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House of Lords Hansard
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Brexit: Risks to NHS Sustainability
12 July 2017
Volume 783

Question for Short Debate

Asked by

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To ask Her Majesty’s Government what assessment have they made of the risks to NHS sustainability arising from the United Kingdom’s departure from the European Union.

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My Lords, we now come down to earth from outer space. This debate combines two public policy areas with what I would say are well above average risks of disaster and on which there seems to be a collective governmental denial of the seriousness of the challenges and dangers we face in both areas. Even without Brexit, the NHS has to cope with major challenges to its sustainability, which is why this House set up the Select Committee on this subject. I was a member of that committee which, after collecting and analysing a massive amount of evidence, published on 5 April its report, The Long-term Sustainability of the NHS and Adult Social Care.

Let me start with what that evidence revealed. We have unrealistic and inconsistent funding for both health and social care, relative to the demands placed on both by the disease profile of an ageing population. The UK has historically spent less per capita on health than France, Germany, the Netherlands and Sweden. There is no long-term strategy to secure an appropriately skilled, well-trained and committed workforce. We have expected staff to work, for approaching a decade, under a system of unrealistic pay restraint; and we are overdependent on EU-trained staff for whom, since the Brexit result, the Government have shown little appreciation.

The NHS performs poorly on many acute area indicators compared with similar European countries in terms of survival rates from stroke, heart attacks and cancer. We are on a trajectory of worsening service access and increased rationing of that access. There are wide variations in provider performance; and the NHS is often a slow adopter of innovative technologies that could save money and improve patient care. Significant health inequalities persist, and we have failed to protect public health and prevention budgets in the middle of an obesity epidemic that could easily overwhelm us—and we are still restricting those budgets.

The provision of publicly funded adult social care is now at a tipping point, which presents the biggest immediate threat and challenge to the NHS. The Government’s proposed funding increases to 2020 are at least £2 billion too little, and they come too late; service providers are leaving the publicly funded care market in big numbers; and quality is falling, often to unsafe levels. A longer-term solution looks as far away as ever after the election fiasco on social care, and the Government will not even commit to a Dilnot cap on personal liability for social care costs, despite having the powers to do so.

The British public still strongly support a tax-funded NHS, free at the point of clinical need, and the Select Committee could find little international evidence to change fundamentally this funding system. But the public are losing heart and now 55% of them expect the NHS to deteriorate. Both these services—health and social care—need a much more consistent funding system, agreed on a more long-term basis, with a stronger real-terms link to GDP growth, which in turn requires an economy that is growing.

There is strong evidence that the way in which we deliver health and care services has to change radically and rapidly if the NHS and publicly funded adult social care are to be sustainable. We have to integrate fully health and care, with much more care delivered in primary and community care settings, and with a greater focus on public health and prevention, especially with our obesity epidemic. All this requires investment and the Government paying attention quickly to the kind of changes set out in the Select Committee’s report, with 32 significant recommendations for the changes required. Crucial to that service transformation are service transformation plans, which are now at various stages of development and implementation around the country. Many are controversial with local communities in terms of closure of hospital beds and services. They often need a supportive and robust Government to amend the failed Health and Social Care Act 2012, which all too easily hampers local reforms. A weakened Government now lack the authority and capacity to do this, as the Queen’s Speech made clear.

I am not going to discuss the Select Committee’s recommendations now. They are matters for debate another day, when the Government finally get around to responding to our report. What I am trying to do today is demonstrate that our health and care system is not in a good place. It requires a lot of political investment of time and money, preferably on a cross-party basis. It also requires a buoyant economy over the next few years to provide the investment that these critical and publicly supported services need. Yet the Office for Budget Responsibility last year projected a £15.2 billion hit to the public finances by 2020-21 after the UK leaves the EU, which would mean a loss of about £2.4 billion a year to the NHS—and even more if there is a more severe economic downturn than the OBR thought.

The harsh Brexit reality is that we face an exit from the single market, with poor transitional arrangements, the loss of trade with our near neighbours, fewer tax-producing financial services jobs, higher inflation and a shrinking economy. We have a dysfunctional Government with no credible plan for leaving the EU without serious damage to our economy over the coming years and not even any agreement on a sensible transitional arrangement. This Government continue to delude themselves about the willingness of the EU to compromise on its fundamental, treaty-prescribed principles.

I do not usually quote trade union leaders, but the head of the Transport Salaried Staffs’ Association seemed to me to sum things up rather well when he said:

“If Brexit goes ahead, future historians will look back and see a carpet-bombing of the British economy and the freedoms enjoyed by people living here”.

This set of circumstances does not bode well for our already fragile health and care system, and the prospects could become worse as a result of other things the Government seem willing to sacrifice in their rush to the EU exit. We have already virtually lost the EU pharmaceutical regulator—the EMA—from London, with the loss of high-quality jobs and the adverse impact on our life sciences sector that this brings.

The Government’s obsession with escaping from the European Court of Justice’s jurisdiction has led to the bizarre and ill-considered decision to quit Euratom, with no credible alternative civil nuclear regulator in prospect and—by the Government’s own admission, it would appear—without any proper assessment of the impact of quitting Euratom. Leaving Euratom now poses another threat to the NHS and its patients, as the Royal College of Radiologists has pointed out. Thousands of NHS cancer patients rely for diagnosis and treatment each year on radioactive isotopes imported from EU countries. The safety regulator for this activity is Euratom, governed by an EU treaty. The best interests of the UK and its citizens would be served by us remaining a member of Euratom, but the ideologues in No. 10 seem to have decided otherwise—despite the European Court of Justice never having made a ruling on Euratom.

On top of this, the health and care system depends on about 150,000 doctors, nurses and other care staff from the EU, because of our failure to train and retain enough home-grown staff. About 7% of our doctors are EEA-trained, and 40% of social care staff in London are from the EU. But the biggest problem may well be a shortage of nurses, because we import about 10,000 nurses a year from the EEA. Already the number of EU nationals registering as nurses in England has dropped by over 90% since the referendum. All this is becoming a serious problem. Because of the Government’s failure to move quickly to reassure EU nationals of their right to remain here after Brexit, many of these EU nationals no longer trust the Government’s belated assurances—in part because EU political leaders do not trust them, either.

In conclusion, this is a hell of a mess. A fragile health and care system badly needing reform and new investment from a growing economy is now facing economic retrenchment, political uncertainty, loss of a key staffing source and collateral damage from ideological obsessions with the ECJ. This is today’s reality, in contrast with the leave campaign’s lies on its red bus about Brexit providing £350 million a week more for the NHS. In the coming months, more people will realise where the Government’s approach to Brexit is taking this country economically and its implications for public services. Then we will see how committed they really are to Brexit. I ask the Minister: what plans do the Government have to protect our fragile health and care system over the next two or three years of great political uncertainty?

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My Lords, the noble Lord, Lord Warner, has performed a very signal service in introducing this debate and I congratulate him most warmly on the way that he did so. We desperately need clarity from the Government—we have not had it, but I hope that tonight we might begin to see it. It could all have been so much more simple. The noble Lord, Lord Warner, referred to the pledge to EU nationals in this country. Would the number of nurses have declined in the way that he illustrated, with that figure of 90%, if we had in fact used our sovereign power, taken control, and said from the onset, as the leave campaign did say from many a platform, “Your position, for those of you who came here in good faith, who have paid your taxes, who have become part of our communities, is not at risk”? It is still not too late for Ministers, led by the Prime Minister, to say this.

The Prime Minister has appealed recently for cross-party work and consensus. When I spoke in the Queen’s Speech debate, I suggested that one way of dealing with these matters was to have a joint Grand Committee of both Houses, which could look at these things. I did not get any answer to that; I hope that I will. The previous week, I was sacked from the Home Affairs Sub-Committee of the European Union Select Committee of your Lordships’ House, on which I enjoyed serving, for my vote on the Article 50 amendments. That is hardly consistent with the principle of appealing for cross-party accord. When we have a Government who do not have a majority and who lost their majority in a thoroughly needless general election, we need a new start and to call upon the talents sitting on all the Benches in your Lordships’ House.

This afternoon, I had the pleasure—I think that others in the Chamber probably also had this pleasure—of hearing in the Royal Gallery a very moving and inspiring speech from the King of Spain, who expressed his wish and determination that relations between our two countries should continue to thrive and prosper. We would all say amen to that. However, he made equally plain his sadness at our leaving the European Union, where we and Spain have, as constitutional monarchies, played a constructive part. We must not be hamstrung by doctrine, particularly the doctrine of those behind the £350 million pledge pasted on buses, to which the noble Lord, Lord Warner, has already referred. We need a real route map; we need to know where we are going and how we are going to get there.

The speech of the noble Lord, Lord Warner, illustrated very graphically that the greatest of our national services—our National Health Service—is teetering on the brink of collapse. We desperately need plurality of funding and to look at some of the proposals of the committee so ably chaired by the noble Lord, Lord Patel, at the end of the last Parliament, which I think reported on 5 April. We have all the pointers. We have diagnosed the disease. The Government seem unable to accept that there is a remedy and it is in their hands. We need to work together across this House and the other place to address matters of enduring importance and continuing worth, of which the National Health Service is perhaps the greatest and most important example as it touches all our citizens at unpredictable as well as predictable points in their lives.

I just hope that my noble friend, for whom I have a high regard—he has competently mastered his brief since he took on his responsibilities—will be able to give us some hope this evening. I hope that he will also talk to the Secretary of State and others because we desperately need a leadership that is not hamstrung by doctrine. Brexit will dominate all our debates for the foreseeable future, but let it not dominate them in a totally negative way.

I accept, with great reluctance, the result of the referendum—of course I do, like others in your Lordships’ House. But we have to start talking in detail about transitional periods. All this cannot be accomplished in under two years, especially as the real negotiations will not begin until after the German election later this year. That gives a period of a little over 12 months. Therefore, if we are to avoid what the Prime Minister has called the cliff edge, we have to have proper transitional arrangements, in particular when we are considering the invaluable, and in the short term irreplaceable, contribution of EU nationals to our National Health Service. That 90% figure is alarming, and if it is replicated across the National Health Service, it will place countless British citizens at risk.

Therefore, in supporting the noble Lord, Lord Warner, I ask my noble friend to forget the lies on the bus and put aside the doctrine that Brexit means Brexit—which I think is the most meaningless slogan I have ever heard in my 50-odd years in politics. Let us now tackle the real issues with a real programme and bring parliamentarians of all parties and both Houses together to contribute their suggestions and their solutions.

I therefore end more or less where I began, by asking my noble friend to pass on to those in high authority—I do not want him to tell us that it is above his pay grade—the idea of something unique: a joint Grand Committee of both Houses of Parliament. A committee can put party political considerations to one side and concentrate on trying to ensure that, from what the noble Lord, Lord Warner, called the mess that we are in at the moment, a stronger nation can indeed emerge.

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My Lords, I am delighted to participate in this debate and to follow the noble Lord, Lord Cormack, and his clear, erudite and free-thinking contribution to the debate. I especially congratulate the noble Lord, Lord Warner, on allowing us an opportunity to debate this issue. When he approaches anything, he approaches it in a meticulous manner. Securing this debate today and concentrating our minds on sustainability and the risks involved with Brexit is a useful exercise for us to undertake, so I thank him for that.

I approach the debate with some hesitation, and I am sure that other noble Lords will feel likewise. At one level, none of us wants to say or do anything that will shake people’s confidence in the National Health Service. It is indeed the most efficient health service in the world, and it still delivers a wonderful service to the general population of the United Kingdom. I would hate to think that anything that I might say might cause distress to patients. However, as the noble Lord, Lord Cormack, hinted, as parliamentarians we are privy to information that is not available to other people. I suspect that I know quite a lot more about what goes on in hospital than even the Minister, whom I hold in the highest regard. I understand his sincerity and his commitment to the NHS, but so much of his information is, naturally, fed to him by his civil servants—I understand that, and I am not attacking civil servants. I looked after the Civil Service in my previous existence.

As the Minister may have noticed, I have tried to take a different approach to collecting information. Of course I accept the facts and look at the statistics but over the years, through my friends and associates, I have tried to build up contacts in the health service. People who work in the health service and in hospitals give me the picture as they see it—how it actually is—and it is up to me whether I believe it or not. I have to say that the picture is far worse than I had imagined, and I will try to develop some of those points today.

However, I start with a point raised by the noble Lord, Lord Warner—Euratom. I spent seven years as a director at Sellafield and I suspect that I know a little more about nuclear reprocessing than perhaps most of the general public do. I simply do not understand the Prime Minister’s obsession with leaving Euratom. Perhaps she does not understand what it is—Euratom is a legal entity separate from the European Union—yet she took a decision on it, apparently against the advice of other Cabinet Ministers. I hope that after this debate the Minister will feel empowered to feed the information up to the Secretary of State.

The issues surrounding Euratom are very serious, and I want to spell them out in words of one syllable because that is the only way that I can understand them. Quite simply, leaving Euratom could—I emphasise “could”—restrict the UK’s access to radioisotopes, which are critical to scans and treatment for cancer. It is as serious as that. We do not have reactors in this country capable of producing radioactive isotopes. We import them largely from France, Germany and Holland, and the control and safety monitoring of those isotopes is carried out by Euratom. By cutting our links with Euratom, we expose ourselves.

To put this issue in context, half a million scans are performed every year in Britain using imported isotopes and, on top of that, over 10,000 cancer patients have treatment involving their use. I just think that it is too big a gamble to take a decision on what I can only think are ideological grounds. That is a big, big error and I hope that the Government will rethink their position.

Going back to the basic issue, I suppose there are two basic problems. One is clearly finance. We spend less on healthcare than any of the other G7 nations, with one exception. I believe that the Government should make a commitment to go for at least the average spend on health among the G7. That would give us an opportunity in the years ahead to start an expansion.

A second problem is staffing—at every level. Throughout the National Health Service there is a panoply of overwork, low morale and staff working in what I can only describe as desperate conditions. Nurses finish their shifts in tears time after time. They are frustrated because they simply do not have the time to perform their job—their vocation of care—and they feel that they let the patients down, simply because they are understaffed. I have heard reports of nurses working a 12-hour night shift—that is the average length of a night shift—without being able to stop to have something to eat. That is happening regularly. The Minister might say, “Ah, but the numbers are made up with agency nurses”—and they are. But one only has to think about it to realise that, as the reports I get confirm, agency nurses can do the mundane things but most of them are not familiar with the work of the hospital or ward in which they are working. So even with the numbers increased by agency nurses, the onus on the regular staff of the hospital is increased.

It is not only about nurses, where we are 40,000 short of what we need, let us consider doctors. Where I live, the north Cumbria trust has 48 vacancies for consultants—we cannot get any consultants or nurses to work on the west coast of Cumbria. Right next to Sellafield, the largest industrial site in Europe, there is no hospital of any quality within an hour-and-a-half’s drive. That is the seriousness of the problem.

For the first time ever, more nurses are leaving the profession than joining. The worry is that the greatest drop was among the English or British-trained nurses, which was far higher than among the European-trained nurses.

I hope the Minister will consider looking again at the abolition of the bursary scheme if the indications at the beginning of September show that there is going to be a fall in the numbers. We cannot stand another decrease in the number of nurses. I say this to the Government because they need reminding: their track record is not good. They were the Government who cut nurses’ training by 10% in the years following 2010, and it has taken us a long time to recover.

I end with a thought on the residency of European Union-educated nurses. From exchanges with the noble Baroness, Lady Williams, I understand that after five years of working in the health service, or any permanent employment, European Union citizens can get the right to residency. Then, after a further year—six years in total—they are entitled to UK citizenship. That seems straightforward, but what concerns the nurses and the European Union is this: can those rights be withdrawn willy-nilly by any British Government in the future? That is a serious problem that the Government have to address in order to reassure people working in the health service.

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Before my noble friend sits down—

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My Lords, I am sorry, but this is a time-limited debate and that is not the way it works.

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My Lords, I warmly thank the noble Lord, Lord Warner, for initiating this important debate. As he said, we are very reliant on EU workers in the NHS and social care, which includes around 10% of doctors and 7% of nurses. Sadly, there is already evidence that they are leaving or not coming to the UK. As well as the alarming drop in nurses cited by the noble Lord, more than half of the 10,000 European doctors working in the NHS are now considering leaving, according to a survey conducted by the General Medical Council.

In social care, 7% of staff, or 90,000 people, are from elsewhere in the EU, but numbers are already dropping. The Brexit squeeze on social care workers is likely to hit the elderly hardest, as it is predicted that there will be almost 3.5 million more over-65s by 2030. That figure could be supplemented by many UK pensioners returning from places like Spain if their rights to residence, public services and especially to healthcare are not safeguarded. We could be losing fit, younger skilled workers just as the pressure of more older people needing the NHS and social care builds ever higher. The exodus of EU staff exacerbates the shortage of doctors, nurses and care staff, which puts a heavy workload on current staff, causing many to leave the service. So we absolutely need to attract EU workers into the NHS and social care rather than deterring them in order to fill the vacancies.

The Liberal Democrats regard the Government’s proposals on EU citizens’ rights as inadequate, and in particular are calling on the Government to guarantee an immediate “NHS passport” for the 60,000 EU nationals who work directly for the NHS. In the future under Conservative plans, the NHS faces an “immigration skills charge” of £2,000 a year for each doctor, nurse and health worker that it brings in from the continent. Will the Government exempt the NHS from this charge?

Then there are all the teachers and academic staff in universities helping to train the next generation of medical professionals. We are already short of STEM specialists and Brexit is going to make this even worse. We will also be outside the EU systems for mutual recognition of qualifications, which will make it more difficult to recruit as well as more difficult for our UK citizens to get experience in other EU countries. As was said by the noble Lord, Lord Warner, both the NHS and social care are already underfunded and they both need immediate injections of cash as well as long-term sustainable funding. Brexit puts this at risk because of the threat to the British economy and the tax take. You cannot have a hard Brexit and a strong NHS.

Some 190,000 pensioners live in other EU countries and can use local health systems thanks only to reciprocal EU arrangements. If those arrangements fall away, UK citizens will have to pay for their treatment abroad, and many may choose to return to the UK. The cost to the NHS of the return of all UK citizens of pension age would be nearly half a billion pounds a year.

As soon as the result of the referendum was announced, there was an immediate effect on international collaborative research projects involving UK researchers. Our scientists were asked to withdraw from funding applications, as it was seen that their presence in a team could put an application at risk. The UK has done extremely well from EU funding for life sciences research, receiving almost €9 billion between 2007 and 2013. How do the Government plan to replace all this money in the future? Apart from the money, the medical, scientific and industry benefits from international collaboration are enormous and I do not know one single scientist who is other than deeply unhappy about Brexit.

I am associated with the Juvenile Diabetes Research Foundation, which has told me that:

“Without EU funding a number of vital research programmes would not exist, as comparable funding, especially to support consortia, is not available elsewhere”.

The foundation participated in a €6 million award for immunotherapy to treat type 1 diabetes, which involved small and medium-sized firms as well as research institutes. It also said that researchers,

“depend on personal funding from the EU, including Fellowships, to enable them to pursue a career in research and start-up their labs”.

I understand that the European Research Infrastructure Consortium, which facilitates cross-border research partnerships, requires that all signatories have to accept the jurisdiction of the European Court of Justice for arbitration. How will our researchers continue to participate in this consortium post Brexit? How will British researchers and those coming here from the rest of the EU be able to move seamlessly across borders in an era without free movement? The then Minister, the noble Viscount, Lord Younger of Leckie, told us in March about a high-level stakeholder working group for universities, research and innovation that the Minister, Jo Johnson, had established to look at the risks and opportunities of Brexit—although no one has actually suggested any opportunities to me. What are the conclusions so far of that working group?

There is great concern that Brexit will mean increased cost, reduced access for UK patients to new medicines and medical devices, reduced patient safety and damage to business prospects. Leaving the customs union will cause delays and extra costs in medical devices and access to medicines. Most of these products cross country borders several times during the process of development, clinical trials, licensing and regulation. The single market has built up a complex and detailed web of protection.

The coalition Government carried out reviews on the balance of EU competences. The review on health noted how collaborative action at European level on medicines and medical devices can be more effective and thus beneficial for patient safety because the EU can,

“effectively tackle … counterfeit medicines, which involve complex global supply chains; share safety information on medicines once they are on the market and quickly detect”,

risks to safety. Far from wanting to pull out of this system, industry welcomed it, stressing,

“the advantages of the common regulatory framework for ensuring a high level of patient safety and secure supply”.

Not only are we losing 2,000 jobs through the loss of the European Medicines Agency, but, as the Association of British Pharmaceutical Industry told that review in 2012:

“The introduction of the centralised procedure, along with the creation of the EMA, not only greatly simplified”,

the processes,

“but also resulted in a system where medicines information such as the patient information leaflet are consistent across all EU Member States, which is good for public health protection”.

How do the Government plan to recreate the regulations that will allow us to buy and sell medicines in the EU? What system will be put in place to ensure that UK regulations keep up with those in Europe? Can the Minister explain more fully what the Secretaries of State for Health and for Business had in mind in their wish expressed in a letter to the Financial Times last week for,

“deep, broad and dynamic cooperation”?

The MHRA chairman, Professor Sir Michael Rawlins, has warned that withdrawing from the EMA could put the UK behind Japan, the US and EU nations in the queue when new drugs are introduced.

Brexit will mean that dangerous or defective drugs that pose a threat to patient safety may be available to British consumers for longer than on the continent. Leaving the EU medicine safety system means the UK will be slower to respond to safety issues, putting patients at risk. Relevant to research and clinical trials is the framework for data protection. How will the Government ensure that UK law keeps up with the future development of EU regulation and ECJ case law, without which we could be excluded from collaboration?

I will not mention Euratom as other noble Lords have done so and we are fortunately going to have a debate, initiated by my noble friend Lord Teverson, next week, but I will mention the business opportunities for our pharmaceutical and life sciences industries, which not only EU research collaboration but EU common regulation open up. They have been very vocal in insisting on those opportunities in improving competitiveness and exports. What will the effect be of the UK losing the life sciences section of the EU patent court if we can no longer participate?

How will all these benefits of being part of the single market in health be replicated if we are outside the EU? No free trade agreement will cover the myriad networks and systems that 45 years of EU membership has created. Finally, the Brexit Secretary, David Davis, says it is an aspiration to keep the benefits for individual travellers of the European health insurance card. A lot of people will realise just how useful European red tape is if they lose the EHIC.

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My Lords, I thank the noble Lord, Lord Warner, for introducing this important topic for us this evening and for his helpful and comprehensive opening remarks.

Ensuring the sustainability of the NHS is undoubtedly a significant challenge, even before the potential consequences of Brexit are considered. The uncertainty surrounding the Brexit negotiations has created significant stress for many working in already pressurised health and social care systems. There is no doubt that urgent action must be taken to ensure the stability of the current system. That being said, I wonder whether we might be able at this time of significant pressure to begin to confront some of the deeper challenges that our health system faces. The challenges of Brexit for our health and social care services might only reveal the deeper, long-term problems of these systems as a whole. It would be unfortunate for Brexit to be only the latest in a long line of short-term crises rather than an additional opportunity for reflection.

The report of the Select Committee on the Long-term Sustainability of the NHS, published in April of this year, stressed:

“Whatever short-term measures may be implemented to muddle through today, a better tomorrow is going to require a more radical change”.

I note particularly its recommendation of,

“a new, independent standing body enshrined in statute to safeguard the long-term sustainability of the NHS and social care”.

The nature of the political cycle means that it is difficult for politicians to rise above the fray and consider the long-term sustainability of the system as a whole, and there is substantial room for a body to oversee and scrutinise independently and to report directly to Parliament. National health and social care service provision affects the lives of citizens in profound ways, quite literally from cradle to grave. It is no surprise that it is of paramount importance to both individuals and politicians, and we should consider novel ways to safeguard these systems. Bold leadership is required, but this should be an area where politicians can show courage in finding common ground to make meaningful and lasting change.

Much has been said in this Chamber about the deep feeling of division in this country in the light of the Brexit referendum. Nevertheless, the NHS, and the importance we place on caring for one another, is at the core of the “British values” discussed in the Queen’s Speech. Indeed, these values are a part of many faiths, including Christianity. Part of what it means to be British is to care for one another, even when it comes at significant cost. We must acknowledge, however, that that cost is increasing, and adjustments must be made at both an individual and societal level. We have a duty to one another and to future generations to ensure that necessary resources are in place and are safeguarded in order for care to be maintained.

It is unfortunate that the NHS is not in a better position to be able to respond to the challenge of Brexit; we are still suffering the consequences of short-term thinking and acting. The waiting list for elective treatment has risen to 3.78 million, which is 5% higher than a year ago, and the number of delayed discharges from hospital caused by waits for home care rose by 45% in 2016-17. Even within my own diocese, two wards in St Albans hospital are scheduled to be closed to cut costs despite the clear demand for beds. By taking a more long-term approach to healthcare, even in the light of Brexit, we may be able to address the issues that have weakened the system substantially and prepare for the additional challenge of our ageing population. If we can work towards preventing weakness in the system, we will be far better placed to respond to sudden challenges.

The potential loss of EU personnel in both the health and social care systems will be an enormous short-term challenge. More than 60,000 people from EU countries outside the UK work in the English NHS and around 90,000 work in adult social care. Support must be provided for these individuals, many of whom work long hours in difficult circumstances and have made significant sacrifices to make the UK their home. We need to take account of them, not just in negotiated discussions but also in any plans, after we leave the EU, to alter immigration policy.

It should never be overlooked that the NHS is heavily reliant on workers from outside the UK. Despite this, the Royal College of Physicians describes our hospitals as chronically understaffed, almost half of community mental health teams had staffing levels judged as less than adequate in 2013-14, and the Royal College of Midwives believes that in England we need 3,500 more midwives to ensure that every woman can receive one-to-one midwifery care in labour.

Not only must we have sufficient numbers of personnel, we must ensure that they have the correct skills and training that the service needs. This means that we need to invest in those currently serving in the NHS, as well as making sure that we train enough doctors and nurses here in the UK. However, in 2016 there were unfilled nursing places in UK universities, and we know that care homes would collapse without their non-UK workforce. This is in part because these roles are not sufficiently valued and hence do not attract UK applicants. Sustainability of the workforce cannot be achieved, even if all EU workers remain, unless attitudes to some health and social care roles change significantly.

As we seek to manage the staff of the NHS wisely—that staff is undoubtedly one of our greatest assets—prudent financial planning will also be required. The quality of care which we have come to expect and demand comes at a significant cost. Some 86% of the NHS’s sustainability and transformation fund of £2.1 billion has been set aside to sustain current services and meet expected deficits. As deficits increase year on year, a radical rethink of healthcare funding is required. We need a broader social dialogue about funding for health and social care, one to which the Church and other faith communities can contribute.

Along with the right to healthcare, which we are undoubtedly privileged to enjoy, as users of health and social care services we have associated responsibilities. In remembering that we both benefit from and contribute to the NHS, we must consider the impact of our own lifestyles on our ability to care for others. In treating others as we wish to be treated, we must be prepared to think creatively and make sacrifices for all to enjoy a good standard of care.

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My Lords, it is a great pleasure for me to congratulate the noble Lord, Lord Warner, on this debate, which I think has been very good and wide ranging. He linked the long-term sustainability of the NHS with the UK’s departure from the EU and demonstrated amply that, even without Brexit, the NHS faces a very difficult challenge in terms of its long-term sustainability. The report of the Select Committee chaired by the noble Lord, Lord Patel, demonstrates very comprehensively some of the questions that we need to consider.

It is abundantly clear that the NHS does not have the required funding. The question we need to put to the Government is: what is their plan for the NHS? Essentially, are they engaged in a wind-down of the NHS’s activities? We know that CCGs are rationing increasingly. We know that the key targets are being missed and I do not know anyone in the health service who thinks that the health service will ever get back to meeting those targets under current circumstances.

A similar question has to be asked of the Government in relation to social care, following the débâcle over the dementia tax. I put it to the Minister that we are still waiting on an answer as to why Dilnot is not being implemented. There has not been a straight answer. We had the report; we had legislation—we spent months taking the Bill through this House. The Government announced the cap at £72,000. They then announced a postponement, but we have yet to hear one reason as to why Dilnot is not being proceeded with. I think we are owed some explanation of why we are in the position we are in.

No doubt the Minister will talk about STPs and the transformation process that is being undertaken in the health service—but there are two things to ask him about that. First, it was the Government’s intention to introduce legislation to amend the 2012 Act to allow the STP process to proceed in a legal way, because clearly it drives a coach and horses through the 2012 legislation. My question for the Minister is: what is now going to happen? I cannot see that the kinds of things that NHS is seeking to do at local level are at all legal in terms of the 2012 Act.

Secondly, the right reverend Prelate put the point very well when he asked: how can it be that in his diocese, in a hospital which is under huge demand, you can justify closing two wards without seeing the commensurate investment in the community, when we are told that if you do that, you will reduce demand on acute hospitals? By the way, I have to say to the Minister that there is no evidence that that will actually happen. No respectable institute has produced any hard evidence that suggests that investing in primary community care reduces demands on acute care. It is much more likely, as Nye Bevan found in 1948, that it deals with unmet demand, but that demand within acute care is likely to continue.

My other question for the Minister is this. The word in the service is that the Government will not support any controversial change in service locally if it will cause angst to local MPs. If that is the case, it is quite clear that the whole STP process will grind to a stop over the next few months as more and more people recognise that it is not the game in town that the Government thought it was going to be.

These are major questions that the Government need to consider. How much worse does the problem become when we come to Brexit? Noble Lords have eloquently described some of the issues that we face—but I put to the Minister the point made by his noble friend Lord Cormack: why are the Government so reluctant to support a Joint Committee of both Houses to consider these matters? After all, part of the debate on Brexit was about the so-called sovereignty of the UK Parliament. Why are the Government so resistant to the UK Parliament exercising sovereignty over the biggest decision this country has faced in 50 years?

The Prime Minister has talked about bringing the country together. How do you bring the country together when your interpretation of a very narrow majority for Brexit is to take an obdurate view that the red lines are around migration and the European court? How on earth is that bringing the country together? Surely a consensus approach would be to find some kind of middle way through the Brexit negotiations, rather than the cul-de-sac the Prime Minister has got herself into—which, of course, in the end she will have to get herself out of because she does not have a majority in the other place for the proposals that she is putting.

We then come to the issues facing the health service. The noble Baroness, Lady Ludford, has already raised the seemingly simple issue of our rights to health treatment in the EU and vice versa. But we are told by the Brexit Secretary that this is now an aspiration. I ask the Minister: what is our policy on this in the future?

We then come to the workforce. We have reached the ludicrous position where the pay policy and the way that professional staff are treated in the health service mean that we have fewer people from this country coming into nursing in the NHS than are actually leaving. We have completely choked off people coming from the EU because of the atmosphere the Government have created with their wretched approach to Europe. My chief exec contacts in the health service tell me that we have dozens of teams in the developing world—India and the Philippines—recruiting nurses to substitute for the nurses we would have had, happily, from the EU. How can that possibly be a sensible approach to the way the NHS is run? It just beats me; it is bizarre. The end of the line is that the Prime Minister will not get anywhere near her immigration target because she will desperately have to approve the recruitment of thousands of nurses from the developing world. Is there any more nonsensical position than that taken by this Prime Minister?

Then there are the life sciences. There are problems around European research. Already universities are losing out on research bids because other European universities will not go into partnership with them. This can have a devastating effect on our life sciences. Our universities are reeling under the ludicrous position taken by the Prime Minister—both as Home Secretary and as Prime Minister—over students coming from overseas to study in our universities. They are a huge earner. Britain has a fantastic reputation. Why on earth are we trying to prevent these people coming to this country? It again defies all understanding.

We then come to medicine regulation. The risk is that if companies continue to develop drugs in this country, they have to have an assurance that when they get a licence from our regulator, the MHRA, it will be recognised throughout the whole of Europe. If they do not get that, we will lose drug development in this country—that is £4 billion of investment. We have seen the letter that the Minister’s right honourable friend the Secretary of State and Mr Clark wrote to the FT a week ago, which makes the right noises in relation to regulation, safety and the interrelationship between what we do in this country and what happens in the EU, but does the Minister agree that in the end the only way forward is an agreement on mutual recognition, even if that involves the European court, as it may well do?

Finally, my noble friend Lord Clark speaks with great authority on Euratom. Why are we risking our energy supply, in many cases, and the safety of patients? For what? It is for some bizarre view that anything with any relationship to the European court is completely out of court.

I fear for the future of the NHS and for the future of this country if this is the Government’s approach. I am confident that Parliament will assert itself to ensure that the Government will have to change course. I hope the Minister will give us a little bit of movement on this in relation to the NHS.

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My Lords, I thank the noble Lord, Lord Warner, for obtaining this debate, and I assure him and your Lordships’ House that this Government are committed to making leaving the EU a success for the health and social care sector as well as for the UK as a whole. I thank all noble Lords who have contributed to the debate.

I have to say, as noble Lords probably expect, that I do not share the gloomy prospectus that has been set out for the NHS in the years ahead or for Brexit. My noble friend Lord Cormack asked for a bit of optimism and hope. He might be interested to know that my youngest daughter is called “Hope”, so I am a great optimist. I will explain why I am an optimist about how the years ahead will pan out for this country and for the NHS.

The sustainability of the NHS is, of course, a timely issue, not least because of the excellent report The Long-term Sustainability of the NHS and Adult Social Care, which the noble Lord, Lord Warner, produced earlier this year. I pay tribute to how well that was marshalled by the noble Lord, Lord Patel, who was in his place earlier. I reassure noble Lords that the response to that report is being drafted, so work is in progress and the response will be coming shortly.

As noble Lords will know, the organisation and delivery of healthcare is a member state competence, and this means that the vast majority of the work to implement the NHS five-year forward view will remain relatively unchanged and will continue to have the full support of this Government. While I am on the subject of policy, the noble Lord, Lord Hunt, asked what happened to Dilnot and social care. As he will know, and as I have said before on the Floor of the House, we intend to consult on both a cap and a floor within the social care funding sector, which is in essence what is at the heart of Dilnot. We will be coming forward with proposals that build on that later this year.

The ongoing work of the department and of the entire health sector is to transform how the NHS delivers care to ensure that it is properly configured for the future and that it remains both sustainable and fit for purpose after we exit the EU, and for many years after that. I completely concur with the statement made by the noble Lord, Lord Clark, that not only is it the most efficient healthcare system in the world but that it delivers wonderful care. Despite the ageing and growing population, it has had a number of successes in recent years: real-terms increases in funding, a greater share of public spending, more people being seen in A&E and seeing specialists for cancer, more doctors and nurses, and rising life expectancy. Public perception as measured in a ComRes poll at the start of the year shows support of the statement that the NHS provides a high standard of care to patients was up 13 points to 71% compared to 2014.

The noble Lord, Lord Clark, who speaks with experience on this, is quite right to point out the issue with sources of information. I can reassure him that I have plenty of friends who are either doctors or nurses, so I do hear from the coalface, if you like, and I know that it is not an entirely rosy picture at times. I pay absolute tribute to the work that our NHS staff and staff in social care do, often in very challenging circumstances. I reassure him that I try to expose myself to the realities of life in the NHS as much as I can.

As noble Lords know, following the publication of its Next Steps on the Five Year Forward View, NHS England is working with local areas to develop them into sustainability and transformation partnerships—moving beyond plans to develop tangible delivery organisations with clear partnerships between local organisations, fairly appointed leaders and clear governance structures. I welcome the support of the right reverend Prelate the Bishop of St Albans for this process, which has been backed by Treasury capital funding announced in the Budget. This is enabling the most advanced STPs, as they are known, to evolve into accountable care systems, which will provide joined-up, better care, breaking down the barriers between GPs and hospitals, physical and mental healthcare, and social care and the NHS.

The noble Lord, Lord Hunt, asked what the legislative framework for this is. I am sure that in the long run, the creation of ACSs, or ACOs as they are sometimes known, may require legislative change, but it is not currently necessary, and we can move ahead with the kind of integration that we all want to see. We are serious about improving care for local communities, and these steps towards integration and collaboration provide a mechanism to do just that.

By redesigning services to make it easier for patients to access health and social care at the right time, in the right place, we can make real progress in improving care for local communities. We can begin to move beyond sterile debates about reorganisation, while making sure—in response to the question asked by the noble Lord, Lord Hunt—that the five principles of when reorganisations should happen stay in place. Of course that became five recently with the addition of patient safety, which I think was a point raised by the right reverend Prelate and others.

As this debate has helped highlight, our work will need to be supported by a strong outcome from the Brexit negotiations. Since the result of the referendum, the Department of Health has worked hard to identify areas of the NHS that will be affected and to put in place plans to mitigate any risks and seize any opportunities. I completely agree with my noble friend Lord Cormack on the importance of working together. The Prime Minister has said just that, and it was rather disappointing to hear the leader of the Labour Party be so scornful of such an approach—I am sure that noble Lords on the Opposition Benches would not share their leader’s dismissal of the idea of working together.

The noble Lord, Lord Warner, described in his speech what could be rightly called the doomsday scenario. I think he is perhaps allowing his own beliefs and views of the referendum to cloud the reality. There is a strong desire to have a positive new relationship, and that is shared by the UK and the European Union. That is one that respects the nature of the European Union. That is precisely why the Lancaster House speech set out the position on the ECJ, the single market and the customs union: to respect the nature of the European Union, rather than to have our cake and eat it. It is important to note that more than 80% of votes in the most recent general election were cast for parties that support the process of leaving the European Union.

One of the main areas that noble Lords have highlighted is the ability to maintain our superb NHS workforce. I reassure noble Lords that we are doing our best to provide as much certainty as possible to the 3 million EU citizens in the UK, including the many who dedicate themselves to the work of the NHS and the wider social care system. It is simply not true that we do not value them; we do, and I never miss an opportunity to say so at this Dispatch Box.

Noble Lords will have seen that the Prime Minister has put forward a fair and serious offer on the rights of EU nationals already residing in the UK, and we expect it to be reciprocated by member states for UK nationals in the EU. There are approximately 150,000 staff from the EU doing a vital job for patients, and we expect and are confident that we will be able to negotiate for them to continue to do so post Brexit.

My noble friend Lord Cormack and the noble Baroness, Lady Ludford, asked about the impact of Brexit on recruitment from EU countries. As we have discussed in this House before, the introduction of the language test has been a much more significant factor affecting the flow of EU nationals into the health service. It is important to note that there are more EU nationals than ever working within the NHS.

In the same vein, we intend to protect the current healthcare arrangements for EU citizens who are ordinarily resident in the UK, an issue highlighted by the noble Baroness, Lady Ludford. We are confident that we can reach an agreement on this important issue early in negotiations. Indeed, there is already much common ground between the UK and EU positions. That is in respect of both the EHIC programme and pensioner benefits. The aim here is to achieve reciprocity, as my right honourable friend the Brexit Secretary, David Davis, has set out.

More broadly on immigration, we will continue to welcome the contribution that EU migrants make to our economy and society. We are considering options for a future immigration system very carefully. New UK immigration rules will be decided taking into consideration the prevailing social and economic circumstances, aiming to recruit the brightest and the best for our life sciences industry and to fill any skills gaps. It is important to state—and I state it to the noble Lord, Lord Hunt, and others—that the purpose of leaving the European Union is not to end immigration; it is to get control of immigration and to build public trust in the immigration system. Any immigration system will clearly need to take account of the economic and social needs of the country.

Turning to medicines, the UK is committed—through the FT article by my right honourable friends Jeremy Hunt and Greg Clark, as many noble Lords have noted—to continue a close working relationship with the EU on matters such as public health and medicines regulation. Indeed, we are planning an ambitious life sciences industrial strategy to make sure that we are one of the three global hubs for medical innovation. Our aim is to ensure that patients in the UK and across the EU continue to be able to access the best and most innovative medicines and to be assured that their safety is protected through the strongest regulatory framework. I point out to noble Lords the three principles set out in that letter: that patients should not be disadvantaged; that innovators should be able to get their products into the UK market as quickly and simply as possible; and that we continue to play a leading role in promoting public health. Whatever happens, as I said, we have set out our desire for a strong and positive relationship with the EU. Those will be our guiding principles.

Of course, that must be backed up by excellent research. As a nation, we have a proud history of leading and supporting cutting-edge research. Indeed, many of the innovations that take place in health systems around the world come from research that took place in the UK. I reassure noble Lords that the Treasury is honouring all Horizon 2020 and other EU-based research funding beyond the time horizon of leaving the European Union.

Finally, I turn to the issue of Euratom, which was raised by several noble Lords—the noble Lords, Lord Warner, Lord Clark and Lord Hunt. I understand that this evokes strong feelings, but it is simply wrong to say that cancer patients will be at a disadvantage after we leave Euratom, because it places no restriction on the export of medical isotopes to countries outside the EU. I acknowledge, in particular, the wisdom and experience of the noble Lord, Lord Clark, in this area, and I would be delighted to discuss it with him in person if he were able to make the time.

I now want to return to the beginning of the theme and talk about optimism. Uniquely, possibly, in the history of the negotiation of free trade agreements, we start from the position of regulatory equivalence. So we can do harm only by deciding to go our separate ways. I do not believe that there is any desire on behalf of the UK and the EU to do that. There are, of course, lots of questions to be resolved, and they have been highlighted in the debate today. I think they can be resolved if we take a positive view of what can be achieved as we go about honouring the decision of the British people to leave the European Union.

I can assure noble Lords that the Department of Health is working hard with a large range of stakeholders, and indeed with Members of this House, to work through the upcoming changes. We remain committed to ensuring that we have a sustainable NHS, free at the point of use, which continues to deliver high-quality care now and after Brexit.

House adjourned at 6.51 pm.