to be an underestimate, given the growing number of hospitals unable to stay within their budget.

I very much support the proposal of the noble Lord, Lord Fowler, supported by others, too, for a royal commission, but if there is no royal commission there should be strong support for Norman Lamb’s proposal, supported by two former Secretaries of State for Health, Conservative and Labour, for a powerful independent commission. One of its recommendations should be to fund health and social care through a specially earmarked, hypothecated tax. The Treasury hates hypothecated taxes. I believe that I am the only former Treasury Minister speaking in this debate, although that was a long time ago, when Roy Jenkins was Chancellor. But the health service is a very special case; its need for funds is greater and grows faster than almost any other public service, and much faster than GDP. At the same time, it is Britain’s most cherished institution. People would be prepared much more readily to pay for its needs than through general taxation if there were a special tax for the health service. The obvious special tax would be a reformed, progressive system of national insurance contributions, which in their present form have neither rhyme nor reason and should either become part of income tax or, much better, finance a special NHS fund.

I have one final, more general point. The needs of the National Health Service are, perhaps, one of the clearest illustrations of why we should reject the Government’s strategy on making us a low-tax, low-spending country, with public spending reduced to 36% of GDP, the lowest in the major countries of the European Union. Health and social spending are already the lowest. Low tax and low public spending societies are the most unequal and dysfunctional; they lower the quality of life of their citizens in numerous ways, as convincingly argued in that seminal book, The Spirit Level, and in Joseph Stiglitz’s splendid volume, The Price of Inequality. One of the main tasks of opposition parties in this Parliament should be to expose the dire consequences for our society of the Government’s declared central aim to shrink the state. One of its most notable casualties would be the National Health Service.

My Lords, in the time I have today, I am going to concentrate on a very specific area, that of wheelchair services. I declare an interest as chair of the National Wheelchair Leadership Alliance, which was set up after NHS England supported two national summits, and a huge weight of academic evidence and case studies offered a compelling case of why action was needed. A 10-point charter was developed which received significant support from the public, Members of both Houses, CCGs, the industry, wheelchair services and charities, to name a few.

It is simply not understood how important the right chair is. In our campaign, I sat in a wheelbarrow. I am not proposing this as a cheap solution to wheelchair services, but in a few minutes it became very painful and it provided a shocking image. We chose a wheelbarrow because it may have a seat, wheels and handles but it does not give independence. That is what the wrong chair means.

During this work, we have seen some dreadful cases, including long waiting times and people dying before they received their equipment. No one is trying to do a bad job—quite the contrary—but it is a Cinderella service and a complete postcode lottery. A cushion can cost £250, while a pressure ulcer from the wrong cushion can cost £100,000 to fix.

The mandate consultation came at a perfect time, and I am delighted that we merited mention in the response. I understand that the mandate is a strategic document and is not meant to be prescriptive, but the response dismisses a focus on individual services. This contradicts the Government’s aim for integrated healthcare, because wheelchair services may be a single service but the outcomes have an impact on every government department. Because of having the wrong chair or not having a chair, children are missing school and people are missing work; it is costing the NHS significant amounts of money through injury and harm. If disabled people cannot get to work, how can Her Majesty’s Government hope to halve the employment gap for disabled people? One person told me that through access to work she would have five-sevenths of her specialised chair funded, but she had to leave it at work at the weekends because it was not for personal use. That is totally ludicrous—how could she get to work in the first place?

I know we have limited time, but I have a few questions for the Minister. Will he elaborate on whether further work has been done on the cost-benefit of providing the right wheelchair? Will he provide an update on the work of NHS England’s data dive and tariff, which is very welcome and crucial to moving this debate forward? Will he confirm that the number of responses to the mandate consultation in this area was among the highest received? Why have the wider benefits of providing the right wheelchair not been taken into consideration? I am not asking for more money; I am just asking for a genuinely integrated approach. Finally, as we are limited for time, can I meet the Minister, as this has been a problem for 30 years and affects millions of people?

My Lords, we are tight on time. May I give a further reminder that in the final stages of this debate, Back-Bench speeches should be concluded when three minutes first appears on the clock?

My Lords, I, too, thank the noble Lord, Lord Turnberg, for bringing this debate to the House. There are demands on our health service, and it is clear that a rapidly ageing society puts great pressure on our NHS in many different ways. My contribution to this debate will focus on local efforts to support these services.

As noble Lords will be aware, responsibility for public health now rests with local authorities, and that is working well. Councils now play a pivotal role in looking at what can be done to care for people in their own community. Integrated care is essential to meet the needs of the ageing population, to transform the way that care is provided for people with long-term conditions and to enable people with complex needs to live healthy, fulfilling and independent lives.

Locally we are delivering the better care fund programme to ensure a transformation in integrated health and social care. For example, in North Lincolnshire, we have joint senior management at clinical commissioning group and local authority level. We recognise that an enhanced out-of-hospital model, enabling health and social care professionals to provide more joined-up services closer to people’s homes and communities, should form the basis of any system-wide model of care. We connect local areas to local GP practices to offer new ways of working with social care, community healthcare, mental health services, voluntary and community organisations and other key stakeholders. We have local teams to enhance existing community services and have already delivered, as I have mentioned before in the House, five well-being hubs, which are fully operational, and are currently developing satellite hubs. These hubs target the most vulnerable people and provide interventions on a one-to-one basis. They actively work with hospital teams to create support links for service users admitted to hospital, helping with discharge. We are also looking at ways to work differently with the intermediate care services. We engage with users to make sure they have the confidence to access services and work, in order to reduce any delays in processing care which could damage that confidence. We are also piloting the healthy and active passport, which will give citizens access to services and schemes aimed at improving health and well-being.

We simply cannot ignore the impact of an ageing population and the pressures it puts on healthcare, both local and national. The current efforts to address projected pressures offer a way to a brighter future for older and vulnerable people, and I welcome the Government’s initiatives to support local areas. They are fundamentally about moving away from a sickness service and towards a system that enables people to live independent and healthy lives in their own communities. We must create wellness, not just treat illness. Through hard work, imagination, commitment, and not working in silos but together, we can meet head on the challenges presented by our increasingly elderly population and aspire to make this country the best to grow old in.

My Lords, I, too, am grateful to the noble Lord, Lord Turnberg, for promoting this debate. I am also grateful to the NHS for keeping me alive when I had cancer, and for the maiden speech of the noble Baroness, Lady Watkins. I look forward to hearing more from her in future.

I shall quickly say something on personal responsibility, public health policy and corporate social responsibility, which I do not think has been touched on so far. On personal responsibility, as leaders, we have to be much more courageous, honest and open about the need for individuals to understand and accept that they are ultimately personally responsible for the state of their health. We need stronger campaigning. As was proved by the noble Lord, Lord Fowler, when he dealt with AIDS, if people are willing to be honest, open and courageous, we can carry all levels of the country, be they poor or rich. People need to be given many more facts about their lifestyles and the damage that arises from some of what they are eating and drinking. Those of us who use the health service should learn the cost of the services that are being provided. Each time I go to the health service, I should be told the cost of the medicines. If there is a combination of all that, we will start to raise awareness and knowledge and to create a different approach to personal responsibility. I will say no more on that because the right reverend Prelate the Bishop of St Albans more than fully covered it.

Linked to that is progress on policy on Public Health England. It is an outrage that £200 million has been chopped from its budget when we face so many problems with the increasing number of people going to the health service for treatment. Fortunately, it was one of the successes of the 2012 reorganisation, with its evidence-based recommendations on sugar taxes and alcohol abuse, for example. We need to co-ordinate policies at different levels to avoid the clash of one organisation trying to reduce alcohol, and the Chancellor then cutting taxes on alcohol last year, meaning that we now have more people drinking than before. We need to get the co-ordination of policy right. This is being addressed by Public Health England.

Deep down, most politicians believe that what they are saying is correct and that they need to take action, but regrettably, we too frequently run away from putting such things into practice. We have too many knee-jerk reactions, such as we had from the Prime Minister on the question of a sugar tax.

In the light of our experience with the responsibility deal, there needs to be a radical review of people’s relationship with the private sector. Retailers, especially supermarkets, food and drink manufacturers, producers and distributors need to accept that they have greater social responsibility than they have been prepared to accept so far for some of the health-related problems in this country. They have to face up to the fact that they need to embrace that change in culture and accept more responsibility for those problems. The Government have failed to achieve real progress with them on a voluntary basis. They should be faced with legislation if they will not move.

My Lords, I draw the attention of the House to my entry in the Register of Lords’ Interests. Last autumn, the Chancellor secured some good headlines by promising an extra £10 billion in real terms for NHS England by 2020, representing an annual increase in NHS spending of 1.75%. But beneath those headlines, NHS cost and demand rises by 3.5% to 4% a year. When trying to explain the problems of the rising cost of pensions and healthcare, I often begin by saying that when I was at school, 40 years ago, male life expectancy was just 67. A man approaching retirement then might well have worked and paid taxes since he was 15. After 50 years of contributions, he would retire at 65 with a pension and the health service would have to provide for him and look after him for just two years. A man who retires this year at 65 will probably live another 20 years. His state pension will have to be paid for from general taxation for 20 years, not two years, and towards the end of his life there will be, on average, a period of eight years when he will be in poor health and in need of greater health and social care support.

In providing for women and men like him, the NHS delivers good value for money compared to healthcare systems in other countries. We achieve a lot by spending just 8.5% of GDP on health compared to the OECD average of 8.9%, but our figure is due to fall to 7.8% by 2020.

If we want a better health service, we have to look at the fact that France, Germany and Holland all spend about 11% of GDP on health. We will certainly never match those levels if the Chancellor is to succeed in his aim, set out in the Autumn Statement, of reducing the overall level of government spending from about 41% of GDP to just 37%. It would, however, be a very brave politician who argued for more than a very modest increase in the basic rate of taxation, even though it is now 15p in the pound lower than in 1975-76, 10p in the pound lower than in 1979-80, 5p in the pound lower than in 1988-89 and 2p in the pound lower than in 2000-01. It may be politically unacceptable to reverse those income tax reductions, made for political advantage, but the time must have come for a hypothecated health and social care tax. I hope that this idea will be considered further by the cross-party commission being launched by Norman Lamb.

My Lords, as a professional economist—the only one speaking in this debate—I should say that any service that is free at the point of use will perpetually suffer from excess demand. The NHS is no different; more or less since its founding, it has faced a continuous demand for more money and the public fisc has been unable to quite meet it, so we have had a history in which it is perpetually in a funding crisis. At the same time, though, there is a great deal of satisfaction with the service, so we need to understand how it works.

We have to be careful about the fact that the percentage of GDP spent on health is not a good measure of outcomes; it is a measure of inputs. As someone has said, we have one of the best-ranked health services, despite not being the highest-spending nation. The highest-spending nation is probably the United States, which has a lousy health service.

Having said that, we need to make the user more aware of the costs of the service, as my noble friend Lord Brooke said. In many previous debates, I have suggested that every user of the NHS be given an annual return showing what they have used it for and how much that has notionally cost the NHS. They should be made aware that even if they miss an appointment it costs money. Whatever they have had, somewhere it has been paid for. They do not have to pay for it themselves, but they ought to be made aware that there is a cost to each thing that they do or indeed do not do. At the same time, we ought to provide people with another sheet of paper showing how the total NHS money is spent, just for information. People ought to understand what their money goes on. Right now they do not understand, and they take it for granted.

I shall say just one more thing because my time will be up very soon. We have made all sorts of predictions about what proportion of GDP should go on health. I can more or less tell the House, with all the certainty that I can command, that the era of high growth is over and that for the next 10 or 15 years the GDP growth rate will not be high, and nor is inflation. Whatever we do, we will have to find ingenious ways to achieve efficiency, perhaps by nudging users to be more economical with their use of the NHS, and somehow changing behaviour so that we do not always take for granted that there will be more money, and if there is not more money, it is someone’s fault. One of the last—no, I do not think I have any more time.

My Lords, I, too, thank the noble Lord, Lord Turnberg, for securing this debate. He and other noble Lords have spoken with much wisdom, expertise and experience. My only qualification in this area may be that I was a board member of the North West Thames Regional Health Authority, a member of the Solihull Family Practitioner Committee and a board member of SCAR, the Sickle Cell Anaemia Relief charity.

As a schoolboy, I attended a university open day as a precursor to studying for a medical degree. I recall that we had to walk through a laboratory where some experiments were being carried out on dead bodies donated for research. It is still vivid in my memory. I passed one corpse that had been drained of all body fluids and dissected lengthways, so that I was looking at a half-body. I recalled that in the Bible Lazarus had been raised from the dead, but I thought to myself, “But that Lazarus was not cut in half; this guy is going nowhere”. I decided at that point that medicine is a special calling, and perhaps it was not calling me. So I have every admiration for members of the medical profession. I just hope that the BMA and the Government can reach an agreement. With the prospect of two further doctors’ strikes, it is surely the patients who will suffer.

It is said that some 40% of diseases are related to lifestyle. Smoking and alcohol abuse are major problems. As the saying goes, Bacchus has drowned more men than Neptune. We need an effective national plan for preventable illness, otherwise the impact of lifestyle-related diseases and longer lifespans will put even greater strain on resources. This may have to be a part of an open, independent inquiry or commission charting the way forward, as the noble Lord, Lord Fowler, stated. It could include an international comparison of the way that other countries deal with these issues, especially the means of funding the service. The inquiry needs to examine a more holistic approach to health, involving health promotion, sickness prevention, mental illness and social care. We have excellent health foundations, such as the Nuffield Trust and the King’s Fund, that can help with this.

The third Gospel was written by Luke, who was a doctor of medicine, but, as a Greek, he was a non-Jew, a foreigner. I mention that to highlight the tremendous contribution made by ethnic minorities to our NHS. Some 37% of doctors and 27% of nurses are from black and minority ethnic backgrounds. In London, 40% of the NHS workforce are from BME communities.

In my student days, my idea of a balanced meal was a biscuit in each hand. Since then, I have had to learn the value of healthy nutrition and exercise. There is nothing permanent in life except change, and there has to be change in our approach to the NHS in order for it to meet its present and future demands. As John F Kennedy once said, our task now is not to fix the blame for the past but to fix the course for the future.

My Lords, I thank my noble friend Lord Turnberg for introducing this debate with great wisdom and erudition. While I entirely agree that the principle underlying the NHS is noble and widely acclaimed, in practice it leaves much to be desired.

Noble Lords have concentrated on funding and other things but I want to concentrate on the more elementary aspect of some of the practices that characterise the NHS. It is very striking, for example, that doctors are inundated with paperwork so that they have hardly any time to talk to their patients or spend much time with them. It is also striking that when a GP refers a patient to a consultant, the consultant’s letter does not arrive until about two or three weeks later, either because—so I am told—he does not have the typing facilities or because he would not use electronic devices to communicate with the GP. I cannot understand why this sort of thing should go on in this age.

As we have talked about our ageing population, it is worth bearing in mind that more and more of our people suffer from Alzheimer’s, dementia and other conditions. The result is that they forget to take many of the medications prescribed for them, or for some reason they take it earlier when they feel ill and stop when they begin to feel better. It may be a good idea to remind them in some way from time to time that they have forgotten to take their medication. I gather that some experiments are being done, and there is no reason why the NHS cannot be technologically more imaginative. Why can blister packs, for example, not be devised so that they warn patients at the appropriate time that they should be taking their medication? Or, for example, why should chemists not be able to monitor whether a particular medicine has been taken by a patient and, if necessary, ring them up and tell them they should be taking it? Therefore, technologically, we ought to be able to produce smarter and more sophisticated packages of medication than we do.

My third point has to do with some of the infrastructure of our surgeries, some of which are located in old terraced houses. Doctors would love to provide all kinds of services but they are unable to do so because of the cramped environment in which they have to function. I cannot see why local authorities and other bodies cannot provide purpose-built medical facilities where GP services can be housed. This would mean that GPs could provide the kind of services they would like to and patients would not be cramped and would feel much more comfortable.

My last point has to do with the way the Government have treated junior doctors. Doctors remain our main asset, and if they are alienated and feel resentful they may leave in large numbers, which would be no credit to our society.

My Lords, I will begin by making an appeal to those who arrange these matters in this House. A three-minute time limit in a debate such as this is absurd, and it is certainly absurd to allow a maiden speaker—we heard a very good one this morning—only three minutes. When times are allocated, a little could be taken off the Front-Benchers to give a little more for a maiden speech. I also endorse the plea made by my noble friend Lord Lansley for a proper annual debate—I do not refer to the Queen’s Speech—on the National Health Service.

Time allows me to make just two points. The National Health Service may indeed be the best in the world. If it is, that is because it is the creation of all political parties, and it is very wrong for any politician to seek to make a political football out of it. Your Lordships’ House sets a much better example than the other place when it comes to debating the NHS.

My second point is very simple. My noble friend Lord Fowler made an eloquent plea for a royal commission. I was privileged to take part in a debate that was instituted by the noble Lord, Lord Turnberg, just over a year ago, when I made for the third time a plea for a commission or an inquiry. I repeat that plea again today and endorse what my noble friend Lord Fowler said. It is important not only that we take the NHS out of the party political arena but, as the noble Baroness, Lady Williams, said in her excellent speech, we have to look to the future because the health service is in crisis. A sticking plaster is not the solution. To lurch from one financial crisis to another does not only the NHS but the whole nation a disservice in the process. As I have said before, we must have a plurality of funding. Whether that comes from taxation—hypothecated or not—compulsory insurance, extra charges such as penalties for those who do not keep appointments or from a combination of all three, we must have a plurality of funding and take away this continual crisis.

We are all beneficiaries of the National Health Service and we will all depend on it in the future. I therefore urge the Minister to give some indication that he has sympathy for the idea of a commission and, at the very least, I should like some sympathy for my noble friend Lord Mawhinney’s plea for a body to be set up in this House, where there is a greater accumulation of expertise on this subject than anywhere else in the country.

My Lords, like the noble Baroness, Lady Ludford, I too will concentrate on diabetes, which absorbs 10% of the national budget—some £10 billion—which will inevitably grow as we move from the current figure of 3.5 million diabetics to some 5 million in 2025. We have epidemics of type 1 and type 2 diabetes. I report from the front; as a high-risk foot person with diabetes I attend a monthly podiatric clinic. Those lists are now being slimmed, including for diabetics. The clinic tells me that it is as worried as anything because future problems, which inevitably arise from diabetics with poor feet, will not be identified. Similarly, I stand here today because I benefit from the shoes that are made for me in Liverpool to protect my feet because of the neuropathy I have—I have no feeling in my feet. That enables me to stand here today and enables other people to be economically active. We must not contract these services, as is now happening, with delays falling upon delays.

Diabetes UK has identified that four out of 10 diabetics do not get the necessary care processes. It has identified that some 135 amputations as a result of diabetes take place every week, when four out of five of those amputations are preventable. What are the Government doing about that startling statistic? The Diabetes Think Tank also recognises that 95% of diabetic care is self-administered, and we should concentrate on this area. However, in January two years ago for some reason the Government gave up the Patient Experience of Diabetes Services survey, which had been so useful in analysing what diabetics felt about the services they received. I therefore invite the Minister, as I did when he first came in, to attend the Diabetes Think Tank, and I hope that he will be able to attend it. I commend what my noble friend Lord Turnberg said in introducing this debate, that there are enormous opportunities in sharing best practice with our colleagues within the European Union which we are about to neglect.

I finish on an optimistic note. When I was declared a diabetic in 1969, they said, “You’ll get a medal after 40 years if you survive that period”. I can now report that I have long been past the 40-year mark, but an 88 year-old type 1 diabetic has recently received the HG Wells medal—he was a diabetic—for surviving for 80 years.

My Lords, like other noble Lords I thank the noble Lord, Lord Turnberg, for securing this debate and for the wise speech which he gave in introduction. I will address one issue only: the cost to the NHS of litigation arising out of cases of alleged medical negligence. Of course this is not a new problem. For at least five years, those who seek to join the UK Register of Expert Witnesses have been told that alternative dispute resolution—ADR—is becoming an increasingly important adjunct to litigation, and in significant parts of the UK this idea has taken grip. None the less, it is hard to believe today that all opportunities for early resolution are being taken in the NHS. There are still cases on treatment issues that may have lasted over decades, which involve hundreds of documents that cover several years. This is obviously very difficult for the patients and inevitably involves a drift of financial resources out of the NHS toward the legal profession.

Finally, in the same context it is important to draw attention to a change in the guidance for experts in such cases. In 2007 there was a total ban on payments to experts that depend on the outcome of the case. This was softened in 2014 but is still greatly discouraged. This is a surprising development and not consonant with the need to protect at all cost the resources of the NHS financial position, which, as every speech in this House today has indicated, is inevitably difficult, and is likely to be for some time to come.

My Lords, first, I thank my noble friend Lord Turnberg for securing this debate. He is not only my noble friend but a personal friend. Few have committed more to the NHS than him. To the noble Baroness, Lady Watkins, I can say, “It’s over. You can relax, and you did really well”.

I speak as a parent of a junior doctor who qualified at the University of Nottingham and now is a resident doctor at NYU medical centre in New York. It might be interesting if I were to compare and contrast aspects of the two systems as seen through his eyes.

The first aspect is the teaching. At NYU each resident receives around 14 hours of high-powered classroom teaching each week. The regime is free food, phones off, high concentration. Lectures are given by specialist consultants. As he puts it, “Every day I lunch with giants”. At Nottingham he was lucky to get two hours per week.

As for attitude, at NYU he feels a valued member of the team; in the east Midlands he and all his colleagues felt underappreciated. Most NHS medical staff were disgruntled and demotivated. Of his colleagues in Nottingham, a third either left the profession or went to work abroad. Each one had cost the NHS £300,000 to train but, when they left to go elsewhere, no one noticed, no one took responsibility, there was no exit interview and no one cared.

Then there is the pay. In his final year in Nottingham, he earned about £40,000. It is true that his basic pay was £23,000 but, with unsocial hours banding, the pay soon mounted. At NYU he earns $60,000—exactly the same amount—but in the United States almost all junior doctors carry student loans in the region of a quarter of a million dollars, and repayment starts immediately.

Finally, there are the hours. Last month in New York, he worked 80 hours per week, as he has done every month. He works six days every week, including many weeks on night shift. Even on daytime shifts, he leaves home at 5 am and often gets home at 8 pm.

The American junior doctors are the ones with really unsocial working hours. They are the ones who struggle to make ends meet and the ones who should be complaining, but there are no picket lines to be seen on First Avenue and 32nd Street. The question is why? Let me hazard a guess. In much of the UK, junior doctors—indeed, even senior doctors—are treated as objects: cogs in the wheel or items on the spreadsheet to be moved here and there at will. There seems to be little realisation that to get the best out of people you have to encourage them, you have to integrate them as part of the team and, most of all, you have to make them feel valued. It is called leadership. Looking at this junior doctor crisis, there seems to be little of that in evidence in our NHS but it is what we really need.

My Lords, we are on the last lap. I thank the noble Lord, Lord Turnberg, for telling us about the enlightened approach of Salford Royal Hospital. It has obviously made great progress since I worked in Manchester and it was known as the “No Hope Hospital”.

It is no coincidence that the London Olympics highlighted the NHS in its very creative opening ceremony. We are all very proud of it, particularly the staff, but it would be stating the obvious to say that it has numerous problems. At a time when it faces unprecedented increases in demand, the NHS has been given its most challenging funding envelope ever. The future of the health service is in jeopardy unless we do something radical. As the noble Lord, Lord Rea, said, it cannot get out of this hole by itself.

That is why my right honourable friend and former Health Minister Norman Lamb introduced a Private Member’s Bill in another place a week ago. He called for the establishment of an independent commission to examine the future of the NHS and social care system, to take evidence and to report its conclusions to Parliament. I pay tribute to those on the Conservative Benches who have called for something similar, but I think that a royal commission may take too long and that something quicker is required.

Norman Lamb was supported by two former Secretaries of State for Health, Members from all parties and the chief executives of more than 40 organisations in the sector. I join with his call today in this debate, along with many of your Lordships. When you get agreement from so many from all sides of health and social care, it is clear that you are reflecting a real need. The purpose of the commission would be to consult widely to find solutions to the massive challenges that face the health and care services, and to establish a sustainable—a crucial word—new settlement which takes into account present and future demands.

In order to calculate future demand, we need no crystal ball—we have a lot of evidence to help us. We know that since the Second World War demand has gone up by about 4% every year. For example, thanks to successful new diagnostics, treatments, drugs and surgical procedures, half of people diagnosed with cancer now survive the disease for 10 years or more compared with only a quarter 40 years ago. Other chronic conditions are also now managed better than ever. We should celebrate all this while being realistic about what it means.

We have heard about the predicted gap of £30 billion in NHS funding by 2020 unless something is done. The Government have committed to providing only £8 billion of this and expect the NHS to find the other £22 billion through efficiencies and new models of care. However, experts involved in the process are unconvinced that this can be done.

The King’s Fund’s Quarterly Monitoring Report, published in October 2015, included a survey of NHS finance directors’ views on their ability to achieve 2% to 3% productivity gains per year, which would be needed to achieve that saving. The vast majority were sceptical to say the least. Eighty-four per cent of NHS trust finance directors and 88% of CCG finance leads felt that there was a “high” or “very high” risk of failing to achieve the target. Here are a few respondent comments:

“I feel strongly that the low-hanging fruit has been taken. The modus operandi needs to change fundamentally”.

“When plans are not credible then it is impossible to enthuse people”.

“Increased national pressures/tying of hands … make it difficult to achieve big savings”.

“The £22 billion challenge requires productivity gains significantly over what has been achieved over the past few years”.

“Unless there is a national debate about what the NHS can provide then there is no way that the NHS can deliver within the financial envelope”.

Jim Mackey, chief executive of the hospital regulator, NHS Improvement, put it in colourful language—and I quote him verbatim—saying that the efficiency targets set by the Government are,

“unachievable and, frankly, bloody stupid”.

That is what he said, my Lords.

Given that the recently announced increases in funding will be swallowed up mostly by paying for the £2.2 billion of deficits in NHS and foundation trusts, increases in payments to pension funds, apprenticeship levies and the new minimum wage, it is pretty clear that this extra money will do nothing to address future increases in demand. Meanwhile, social care funding has been cut in real terms and faces a funding gap of £6 billion by 2020 according to the Health Foundation, but this does not take into account the effect of the new minimum wage in a sector where so many workers are on the minimum wage. The LGA estimates that this will add a further £1 billion to the gap. Now Ministers have decided to stop the £1 billion payment-for-performance element of the better care fund and, instead, have mandated local targets for the reduction of delayed transfers of care. So the Government give with one hand and take away with the other.

Did the Chancellor provide the answer to these problems in the autumn spending review? I think not. The new provision for councils to raise a 2% social care precept would provide only an extra £1.7 billion by 2020 if every single council did it. In poor areas the ability to raise significant extra funds in this way is in inverse proportion to the need—not a very clever solution.

The increase in the better care fund will not come until 2019. Sadly, this will mean that the better-off will be able to pay for good care and the poor will get either no care at all or a substandard package—the best their poor stretched local authority can manage—adding further to our appalling health inequalities. The inevitable pressure that these cuts to social care will put on the NHS is obvious and has been clearly outlined by Simon Stevens, the head of NHS England. So current and projected NHS funding does not allow the service any chance of fulfilling the mandate, mentioned by the noble Lord, Lord Lansley, put upon it for the next five years by the Government themselves. Beyond 2020, it will just get worse if nothing is done, and our precious NHS will no longer be the envy of the world. Mention of the mandate reminds me to endorse the call of my noble friend Lady Tyler and the noble Lord, Lord Bradley, on mental health. We need to find new answers.

All Governments pledge themselves to protect the NHS, yet our spending as a proportion of GDP is low, as we have heard, compared to that of other developed countries. According to the Office for Budget Responsibility, it will decline further by 2020. The position of social care is even more dramatic.

What is the point of growing our economy if we do not spend the money on the things that most of the population would like it spent on—and what they vote for? Given what we know about rising demand, it makes no sense at all. The consequences of the Government’s failure to address this are very serious and completely contrary to what they say they want according to the latest mandate. Standards will not rise, new technologies will be unaffordable and services will not be able to address our health inequalities—an absolutely top priority in my book.

The silly thing is that nobody really believes in the ability of the system to fill the gap through efficiency savings and new models of working, desirable though they may be. Money is so tight at the moment that many parts of the system are struggling with crisis management, let alone improvements. To make things worse, there are numerous financial disincentives. For example, where is the incentive for acute hospitals to work with local services to keep patients out of hospital when they rely on the payments for activity when they come in?

The social care system is living on borrowed time. Eligibility criteria are getting tighter every day. Will the Government face this crisis head-on, take politics out of it and support my right honourable friend’s call for a commission to bring together all the evidence, the brains and the expertise available?

I think it boils down to five simple questions. How much should we be spending as a country and how should it be raised? How can we spend it better and have all services reach the standard of the best? How can we end the artificial divide and conflicting incentives between health and social care? How can we minimise future demand by avoiding preventable diseases? How can we reduce health inequalities? It is time for a new Beveridge commission.

My Lords, if the Minister is going to have any time at all, I should cut my contribution short. First, I declare an interest as president of the Health Care Supply Association and the barcoding association GS1, because I want to comment on the remarks of my noble friend Lord Carter on efficiency.

I very much welcome this debate. I was very taken with my noble friend’s description of the ideal world. I wonder if noble Lords think, as my noble friend Lord Carter does, that elements of that are in existence in the NHS at the moment, and that the issue is how to get that going in every part of the NHS. That is one of the essential conundrums.

I will focus also on the very important contribution of my noble friend Lord Winston, who talked about the risks to our medical research. Our medical research has always been one of the best in the world. On it our whole life science sector has depended. The fact is that we in this country have always had a very strong, innovative pharmaceutical and diagnostic industry. When my noble friend says that all of that is at risk, we need to listen.

There is no doubt—I pick this up consistently—that there is a hostility in the NHS to the kind of time that is needed for doctors to practise in research, and even to take part in Royal College activities. This has really got to stop. Seeing the noble Lord, Lord Lansley, here, I have to say that the introduction of NHS England does not help, because, for all the fine words that are in both the mandate and what NHS England says, I do not see any commitment in NHS England to these kinds of issues.

I will raise one further issue in aid of that. Our record on the introduction of new, innovative medicines in this country is a disgrace. We have some fantastic inventions, but the NHS is pathetically slow in introducing them. The noble Lord probably knows very well that we have an accelerated access review under the chairmanship of Sir Hugh Taylor. The word on the street is that it is simply not going to get anywhere because the NHS is not going to play ball and is not going to insist that NHS bodies invest in these medicines. A whole sector of our economy is at risk because of this. I know that the Minister is as concerned as I am and I hope that he might say something.

I come to the issue of junior doctors—not to talk about the dispute but because both my noble friends Lord Winston and Lord Mitchell raised the issue of why junior doctors are so disengaged. Anyone who has met them will know how angry they feel. It is partly about the Secretary of State’s manipulation of statistics—which, frankly, given the brightness of junior doctors, was always going to be very unwise. It is also about their distrust of management. Part of the problem is that they just do not believe that, locally, NHS employers will do the right thing.

My noble friend is right. Why are junior doctors treated so abominably by NHS employers? Why can they not get access to decent hot food at night? Why are the junior messes not in places where they can go and meet? I do not know what can be done to get this home to the NHS. Anyone who meets our juniors knows that they are the brightest of the bright and are hugely committed—yet, somehow, we seem to have made them wholly disenchanted with the NHS. It is a very serious issue.

This brings me to the issue of leadership, which my noble friend mentioned. In June last year, the noble Lord, Lord Rose, produced an excellent report on how to enhance and improve leadership in the NHS. He asked the Government three questions. How do we get better leadership? How to we recognise it? How do we find and mature the people who are needed to lead the NHS? I am afraid that there has been virtually no response to this from the Government. That is very disappointing. In fact, all that has happened is that the turnover of chief executive officers has continued at an alarming rate. Again, as one of my noble friends said, we have got to get rid of leadership by bullying. There is a bullying culture throughout the system and it is having a corrosive impact on the ability of people locally to lead organisations.

Of course, funding is very important. I do not need to repeat all the arguments that noble Lords have put forward. Essentially, they concern growing population and demographic pressures. We in this country spend less on health than any comparable country. The OECD figures that came out just before Christmas were very convincing on this. The Government’s claims in the Autumn Statement frankly do not ring true. We know that they are front-loading some of the money for the next five years, but the annual increase from here to 2020 will be 0.85%— even less than the average increase from 2010 to 2015.

At the same time, we know that half of that extra money has come from raiding the budgets of Health Education England and Public Health England, from capital funds and from the cost of pension payments. At the same time, what do Ministers do? They pile on more pressure. Not a week goes by without another press release from the Department of Health or an announcement by the Secretary of State that something else has got to be done. No wonder his credibility is shot in the NHS.

Of course, the gap between the money that is going in and the £30 billion per annum that it is generally believed will be required by 2020 is huge. I pay great tribute to my noble friend Lord Carter, because obviously he is helping the NHS to see if it can close part of that gap. I am sure that is right and that, on procurement in particular, a much more cohesive national approach is needed—but at the end of the day, there is still going to be a gap.

Should there be a royal commission? I cannot help repeating Harold Wilson’s famous diktat that royal commissions take minutes and waste years. That is, of course, when they are used simply to postpone a decision. I understand why noble Lords want some kind of neutral and impartial commission to look into those issues. However, we have already had the Barker commission, and I doubt whether anyone is going to improve on that. In the end, it is a matter of political will. I say to the Minister that, at the very least, what we seek is some honesty from the Government: admit that the financial gap is not going to be met and stop piling on the pressure.

I apologise to the noble Lord, but there is a question that is central to this: would he and his party be prepared to take part in an all-party commission, possibly a parliamentary one, in order to get the quickest possible effective answer for the terrible crisis that has been outlined in this debate?

My Lords, this is a time-limited debate and I want to leave the Minister a little time to respond. I would certainly be very happy to discuss the issues with noble Lords here—I like the idea of a group of politicians in this House looking at it. On the subject of a royal commission, I do not think I can go as far. In the end, we sometimes have to have the courage of our convictions and come up with proposals to sort this out.

My Lords, first, I thank the noble Lord, Lord Turnberg, for bringing this debate, and I thank the 45 people who have contributed to it. That shows that the noble Lord has touched an important nerve. The future of the health service and of social care in this country is hugely important.

The noble Lord, Lord Turnberg, talked about his experience at Salford, where they have a fantastic hospital with a joined-up system. This shows that it can be done. Around the country, there are hospitals and healthcare systems that are doing it; they are doing a fantastic job by good standards. Of course, that requires great leadership, and leadership is not something that can be cloned; there just are not that number of great leaders in any system. However, in Salford, under David Dalton, they have a great leader.

The fact that it can be done lies behind the work that the noble Lord, Lord Carter, has done. Hospitals around the country are achieving great performance. However, the noble Lord, Lord Carter, has uncovered a huge amount of what he would call “unwarranted variation”; that could be unwarranted clinical variation, operating variation or any other kind of variation. That has to be addressed, and the noble Lord, Lord Carter, has given us a methodology for doing that. He, along with other noble Lords in this debate, points out that unless we can crack delayed discharges in hospitals and delayed transfers of care, many of our hospitals are going to struggle.

I also pay tribute to the noble Baroness, Lady Watkins. In her maiden speech she very properly reminded us of the importance of training and community-based services. Her mentor, the noble Lord, Lord Patel, who was watching as she gave her address, is no doubt watching me from India as I speak to the debate.

I want to mention two particular contributions. The first is the speech by the noble Lord, Lord Winston. The noble Lord, Lord Hunt, picked up on his point about academic medicine. That is a crucial issue and one that I cannot address head-on today, but perhaps we might have a meeting involving others, including Hugh Taylor, to talk about it further. The second is the contribution by the noble Lord, Lord Mitchell, about the contrast between his son, who is a junior doctor, working in England compared to working in New York. I thought that that was a very revealing contribution, if I may say so.

I want to preface all my remarks by paying tribute to not just junior doctors but to all those who work for the NHS and in social care. They do an extraordinary job and have a true vocation, and many noble Lords have experienced the benefit.

This is the third general debate that we have had on the NHS since the election. The first was introduced by the noble Lord, Patel, and the second by the noble Lord, Lord Crisp. In that debate, we talked very much about prevention. We could be here for many hours talking about prevention. The noble Lord, Lord Rea, talked about the importance of housing and employment, and there are so many other issues that we could talk about in the context of prevention. Therefore, I hope that noble Lords will excuse me if I do not address prevention as much as they might like me to.

I want to go back to June 1948 for a minute, and to Nye Bevan talking to the Royal College of Nursing. He said:

“We shall never have all we need. Expectations will always exceed capacity. The service must always be changing, growing and improving—it must always appear inadequate”.

The noble Lord, Lord Desai, made the point that when you have a service that is free, demand will always exceed what we can provide. Nye Bevan saw that back in 1948, and it is important to hold on to that when we look at our funding situation at the moment.

We do have a plan: the NHS Plan. The NHS Five Year Forward View was produced by Simon Stevens of NHS England and supported by all the arm’s-length bodies. It is not the Prime Minister’s plan, it is not my plan and it is not the Secretary of State for Health’s plan. It is the NHS’s plan. It called for £8 billion of real investment over that five-year period, and the Government have given the NHS that amount of money: it is £16 billion in cash terms and £8 billion, or arguably £10 billion, in real terms. This is broadly what the NHS wanted.

The NHS is actually doing quite well. I will come back to some areas where it is not doing as well as we would like but, broadly speaking, it is doing quite well. The Commonwealth Fund said that it is first overall compared with other OECD countries, scoring highest on quality, access and efficiency and second on equity. In the recent Economist review looking at end-of-life care, we came out top. However, that is not perfect. The noble Lord, Lord Freyberg, pointed out that our cancer outcomes are not as good as they should be. The noble Lord, Lord Bradley, talked about mental health, and clearly we can do better there and in other areas too. There is too much variation in what we do. However, if we look at medical research, the quality of our education in most of our medical schools, medical publications and clinical outcomes, the NHS can still be regarded as a world-class health service.

Other noble Lords have already made the point that we do this at very low cost. In America, they spend 16% of GDP on healthcare; we spend around 8% and most of Europe spends around 10% or 11%. We do it at very low cost and we get very good results. On that basis, when people say that it is not affordable—an issue my noble friend Lord Fowler and others have raised in this debate—I say that it is affordable. We are doing it at 8% of GDP at the moment but we could choose to spend 10% or 11%: the country can afford good healthcare. I would argue that we are providing good healthcare at the current level of spending.

There is no evidence that a tax-funded system is any less efficient or effective than other systems of funding healthcare. Indeed, I would argue that, on the contrary, the NHS, for the reasons that I have given, is an efficient system. The OECD made a more neutral comment, saying that,

“no broad type of health care system performs systematically better than another in improving the population health status in a cost-effective manner”.

Therefore, I do not think there is an argument for questioning whether we can afford a good healthcare system in this country.

I turn to the various questions that were raised. Is it affordable? Yes, it is affordable, and we are demonstrating that. Is a tax-funded system viable? Yes, it is viable, and I will go further and say that there is evidence to suggest that it is more viable than any other way of funding a healthcare system. Do we have a viable plan in this country? Yes we do, and I will come to that in a minute. Do we need another plan or another commission? I do not think we do. It would be an enormous distraction at a time when we have a five-year forward view. At a time when the whole of the health service is committed to that view, there would be immense concern if we embarked on yet another review or commission of any kind. We would go through a two-year hiatus waiting for that report and would not be able to get on and deliver what we have at the moment.

What is that plan? It falls into two parts. First, can we make the existing system more efficient? The answer is: of course we can. We have some of the best hospitals, wards, clinics, laboratories and specialties in the world in the NHS. Our problem is that there is so much variation across the system—clinical variations, staffing variations, property utilisation variations, procurement variations, pharmacy and medicines utilisation variations and back office costs variations—all of which have been identified, as shown by the extremely important work done by the noble Lord, Lord Carter, assisted by clinicians such as Professors Tim Briggs and Tim Evans. They have given us an improvement methodology based on transparency which will deliver huge improvements over the next five years. A great deal of their work is mirrored on commissioning through the use of the Right Care programme and the Atlas of Variation that has been developed largely by Dartmouth in the USA.

The second part of our plan concerns the new models of care—an issue raised by the noble Lord, Lord Turnberg—and we have already seen these operating effectively in Salford.

This is a move from institutions to systems. We are now trying to develop a place-based care, a population-based care. Although there were many benefits from foundation trusts—I believe wholly in the principle of earned autonomy—one of their unintended consequences is that they have created a fortress mentality in some parts of the country. The King’s Fund has used the analogy of the tragedy of the commons, where everyone is looking after their own interests rather than the interests of the wider system. It has also left patients having to navigate a complex, unjoined-up series of different organisations. We will see over the next four or five years the emergence of new systems of care, including PACS and MCPs, and the Accountable Care Organisation, ACO, will become increasingly familiar to us.

We will also see different outcome-based payment systems and incentives as we move to integrate with social care. There will be many cynics and sceptics because some people, as the noble Lord, Lord Turnberg, said, have seen all this before. We have been talking about integrated care for 20 odd years. I think it is different this time—but I would say that, wouldn’t I?

We have to ask why change is so difficult in healthcare—and not only in the NHS. Why has there been such dramatic change in car manufacturing and retailing across the world, when healthcare systems have proven much more difficult to change? Interestingly, in the 2000 NHS plan, echoed in the five-year forward view, were two comments: that we have a 1940s system delivering care to a 2016 population with entirely different needs to the population of 1948; and that healthcare has been slow to move, not only in the NHS but around the world. Changing that system will be difficult but very important.

Why am I optimistic about it? First, we have a narrative. The five-year forward view gives the whole service a very powerful narrative around which it can combine and work together. Secondly, the architecture of the system is not perfect—I know that the noble Lord, Lord Lansley, is sitting behind me—but it is serviceable. We do not need another top-down reorganisation. We can work with the bodies created through the last reorganisations, and NHS England is now building resources and a team of people who can truly deliver on its plan. The new purpose of the NHS is based around improvement and learning rather than regulation, which is important, and the independent CQC.

There are two other reasons for optimism. Transparency will be a much better improvement mechanism than targets, regulation, competition and the command and control structures that we have had in the past. The financial crisis we have gone through has made hospitals look more radically at how they can change their models of care. Finally, we have not spoken in the debate today about the huge impact that technology will bring in empowering patients to look after themselves and take greater personal responsibility, as other noble Lords have mentioned.

I have to conclude. I thank the noble Lord, Lord Turnberg, for introducing this fascinating debate, which has raised important issues. I look forward to reading it in the cold light of day over the weekend.

My Lords, it has been a fascinating debate and I am grateful to all speakers who have participated in it. It is amazing how much information people can pack into three minutes. It has been very helpful. I was bowled over by the maiden speech of the noble Baroness, Lady Watkins.

There is no way in which I can summarise the debate in no time at all but one or two themes have emerged. Everyone agrees that we should focus to a greater extent on prevention. That makes it seem even more ridiculous that we are cutting funding for public health at this time. Most people agree that there is a need to integrate services across the social care/hospital divide, and most people feel that we should begin to appreciate our staff to a much greater extent than we do. To alienate them at a time when we need them so desperately is counterproductive.

On the point that we are seeing a rise in demand and the costs of healthcare, I detected more than a hint from the noble Lord, Lord Prior, that he might believe that the spreading of good practice—there is all sorts of good practice around—and increasing efficiency will solve the funding crisis. I suspect he is the only speaker in the debate, on either side of the House, who believes that. It focused the minds of most people on how we fund the gap.

If one thing has come out of this debate it is that we have begun to think about how—

Motion agreed.