House of Lords
Thursday 5 July 2018
Prayers—read by the Lord Bishop of Rochester.
Introduction: Lord Garnier
The right honourable Sir Edward Henry Garnier, Knight, QC, having been created Baron Garnier, of Harborough in the County of Leicestershire, was introduced and took the oath, supported by Lord Goodlad and Lord Young of Cookham, and signed an undertaking to abide by the Code of Conduct.
NHS: Equitable Access
My Lords, the NHS was founded on the principle of universal access and we are committed to making sure that that remains. To achieve this we are establishing a genomic medicine service to provide equitable access to testing across the NHS. We have commissioned the Topol review so that our staff can maximise patient benefits from technological advances and we are accelerating access to innovation across the country by expanding the role of academic health science networks.
I thank the Minister for his detailed Answer. My Question concerns the future in the next 70 years. One of the key barriers to ensuring that NHS patients have equitable access to genomic medicine, new drugs and innovative treatment is the pressure on the workforce and lack of protected time for the workforce to develop research and to translate new research into practice. Some 25% of medics do research in their own time. This suggests a welcome hunger for innovation, but only 0.1% of NHS money is set aside for the adoption and spread of innovation. That seems modest. With the new funding agreement and the 10-year plan in preparation, will the Government support and enable our research base and ensure the continuation of clinical trials across the EU post Brexit?
I thank the noble Baroness for her Question and join the whole House in wishing many happy returns to the NHS on its 70th birthday. She asked an extremely good question: how do we make sure that the NHS is equipped for the future and that everybody can benefit from the technological advances we are seeing take place? I point her in the direction of three issues. First, the National Institute for Health Research has more than £1 billion of funding and supports the translation of research into new technology every day. It is based in the NHS and uses NHS staff. I have also recently commissioned the department to look at the money spent on innovation, which we think is around £750 million in total, to make sure that it supports the uptake of effective medicines and treatments better than it does today, and to make sure that staff have time. Finally, in response to her last question, as we set out during the passage of the withdrawal Act, we will align ourselves to the clinical trials regulation as much as possible, whatever the outcome of Brexit.
My Lords, as a member of the Parliament choir I am a bit tempted to start singing, but I will resist. Given the remarkable success of the various vaccination programmes during the 70-year history of the NHS, will the Minister say when preventive measures for two modern-day diseases will be made equitably and nationally available? I refer to pre-exposure prophylaxis for HIV, which has already been shown by the trials to be remarkably effective, and vaccination against human papillomavirus, which should be made available for teenage boys as well as teenage girls to ensure full protection.
I am sorry that the noble Baroness has not started singing; I am sure that we would have all joined in. As she rightly said, the NHS carried out the first major public vaccination programme in the world. We have always led the world in vaccination programmes. As she said, prophylaxis has been deemed to be successful; I will need to write to her on the specifics of the rollout. On the HPV vaccine and its availability for boys, we are still waiting for the final recommendations of the joint committee on vaccinations. We will act on those as soon as we get them.
My Lords, despite starting a chain of karaoke bars, I will also not sing. The noble Baroness, Lady Thornton, is right to talk about the advances but there are also some fundamentals to improving patient care. Two years ago, I made some recommendations to the Secretary of State about basic digital skills for NHS staff and free wi-fi in hospitals, which we decided would be the most important building blocks to dramatically improve things for those working in the NHS and people in the system. Can the Minister update us on the progress of those recommendations?
The noble Baroness made some fantastic recommendations, which we have adopted. I mentioned the Topol review of skills, which will make sure that clinical skills are there to adopt technology. It is expected that all GP practices and secondary care trusts will offer free wi-fi by the end of this year.
My Lords, the Question is on the availability of new drugs equitably across the NHS. Is my noble friend satisfied with the independence of NICE, given that ibrutinib is not available to patients in England after a round of chemotherapy of more than three years, but is available to patients throughout the rest of the United Kingdom?
I am more than satisfied with the independence of NICE. I am grateful to my noble friend for raising this issue, which we have talked about both in and outside the Chamber. NHS England is currently considering further evidence on the prescribing of that drug for that group of patients, after I asked it to do so.
The noble Lord picks a very good example of a technology that is transforming diabetic care, as he knows. A few months ago, I was pleased to be able to approve it for prescription in the NHS; it is now available across the country where clinicians think it is the appropriate course of treatment.
My Lords, the Question also asked about artificial intelligence. Can the Minister comment on the steps being taken to improve data transfer across different NHS trusts, and standardisation? Are steps being taken to ensure the ethical release of data for research purposes?
I thank the right reverend Prelate for asking two very good questions. We recently announced the first local health and care records, covering around 40% of the population. Sometimes, you can pitch up in one part of the NHS and they cannot access all your patient and care data; this measure will make sure that that does not happen. Patients want this; it is essential for good direct care.
The right reverend Prelate is quite right about the ethical considerations. We will publish a code of conduct on the proper use of AI in the NHS later this year. We are working with the new Centre for Data Ethics to make sure that this happens.
My Lords, will the Minister elaborate on how the forthcoming NHS digital innovation hubs, combined with the Data Saves Lives campaign, can deliver a fairer distribution of excellence in the regions with the greatest health and social care needs?
One thing that has become apparent to me in 18 months of being a Minister is that the data in the NHS about patients and their needs, diseases and care is a unique asset. We have to ensure that patients trust the way that the NHS uses that data, which is why we have created things such as the national data opt-out, cybersecurity and so forth. If we can bring that public trust, that data can be used for research through these digital innovation hubs to develop new treatments and make sure that they are available for NHS patients first.
NHS and Social Care Services: Parity of Esteem
To ask Her Majesty’s Government what action they will take to ensure that their strategy for National Health Service and social care services recognises the importance of parity of esteem, including pay and professional standing, for staff across hospital, community and social care settings.
My Lords, having the right number and quality of clinical and non-clinical staff is essential to realising our ambitions for the NHS, community and social care. Last week we agreed an Agenda for Change multi-year pay and contract deal, while the introduction of the national living wage has boosted pay for the social care workforce. Later this year, we will publish a 10-year integrated health and care workforce strategy informed by our recent consultations.
I thank the Minister for his response. It is right today to pay tribute fully to the work and dedication of staff across the whole of health and social care. But for the future, both the NAO and our own Long-term Sustainability of the NHS Committee strongly criticised the absence of any long-term joint strategy to secure the well-trained and committed workforce that we need for a fully integrated service. The Minister told the House on 18 June that he is considering the implications of the very recent and welcome NHS staff three-year pay increase for the independent care sector. He recognised the need for the latter to be able to compete on a “level playing field”. Does he acknowledge that for the social care sector in particular that means aiming to level-up pay and professional standing between social care and the NHS, and accepting that parity of esteem is one of the key drivers to building integrated services for both patients and service users?
I join the noble Baroness in paying tribute to staff, not just across the NHS of course but across all the caring professions. We published the draft strategy and will publish a joint strategy for the health and care workforce precisely for the reasons that she set out. We need to make sure that there is joined-up care across all sectors. That means that we need extra funding—a sustainable funding solution—for the social care sector. We have put in an extra £9 billion over the course of this spending review since 2015 to provide a short-term solution. The Green Paper is about providing a long-term solution. Some of the principles in the Green Paper emphasise the importance of this integration, delivering quality and integration, a valued workforce and sustainable funding. Those are the conditions necessary for what she wants to achieve.
The noble Lord is right to point out that there are differences between the two workforces: clearly the NHS has a largely publicly employed workforce and social care has a largely privately employed one, so there will inevitably be some differences in form. We need to make sure that those workforces work together and are as attractive as one another, which is why finding a sustainable funding solution is so important so that those private contractors have the ability to pay what is necessary to attract the right staff.
My Lords, the NHS proves that, with determined leadership, democracy can deliver long-lasting benefits to society. Will the Minister join me in paying tribute to those parliamentarians—in spite of them all being Labour—who, over 70 years ago, time and again traipsed through the Lobbies to bring about the National Health Service?
Well, they say that success has many parents and we should pay tribute to the Liberal MP William Beveridge, the Conservative Health Minister Henry Willink, and the Labour Health Minister Nye Bevan in the founding of the NHS. It is important to point out that the Conservative Party has been in power for 43 of the NHS’s 70 years and it has thrived under our leadership.
Limiting demand is one of the challenges that we face to make sure that we are able to deliver a health service, but the NHS has proven to be highly effective not just in dealing with acute disease but now in supporting people with chronic disease, which is the greatest health challenge that we face.
My Lords, what advice would the Minister give to the management of organisations throughout the NHS and social care services about maintaining morale, retaining staff, promoting professional development and rewarding good work when there is often little increase in funding from local authorities, which themselves face continuing cuts in their grant from central government?
I recognise that staff work under a great deal of pressure and there are two ways we can help alleviate it. One is obviously to have social care and NHS staff work more closely together, and that is a stated ambition that we all want to achieve. The other is making sure that there are more resources, both to pay people better and to make sure that there are more people. That is what we are focused on delivering.
My Lords, is the Minister concerned to hear that, when speaking recently to a mental health nurse, I was told that she had received only four of her monthly supervision sessions in the last eight months? Does he agree that to ensure high-quality care across health and social care, all professionals and carers need their entitlement of regular supervision? Will he discuss with his colleagues in the education department whether there might be clinical supervision in some schools, to allow the mental health of children in schools to improve?
I am concerned to hear the story that the noble Earl has raised: I am sure that he will write to me with specific details. We know that at the moment only 25% of people with a mental health problem are seen. That needs to rise. We want to get that up to 33%, but clearly that is not enough. To do that we need more staff at every level. We have committed to training another 21,000 mental health workers to provide exactly the kind of leadership and support that he describes.
Is the noble Lord aware that on 4 July 1948, on the eve of the creation of the National Health Service, Aneurin Bevan also said that the NHS was the highest expression of moral leadership? Does he agree that we now need an equally high expression of political moral leadership? The fundamental of that is to tell the truth about the funding challenges facing the NHS, whether they are in manpower or in innovation and drugs. Does he agree, therefore, with the Prime Minister that there will be a Brexit dividend? How much is it going to be and where is it likely to be accounted?
I agree with the noble Baroness about the need for leadership and I think the Prime Minister has shown that leadership. Despite the many challenges that we face at the moment as a country and have done for many years, she has committed to a five-year funding settlement worth more than £20 billion extra in real terms by 2023-24. That is an admission that there are funding challenges, not just in the NHS and social care, and of course one of the ways that that will be funded will be through our not paying subscriptions to the European Union any more.
Health and Social Care Act 2012
To ask Her Majesty’s Government, in the light of the Prime Minister’s criticism of the regulatory framework established under the Health and Social Care Act 2012, what plans they have, if any, to bring forward measures to amend or repeal that Act.
My Lords, the Government have announced a five-year funding settlement, and we have asked the NHS to develop a 10-year plan to transform health and care. As my right honourable friend the Prime Minister said, as it develops its plan we will listen to the NHS about whether there are any barriers created by legislation. We will consider, after that, what changes may be needed.
My Lords, in her speech on 18 June the Prime Minister referred to chief executives of NHS organisations having to make so many reports to different regulators that they have no time to improve their own organisation, and to a typical clinical commissioning group having to agree 200 contracts with other parts of the NHS. Is not the answer to the first question from the noble Lord, Lord Hamilton, that the NHS, employing 1.3 million, is not hard to manage, but the fact is that the Government have bequeathed to it an organisational structure that is dysfunctional and costs billions of pounds? If he really wants to help the NHS, will the Minister not come forward with a Bill to repeal the Health and Care Act 2012?
My Lords, since the 2012 Act was passed, there have been some significant improvements in NHS performance, not least in cancer outcomes, for example. There are also around 42,000 more staff since 2010. So improvements have clearly been able to happen within the legal framework set by Parliament in 2012. Nevertheless, we recognise that as the service is required to become more integrated and people across different care functions are required to work together, we need to look at the structure. There is already joint working, for example, between NHS England and NHS Improvement at the regional level. But if the NHS identifies any barriers, we will look at those.
My Lords, when we are looking at the structure, which is clearly important, can we also look at priorities within the National Health Service? I heard this morning that certain treatments and unnecessary medicines are to be ruled out. Can we have a comprehensive list of those? It is not right that dandruff shampoo should be on prescription. It is not right that we should be looking at funding the treatment of gaming machine addiction. Can we have a real look at the priorities?
My noble friend makes a very important point, which is that as we move ahead, even with the funding settlement, it is essential that the NHS becomes more productive. That means looking at whether there are medicines or treatments that are no longer producing the outcomes it was suggested that they would and taking those out of service. It is very important to state that this has to be a clinically led process. We have already begun that with certain low-value prescriptions. NHS England is now leading that process—as I say, it is clinically led—to look at whether there are other treatments that could be discontinued.
My Lords, have the Government made any estimates of the cost of the extensive and in some cases overintrusive regulatory system? The Minister has rightly said that the Government are looking for savings in the NHS. Surely this is an area where savings can be made, as well as that of questionable surgical procedures.
That is one of the areas we need to look at to make sure that there is proper regulatory reform. It does not necessarily require legislation, primary or secondary. There are actually fewer managers in the NHS today than in 2010. We have tried to transfer responsibility to clinical staff. But if the NHS identifies any barriers, we are committed to looking at them.
I absolutely agree with the noble Baroness that they have to go hand in glove. That is why the Green Paper has been delayed, so that it can co-ordinate properly with the NHS plan. It is also important to point out that the Prime Minister was very clear in her announcement that, as a result of the settlement on social care, there would be no further pressures on the NHS.
As we are looking for savings in the National Health Service, perhaps my noble friend can explain why the National Health Service does not reclaim crutches, Zimmer frames, moon boots, et cetera. Even wheelchairs are found in the attics of deceased former patients. There must be quite a reserve in your Lordships’ attics, which would be very helpful.
I could not possibly comment on the latter point. My noble friend makes an important point. Of course it is right to be judicious with the use of these kinds of products. However, they are sometimes damaged in use and are not always reliable, which is one reason they cannot always be reclaimed and reused.
My Lords, we should first congratulate and celebrate the establishment of the first NHS hospital at Park Hospital, now Trafford General Hospital, in Greater Manchester. But we should also have concern that the devolution deal for health and social care for Greater Manchester is being impeded because of the Health and Social Care Act. What changes would the Minister recommend to ensure that the ambitions of the devolution deal to integrate health and social care and physical and mental health are progressed as rapidly as possible?
I join the noble Lord in congratulating Trafford General Hospital. I think that one of my colleagues is there today, unveiling a plaque. I am grateful to him also for raising the devo deal for Greater Manchester. It is a very important deal that goes further than any other in the area of health and social care. If it is the case that it is impeded by the Act—and I do not think that that is necessarily a given—I would say that the changes that need to be made ought to be promoted and proposed by Greater Manchester and by the clinicians themselves. That is exactly the sort of thing that the Prime Minister has asked for.
My Lords, perhaps I may pursue the question asked by the noble Baroness, Lady Blackstone, to which the Minister responded, “Yes, we need to look at regulation”. The Minister knows that GPs are leaving the service at an unprecedented rate, and a large part of the reason for that is the regulatory burden. Will he make a commitment to undertake a full investigation of the regulatory burden on NHS staff, with the terms of reference being to reduce that burden?
I agree with the noble Baroness about the importance of bolstering our GP workforce—that is one thing we are absolutely focused on. It is part of the five-year forward view and clearly of the long-term plan as well. I will identify one area where we are trying to make a big difference, which is indemnity insurance. We know that this has been a financial burden on GPs and we are looking at creating a state-funded scheme to provide reassurance. This is just one way in which GPs are looking for support from government.
NHS: Brexit-related Risks
To ask Her Majesty’s Government what assessment they have made of (1) the risks to the National Health Service, and (2) the implications for access to medical supplies, of the United Kingdom leaving the European Union without a withdrawal agreement.
My Lords, patient safety is our priority in the exit negotiations, and maintaining continuity of supply of medical products is a key part of ensuring that patients continue to receive safe, high-quality care from day one after we leave the European Union. Extensive work has been undertaken to understand the implications of our EU exit on the NHS, considering a range of negotiation outcomes, including exit without a withdrawal agreement. This has included a focus on continued access to medical supplies.
My Lords, I congratulate the noble Lord on his stamina this morning—more Fleetwood Mac than Iron Maiden. Given that the Government seem a long way off getting any sort of Brexit deal on goods and services, will the Minister tell the House whether there is a plan B to ensure that the NHS has continuity of medical supplies, and will he explain how he expects the interface of the medicines approval regime and the international regulation of medicines to work post Brexit? Will he also guarantee comparable levels of patient safety after we leave the EU?
I am glad that the noble Lord’s train got him here in time for him to ask his Question. First, I do not share his pessimism about the outcome. We will publish the White Paper on our proposals next week and we expect it to get a warm welcome—and not just in this House. Nevertheless, it would be wrong if we were not working on contingency options. I think that the public would be surprised if we were not planning for every scenario. That is precisely what we are doing at the moment, and of course, as we do that, patient safety is our number one priority. We need to make sure that the supply of medicines and medical devices can come in to the country and be used by NHS patients, come what may.
My Lords, I declare an interest as the son of an ambulance driver who drove ambulances for the NHS for nearly half of its existence. Some 45 million packs of patients’ medicines are exported from the UK every year, and 37 million are imported into the UK every month. Merck, GSK and AstraZeneca have all forecast that if we leave the customs union, it could take five to 10 years for any technological solutions to replace the system we have at the moment. They are now considering stockpiling, given the levels of extra documentation and checks that will be required. This will place an increased burden on the NHS. Would not the best thing for the NHS be if the Cabinet tomorrow agreed that we will continue as part of the European Medicines Agency and the customs union? Given that the Minister has been on his feet so much this morning, the simple answer “yes” will suffice.
My Lords, I am glad that contingency plans are being made. The British public voted to leave the EU because of the promise of £350 million a week to save our NHS. We now hear, however, that Brexit could have catastrophic consequences for the NHS in areas such as staff recruitment and essential supplies and for the adequate resourcing of the NHS to the standard of our EU partners—a standard that we do not yet reach. Will the Minister admit that these promises were wrong and tell the British people that we may need to think again?
It would be a big mistake for anybody to tell the British people that they voted the wrong way. I point out to the noble Baroness, however, that, whatever was on any side of the bus, as a result of the funding plan announced by the Prime Minister there will be £394 million a week more in real terms for the NHS by 2024. I am also pleased to say that there are more EU staff working in the NHS today than two years ago.
My Lords, the problems and challenges of Brexit will only add to the massive challenges which, in our enthusiasm for the birthday of the NHS, we sometimes underestimate. These include demographic change, an ageing population, new inventions and therapies, new pharmaceutical products and so on. Although I very much welcome extra money, this problem will not be solved just by extra money; it will require massive organisation, radical restructuring, and innovation in technology on a massive scale. That will not be achieved by one party on its own. Why, therefore, do the Government constantly refuse the recommendations of some noble Lords and committees in this House to establish a cross-party consensus on this and take party politics out of it to the maximum extent? That is the only way—accompanied by money—that we can save the NHS for the next 70 years.
The noble Lord knows better than most the challenges of transforming the National Health Service, and is right about the big challenges that we face—although I think it is better to look at them as opportunities. He is also right that reform has to go hand in hand with extra money. We promised the extra money; we now need to see the reform. Every part of the health service—the department, the NHS, and others—needs to drive that through. On his point about consensus, I do not think there is anything stopping that consensus: the Government want consensus. We do not necessarily think that it needs to be in the form of a royal commission or a parliamentary commission. We want to work with all corners of this House and the other place to make sure that there is support for a broad plan for the NHS for the next 10 years.
Clean Air (Human Rights) Bill [HL]
A Bill to establish the right to breathe clean air; to require the Secretary of State to achieve and maintain clean air in England and Wales; to involve Public Health England in setting and reviewing pollutants and their limits; to enhance the powers, duties and functions of the Environment Agency, the Committee on Climate Change, local authorities (including port authorities), the Civil Aviation Authority, Highways England, Historic England and Natural England in relation to air pollution; to establish a Citizens’ Commission for Clean Air with powers to institute or intervene in legal proceedings; to require the Secretary of State and the relevant national authorities to apply environmental principles in carrying out their duties under this Act and the clean air enactments; and for connected purposes.
The Bill was introduced by Baroness Jones of Moulsecoomb, read a first time and ordered to be printed.
Supply and Appropriation (Main Estimates) (No.2) Bill
The Bill was brought from the Commons, endorsed as a money Bill, and read a first time.
The Bill was brought from the Commons, read a first time and ordered to be printed.
Business of the House
Timing of Debates
My Lords, with the leave of the House, I shall repeat as a Statement an Answer given to an Urgent Question in another place by my right honourable friend the Secretary of State for Work and Pensions on the National Audit Office report.
“I had information on the Question being the letter I received yesterday, so that is obviously where we will be going on the letter that I received yesterday. Opening up on that letter was about a meeting that the Comptroller and Auditor-General had asked to have with me on 27 June, when he wrote, and our department got back at the end of the week. That meeting will be on Monday. There was possibly an inference from that that I had not accepted the meeting, or that there was not going to be one, but that had not been the case and it is diarised for Monday.
The next bit was about the information we received and accurate, up-to-date information being shared with the department, to which we agreed information had been shared up to 6 June. But what we talked about is when we signed off the factual information contained within it, raising the concern about the context and the conclusions drawn from that information and where we went from there. That goes on to the impact of those changes and if we look at the impact of those that were brought through—the waiting days being abolished on 14 February, the housing benefit being run on 11 April and the advance payment of 3 January—as I said in my apology yesterday, the impact of those changes is still being felt. Therefore the definition could not or cannot be that they have been fully taken into account by the NAO.
The Auditor-General also talked about slowing down the process, which we always agreed with, which is about the test-and-learn process. We will learn as we go along; that is what we agree with, too. But when he said,
‘I am also afraid that your statement in response to my report … has not been proven’—
the case for universal credit—that is where we differ in the conclusions. So while the NAO had the same factual information either way, depending on where you looked at it and how you then come to conclusions, we then came to very different conclusions because of the impact of those changes that we had brought in at the end of that period, which are still being felt.
That is where I would like to leave it. It said that you cannot measure the exact number of additional people in employment—we will agree with that. You cannot measure the exact number of additional people but we knew there was a plausible range which we had support on. There is a plausible range of people going into employment and we know that employment is increasing. Those are the key pertinent points from the letter and included with my apology yesterday for the phrasing of the words that I got wrong, which I fully accept, hence I came to the House. I will end that bit of the Statement there”.
My Lords, I thank the Minister for repeating that deeply unsatisfactory Statement. This is quite extraordinary. The Comptroller and Auditor-General has been forced to issue an open letter to the Secretary of State for Work and Pensions to point out that she repeatedly misrepresented to Parliament the content of the highly critical NAO report on the rollout of universal credit. She has now apologised, up to a point, for one of the errors, in which she wrongly claimed that the NAO wanted UC rolled out more quickly.
However, Sir Amyas challenged two other misleading claims for which she has not apologised. The Secretary of State claimed that the NAO report had not taken account of the impact of recent changes to universal credit, even though her department had agreed the report just one week earlier, based on the latest information, and she repeated her unfounded claim that universal credit is working. Sir Amyas pointed out that the DWP has not even measured how many UC claimants are facing difficulties and hardship. I was particularly disappointed to see her repeat the claim that universal credit will help an extra 200,000 people into work, even though the NAO said:
“The Department will never be able to measure whether Universal Credit actually leads to 200,000 more people in work”,
because it is not able to separate other factors.
Anyone can misspeak—goodness knows, I have done it myself—but if the NAO says there is not and never can be evidence for a claim, you cannot simply say that it is a matter of interpretation. This is dangerous ground. The Secretary of State is entitled to her own opinion; she is not entitled to her own facts. The Government have told this House too many times that all is well with universal credit when manifestly that is not the case, so I have just two questions for the Minister. First, will the Government stop pretending that all is well and will they, in particular, stop using the misleading 200,000 figure and start telling the House how things really are? Secondly, will they implement all the recommendations in the NAO report? The DWP needs to put things right before anybody else is put through the misery of universal credit.
My Lords, first, I make it absolutely clear to your Lordships’ House that right from the start, when the report was published, there has been no issue with the factual information that the National Audit Office has used. In collating that information, there has been and continues to be a strong relationship between the National Audit Office, the Department for Work and Pensions and the officials. That is important. It is the interpretation of these facts and the conclusions drawn as a result that the department questions, as I said in the Statement. A lot of it is about context rather than saying that there is any issue with the facts.
We are absolutely clear that, as the report says, the National Audit Office completed its independent review of the universal credit programme after analysing evidence that we collected between August 2017 and April 2018. The issue we have is that we are still not able to judge, and nor is anyone, the full impact of significant policy changes that we have announced and implemented since the Budget last autumn. They include extending advances, which was implemented in January 2018, removing waiting days in February 2018 and the housing benefit run-on. The report makes it clear that it is referencing evidence up to April 2018. On the housing benefit run-on, it was impossible for us to measure the extra two weeks’ additional cash to cover people transferring from the old legacy benefit on to universal credit, which they would not have to repay. Each of these measures will take time to impact on the experience of claimants and stakeholders. Although some of these measures were mentioned in the report, their impact would not have been felt during the evidence-gathering period.
My Lords, I am absolutely in agreement with the noble Baroness, Lady Sherlock. This is a quite extraordinary state of affairs. I have been following social security since 1986. I have never seen such an explicit letter of correction from such a distinguished public servant as the Comptroller and Auditor-General, Sir Amyas Morse. Two things follow from it. First, I hope the noble Baroness can give the House an assurance that the Secretary of State will take whatever steps are necessary to repair the relationship between the political leadership of the DWP and the Comptroller and Auditor-General’s office. That is essential for the good conduct of the universal credit programme in future, and that work needs to be done.
What I find extraordinary, because I know how much trouble goes into negotiating reports—and this one was signed off on 8 June—is that if the Secretary of State is founding her defence on the fact that she does not think that the NAO knows about the recent changes to waiting days, advance payments and HP run-ons, she is demeaning the value of the historical analysis that is so valuable to the prosecution of public policy. That must be put right too. This is serious territory that needs to be addressed urgently.
My Lords, it is important for me to make clear that my right honourable friend the Secretary of State for Work and Pensions has already apologised, and that apology has been accepted by the House of Commons and the Speaker of the House of Commons. Following Oral Questions on Monday, my right honourable friend was afraid that she had mistakenly used a term that was not an accurate term reflected in the report. My right honourable friend therefore went to see the Speaker. This was entirely independent of the letter produced on Wednesday, so there is no question that my right honourable friend has tried to avoid, evade or do anything untoward. My right honourable friend was very clear that she was mistaken, she was wrong and she was very keen to put that right at the earliest opportunity. Hence, the Speaker accepted that apology yesterday.
The meeting on Monday will of course be extremely important. We accept the facts in the report. We do not deny the facts; we support the facts. In a sense, we are saying, “Please, please, National Audit Office, we want to demonstrate that the impact of the changes undertaken, particularly those made last autumn, is yet to be proven”. She will want to make that absolutely clear.
There is no question but that we will look with care at what has been said in the report. I am sure that we will implement those recommendations that we feel able to from the report.
My Lords, I do not think the House can ever have heard a less clear Statement than the one repeated today. I appeal to my noble friend to ask the Secretary of State—although I am not impugning her good faith in any way—to realise that it is important that when she communicates with either House of Parliament, directly or through another Minister, she does so with clarity and in plain English. Perhaps it would be a good idea if Sir Ernest Gowers’s book on plain English was circulated to all Ministers and civil servants before we have that gobbledegook reported from the Dispatch Box ever again.
I say to my noble friend that, given his extensive years in another place, he will appreciate that the job my right honourable friend is doing is very tough. She is involved with the most important, fundamental and huge piece of welfare reform that has taken place for many years. It is close to her heart, as it is to all of us in the department. We absolutely accept that it is important that we reflect the need to be agile. Indeed, one of the incredibly positive aspects of the NAO’s report is on page 15, which is all about the development of the full-service system. It talks about the department using an agile approach for the full service and the need to constantly test and learn, test and learn. We are doing this continuously.
I am sorry if my noble friend feels that my right honourable friend has been less than clear, but the reality is that we are very keen to explain to all noble Lords and Members of another place that what we are doing is the right thing. We just want to stress that it is important to reflect the impact of changes that are still coming through the system.
Part-time and Continuing Education and the Open University
Motion to Take Note
My Lords, I am pleased to rise to open this debate. Right now, in Westminster Abbey, a service is being held to mark the 70th anniversary of the NHS, an institution created under the outstanding post-war Labour Government of Clement Attlee. I am delighted to introduce a debate on another Labour achievement: the Open University, founded in the 1960s by the then Education Minister Jennie Lee— incidentally, the wife of Aneurin Bevan, creator of the NHS. The OU’s purpose was to promote greater equality of opportunity and widen access to the highest standards of education, endorsing those same values of civic life and mutual responsibility as the NHS. Like the NHS, cherished as it is, the OU also has current problems that threaten its survival. Next year it will be 50 years old.
In 2023, five years from now, another educational institution will celebrate its bicentenary. Birkbeck, of which I am proud to be president, was created in 1823 when philanthropist George Birkbeck pioneered a pattern of education by which working men—and it was working men in those days—could study while also earning a living. It was a system of part-time study that would lead to degree qualifications. To this day, it shares with the OU a commitment to part-time education, tutor-marked coursework and extended study that leads to full university degrees of international standing. There are of course other universities across the country that provide mature and lifelong learning as part of their student offer; several have over 30% of their students studying part-time. They too recognise the direction that future education provision should take and are keen to see it thrive. They too are confronted by problems. I would not trouble noble Lords with a history lesson that had no significance for today. I raise this debate because the needs are pressing, the system is in crisis and the Government have now the chance to address this in its policy review.
First then, are the needs. As a member of the Lords Select Committee on Artificial Intelligence, I was made keenly aware of how much change to the labour market lies ahead. Many existing jobs will go, many jobs will be enhanced by AI and many new, as yet unknown jobs will be created. The one constant is change—ongoing change to the labour market and to the lives of individuals. The Government will need to plan for the negative effects of AI, and to plan to maximise benefits from it. New skills will be needed; retraining will become the norm; and individuals will need to expect shifting patterns of employment, portfolio careers and mid-life career changes. Retraining, as the Select Committee emphasised in its report, will become a lifelong necessity. The Government agree: at the inaugural meeting of the National Retraining Scheme, earlier this year, the Education Secretary, Damian Hinds, declared that,
“we need everyone, regardless of their age, to be able to gain the skills they need to make the most of the opportunities that lie ahead”.
Such ideas are endorsed on every hand from every discipline. Sarah Harper, professor of gerontology at Oxford University, in evidence to the House of Lords Select Committee on Intergenerational Fairness and Provision, declared that, with longer life expectancy, there is a need for longer working lives that has to be supported by a move to lifetime education.
Thus, we have the state affairs and the need. Now the crisis, for crisis there surely is: a catastrophic fall in numbers of part-time and mature students. The OU has been hit especially hard, its numbers falling by 30% between 2010-11 and 2015-16. Numbers at Birkbeck have suffered too. The numbers for part-time study are falling everywhere. Social mobility has crashed. The decline in mature students has disproportionately hit certain important courses. Between 2009-10 and 2016-17 the number of part-time mature nursing students fell by 49%.
Institutions have been tracking the reasons and it is quite clear that this steep decline was triggered when the Government raised the cap on part-time fees to £6,750 a year. Their effort to address the crisis by improving financial support for some part-time students through the introduction of maintenance loans has not gone nearly far enough. Restrictions on maintenance loans to certain subjects—the STEM subjects—leaves the humanities beleaguered.
Government policy increasingly sees higher education as a marketplace where students shop for qualifications rather than as centres of learning, broadening student horizons across the whole range of human knowledge. Into this marketplace have come new for-profit universities, some only recently granted degree-giving powers. They offer students long-distance learning towards degrees in the most popular subjects. The insights of face-to-face learning are undervalued and under threat.
Other considerations also explain the collapse. There is no longer a pool of young people denied tertiary education: sixth-form take-up of university places is at an all-time high. Then there is austerity. Mature part-time students faced with the continuing levels of austerity have become debt averse. Many have mortgages to pay and young family commitments. With such responsibilities, taking on further loans is a push too far.
That the Government are aware of all that is evident in their establishment of a post-18 review, which we all welcome. It has now completed its consultations and is expected to report later this year. This is a major opportunity and one that must not be missed. The Higher Education and Research Act and the creation of the Office for Students have ushered in a new era. A Lords amendment to that legislation established that the Office for Students has a specific legal duty to consider different forms of learning, including part-time study and distance learning. It must now deliver on that commitment. I ask the Minister to ensure that the post-18 review addresses a major review of student finance and that it considers different policy responses for different types of students. It must reappraise the availability of maintenance grants and the restrictions on maintenance loans, and it must further relax restrictions on equivalent or lower qualifications, ELQs. I ask, above all, that it prioritises mature students and lifelong learning—
I am listening very carefully to the noble Baroness’s speech and I agree with much of it, but she has been quite partisan in her comments. Will she acknowledge that the ELQ rule was brought in by a Labour Government and that it has been a major factor in the decline of part-time education?
I think that it is a contributory factor. I certainly do not deny it being brought in but I am constantly interested in revising the existing situation to make it better. That is why I raised it.
Above all, the Government should prioritise mature students and lifelong learning as the key to the country’s economic future and continuing prosperity. The needs are critical but the means are there. I am delighted to see so many speakers of experience and authority in this debate, and I am glad that they are here, even though the time for the debate has been cut short. I urge the Government to rescue a sector of education that has served, and continues to serve, students of all ages and backgrounds. I beg to move.
My Lords, the whole House should be grateful to the noble Baroness, Lady Bakewell, for initiating this debate. I declare an interest in that my wife, who was born and educated in Canada and who never went to university, has recently started an Open University undergraduate course in history and history of art. I am already impressed with the variety of essay subjects she has had to cover, from Antony and Cleopatra to Stalin and Khrushchev, religious dissent in the 18th century, the art of Benin, and colonial attitudes to African societies. I am also impressed by the attention to detail in the marking of her essays.
I asked my wife to obtain her tutor’s views on the state of the OU and she replied as follows, giving me permission to quote her views. The most important point she made was that after the vice-chancellor, Peter Horrocks, resigned,
“the first thing the acting vice-chancellor did was scrap the ‘Students First’ brand which just about everyone working for the OU found to be toxic. It implied we had previously been putting something else first, and many, including me, found this to be an insult”.
Her final comment was:
“Most of my colleagues have felt so impotent having to stand by and watch whilst the OU has been forced into some kind of weird and inappropriate business model”.
I refer now to the petition organised by Change.org to give an indication of the concerns about the previous vice-chancellor. The petition states:
“The detrimental changes that have occurred include tutorial system changes, meaning that many students are allocated a tutor with whom they couldn’t possibly attend a tutorial”—
due to geographical location—
“and therefore have to attend a tutorial with another tutor; often leading to confusion on assessment criteria. Furthermore, the Open University has continued to alter the way they present their modules, moving away from print books towards online material. This is despite many students voicing their preference of print books to work with”.
A final issue were his comments,
“claiming that Open University academics ‘don’t teach’. The blatant disregard for the work and effort put in by OU academics leads to the final conclusion by many that Peter Horrocks needs to be replaced as Vice-Chancellor in order to save the Open University from irrelevance”.
In the time available, I want to make a very few points. The number of part-time entrants to higher education across the UK has fallen by 47.5% since 2008-09, with all types of course affected. The most striking fall was in those enrolling in foundation courses, certificates and diplomas. A 2014 report said that,
“falls in employment – particularly in the public sector”,
have been a major contributing factor.
My Lords, I begin by reinforcing what my noble friend Lady Bakewell said on the principle of lifelong learning. I have little doubt that all speakers in this debate will accept this principle. It is of course absurd to think that we have finished learning at the age of 21 or 22. We need to continue learning throughout our lives and to be helped to do so by access to education and training. Therefore, we need to invest in adults, not just young people, studying in universities and colleges. This is necessary first to enhance skills and knowledge and, secondly, to provide social justice and create social mobility.
At the higher education level, there are two institutions that focus on part-time undergraduate courses: Birkbeck and the Open University. I was privileged to be the head of Birkbeck for 10 years. What motivated me most was the commitment, determination and enthusiasm of its students studying in the evening, coping with families and jobs, and making sacrifices to achieve their educational goals. Those who have worked at the OU will have had similar experiences. Both institutions have been threatened by the collapse in part-time student numbers. Birkbeck has been forced, for the first time, to admit full-time undergraduates, and the OU has had to slash its courses and sack staff. Birkbeck will soon celebrate its 200th anniversary and the OU its 50th. We should do all we can to ensure that their special remit continues and that their celebrations are real.
Many other universities offer part-time undergraduate provision, especially post-1992 institutions. Sadly, many research universities have done too little for part-timers. FE colleges, however, have made a considerable impact in supporting them. Too often their contribution is forgotten, and the Government have not provided them with the resources that they need. Perhaps the Minister will say why.
The main cause of the collapse in part-time numbers is the foolish decision by the coalition Government to treble tuition fees. Of course, they probably needed to go up—but to treble them in one go! As my noble friend has already said, part-time mature students with mortgages and families are both debt adverse and price conscious. They have opted out because they will not take the risk of more debt. I applaud the noble Lord, Lord Willetts, the Minister who was responsible, for now expressing his regret, but I am puzzled that he did not see it at the time.
Will the Government make three specific changes? Will they provide a part-time premium to universities and colleges to promote the supply of part-time courses? Will they stop relying on their solution of maintenance loans for part-time students? Few of them will take them up, since the effect will be simply to increase their debt further. Thirdly, will they reduce the level of fees for part-time courses in line with any premium provided for universities, so that part-time students are not burdened by such harsh loans?
Lastly, will the Government remember that many part-time mature students are from disadvantaged backgrounds? If they are serious about promoting social mobility and genuine in this aim, they should urgently address this problem.
My Lords, I join in thanking the noble Baroness, Lady Bakewell, for introducing this debate. She is a great champion of part-time and adult education, which is an enthusiasm I share—as, indeed, we share concerns over the Open University. I wafted from school to university and sort of worked for three years to get my degree. My sister did an OU degree while working full-time. Her commitment, dedication and hard work makes her degree a far greater achievement than mine ever was.
The OU was a visionary initiative when it was founded in 1969, and has been transformational for so very many people. It has opened horizons and opportunities to those enthusiastic to learn, many of whom missed out on education the first time round, and many, as we have heard, from disadvantaged backgrounds. Yet we have seen a catastrophic drop in numbers in recent years.
I was invited a while back to an OU degree ceremony at the Barbican, where Joan Armatrading was being awarded an honorary degree. In her speech, this internationally renowned singer and musician said that her greatest achievement was her OU degree. She was on world tours, before the days of internet or email, and in each country would have to find a post office and the last posting date for her assignments to get them back to the UK to be marked. What energy, what dedication, and how well deserved her results.
The ceremony had hundreds of people—some quite young and some very old. One woman must have been at least nine months pregnant, and there were members of the military in uniform—a total mix, all of them brimming with a well-earned sense of achievement. Celebrating such success was exhilarating. It is seriously bad news that the numbers have dropped.
Similar work is undertaken by Birkbeck. I declare an interest as a newly appointed fellow of the college, a great honour from an institution which I have long held in very high regard. Since 1823, it has championed the importance of educating the working people of London, with its evening teaching enabling people to work and study, as does the OU, and through study to aim high and to be ambitious in their life goals. This is good for social mobility and good for the economy. Yet Birkbeck, too, has seen a fall in its numbers.
How can the Government justify policies which result in such worthwhile institutions finding their numbers so reduced? We know that further education colleges are critical to continuing education, yet they, too, are suffering from loss of funding, a reduction in students able to self-fund and reduction in the number of employers willing to support employees through part-time study.
When will the Government release colleges from the tortuous and pointless demands of GCSE maths and English resits? This does nothing but entrench a sense of failure for young people who may have great practical talents where these GCSEs will be entirely irrelevant. Can the Minister reassure us that the Government are rethinking their damaging obsession with these academic subjects? If colleges could spend precious time and resources instead on adult and continuing education, it would make a significant and worthwhile contribution to society and the economy. I hope the Minister can reassure us that the Government are not only listening but acting to support part-time learners, whose skills are essential to the workforce.
I end by looking forward to the maiden speech of the next speaker.
My Lords, it is with considerable surprise that I find myself here today making my maiden speech in your Lordships’ House—you will appreciate that I will have to be brief. I have received nothing but kindness and encouragement since I arrived. The staff in Black Rod’s office, and Black Rod herself, are so helpful, as are the doorkeepers and all the staff and Members who have helped me feel so much at ease. I owe particular thanks to my supporters, my noble friends Lady Hayter and Lady Chakrabarti, who both gave me moral support at my introduction but were also ready to catch me if I keeled over.
In my early political life, I was a member of the Independent Labour Party, so I cannot help but reflect on the ILP members who graced this place: Fenner Brockway, Neil Carmichael, Barbara Castle and, of course, Jennie Lee. Jennie Lee understood the value of education. She came from a mining village in Fife and, unusually for a working-class woman, gained a university degree. She was the first woman to be elected as a Labour MP in Scotland. She was only 24, but had 10 years of campaigning and public speaking experience. A maiden speech held no terrors for her—lucky woman. Many decades later, Harold Wilson gave her responsibility for establishing a University of the Air. She felt that adult education should be more than,
“dowdy and mouldy … old-fashioned night schools and … hard benches”.—[Official Report, Commons, 2/4/1965; col. 2062.]
She wanted a university to match the best available anywhere.
As an Open University graduate, I have a first-hand appreciation of the high standard of its courses. The downside when I was a student was that the courses ran right through the summer. Fellow students could easily spot one another at airports or on beaches because of the heavy course books that never left their side.
I know that in recent years lecturer contact with students has been reduced and that the OU has closed most of its regional offices, but worse could still be to come. Its lecturers say that the latest round of cuts will,
“destroy the OU as we know it”,
by reducing it simply to “a digital content provider”. Instead of being part of a learning community, students will be dependent on “virtual” support from staff and fellow students. There will be only limited opportunities for face-to-face contact and working in collaboration with fellow students.
For many students, the OU is the only realistic way to access higher education, but, as with other higher education institutions, the cost creates a barrier. The OU has a better record than most in reaching disadvantaged students, but the cost can still be prohibitive.
When I was an OU student in Scotland more than 25 years ago, I studied the same courses as students in the rest of the UK and, significantly, paid the same fees. Now, an OU student in Scotland pays only one-third of what a student from the rest of the UK has to pay.
Being able to offer people a second chance for learning or to take part in lifelong learning should be valued in every part of the UK. We should pool our resources to make sure that the Open University lives up to its aims, which were described by Jennie Lee as being,
“a great independent university which does not insult any man or any women whatever their background by offering them the second best, nothing but the best is good enough”.
My Lords, it is a great pleasure to follow the noble Baroness, Lady Bryan of Partick, who also hails from my home city. It is wonderful to see her here joining us in this House. I welcome her, as do all our colleagues. It is clear from what she has said that her experience will be invaluable to this House. She has a well-documented commitment to social justice. I should let your Lordships know that she edited a book, What Would Keir Hardie Say? I have no doubt that, in the months and years to come, she will tell us what Keir Hardie would say about the state of our world at the moment.
I want also to congratulate my noble friend Lady Bakewell on bringing this debate before the House, but I am sorry that we have so little time to speak. I agree with her about celebrating the Open University and in expressing regret about what is currently happening. Education is a social good as well as a good for the individual. It hugely benefits society as a whole to have a well-educated and well-trained populace, and learning is central to our economic success and social cohesion. It is particularly important just now as we address national skills shortages and the challenges of a changed world of work, an environment in which there is huge technological change.
Those who are disadvantaged educationally are also disadvantaged economically and socially. We have to place learning at the heart of a national common purpose and draw into learning and training those who missed out the first time round and have come late to the party, but who want a change of direction. Turning education into a commodity has not served our nation well, but I am afraid that that is what is happening. Turning universities, colleges of further education and the Open University into businesses is not appropriate. While all of these institutions absolutely should be business-like in the way they work, they should not operate as business models, as they are currently being asked to do.
Large numbers of young people still leave school and begin adult life in need of compensatory education. School does not work for many people for reasons that are often related to their family circumstances, but sometimes it is because they have breathed in a sense of failure at an early stage in their lives and they do not go on to do what they could do. We see a great deal of thwarted potential in our society. However, a moment will come for someone in their late 20s, 30s or sometimes their 40s when they want a second chance. I have seen this because my name is borne by a small foundation that gives bursaries to people in this category. They know about real hardship. The financial model and the insistence on paying for everything is now putting them off and it is the reason we are seeing such a drop in the number of people taking up those second chances. I could tell noble Lords many stories of triumph over adversity, but we have not got the funding right.
I want to make two brief points. The Open University was a visionary initiative and what we need now is a new vision. I suggest that we draw on lottery funds that were put to one side for the millennium projects in order to create a “learning nation fund”. We should create a learning regeneration fund to go to the parts of the country where there are no opportunities but there has been great neglect. In that way, people would be given those second chances. We should also create more pathways from further education into higher education, thus giving people the know-how for their lives. Let us celebrate continuing education and the institutions that deliver it, in particular the Open University, Birkbeck and many others. I am about to become the chancellor of Sheffield Hallam University, which does this work very well. These institutions are part of the lifeblood of our nation. Let us seize the chance provided by the policy review to revitalise these educational opportunities.
My Lords, I declare not only an interest in but a deep love for the Open University as I am proud to serve as its chancellor. I also thank the noble Baroness, Lady Bakewell. I am sure that she will hate me for saying this, but it seems appropriate that on the day that we are celebrating the NHS and the Open University, we can also honour her as a great national asset.
As many other speakers have said, the Open University is an extraordinary and important institution which we must all continue to support. It is the only university in the world where access is open to anyone, whatever their background and previous educational record. Some 24,000 of the Open University’s 174,000 current students are disabled, more than many universities have in their sum total. The Open University has deep links with military personnel and veterans, providing programmes to help them back into education. Moreover, it has had extraordinary success with prisoners and is the only official academic institution working to help them get back into education. These are all fundamental tools for social mobility.
Unknown by many people, the average age of an Open University student is 28, and over 75% of our students are in work. As I say at our degree ceremonies, just after I have made the students do a Mexican wave—noble Lords should not worry; I am not going to attempt to do that now—the OU is not part-time learning, it is double-time learning. These are people who have put education above many priorities in what are often already stressed and complicated lives. You need only look at their faces as they walk across the stage to collect their degrees and you will see the emotion, the relief and the dedication in them. I am not a person who is drawn to tears easily, but I find myself fighting them back, often unsuccessfully, as I see the incredible dedication of the learners at our university.
As has been stated, this has not been an easy time for the university. The macroclimate, the funding situation and the decline in part-time learners have to a degree been compounded by some of the internal challenges. It is not my role as chancellor to behave like an executive. I simply stress to noble Lords and the wider communities beyond that the Open University is still an innovative place and still has a bold vision for the future. Next year is our 50th year, as the noble Baroness, Lady Bakewell, alluded to, and there will be some extraordinary and interesting things happening. But we do need to rebase the university for the modern age. No one believes that it should be a digital-only university; everyone believes in the power of the combined ways of learning. But we also have to be realistic that this is 2018, not 1968. Things need to be and to feel different. I am a firm believer that we need to build wider partnerships into different communities, with employers and with government, with the skills we need to build a modern and resilient society.
It is an irony—more than an irony, a tragedy—that at a time when, more than ever, we need continued learning as part of our culture, there has been such a dramatic fall in part-time learning. As the noble Baroness, Lady Bryan, who I welcome to the House, said in her brilliant maiden speech, Jennie Lee, who is such an inspiration—I wish I could have met her—said in 1973, “We cannot strive for anything other than the best for people, whatever their background”. I will do my absolute best to ensure that the Open University is fit for purpose for the future. I thank noble Lords for their support, but that is not enough. We need government support as well. I ask the Minister: what is the cohesive plan for part-time and continued learning? What signposts will learners have to understand the options open to them? What funding support do the Government plan on giving?
My Lords, it is an absolute scandal that we have only three minutes to talk on this very important subject. I am very grateful to the noble Baroness, who introduced this debate so brilliantly, for taking only 10 minutes, which perhaps gives us a little leeway.
If the last coalition Government and the previous Labour Government had set out deliberately to destroy part-time education, they could not have been more successful than they have been. Of course, that is not the case: it is the unintended consequence of two reforms. One, which the noble Baroness, Lady Bakewell, mentioned in her speech and to which the noble Baroness, Lady Kennedy, also referred, was the decision to triple tuition fees and create a funnel that is driving people into doing traditional three-year degrees, as opposed to other forms of higher education.
In part-time education, the results have been absolutely catastrophic. I hope that we will have more time to debate this when we debate the report of the Economic Affairs Committee, which I have the privilege of chairing, which, in chapter 5, deals with many of these issues. I am very much in agreement with what the noble Baroness, Lady Bakewell, had to say. From 2010 to 2016, the Open University saw an 80% fall in sub-degree level qualifications. There has been a 60% fall in part-time education over that period. At Birkbeck, which the noble Baroness knows so much about, the figures are astonishing: a 64% fall in people doing part-time degrees and a 68% fall in sub-degrees.
Then there is the decision to bring in the ELQ rule, which says that students get no support, including tuition fees and maintenance loans, for qualifications that are equivalent or lower than they once held. How on earth are they meant to retrain or advance if that is the position? Indeed, before the rule was implemented by the previous Labour Government, 90% of those people were part-time students. Why are we surprised that the number of part-time students has fallen? For as long as I have been involved, the rhetoric of successive Governments has said that we need to increase our skills and people’s ability to retrain and to have lifelong learning, yet the financial policies and systemic structure are driving things in exactly the opposite direction.
Why has Birkbeck seen such a catastrophic reduction? Fifty per cent of its students were ELQ students; now it is 5%. Of course, they now have to find the fees and because the fees are higher, costs have gone up. Therefore, the burden on people who have to look after their families—and all the other pressures on people at present—is even greater. Even if they can get a loan because of the government changes in respect of STEM subjects, which benefit a few hundred people, they have to pay it back before they complete their course because part-time courses take longer than four or five years, as a rule.
It is not only the funding of students that is responsible for the decline. If institutions find that no students are coming, they do not run the courses. We have seen a catastrophic fall in the number not only of students but of opportunities, because the funding is not there. We need a radical change and we need to acknowledge that mistakes have been made. Funding is key to this. Why was it changed? George Osborne worked out that making the money follow the student—who would be largely dependent on tuition fees—would result in no increase in the public sector deficit. Instead, it will be met 30 years down the line when the bill will be £1.2 trillion. We have to be realistic about the true cost of higher education and we need urgent reform. I commend the noble Baroness, Lady Bakewell, for introducing the debate, albeit that there is little time to discuss it.
My Lords, it is always nice to follow the noble Lord, Lord Forsyth, especially on the rare occasions when we speak on the same side of the argument. It is a particular delight to follow my noble friend Lady Bakewell in bringing this important subject before the House.
Higher education is a devolved area. The Welsh Government have been active on this subject and may have some light to throw on the situation we are discussing today. They are introducing a new student support package, the only such system in the United Kingdom, to offer parity of support for full-time and part-time students alike. New part-time students starting their studies in September, in two months’ time, will be eligible for a non-means-tested grant of up to £750 towards their living costs, plus a further means-tested £3,750, dependent on household income and study intensity. Students who do not receive the full grant amount can apply for maintenance loans, ensuring that there is no barrier to study.
This approach, treating full-time and part-time students equally, may be a measure that addresses the “unforeseen consequences” described by the noble Lord, Lord Forsyth. It is a progressive measure that has the potential to make a significant difference to the number of part-time students in Wales. For instance, the new funding arrangements are already generating significantly increased interest in studying with the Open University in Wales. The university there is experiencing substantial increases in early registrations for study in the coming year, with figures currently running around 30% higher than at the same point last year. It is hoped that the UK Government can learn from the Welsh experience. Let Wales bring in the cavalry.
That underlines the importance of a flexible learning incentive. I am the father of a child who got her second degree from Birkbeck. My career started as a result of the Robbins report in 1963, with new universities and expansion of the sector. Many of my friends went to teach in the Open University at the end of that decade. It was a great moment for us to be alive—oh, that it were so for our children and our children’s children.
My Lords, this is one of those debates when you could spend all your time saying that you agree with everybody who has gone before you. The noble Baroness, Lady Bakewell, has started something that we are in only the first act of. She is clearly pointing out something that has gone wrong because, whatever is said about the Open University, it has been a tremendous success and has the structure to reach people who are not being trained when everybody else is. This is one occasion when, very boringly, I agree with virtually every syllable said by the noble Lord, Lord Forsyth. We have to try to preserve the Open University and use it. The noble Lord, Lord Forsyth, pointed out two things: ELQs and fees. We have to find some way of removing these barriers because reskilling is not always upskilling and upskilling may require some reskilling to get people ready.
One thing that the Open University has a tremendous capacity for is credit transfer. It is a conduit between different skills being credited in another institution. We have probably not made the best of this institution yet. We have a structure and redistribution and we could get people ready for study courses somewhere else by using that. If we get radical and look at this as part of the university sector as opposed to something in a corner screaming and fighting for its bit of attention—all higher education institutions have a tendency to do that—and bring this together, we will get better results.
The Open University has a tremendous reputation. As the noble Baroness, Lady Lane-Fox, said, it is probably the best university for helping the disabled. We have to try to use this national system for reaching the public to enable us to get the best out of the higher education system as a whole. Unless the Government realise that and support it, we will be throwing the baby out with the bath water, and possibly its sibling as well.
My Lords, the biggest provider of part-time learning services is learndirect. Although it has contracts with clients such as Sainsbury’s, the quality of training and supervision has drawn much criticism and dissatisfaction. We now learn that last week learndirect, on the verge of bankruptcy, was sold by a private equity company for a nominal sum. That was followed by an announcement that 22 senior managers are leaving the company. Does the Minister think that part-time learning is a suitable commodity for commercial and financial manipulation this kind? Obviously, our colleges will have to pick up the pieces. We are going to have to do a lot better than this, because delivering these skills and the productivity that will enable us to exploit new technologies and make our way in the world post Brexit is a central pillar of our industrial strategy. The industrial strategy recognises that without part-time education, even with a high level of employment, people will be stuck in low-paid jobs.
As the Taylor report indicated, the world of work is becoming more flexible, more connected yet more remote. In their response to the Taylor report, the Government promised an assessment of these jobs and what needs to be done so that people in the so-called gig economy and on zero-hours contracts will have the encouragement and the means to take on part-time education. By their very nature, these gig companies have very little motivation to encourage part-time learning. Surely all this is part of the need to improve and build on the current work of the Careers and Enterprise Company and the National Careers Service to advise young and old about part-time education. Is this work in progress? It is promised in the industrial strategy.
Some think that one way to improve these services is for contact with the training organisation or college not to finish when the course ends. Some colleges or organisations are trying to work out how they can continue the relationship and find out how well the skills and knowledge of past participants are keeping up with change. In this way, they hope to tell people when they need to return for an update or an upgrade. Will this be introduced as part of the national retraining scheme mentioned by my noble friend Lady Bakewell? Such a scheme was promised by the end of this Parliament. Can the Minister give us an update? Thanks to my noble friend, who introduced this report in such a brilliant manner, I think we are all convinced that enabling people to study part-time while earning, in order to improve their skills and knowledge, benefits not only the individual but the economy and society as a whole. The industrial strategy commits the Government to making it happen. Is this work being done?
My Lords, I am an A-class student of the Open University. I hasten to add that this is not for academic ability but because I was a student joining in the first year, 1971. My wife enrolled in 1972 and by the end of 1976 we produced between us two BA degrees and two wonderful baby boys. In the time available I wish to comment positively about the Open University in Northern Ireland.
The number of part-time Open University students in Northern Ireland is increasing. At the moment we have 3,967 students. Interestingly, in the Republic of Ireland there are 1,077 OU students. Students in Northern Ireland may apply to the Student Finance Northern Ireland fund for a part-time fee grant or fee loan. Part-time student loans were introduced for the first time in the 2017-18 academic year. The Open University in Northern Ireland has introduced a significant paid work experience programme for its part-time students, initially working with companies in the STEM sector. There has been strong, positive feedback from employers about the work ethic, resilience and focus of OU students. Several have been given full-time jobs before completing their placements.
Furthermore, the Open University in Northern Ireland is now a major provider of graduate nurses to the Northern Ireland health sector. Its unique part-time programme works with healthcare assistants to develop their skills and knowledge: those staff remain in their substantive roles, so they bring their new skills directly to the work environment. This partnership programme is with the Department of Health, the Northern Ireland health trusts, the Royal College of Nursing and Unison. Perhaps this could be replicated throughout the Open University.
The UK Government have taken steps to promote part-time learning, such as relaxing the equivalent lower qualification restriction in STEM subjects, introducing maintenance loans for part-time students and consulting on accredited degrees. While these are welcome, they are piecemeal. It is clear that fundamental action is needed.
My Lords, the crisis of the Open University, which has entailed a massive loss of income and a halving of student numbers, is rooted in the Conservative Higher Education Act 2012. The administration of the Open University has reacted to the financial crisis by declaring large-scale staff redundancies. It has also attempted to make savings by closing seven out of nine regional centres, which are where OU students gather for contact with each other and with their tutors. As well as declaring mass redundancies and closures of courses and regional centres, the proposals of the vice-chancellor, who has since resigned, included the elimination of the costly research activities of the university. Henceforth, the university was to become a provider of online courses, to be propagated via the world wide web from a platform called FutureLearn. The resulting MOOCs— massive open online courses—which are freely available to consumers, were extolled by David Willetts, the erstwhile Science Minister—now the noble Lord, Lord Willetts—as
“revolutionising conventional models of formal education”.
The current offerings of FutureLearn are threadbare and compare unfavourably with the traditional course materials of the Open University. They are more appropriate to recreational education than to serious academic study. The idea that university lecturers can be replaced en masse by static electronic material, which is attractive to administrators and paymasters seeking to reduce costs, is both fatuous and dangerous. If there were any validity in it, we would have seen the growth of academic libraries instead of the growth of universities.
I turn to the wider issue of the importance of adult education to the welfare of our society and our economy, and the seeming disregard of this by the Conservative Government. It is an oft-repeated truism that, if we are to profit from the scientific and technological advances that are occurring with increasing rapidity, we need a workforce that is constantly learning new skills and upgrading existing ones. This can be achieved only by a systematic programme of adult education and re-education. In many ways, we have regressed. Our provision of adult education is not what it once was. Large industrial enterprises are no longer as keen as they once were to sponsor the education of their workforce. Instead, we hear a chorus of complaints, mainly against our universities, about the skills shortages in the workforce.
In the meantime, opinions have changed regarding the purpose of education. The Russell report, which was presented to Margaret Thatcher when she was Secretary of State for Education and Science in the early 1970s, emphasised the necessity of providing,
“the fullest opportunities for personal development and for the realization of a true conception of citizenship”.
Nowadays the emphasis is on manpower planning. The Russell report was cold-shouldered by the Conservative Government, and their negative attitude has continued to affect the provision of adult education.
The attitude of the Labour Party has been very different. The Open University, established in 1965 by the Wilson Government, had its immediate antecedent in the Workers’ Educational Association, which was strongly supported by the Fabian socialist movement. The WEA embodied the spirit of the dissenting academies, which had a much earlier origin. Our party has been characterised by a studious and a pragmatic approach to all manner of social and economic issues, which has gone hand in hand with its approach to learning and education. It has tended to reject political and ideological dogmas in favour of careful policy-making. In this respect, it is very different from the party in power. The Conservatives express impatience with the advice of experts. They are liable to ignore issues of detail that can detract from the clarity of ideologically motivated policies. We are presently witnessing, in connection with the Brexit agenda, some of the most damaging effects of this Conservative mindset.
My Lords, like others, I warmly welcome this debate and thank the noble Baroness, Lady Bakewell, for introducing it so ably. Student numbers in part-time education are moving dramatically in the opposite direction to the one I am sure we all want to see, potentially with really dangerous consequences for our economy and society.
The Open University has its headquarters within the diocese of Oxford, in Milton Keynes. It is a remarkable institution, as others have said, which has pioneered access to higher education and the use of technology, supported by face-to-face learning. It remains at the forefront of all of that, and I echo the affirmation others have made of the need to preserve, develop and build up its contribution to our national life and its international reach.
Together with the noble Baroness, Lady Bakewell, I have recently been a member of your Lordships’ Select Committee on Artificial Intelligence. As we have heard, we examined the changing nature of work. AI can drive our economy forward, but it is a disruptive technology. We know that many jobs will go. Some new jobs will be created. It is not clear what the net effect will be. But we do know two things.
First, the effects of job reductions will not be even across the economy; they will disproportionately affect traditional post-industrial areas and sections of society. The Centre for Cities estimates that 27% of current jobs will be lost by 2030 in Doncaster and Wakefield—towns which already have a higher level of unemployment. That is really significant for those communities.
Secondly, what can be done to mitigate the effects of these massive societal changes? The key is what we are discussing today. It is the only key that has emerged from the work done so far: a really significant—bigger than we have yet imagined—proactive investment in part-time, continuing, lifelong education, accessible in every place and to every part of society. We need a more radical reimagining of our continuing education than the Government have yet embarked on: a part-time education revolution for the 21st century equivalent to the large education revolutions of the past that we heard described.
The technology that is so disruptive to jobs can actually help us achieve that—supported by face-to-face and community learning. This new deal needs to be means tested, as we have heard, at the point of delivery, to prevent the stagnation of much of our economy; it needs to focus on the building of character and the formation of wisdom, as the Open University and others have done in the past; it has to be about more than knowledge and skills; and it needs to be focused disproportionately on the areas of greatest need.
My Lords, it is a pleasure to take part in this debate. I declare my interests as set out in the register. I congratulate the noble Baroness, Lady Bakewell, on securing this debate and on the way in which she introduced it. I, too, was lucky enough to serve alongside her on the Artificial Intelligence Select Committee, and what we all saw from the noble Baroness there was that it will be a long time before artificial intelligence gets close to the brain power stored in her skull. I also welcome the noble Baroness, Lady Bryan, and her excellent maiden speech.
In the time that I have, I will focus on two areas: the fourth industrial revolution and unpaid internships. It seems clear that we are in a time of tumultuous change, where everything is changing: the tools we use, how we work, where we work and when we work. If this is indeed the case, it seems clear that education—higher, further, primary, secondary—needs also to change, not just to be relevant but to address the ongoing needs of individuals. Everything that education should have been, it now absolutely needs to be. It seems that flexibility needs to be at the core of that.
I take every opportunity to crowbar unpaid internships into every debate, and I got my Private Member’s Bill through your Lordships’ House. How can someone, if they are forced to do an unpaid internship, hope to undertake part-time or further education? It is most likely that the people who most want to secure internships and part-time and continuing education—if we believe in social mobility, which I do and which the Government and Prime Minister have stated a commitment to—will not be undertaking unpaid internships or part-time, continuing education. They will be locked out of both routes to social mobility, locked out of both routes to being able to play their full part in our society, and we will not be able to address all the social, cultural and spiritual issues, and address the productivity crisis, that we have.
On those people whom the figures show are not able to continue part-time education and have dropped out, I ask the Minister what research the Government have done on who is in those groups. What are they now doing, and what is the Government’s view of that situation? Does the Minister agree that it is all about flexibility? Without that flexibility matched with relevant resource, people will continue to be unable to participate.
Do the Minister and the Government believe that the current student finance system is fit for purpose? Is the 6% rate in any sense realistic, satisfactory or designed to achieve the policy objectives and educational outcomes that we all want?
Ultimately, it seems pretty straightforward. We either have part-time education, continuing education, higher education and further education founded on flexibility, or we fail.
My Lords, I welcome this debate, which was brilliantly introduced by my noble friend Lady Bakewell, at this critical time. The UK needs to increase the number of those taking part in part-time education, not the other way around. The OU and many other educational institutions have played, and will play, an important role.
The OU has been a great leader in the UK and abroad. I worked with the OU on a TV programme about air pollution dispersion—still important, as we discussed earlier this afternoon. It was broadcast in the middle of the night, whereas my son’s history programme was broadcast at about 8pm. That is the world we live in. My programme, however, which was made 30 or 40 years ago, is still used around the world. There are many other institutions providing part-time courses, in companies and governmental institutions such as the Met Office. In fact, incoming chief executives were given a very stiff day of introduction in the courses at the Met Office.
There could be much more collaboration between different types of part-time courses. During part-time lecturing to industrial engineers at what is now Coventry University, in the 1960s and 1970s, I learnt how such part-time courses can have the practical focus needed by industry—a focus that differs considerably from, while complementing, the fundamental courses taught at universities. This needs to be understood by educational policymakers concerned about the UK’s shortage of apprentice-level engineers and specialists. For example, there is a tremendous need for practical courses in innovative construction—areas such as green technology and remote offsite construction—which the House of Lords committee has just been looking at.
In the United States, however, universities have an alternative approach that has so far not been mentioned. There, part-time further education is integrated into full-time education: part-time students attend courses organised for full-time students. Seeing this in Arizona, I was very impressed that such part-time students can bring new and practical ideas—sometimes quite revolutionary—of value to the whole class.
Advanced postgraduate and doctoral part-time courses are also very important for specialised topics. In London there are many evening courses, in all sorts of places, on finance, but very few advanced, open evening courses of the kind that are easy to find in Chicago or Los Angeles. We tried it in London by setting up the Lighthill Institute, which I helped to run for a few years, offering evening courses in mathematics and advanced technology. I am afraid, however, that it no longer exists.
Finally, the OU is justly famous around the world for its teaching and research—for example space research—but is uniquely distinguished for its highly original and professional TV programmes. My point is that, while other universities also make online programmes, the OU needs to expand its excellent programmes and to continue its broad approach using the greatest talents from around the world.
My Lords, I too thank the noble Baroness, Lady Bakewell, for enabling this debate, which is particularly timely given the recent excellent report by the Economic Affairs Committee and the Government’s forthcoming review of post-18 education, which will inevitably wish to address the problems that part-time higher education has faced over the past few years—and to find urgent solutions. I declare my interest: I was privileged to be a member of staff of the Open University for some 34 years, from the heady days of the early 1970s to my retirement. Those early years saw the Open University establish itself in terms of both the extensive demand for distance-learning opportunities and the quality of its learning materials, underpinned by personal support for students. Applying rigorous standards, the Open University innovated in its teaching methods and was helped immensely by its association with the BBC. It became, and remains, a world leader.
The OU was very much the university of the second chance—except that for many students it was their first chance. It has thrived on open access and the desire for self-improvement. All of those principles remain vital for an inclusive and skilled society. As we have heard, however, numbers of part-time students have fallen heavily in recent years, right across the sector. The introduction 10 years ago of the rules that cut funding for students taking qualifications at the same level as, or a lower level than, the ones they already held was a serious financial disincentive for those seeking personal enrichment or professional updating. It was a mistake.
It is not, however, the whole story. As we have heard, it seems that students with families and higher living costs than 18 to 21 year-olds have found the cost of study a major disincentive. This is a huge disbenefit for the individuals concerned and is almost certainly not in the national interest. As we have heard, part-time nursing student numbers have fallen by half. I hope the Government will urgently look at whether it is justifiable for tuition fees for part-time students in England to be two and a half times higher than in the rest of the UK. It does not seem right to me that students in England should be so disadvantaged. Ways must be found to reduce the cost.
I hope the Government will look again at the benefits of lifelong learning for part-time and mature students for our productivity and skills base as we train people for a new generation of jobs. I hope too that the Government will examine the potential for individual lifetime learning accounts, which could prove extremely helpful. Finally, the Government could bear in mind one further fact: around 20 million adults in the UK do not have level 4 qualifications. That is a huge untapped resource.
My Lords, I begin by congratulating the noble Baroness, Lady Bakewell, on securing this debate and introducing it so well. I am only sorry that it has taken so long to organise. We are also limited to about to about three minutes, which is hardly enough to cover an issue of this importance. That is, however, where we are and where I will begin.
We all agree that we live, as the noble Baroness pointed out, in a world of constant change—technological, social and cultural. Thanks to globalisation the world is increasingly becoming one, as different cultures and societies come together. In this situation it is vital that part-time and continuing education keeps pace with the world around us. If the world constantly changes, education must constantly change and expand. I do not really like the term “part-time education”, because it is lifelong education: the “full-time” and “part-time” distinction does not make much sense. Nevertheless, when one is employed in a full-time job and takes on a course, we call that part-time. That is fine. What it does, however, is increase social mobility and economic productivity, and provide skills that one may lack and—most important of all—job satisfaction. It makes for a contented workforce that can see the world as an expression of its own skill and powers, rather than as an alien entity trying to dominate it.
In that kind of world, part-time education becomes a form of self-expression and self-development. It is, therefore, natural to worry about the decline in the number of part-time students: a fall of 47% between 2008-9 and 2016-17. In England the fall is even greater: 59%. That is very disturbing. How have we come to this and what can we do about it? Three minutes, as I said earlier, is too short a time to explore those questions, so I will just make some quick points. First, it is a great mistake to regard so-called part-timers as being like full-timers. They are not, and that is a serious mistake. Part-time students form a distinct group with their own historical experiences. They are mainly older and mature, with family responsibilities, mortgages, and a reluctance to take out loans: they are notoriously debt-averse. In that situation, if they are offered a grant in the same way it is offered to undergraduates—by saying that payment will be deferred—they are not going to take it. The result is that when these grants are offered, they are certainly not taken up. That is not how mature students respond.
Finally, a word in half a minute about the Open University. Again, it puzzles me why it is called the Open University, which by definition implies that other universities are closed. Happily, we are not. I am a university professor and my university is not closed, as in the Soviet Union or anywhere else; it is open. However, the Open University is open in a special way. It is independent of qualifications that have been obtained at A-level; it is also independent of space, so that it can teach wherever students are. The Open University is one of the great achievements, like the NHS. It has had a great impact on India and other countries. I would even be inclined to say that it is a jewel in the crown. Nothing should therefore be done to damage it. That depends not only on the Government but on the Open University itself. It is important that the Open University should remain innovative and make savings, but at the same time the Government should be more hospitable to the presence and contribution of the Open University.
My Lords, the noble Baroness, Lady Bakewell, has vividly and starkly analysed and shown the scale of the problem we are talking about today. I was chair of the council of the Open University for 10 years, between 2004 and 2014, when these changes began to emerge. The reality has come home to roost only in the last couple of years.
The first change was the introduction of student loans. As the noble Lord, Lord Forsyth, clearly said, that was a piece of financial engineering and chicanery by the Treasury, introduced by Gordon Brown and accelerated by George Osborne. It was a completely unnecessary and cynical piece of financial engineering. Secondly, we had the elimination of ELQs, which were not a huge issue in money terms but were huge symbolically. They were part of the values that the Open University stood for; never mind the financial side, they were a cornerstone of it. The third trend which I found strange was, on the one hand, the championing of the devolving of power—I championed it very much—away from Milton Keynes to the Celtic nations while at the same time, rather against my best interests, there was the increasing centralisation of power in England towards Milton Keynes. We have an English problem here because the trend in student numbers, awful as it is in the Celtic nations, is twice as bad in England. There is a lesson there to be learned.
There are two issues for the OU to consider. First, is the model of 50 years ago, modified as it has been as things have gone along, still up to date with today’s student requirements? Secondly, has centralisation in England gone too far? I suggest two possible initiatives for the OU to consider in getting out of this difficulty. One is collaboration with universities across the United Kingdom, locally and regionally, to develop a new form of distance learning. Those local universities have their feet on the ground and collaboration seems an interesting proposition, which would not cost much money. We have to remember that part-time education has virtually disappeared from the curriculum of most universities anyway, so it would revive that. The other is that I chair one of the local enterprise partnerships in the north of England, where the biggest problem we face is the lack of skills and training in non-academic jobs and circumstances. Could not the Open University model be adjusted to address that need in society, which is not academic, using the technology and the distance-learning skills the university has in an innovative way to deal with a local problem?
What should the Government do about all this? First, we welcome the post-18 review and we obviously consider that it must primarily review the impact of student loans on part-time education, because a loan to a 28 year-old is very different from a loan to an 18 year-old. Secondly, they should restore the priority of lifelong learning, which for 20 or 30 years had become a stronger and stronger issue in government. They should change that and put it back as a policy priority. Thirdly, they should consider incentives for employers to use the Open University more than they do. There has been a significant fall in the number of employers sponsoring students going to that university, which is a disgrace and a bad reflection on those businesses, which cannot see beyond the end of their noses. Lastly, the Government should pay far more than lip service to devolution in England and recognise that it makes huge economic and social sense in the way that we deliver economic development, health and education.
My Lords, if the Minister entered the Chamber this morning with any doubts as to the significance of the Open University, those doubts should by now have been well and truly extinguished. I declare my interest as a former chancellor of the Open University, a role in which I served from 2007 to 2014. If I regret any one thing during my term as chancellor, it is my failure to persuade any Minister to attend an OU graduation ceremony. Had it been any other university, this would just have been a pity but, for the reasons touched on by the noble Baronesses, Lady Lane-Fox and Lady Garden, in the case of the OU it is tragic. It is tragic because unless you have experienced one of those celebrations—and celebrations they are—you can never truly understand the impact of the OU on the lives of its graduates.
One of the assets that this House brings to the national debate is informed experience, so allow me to quickly set out the actual experience of being a part-time learner. I had failed badly at school and belatedly realised that I needed some sort of education if I was to make anything of my life. In that pre-OU era, I enrolled at the City & Guilds. I studied nine subjects at what was then called night school. I was up before 7 am to get a bus and a train to where I worked as a messenger in an advertising agency. Three evenings a week, I would cross London to study from 6 pm until 9 pm. I then got the Tube and a bus home, reaching there just before 10 pm. I did that for four years, during which time I got married and our first child was born. I am in no way regretful but that allows me to know that unless you have lived with the challenge of doubling up on childcare and doing your homework on a train while juggling with every other facet of adult life, you are very unlikely to have the imagination to understand—let alone appropriately legislate—for non-traditional forms of education. Those forms of education are imposed by circumstance rather than privilege, be that privilege intellectual or financial.
I sincerely hope that the Minister, when he replies, will prove me wrong but I get no sense that the Government have demonstrated a full understanding of the role that the OU could play in a post-Brexit, productivity-challenged Britain. Surely, one of the few issues on which remainers and Brexiteers ought to agree is the overwhelming importance of developing a workforce in which every person, no matter what their age or background, can develop an active and constructive role. In my opinion, this is a task that the Open University is better equipped than any other institution in the country to fulfil.
My Lords, I too congratulate my noble friend Lady Bakewell on achieving this debate and regret that we have only three minutes. I should draw attention to my university declaration in the register but the reason that I wanted to speak in this debate is that many years ago, I taught with the Open University. One of the common themes that we have seen in this debate, whether we are talking about people who have been students, the families of those who have been students, people who have been tutors or those who have served in governance at the Open University, is the enormously high respect that every single person who comes into contact with the university has for it. I was going to make the point that my noble friend Lord Puttnam has just made: if anybody has not been to an Open University graduation ceremony, they really should go. But they should also take a box of handkerchiefs because it is an incredibly moving experience.
In my days in the Open University, many years ago, I was always impressed by the quality of the course material. It was interesting to see how much of it was then used by other conventional universities. More than that, I was particularly impressed by the students and their motivation. My noble friend Lord Puttnam has just outlined what he went through. It proves that the motivation of students who come to the Open University or to Birkbeck must be very high. Many of us were the first in our families to go to university but, for the most part, those who are the first to go to university have full-time jobs, families and mortgages. If anybody thinks that the funding arrangements do not matter, they should look at what has happened with bursaries for nurses. Nursing places are still being filled by very good candidates, but they are not being filled by mature students, as they were a few years ago, because those people do not want to inflict an extra burden on their family, especially when they are taking time away from them.
The OU briefing that we have all been sent sets out several points it would like to be pursued. I shall concentrate on and explore one factor that has not been mentioned too much today. It is the need for this sector of education to be very flexible and to provide progressive pathways. It is desperately important that people can move from one sector of education and one type of qualification approach, and we need credit accumulation and credit transfer to become an integral part of all we offer to part-time and mature students. I do not think we are talking about the US model of a credit for basketball, although what my noble friend Lord Hunt said was interesting, but the Open University’s foundation courses—the building blocks and segment approach—is vital if we are to be able to provide people with the multiple skills that they will need in the future. The report on AI has been mentioned, as has the fact that people no longer have jobs for life. We have enough experience to design this for the future. I am glad that we have this debate today. We are celebrating the National Health Service, but the Open University is the other great achievement, of Harold Wilson and the Labour Government.
My Lords, I agree with the noble Baroness. The noble Lord, Lord Forsyth of Drumlean, referred to the report of the Economic Affairs Committee. He chaired the work, he is an extremely skilful and wholly impartial chairman and we never discuss Brexit. I am a member of his committee and I want to draw attention to one terrifying statistic that we came across in writing the report. The number of part-time students aged over 30 fell by 41% in the four years to last year. The trend had been going on for 10 years, but it accelerated. That is a terrifying number when we think of the needs of the economy, as the noble Lord, Lord Shipley, did. It is a story not just of personal opportunities forgone but of national self-harm. I think we have a crisis on our hands.
My Lords, I thank the noble Baroness, Lady Bakewell, for this debate, I congratulate the noble Baroness, Lady Bryan, on her maiden speech and I wish the Open University happy birthday. I congratulate all the other colleges, whether higher or FE, that do a tremendous job in continuing education. I taught all my life in deprived communities on Merseyside. One of the things I vividly now remember is the number of parents who ventured into school to help out. They were often single mums whose children were no longer in the home so they could come into school to help out. They suddenly got a taste for learning and thought to themselves, “I can do that”. Sometimes it was retired dads as well. Guess what? They went on to do courses and degrees because they had the confidence from being in school and seeing they could do that and had the provision available.
The traditional pattern for the most able, often well-off, students is well-known: primary education, secondary education and then on to further education or university. Indeed, I assume that many, if not all, of my noble colleagues followed that path, en route to a distinguished career in their chosen field and then into this Chamber. However, although this is a path trodden by many more students than was the case 49 years ago—I will explain the significance of this later—the majority of young people do not follow this route, and it should not be the only route to acquiring knowledge and skills.
Further and continuing education offers a door into personal development and skills that is never closed, whatever your age or circumstances—although the Government seem determined not to shut the door, but to make it more difficult to squeeze through. In addition to offering a chance to those who did not, at 18, move on to higher education, the further and continuing route is now even more necessary. The changing pattern of employment and the new skills demanded by the speed of developments in industry mean that updating skills and learning new ones is vital to our economy.
I had the pleasure of meeting Harold Wilson when he was president of the North of England Education Conference. I had to collect him and take him to his room at the Adelphi Hotel—remember “Just cook, will yer?” He met Sir Keith Joseph, who was then the Secretary of State for Education. I was 26 or 27 and the chair of education. I was amazed how well those two individuals got on. I was a bit overpowered by them, but Harold Wilson started to talk to Sir Keith about his greatest achievements in government. This is true: he said to Sir Keith Joseph that one of his greatest achievements in government was establishing—yes, you guessed it—the Open University. I always remember that, and it was important to me.
The most important word in the title of the Open University is not, in my view “university”, but “open”. When the Open University admitted its first students in 1971, only a tiny fraction of 18 year-olds went on to study for a first degree. The barrier then was not the thought of a debt of tens of thousands of pounds. In the 1970s, tuition was completely free and the means-tested maintenance grant of £10 a week during term-time meant that the poorest student could pay for accommodation, food and clothes and still have enough for an occasional pint or Babycham. The barrier then was aspiration. For many young people whose parents had left school at 14, even those who had passed the 11-plus, university was not an option and even staying on until 16 to take GCEs was not automatic. I remember one student who on his 15th birthday, the school leaving age then, had among his birthday cards a letter giving the time and date of the dockyard apprentice exam. A friend of mine was allowed to stay on to take A-levels against his parents’ wishes—they wanted him to get to work—only after his English teacher went to plead with them and tell them how important doing an A-level at school was. His parents wanted him to bring home a wage.
Noble Lords may wonder what any of this has to do with the Open University. Well, when it was established it offered, for the first time, a university education to those who would never have dreamt of the traditional university route. Since 1971, more than 2 million students have studied its courses, many of whom have used their higher education to contribute to an economy which is always in need of a well-educated and highly skilled workforce, but never more so than in the 21st century.
We have heard many statistics about the Open University, the most alarming of which is the 63% drop in undergraduate entrants between 2010 and 2015, which was even worse than the 51% nationally. It is the number of disadvantaged students that has fallen the greatest, which is another blow against the Government’s fine words about social mobility. The Centre for Cities says that rather than replacing low-skilled jobs with more of the same or welfare, we need greater investment in lifelong learning and technical education to help adults adapt to changing labour markets and better retraining for people who lose their job because of those changes. It is worth noting that there are 20 million adults who do not even have a level 3 qualification. Imagine if they had the opportunity to do that. Imagine how it would change their lives and how it would help our economy as well.
Time, tide and the changing labour market wait for no man. It is not a matter of the Minister being carried to the beach and commanding the waves to stop. Whether or not we are in Europe we are just a small island 40 kilometres off the coast of mainland Europe. We cannot afford to lose our place as a high-tech, well-skilled and competitive economy. I was taken with the important contribution by the noble Lord, Lord Forsyth. Like other colleagues, I agree with every word he said. We have created a vicious circle. The decline in numbers leads to a decline in courses and a decline in courses leads to a further decline in students, so we need to look at radical solutions.
One solution, which my noble friend Lord Shipley mentioned, may be to support all young people with an endowment or individual learning account, which they can use at any stage—early or later in life—to help to finance further or higher education. I was taken by my noble friend Lady Garden’s description of how she did her degree at the Open University. She used the phrase, “I wafted in”. I cannot imagine my noble friend wafting into anything.
We as a party are not simply waving a shroud on this matter. Vince Cable has made continuing education a priority of his leadership, and has launched an independent commission on lifelong learning to develop new proposals to give everybody the chance of self-improvement and employment at every stage of their life.
I have a few simple questions for the Minister which have been alluded to. When can we expect the review of post-18 education to report back? When will the Government respond to the recommendations? What does the Minister have to say to those students who will not be able to start a continuing education course or a degree next September?
As we have heard, 2019 will be famous for two fifties: one is to do with Article 50; the other is the 50th birthday of the Open University. I hope that the Government will give us and the Open University something to celebrate.
My Lords, my noble friend Lady Bakewell is due our gratitude for securing this timely debate on a subject of real importance to the economic future of this country. That fact is not reflected in the mere three minutes allocated to Back-Bench speakers, although I think we all understand the need to accommodate more time for the debate marking the 70th anniversary of the National Health Service. I am wearing the sticker commemorating that today, and have a personal interest as someone born in the first year of the National Health Service.
None the less, it has been an excellent debate. I start by congratulating my noble friend Lady Bryan of Partick on a fine maiden speech. We first met many years ago, and I welcome my noble friend and her brand of socialism to your Lordships’ House. I can tell your Lordships: “You ain’t heard nothing yet”.
My noble friend Lady Bakewell opened the debate most effectively and highlighted the fact that, as the National Health Service celebrates its 70th anniversary, the Open University is preparing to celebrate its 50th. I had not made the link between these two events but, as my noble friend reminded us, that link is, of course, Aneurin Bevan and Jennie Lee. Surely in terms of the foresight of their socialism and the legacy it has produced, they must qualify as the all-time power couple.
Last year, the OECD highlighted the fact that the United Kingdom is full of highly educated workers with skills that often do not match the jobs available. Its report said that employers often do not train enough of their employees for new skills and that they should work more closely with the education system to ensure that school pupils and college and university students achieve the skills that the economy requires.
Research suggests that there are key process stages which influence school leavers’ decision-making: the UCAS cycle, open days and published information—whether comparison sites or league tables. These are all places where part-time or distance learning options tend not to feature. Prospective part-time students are generally much less well informed. A study commissioned by the Open University earlier this year showed that nearly three-quarters of prospective part-time students in England, all of whom were interested in studying part-time at higher education level in the next five years, were unaware that tuition fee loans were available for part-time study.
We need a single national portal which shows career opportunities with available jobs, apprenticeship options and links to training requirements and where and how study can be pursued. This would need to be strongly supported by face-to-face mentoring and guidance to give people the best knowledge of their options, and should come under the Government’s careers strategy.
That strategy needs to go further and address retraining and upskilling at all levels. The National Careers Service needs to be more ambitious and have a more innovative design, including better search facility and more advice, with direct links to taster courses to help build confidence and inform the decisions of those wanting to learn. Part-time higher education will be a determining factor in confronting skills gap issues, as well as the other major economic challenge that the UK faces: low productivity. However, part-time higher education in England is in crisis, with the continuing fall in the number of part-time and mature students, to which many noble Lords have referred, largely the result of the huge increase in tuition fees since 2012. With Labour’s pledge to end fees, that barrier will no longer face those who want to combine work with adding to their skills.
It must be acknowledged that those challenges cannot be met by relying on young people alone. The skills gaps are too many and too pressing. All adults of working age, whatever their background or level of qualification, need regular opportunities to upskill or reskill throughout what we all know will now be lengthening working lives. That fact was firmly grasped by the Economic Affairs Committee of your Lordships’ House, ably chaired by the noble Lord, Lord Forsyth. I chuckled rather when the noble Lord, Lord Kerr, said that the noble Lord, Lord Forsyth, had been impartial. I guess he would be in that committee, but the noble Lord and I go back some way, and one adjective that he is not usually associated with is impartial. I certainly welcome the fact that the committee produced a report containing much wisdom. I was particularly struck by the chapter on flexible learning, where it recommended the introduction of a credit-based system allowing people to learn in a modular way at a pace that suits them and their circumstances.
The Government have recognised this by launching their review of post-18 education and funding. That is to be welcomed, as is the fact that they will consider how to encourage more flexible learning, including part-time and distance learning. The review represents an opportunity for a fundamental rethink of the system of further and higher education that has developed in England over the past 20 years. For the first time, it is considering adult education and training at the same time as university-level education.
I hope that the Minister can explain how he sees the opportunity to strengthen the pathways between further education, apprenticeships and higher education to ensure there is joined-up thinking to enable young people to see their training as not just for a job but for a career. Flexibility must be placed at the heart of the post-18 education review. The Government have taken steps to provide part-time learning by introducing maintenance loans for part-time students, but they do not apply to those studying via distance learning. When will that gap will be addressed, because it currently acts as a disincentive to mature students returning to education?
As I said, the main priority for the UK must be lifelong learning, with individuals having both the incentive and the opportunity to develop and update flexible skills that are not attached to a particular employer. That philosophy will be central to the national education service which Labour will deliver in government, and will encompass further education colleges. They will continue to have an important role in earning and learning. They are drivers of social mobility, as various noble Lords said, including my noble friends Lady Bakewell and Lady Blackstone. I believe that the role of further education colleges is underplayed. It certainly seems undervalued by the Government in the funding that they get, but they will have a continuing role to play in economic growth. Part-time higher education students at colleges are typically aged over 25, although, worryingly, the Association of Colleges points out that their numbers have declined by more than 10,000 over the past four years.
However, the Open University will remain at the forefront of access for second-chance and, indeed, third-chance learners. A third of its students have only one A-level or a lower qualification when they join. As the noble Baroness, Lady Lane-Fox, said, 75% of them are in work. The Open University is responsible for one of the least-known facts, I believe, about first-year undergraduate students in English universities: almost one in five of them study part-time. With increasing degree apprenticeships, FutureLearn and OpenLearn, the OU will, as it approaches its half century, continue to push the boundaries of education technology into its second half.
Yesterday, I attended a reception in Parliament hosted by the Royal Academy of Engineering and EngineeringUK. That industry will be central to the ability of this country to build a strong economy when the shockwaves caused by leaving the EU are felt. Some 125,000 engineers and technicians with core engineering skills are required every year and the OU is already playing its part, with more than 40,000 STEM students preparing themselves for those demands.
This has been a debate high on quality in terms of the contributions by noble Lords, many with vast experience of the Open University itself or of part-time learning in other institutions or sectors. Much more could have been said were greater time available but, as the noble Lord, Lord Forsyth, said, we shall have the opportunity to revisit some of the issues around lifelong learning when your Lordships’ House debates the excellent report of his committee. I echo the question put by the noble Lord, Lord Storey, about the post-18 review and report. My noble friend Lady Bakewell said that she anticipated it appearing by the end of this year; my information was that it will be into next year, so it would be helpful to have clarification from the Minister. I trust that he has absorbed the many important routes signposted by noble Lords on how to promote and expand on part-time and continuing education and I look forward to hearing his response.
My Lords, it is a great pleasure to respond to this debate on part-time and continuing education, and I note the specific reference to the future of the Open University. I thank the noble Baroness, Lady Bakewell, very much for raising this subject again. Studying part-time and supporting the education of individuals throughout their lives can bring considerable benefits for individuals, employers and the wider economy.
Let me start by setting the scene. Noble Lords have spoken at length today about the importance of the Open University, and they are right to do so. It has been particularly interesting to hear remarks from those who have been its previous leaders and from its current leaders and alumni, and particularly from those who have taught at it—including, if I picked it up correctly, the noble Baroness, Lady Taylor, and the noble Lord, Lord Shipley. Since 1969, the Open University has brought the opportunity to engage in higher education to people across the country who would not otherwise have had the chance to do so. There has been a theme of social mobility in what has been said today.
I also say at the outset how much I appreciated the maiden speech of the noble Baroness, Lady Bryan of Partick. She gave a particularly warm and thoughtful speech and I am certain that her experience as a graduate of the OU has added greatly to the debate today—and that she will continue to do so in the future. We also look forward to no doubt hearing the views of Keir Hardie transmitted from above via the noble Baroness in the future. Given that football is in vogue, in addition to the importance of study, I hope that she is a keen supporter of Partick Thistle.
The Minister for Universities, Science, Research and Innovation last month described the Open University as,
“essential to our future higher education landscape”.
I agree with Sam Gyimah on this point. I can also report that the Minister took part in an online meeting with Open University students on Monday, making use of the same videoconferencing technology that they use for their studies, to join in a conversation with students from all parts of the country. I am myself looking forward to joining the noble Baroness, Lady Lane-Fox, chancellor of the Open University, and others at a round-table meeting to discuss the work of the OU on 16 July. I note its important work for education in prisons, which we are reminded of today.
It stands to reason that part-time education offers opportunities to many people who are not catered for by the traditional undergraduate model of university. We know that the part-time student population in higher education is different from that for full-time—the noble Lord, Lord Parekh, cited some demographics. Over half of part-time students are older than 30, while this is the case for only 7% of full-time students. As an observation, part-time students also happen to be nearly 10 percentage points more likely to be female than their full-time equivalents. There are numerous testimonials provided by Open University graduates over the years that speak to this. These include people whose caring responsibilities or disabilities made part-time study the appropriate choice for them. Part-time education, however, also carries benefit that will follow an individual throughout their career. Many of those who choose to study through such routes do so because it can complement their existing job roles. Research has found that there are significant employment advantages for those who complete part-time courses, when they start with only a level 3 qualification or below.
Education is of course considered to be a pleasure and a challenge in itself, stimulating and maintaining what Monsieur Poirot referred to as those “little grey cells”. I hope that this will be the experience of the lady wife of my noble friend Lord Northbrook when she graduates. Part-time and continuing education allows this pleasure to be extended to a broader span of the population. Put simply, it is good for people’s well-being and mental health, where appropriate. Contrary to what the noble Viscount, Lord Hanworth, said, we do understand this and I hope that he realises that.
The Open University stands out as by far and away the largest provider of part-time higher education in England. In 2016-17, over a quarter of all entrants to part-time undergraduate study started at the OU. I will though also pay tribute to other universities and institutions, such as Birkbeck—where the noble Baroness, Lady Bakewell, is president, and where the noble Baroness, Lady Blackstone, was previously and the noble Baroness, Lady Garden, is now a fellow. I also mention Teesside University. All make important contributions to part-time study in this country. I also point out that—as the noble Baroness, Lady Bakewell, will know—over 93% of part-time undergraduate qualifiers at Birkbeck were in further study or employment six months after graduating. As noble Lords know, outcomes are a very important part of our government policy.
The noble Baroness’s Motion refers to continuing education as well as part-time education. Continuing education of course extends beyond what we may commonly refer to as higher education and I will return to this theme later on.
Let me now address directly the challenge posed by the changes observed in participation in part-time higher education in recent years. There are now record numbers of 18 year-olds going to university to study full-time, including those from disadvantaged backgrounds. However, we know that there has been a marked decline in the number of people studying part-time in higher education in England. This downward trend goes back to 2008. The noble Baroness, Lady Bakewell, eloquently highlighted the statistics, and a number of reasons for this have been given during the debate, which I will not rehearse again. The Government have taken a number of steps to address the decline in part-time study in higher education. First, noble Lords will recall that, during the passage of the Higher Education and Research Act, the Government brought forward an amendment that gave prominence to part-time study, distance learning and accelerated degrees. This amendment set out that such types of study are included in the need to promote choice for students, which the Office for Students must have regard for in pursuit of its wider functions. The Government also offer part-time tuition fee loans. I am pleased to note that in 2016-17, 47,000 OU students were able to benefit from a tuition fee loan for undergraduate courses. OU students made up around 64% of all the part-time students supported by English tuition fee loans in that year.
I pause for a moment to note that, just this week, the Government have announced that the maximum tuition fees that a university will be able to charge in the 2019-20 academic year will be frozen for the second year running. My noble friend Lord Forsyth spoke passionately on this particular matter. The Government have removed, as he has said, the “equivalent or lower qualification” restrictions—the so-called ELQ restrictions —for all science, technology, engineering and mathematics part-time degree courses. This means that students who already held a degree on these courses were then able to access support through student loans.
My Lords, I am most grateful to my noble friend for giving way, and for the initiative that has been taken in respect of that particular group of students. However, if the Government have conceded the principle, why not extend it more broadly? Am I right in saying that the number of students who have benefited from that are a few hundred? After all, in the whole of England this year, the number of students who did A-level engineering was 10.
My noble friend will know that I do not have those statistics to hand but I take note of what he has said. It ties into the report that he has produced, and I hope that at a later point we will have time to debate the details of that report.
I turn to HEFCE—now replaced by the Office for Students—which targeted an element of the teaching grant in recognition of the additional costs of part-time study. Twenty-nine and a half million pounds of the £72 million made available through this allocation was granted to the Open University. Importantly, in addition, this Government have in recent months tabled regulations that will allow part-time students on higher education courses to access maintenance loans similar to those received by their equivalents on full-time courses. These loans will be available to students starting honours and ordinary degrees, and equivalent qualifications, on or after 1 August this year.
I mentioned the likelihood of the take-up of these loans being very low because they will simply add to the debt of these debt-averse students. Perhaps the Minister would like to comment on that. What number does he believe will take it up? I suspect that it will be very small.
We hope to be more positive on that. However, on a specific question like that, I think that it would be wise for me to write to the noble Baroness with details of how we see this going forward.
In their response to the part-time maintenance loan consultation in March 2017, the Government committed to seek to introduce maintenance loans for part-time distance learning courses. This is subject to the development of a robust control regime to manage the particular risks and challenges associated with this mode of study.
The noble Lord, Lord Addington, asked a question about credit transfer. He may know that Section 38 of the Higher Education and Research Act provides the OfS with the duty to monitor and report on the availability and take-up of student transfer arrangements, together with the power to encourage or promote awareness of such arrangements.
I turn now to the post-18 review. Your Lordships will know that the Government are undertaking a major review of post-18 education and funding to ensure that we have a joined-up education system that is accessible to all and encourages the development of the skills that we need as a country. It is looking at how to ensure that funding arrangements across post-18 education and training are transparent and do not act as a barrier to choice or provision. The noble Baronesses, Lady Bakewell and Lady Blackstone, asked a number of questions about this review. It will look at how we can ensure that the system is supported by a proper funding system that provides value for money and works for students and taxpayers alike. It will also ensure that the system gives everyone a genuine choice between high-quality technical, vocational and academic routes.
The review is being informed by independent advice from an expert panel chaired by Philip Augar. Indeed, the noble Baroness, Lady Wolf, is a member of the independent panel, sitting alongside representatives from further education, higher education and industry. My understanding is that the panel will publish its report at an interim stage at some point this year, before the Government conclude the overall review in early 2019. That is as far as I can go in answering the question raised by, in particular, the noble Lords, Lord Storey and Lord Watson.
Of particular relevance to this debate, the review’s terms of reference state that it will address:
“How we can encourage learning that is more flexible (for example, part-time, distance learning and commuter study options) and complements ongoing Government work to support people to study at different times in their lives”.
To reassure my noble friend Lord Holmes, the word “flexible” is very much in there.
My noble friend Lord Forsyth and the noble Lord, Lord Kerr, shared with us a glimpse of the findings of the important work that the Economic Affairs Committee has done. We agree with the committee that for too long young people have not had a genuine choice post-16 about where they study and what they study. For exactly that reason, we have overhauled apprenticeships to focus on quality and are fundamentally transforming technical education. As I said earlier, there will no doubt be an occasion when we can more fully debate the committee’s findings in this area.
The noble Baroness, Lady Kennedy, raised her concern about turning universities into businesses. Students and taxpayers all contribute to our higher education system and rightly expect value for money. Our reforms are continuing to open up access to higher education, enabling students to make more informed choices. However, I say to the noble Baroness that there is a balance to be struck, because part of that value is having the student experience at university—that is equally important—and I think that she has probably heard me say that before.
The noble Lords, Lord Rogan and Lord Griffiths, asked about funding arrangements in Wales and Northern Ireland. The review is looking widely at the evidence and ideas available, including those from other countries such as the devolved Administrations. The Government noticed with interest the recent changes in Wales.
I said earlier that continuing education, of course, extends beyond what we might commonly refer to as higher education. In order to respond to changes in the labour market, including from the impact of automation, which includes artificial intelligence, it is becoming increasingly important that people both upskill and reskill throughout their career. The right reverend Prelate the Bishop of Oxford and others rightly pointed out the changes that we must acknowledge and address to help the next generation and those beyond. The right reverend Prelate and the noble Baroness, Lady Bakewell, spoke about changes that have come about with the digital revolution. Through innovative industrial, skills and digital strategies, government departments are working together to ensure that the population is prepared to seize the opportunities that the fourth industrial revolution might bring.
Following a manifesto commitment, the Government announced at the Autumn Budget 2017 that the national retraining scheme would be set up by the end of the Parliament. This is an ambitious, far-reaching programme to drive adult learning and retraining. The noble Baroness, Lady Lane-Fox, and the noble Lords, Lord Haskel and Lord Watson, asked whether there is a cohesive plan or strategy. They also asked for an update on career learning. In response, I can say that the strategic direction of the national retraining scheme is being set by the National Retraining Partnership, which is a coming together of employers, workers and government. The national retraining scheme will include a series of phased interventions and pilots, starting this year. As part of these, the flexible learning fund pilot, launched in October last year, is designed to address barriers relating to the “delivery side” of learning. It aims to do this by supporting providers to develop and test ways of delivering accessible learning for adults with low or intermediate-level technical skills or those who simply lack basic skills.
The Open University, in partnership with the Bedford College Group, Middlesbrough College and West Herts College, was successful in its £1million bid to develop its “bringing learning to life” proposal. Targeted at adults in paid work, or those looking to return to the labour market following an absence, it proposes to expand its existing online platform, OpenLearn, to include functional skills English and maths provision.
I was going to go on to talk about apprenticeships but that subject did not crop up in the debate as much as I thought it might, so I will move on swiftly to some concluding comments. I should like to focus on an important subject raised by the noble Lord, Lord Puttnam—productivity. The positive effects of part-time and continuing education should not be considered through the prism of individual benefit alone. We should also bear in mind the impact that they have on our nation’s productivity and broader economy.
Education and training make people more productive and they contribute more to our economy as a result, which I think was the gist of the noble Lord’s argument. Some estimates value universities’ contribution to human capital in one year alone to be as high as £63 billion. This Government therefore, rightly, value the world-class higher education system that exists in England, and they are taking steps to transform the other post-18 education options that are available. At this point, perhaps I will sympathise with the noble Lord, Lord Addington, who said that we are “in the first act”. I do not know how many acts he has in mind as part of his play but, to reassure him and the House today, I can say that there is an awful lot of work to do.
As the largest provider of part-time higher education in this country, the OU plays an important role in this system as it approaches its 50th year. I have two or three more questions to answer but I fear that we are running out of time. I will therefore write to the noble Lord, Lord Haskel, and the noble Baronesses, Lady Blackstone and Lady Garden, on a number of questions that they raised. However, I hope that today noble Lords have been left in no doubt that we hold the OU in high esteem and will continue to support and applaud its successes.
My Lords, I thank the Minister for his response to this debate, which has been extremely vigorous and well informed. First, I have to honour my colleague, my noble friend Lady Bryan, who demonstrated in her maiden speech that her values and her heart are in the right place. I look forward to her expressing those values in future.
A lot of people in this room know a lot of things about further education. We are a room full of experts and we should not be ashamed of that: we know what we are about. We have high hopes that the Government, in their post-18 review, will tackle what many of us perceive as a major contributor to this country’s economy. I feel that there is passion and information, and plenty of suggestions to be read in Hansard and noted. I commend the report and look forward to its application.
Social Care: Funding
Question for Short Debate
My Lords, today, the country marks the 70th anniversary of the NHS, but another equally important anniversary next month is not getting the publicity it deserves. The Seebohm report, which laid the foundations for adult social care, was published 50 years ago in August. It was an important next step that set out the way for society to provide the right support for those in our communities who needed care, whether at home, in sheltered accommodation or in a residential or nursing home. I can remember, as a schoolgirl in the late 1960s, visiting a lady in my home town’s elderly care home. It was the old workhouse, with long wards and little communal space. It was a grim and desolate place to live. Most of the residents had no visitors. How different many of today’s services are, where the focus is on keeping our elderly active and independent for as long as possible, with rooms of their own for privacy. We know that good adult social care is an absolutely vital service that transforms people’s quality of life and that it is inextricably linked with the NHS. The sustainability of the NHS cannot work without a sustainable social care system.
Much has happened in the intervening 50 years since the Seebohm report but, shockingly, over the last few years much has also gone backwards. Many of us were encouraged when the 2011 independent Dilnot Commission on Funding of Care and Support proposed a carefully structured new integrated system with a cap on social care costs, which could enable people to plan for their old age. However, since 2015, the Conservative-majority Government—and now Conservative-minority Government—have dithered and delayed, repeatedly promising that they would sort out the social care funding problem. We still await the Green Paper promised in the Conservative manifesto last year, and have seen the side skirmish of the dementia tax, a form of inverse Dilnot which so outraged voters it was dropped by the Prime Minister mid-general election.
The aspirations for a sustainable social care system, fully integrated with the NHS, are, I think, all agreed in principle. However, the current funding mechanisms make it impossible to deliver. Local authorities have faced massive cuts to all services, making £6 billion of savings in adult social care since 2010. They are still being asked to make more each year at the same time as coping with increased numbers of elderly living in their communities and an increasing number of disabled adults and children. Worse, public health, one of Seebohm’s key pillars, has taken a double hit, with £200 million cut in 2015 and a further reduction of over £300 million proposed.
These numbers are shocking enough, but the reality of reductions in funding is a reduction in services for vulnerable adults, increased charges to clients and distressing waits for people to be discharged from hospital to receive care in their communities. It is also affecting our NHS, minute by minute, hour by hour, day by day. The A&E crisis, with ambulances queuing for hours, typifies how failing to tackle social care funding impacts on the NHS. I applaud the recent announcement by the Government to rename the Department of Health as the Department of Health and Social Care, but the renaming will do nothing without the funding. The King’s Fund has identified a local government funding gap of over £2.5 billion by 2020, which is close to the Local Government Association’s own estimates. The NAO said, as it published its recent report on the health and social care interface:
“The report finds that the financial pressure that the NHS and local government are under makes closer working between them difficult and can divert them from focusing on efforts to transform services. Short-term funding arrangements and uncertainty about future funding make it more difficult for health and social care organisations to plan effectively. Although the report acknowledges the recent announcement of extra funding for the NHS, additional funding has, at times, been used to address financial pressures, rather than to make essential changes to services or adopt new technologies”.
It is those efforts to transform services that are most affected.
That is why it is good to hear that a number of think tanks and other organisations are researching this. For example, Independent Age has commissioned a series of ground-breaking data to identify the costs of social care. The project will look at the social care funding gap going up to 2031 and hopes to offer financial options that can help provide the resources needed for free personal care, as well as reporting on how these funding options will affect different social groups across the regions. The data from these reports will highlight how much the social care gap will increase without intervention, but will also offer solutions on how the Government can fill the void by modelling various revenue-raising streams, such as changes to income tax, national insurance, an age-related levy, council tax, business rates and corporation tax. It hopes also to calculate the income distribution across local authorities for each funding option.
I have one main question for the Minister. The long-promised government Green Paper must have exactly this sort of data and research sitting alongside it, along with a promise of how services will be funded. This must happen as soon as possible—there can be no more delays. Can the Minister guarantee that there will be no further delays in bringing forward a proposal to provide a real, fully funded way forward? This is necessary because behaviour in both the NHS and the social care system is being driven by financial constraints, not by the needs of individuals.
One of the more shameful periods of our history has been the warehousing of children and adults with learning and physical disabilities, who were removed from their families and even their communities. That was the norm 50 years ago, and 30 years ago there was a recognition that this was—to use a parliamentary word—inappropriate. It was more than that: it was just wrong. Over the last quarter of a century, we have moved to a better—but not perfect—system of providing where possible tailor-made support to individuals. Surely that is what a society should do for its most vulnerable members. But cuts are now driving a different behaviour.
The disability champion Lucy Watts, who was awarded an MBE for her services to young people with disabilities, lives at home with her family, who help to provide her social care support, alongside a complex care package to meet her needs. In March, when her mother was taken into hospital with a brain tumour, Lucy was told by Castle Point and Rochford Clinical Commissioning Group that she would have to move into an elderly nursing home or a learning disability home instead of staying in her own home. She is neither elderly, nor does she have a learning disability. Worse, she was told that she would not be allowed to go out, not even to visit her mum in hospital, because as a resident she would have no right to be independent. There is a happy ending to Lucy’s story: the CCG backed down. I have to say that taking on one of the country’s best young advocates for disability did not work well for it, but there are increasing reports of new care packages not offering supported living at home but a cheaper, institution-based package that removes independence but may save the funders money.
Other behaviour is worrying too. Your Lordships may know that I work closely with the Disabled Children’s Partnership, and especially with parents of the most severely disabled children in Hertfordshire, who have been fighting to keep their short-break centre open. Nascot Lawn, funded by the CCG, is special because it offers proper medical support, which these children need. The Disabled Children’s Partnership report that short-break support and social care support, whether provided by the NHS or by local authorities, is being limited and cut across the country. In the case of one family, this has meant they cannot manage their child 24 hours a day, seven days a week, 52 weeks a year, and their child has now been moved to a long-term hospital. Instead of costing the state a few thousand pounds per annum, the cost is now closer to £250,000. Some CCGs now have funding people sitting on assessment panels. That is wrong. The law is clear: an education and healthcare plan for someone aged under 18 must address the needs of the child.
The better care fund, created by the coalition as a pilot for the sharing of good practice and for helping more funds to go into local authorities to ensure that people are moved out of the NHS and back into their communities with social care support, is important and remains an excellent interim plan. Since 2015, the Government have increased the funding going into it, but they have repeatedly delayed the new funding mechanism for social care. Specifically, the delays to the Green Paper, at the same time as announcements about the long-term funding of the NHS, demonstrate that there is a failure to grapple with the social care system in England and its systemic fault lines with the NHS.
Integration is essential, with new partnerships across England—real partnerships, with joint funding and shared KPIs. A long-term funding settlement, owned by government, Parliament, all political parties and the people, is essential if we are to have a social care system of which we can be proud.
My Lords, I declare my interest as a vice-president and former chairman of the Local Government Association. I start by thanking the noble Baroness, Lady Brinton, for initiating this important debate.
Adult social care is a vital council service that helps to transform people’s quality of life. It supports adults of all ages with a range of different needs and it supports their carers. Despite the fact that it is so vital to the fabric of our society, there is a crisis in social care. We are grappling with the challenges of rising demand, people living longer and needing extra support in older age, care providers closing and contracts being handed back to councils. In my view, we need to invest new money into social care and we need to do it urgently. Despite this point being recognised across the Floor of this House, successive Governments have to date struggled to get political consensus on the long-term solutions to our national care crisis.
In my time as chairman of the Local Government Association, I was involved with many initiatives and we put forward solutions that in the end did not lead to positive change. From my many years’ experience in politics, I have to say that unfortunately sometimes our electoral cycle hampers our ability to deliver long-term solutions. But it does not need to be like that. Pension reform is a recent example of consensus and, of course, the post-war experience showed what was possible as our modern welfare state emerged.
This is not just about past precedent. Only last week, a cross-party group of Members from the Health and Social Care Committee and the Housing, Communities and Local Government Committee published their report on this issue. They called for new funding for adult social care and made it clear that bold decisions are needed if we are to solve the crisis facing the sector.
Last week’s commendable report is not the only one that has contributed to establishing cross-party support for a new way forward. The noble Lord, Lord Warner, led an excellent inquiry last year and his committee’s report, The Long-term Sustainability of the NHS and Adult Social Care, made a significant contribution to moving this conversation forward.
We also know that Members of this House and the other place recognise the need for additional funding for social care. A recent ComRes poll commissioned by the Local Government Association found that the vast majority of parliamentarians agree that additional funding should go to councils’ social care budgets to tackle the funding crisis. There is agreement among many national and local politicians that we need new money for social care. We need to work with the Government to deliver this.
As I said, there is now a clear political consensus that new money must go into social care via councils to help them to protect care services. Many council services, including housing, leisure and libraries, also help to save the NHS money. Without essential council services, we will almost certainly see further rises in demand and the accident and emergency crisis spiral to an unresolvable, year-round problem. Investing in social care will help to prevent crises in the NHS by reducing the number of people who are admitted to hospital in the first place.
Local government is absolutely essential to resolving the problem and helping people to live independent lives. Councils are the most efficient, transparent and trusted part of the public sector. They are effectively managing ever tighter budgets to maintain their track record of delivering quality services. The latest figures show that councils have reduced delayed transfers of care from hospital due to social care by 33% since July 2017. This has been at a faster rate than the NHS. This should surely help to persuade the Government to fully fund our social care system.
To conclude, I am sure that all sides of the House will welcome the new money for the NHS; the 70th birthday bonus funding is great news and much needed. We now need a similar funding boost for social care and prevention services. We need more money spent on preventing ill health. This is good for our communities and an efficient use of taxpayers’ money. I look forward to the publication of the Government’s Green Paper on social care in the autumn and with it, I hope, new money for social care services and new innovations to create a system fit for the people of the 21st century.
My Lords, I congratulate the noble Baroness, Lady Brinton, on securing this debate, although it is slightly overshadowed by the following debate, which seems to be concerned with the same issue. As a result, attendance in this debate is slightly thinner than it should be. Nevertheless, the noble Baroness has addressed an important question and I am happy to participate in the debate.
For purely historical reasons, healthcare and social care have been separated in Britain. Both were established in 1948 but under different Acts and based on different operational and funding models. The NHS was largely free at the point of delivery, whereas social care was needs or means tested. That created inequality. For example, a cancer patient could get full state funding, whereas somebody suffering from dementia could not. The question is how, in the eyes of neutral people, to justify this moral or medical asymmetry.
There is a further question. NHS funding came from central government taxation, whereas social care funding came from non-ring-fenced local authority budgets or private individuals. That was contingent, as local budgets change a great deal and do not have the same degree of certainty as central government funding does. For all those reasons, we have two separate streams with different consequences. The lack of integration between the two has cost quite a bit of money. In October 2017, there were 145,000 delayed days, as they are called, when hospital beds are taken by people for whom no home help can be found for them to be discharged to. There is a need to look at this binary distinction and see how the two can be brought together.
Need will be greater, because the population is ageing and younger people with a disability are living longer. The number of adults aged 85 or over has increased by 31%, whereas the population as a whole has increased by only 8%. So the question of social care is important. How should we handle this? What are the means to deal with it? Should we look to central taxation, which would be my suggestion? The question is whether such care should be entirely free at the point of delivery, in the same way as healthcare. I am not entirely sure that it can be, for at least two important reasons. The first is the issue of intergenerational fairness. Older people are wealthy, own houses, have assets and savings, and receive pensions, while many young people are paying off student loans, have family commitments and face higher housing costs, so they are not as well off as some elderly people. The second reason is that the personal care component of social care is different from the other components, and while that care can be guaranteed by the state, factors such as the accommodation cost component of social care perhaps need not be. We have to discuss these matters because they involve issues of moral principle. The two parties are bound to disagree, but it is important to build a cross-party consensus in this area.
There is a further question: when social care payments are made, what are the best ways of handling that? You could give cash to the individual being cared for, and in turn she or he might give that cash to the friends and relations who work for them. There are ways and means of handling social care and of getting the funds required, but again, some kind of cross-party consensus needs to be established. For me, that is a priority.
My Lords, I too join in with the general rejoicing on this the 70th anniversary of the NHS, but as others have observed, I am glad that this debate has been brought forward by the noble Baroness because it is a necessary counterpoint to that. I join the noble Lord in expressing slight surprise at how few people have wanted to contribute to this debate, but that does give those of us who are speaking a little longer to do so.
As the recent National Audit Office report, referred to by the noble Baroness, into the interface between health and social care indicates, the two areas are inextricably linked. Indeed, the dividing line can be quite hard to define, and that is one of the difficulties. For example, an exchange earlier today in your Lordships’ House touched on the different regimes in the two different worlds in terms of pay and conditions and the issues that that raises. That is but a single, tiny dimension of the challenge of joining up these two worlds. In a speech in March the Secretary of State talked about,
“whole-person integrated care with the NHS and social care systems operating as one”.
That is of course a laudable aspiration which many of us have already affirmed. He also spoke of the desire to find a sustainable funding model, and therein lies the challenge given the tendency over many years for social care always to find itself the poorer of these two siblings. Along with others, we await the Green Paper and what it might say.
Perhaps I may approach this subject in a slightly different way from other speakers by focusing on two specific areas in which I have some experience. As Bishop to Her Majesty’s Prisons, a few months ago I visited HMP Stafford, which is a prison with a growing elderly population. Carers commissioned by the local authority go into the prison to provide personal care for elderly prisoners, and when I met the governor and his senior team they were thinking positively and practically about adapting buildings and regimes to provide, in effect, a care home within the prison. As the Prisons and Probation Ombudsman observed in a report last year,
“prisons designed for fit, young men must adjust to the largely unexpected and unplanned roles of care home and even hospice”.
The challenge in HMP Stafford was clear, and while I commend those on the ground there for seeking a response, it did feel rather as if they were working on their own to find solutions; perhaps something more substantive, structured and deliberate is needed.
Some 17% of the prison population is now aged over 50. While, dare I say it, that in terms of your Lordships’ House that may not seem very old, it is the case that people in the prison population by and large age 10 years in advance of the general population, so it is a serious issue. A possible way forward was suggested when, later in that series of visits, I went to HMP Oakwood where I met fit, young prisoners who were offering informal care and support to older, infirm prisoners. While not wanting to let the public purse off the hook, I did wonder whether prison training programmes might be extended to include training and qualifications in care, thus enabling properly trained prisoners formally to support those prisoners who are their neighbours and in need of some care. Not only would the training do that, but it would give those prisoners a qualification which would enable them to find employment on release from prison. Perhaps the Minister might care to discuss that in due course with colleagues in the Ministry of Justice.
I also wonder whether there is a mechanism whereby local authority funding formulae might be adjusted where there is a prison within the local authority area which houses a disproportionate number of elderly prisoners, given the demands that that places on the local authority concerned.
My second area of comment concerns partnerships between the voluntary, community and faith organisations with statutory and other agencies. Voluntary action and activity does not mean that it is unprofessional, nor does it mean that it should come on the cheap. Many voluntary and community sector organisations employ seriously professional people at proper wages. There is also, however—I hesitate a little in talking about this because again I do not want to let the public purse off the hook—a role for that which is voluntary, in terms of time and remuneration, where people offer their expertise and their skills.
In my own diocese of Rochester, we are working with a national charitable initiative called “The Gift of Years”, with funding from the Henry Smith Charity, to establish a network of Anna chaplains and Anna friends—Anna being an elderly woman mentioned in the gospel of St Luke. Our particular focus is the pastoral care of those living with dementia and that of their carers. After a relatively short period, we now have more than 30 trained and commissioned volunteers. We have one paid professional specialist, funded by the Henry Smith Charity, and our first remunerated dementia chaplain who is funded locally by churches in Bromley. On the partnership side of this initiative, we are finding that—surprise, surprise—the local authority is increasingly beating a path to our door. There are opportunities to work closely with other organisations such as the Abbeyfield housing society and the Heart of Kent Hospice, where our pastoral carers go in to offer support to residents and patients, and of course to their families.
I hope that as government policy develops in this area and as the Green Paper is brought forward, some attention might also be given not just to, as it were, the voluntary and community sector in its big institutional forms but also to the role of local initiatives and how the relatively modest funding that is needed for them might be provided in various ways, possibly by means of grant funds for which people could apply.
I believe that there may be patterns in both of the examples I have given for other places and in other dimensions of care. In relation to the Anna chaplaincy model, it is worth noting that many of those who offer their time and skills as chaplains and friends are themselves relatively elderly people. They find huge fulfilment in serving the needs of those in their own communities.
My Lords, I declare my interests as set out in the register as chair of a charity providing services for adults with learning disabilities, and I thank my noble friend Lady Brinton for securing this important and timely debate.
The social care sector provides invaluable support to some of the most vulnerable adults in society: those who are old, frail and unable to look after themselves; those with a learning or physical disability or suffering from mental health issues or alcohol and substance abuse; and people with severe dementia. Their care is delivered thanks to the recommendation made in the Beveridge report and the subsequent legislation, but more of that in the next debate.
Learning disabilities account for one-third of the adult social care provision in England, and it is also the fastest growing sector. In 2005, only six of the 151 local authorities in England spent more on care for working-age adults than they did on care for the elderly. By 2017, 57 authorities did so. Adults with learning disabilities are living longer, although, sadly, they will still die 28 years younger than non-disabled adults. I would say to the right reverend Prelate that there are also many people with learning disabilities in prison.
In general, people with learning disabilities are leading better lives. They are moving out of institutionalised, health-based settings into supported living settings in the community. Although supported living undoubtedly delivers better life and health outcomes, it is also a more expensive option for providers. This increase in costs is increasingly not being factored into the rates paid by local authorities.
The funding gap in adult social care has been widely reported and debated in your Lordships’ House on several occasions. Several organisations have now agreed that there will be a funding gap of around £2.8 billion by 2019-20 unless we have decisive action from government. As financial pressures—such as costlier methods of support, unfunded increases in the national living wage and the apprenticeship levy and the uncertainty surrounding historical liabilities for sleep-in pay—all continue to plague the sector, a sustainable funding solution becomes increasingly vital.
The learning disability sector would like to see an annual uplift in funding of 5% each year to remain financially viable. According to the IFS, the total amount spent on adult social care in 2015-16 was £16.8 billion. To remain stable, the sector would have needed an additional £840 million for 2016-17. Instead, the IFS reported a cut of £300 million, with total expenditure falling to £16.5 billion in 2016-17. The CQC has already reported that the social care sector is at “a financial tipping point”. Earlier this year, the Government were warned that the proportion of providers in the learning disability sector now reported to be running at a deficit has more than trebled, rising from 11% in 2016-17 to 34% in 2017-18.
The sector was denied a place in the social care Green Paper, being instead part of a so-called parallel body of work that is to encompass all working-age adult social care, while the Green Paper focuses almost exclusively on older people. With the recent announcement that the Green Paper is to be postponed until the autumn and with little public detail on the parallel body of work, local authorities and social care providers alike are becoming more concerned about the financial viability of essential support services for vulnerable adults. In their recent joint report on the future of adult social care, the House of Commons Health and Social Care, and Housing, Communities and Local Government Select Committees called on the Government to widen the scope of the Green Paper to incorporate all of adult social care. When can the sector expect to hear more concrete proposals about the parallel body of work? What are the work streams? Who is on the panel? Who has given evidence and when might it report?
All of this uncertainty is overlaid on the anticipated costs as a result of sleep-in. For the sector as a whole, this should be around £400 million. I appreciate that the Government are now engaged with this situation and the results of a judicial review are awaited, so any way forward is unclear, but I would be grateful if the Minister could give me details of what consultation was done on these regulations, or even an impact assessment. If she does not have the details, I would be grateful if she would write to me and place a copy in the Library.
The funding situation is now so critical and our care and support system is in crisis. This message comes from right across the sector, the CQC and the LGA. Of course, any failure in the social care system impacts directly on the ability of the NHS to function effectively. We also need interim funding to stabilise the system as a whole. Then, new money will be needed until well into the next spending review period in order to be sustainable and to maintain quality. Without funding, we risk implementing Green Paper reforms to a system that is too destabilised by financial pressures.
Do the Government have plans to deal with failing providers, and do they understand that the tipping point is nearer than ever before? How many organisations will need to fail before the Government come out of their corner to defend the most vulnerable people in our society?
My Lords, I refer to my local government interests and I congratulate the noble Baroness, Lady Brinton, on securing this debate. When I chaired Newcastle’s social services committee in the 1970s, we trebled the meals on wheels service and doubled home care provision. We created a welfare rights service—one of the first in the country—that is now helping citizens in Newcastle to receive £8 million of benefits, and we improved residential care. Forty years on, we see a service struggling to cope with the growing needs of an ageing population, while the council’s budget, like those of councils up and down the country, has suffered savage cuts. Never before in a long political life have I witnessed Conservative councils, and the national local government bodies they lead, being as critical as they now are about the policies of a Conservative Government and their impact on local authorities and communities.
The funding cuts have been dramatic. Critically, they include £890 million in preventive services, including measures to avoid the need to admit people to hospitals, thereby adding to the problems of a radically overstretched NHS. Yet the Government expect councils somehow to reduce the number of what are described as “social care attributable delayed transfers of care”. As the LGA points out, such delays are a symptom of the problems of pressure on the NHS, not its cause. Even if the funding gap were closed, this would still leave the service significantly less well funded than in 2010, before taking into account the increasing demand of an ageing population and greater recognition of the need to tackle issues such as mental health in adults and children, which have manifested themselves increasingly over time.
Meanwhile, the Association of Directors of Adult Social Services points out that, in addition to an extra £2 billion by 2020,
“just to stabilize the market and to enable key statutory duties to be fulfilled”,
an additional 29%—£3 billion—would be required to bring social workers’ pay into line with their NHS counterparts. The 1.5 million people working in social care, as the association states, deserve such parity of esteem and should have a common structured training programme and a defined career pathway.
There are also issues, as the LGA points out, with the public health budget, which has also been hit hard, with cuts of £200 million a year and plans for a further reduction of £331 million. Such cuts, in what is essentially a preventive service, are likely to generate more demand for the NHS and social care, in addition to impacting on the lives of those the service should be protecting and enhancing. Furthermore, the early intervention grant has been slashed by £500 million since 2014, with an anticipated further fall of £183 million by 2020.
The prevention of hospital admissions per se demands a higher focus. The LGA cites evidence from a Public Health England report on falls prevention, demonstrating that for every £1 spent on assessing the home and modifications for elderly people—I declare my interest in that respect—£2.17 is saved on primary and secondary care while reducing hospital admissions by 23%. Of course, this group is growing. As Age UK reports, 1.2 million—12.5% of the age group—are living with unmet care needs.
Alarmingly, less than a third of directors of adult social care are confident that their authorities will meet their statutory duties this financial year. Councils and other providers, including charities, have hanging over them potentially large claims for payment of the national minimum wage for care workers on sleep-in shift, with HMRC pursuing providers for up to six years’ back pay. Charities estimate that HMRC could be seeking as much as £400 million to meet this bill. Given that the Government instructed local authorities to make such payments only as recently as last July, will they meet this cost? If not, what is their estimation of the impact on councils and providers?
The sector, as ADASS has pointed out, is fragile, with the percentage of the budget of county and unitary authorities spent on social care rising from 34% in 2010 to 38% now. There is concern that the growth in the number of older and younger adults with complex needs is likely to cost an additional £448 million this year. In addition to that, the so-called national living wage will cost around £585 million—essential if quality staff are to be retained and recruited. On top of all this, the expectation is that by 2025 another 350,000 people will need high levels of social care from councils.
Moreover, although the return of public health some five years ago from the NHS to local government and Public Health England is welcome, there are profound concerns about funding. Councils suffered a £200 million cut five years ago and now face a further cut of £331 million, while the early intervention grant faces a further cut of £183 million by 2020, in addition to the £500 million cut since 2013. At the time, the Conservative-led Local Government Association protested that this risked underresourcing councils in delivering early support to the children, young people and families who needed it most. It warned that councils would be,
“less able to provide support for children and families affected by disabilities or existing/potential development delays”.
All of this will surely generate greater needs and greater costs.
In Newcastle, where we are losing £280 million a year, the number of people receiving home care has fallen from 3,000 to 2,000, while adults with learning difficulties are getting four hours less of support per week. We have 71 fewer social workers than in 2014—a 12% reduction—while there has been an 86% increase in the number of safeguarding alerts. The Government have belatedly announced an increase in funding for the NHS, albeit less than is needed. When will they realise the need to increase funding for social care substantially, which would contribute to reducing the burden on the NHS? I join Sir David Behan, chief executive of the Care Quality Commission, in,
“calling for a bold and courageous settlement for future social care because we must address the quality and experience of care that older people receive”.
I would add all other people in need of such care to that.
My Lords, I thank the noble Baroness, Lady Brinton, for bringing this important debate on social care funding to the House. I thank all noble Lords for their valuable contributions. I want to take this opportunity also to personally wish the NHS and our social care system a happy 70th birthday. I thank all the people who work in it for their commitment and dedication in often difficult and challenging circumstances.
Everyone is entitled to good-quality care and support; as the noble Baroness, Lady Brinton, and the noble Lord, Lord Beecham, said, they are vital. We recognise that, as the noble Lord and others said, there are challenges, and we are doing something about them. Although 81% of adult social care providers are rated “good” or “outstanding” by the CQC, as of March 2018, it is completely unacceptable that standards in some settings fall below those rightly expected by care users and their families. That is why the Government have introduced tougher inspections, led by the Care Quality Commission, to make sure that services meet quality and safety standards.
The noble Lords, Lord Parekh and Lord Beecham, the noble Baroness, Lady Jolly, and my noble friend Lady Eaton stated that social care spending has stopped or has gaps in funding, but over the years, more money has been spent on social care. However, the growing population and the fact that people—including people with disabilities—are living longer are contributing factors, as acknowledged by my noble friend Lady Eaton. The noble Baroness, Lady Brinton, acknowledged that in the short term, the Government have given councils access to up to £9.4 billion more in dedicated funding for social care over the three years up to 2019-20. This means that overall funding for social care is increasing by 8% in real terms over this spending review period.
The additional resources are helping councils to commission care services that are sustainable and diverse, offering sufficient high-quality care and support for people in their areas. As I have already said, I recognise that there is much more to do, as stated by the noble Lord, Lord Beecham, the noble Baroness, Lady Brinton, and my noble friend Lady Eaton. Performance is not just about money. Funding will be supplemented with targeted measures to ensure that the areas facing the greatest challenges improve services at the interface between social care and the NHS.
My noble friend—he is a noble friend—Lord Beecham mentioned Newcastle. Thanks to a range of government actions, Newcastle-upon-Tyne received an additional £20.4 million for adult social care in 2018-19. We have already seen a real difference to services across the country. Social care-related delayed transfers of care had been rising year on year between 2014 and February 2017, but since taking action last year, we have achieved a reduction of 40%. Some councils, such as Darlington, Slough and Telford, had no delayed discharges, which I know my noble friend Lady Eaton will be pleased to hear.
Looking ahead, it is right that social care funding be agreed alongside along the rest of the local government settlement at the forthcoming spending review. Decisions on future reforms must be aligned, which is why we will publish the Green Paper in the autumn, around the same time as the NHS plan. As identified by the noble Baroness, Lady Brinton, yesterday’s NAO report also made it clear that,
“the changing needs of the population require changes to the way health and social care services are organised and delivered”.
I cannot give the guarantee that the noble Baroness requested regarding the timing of the Green Paper, but I will return to some of the issues that she raised. The NAO also stated that carers and those who need care must be put at the centre of any reform. The Green Paper will take its report into account.
The noble Baroness, Lady Jolly, and the noble Lord, Lord Beecham, raised the issue of the Competition and Markets Authority report, which also presented important findings on the care market, the need to strengthen consumer protections and the importance of supporting people to make choices about their care. Having accepted all of the CMA’s recommendations earlier this year, we are now working closely with industry, wider stakeholders and the CMA through the implementation phase. Those issues will be further addressed in the Green Paper.
As stated by a number of noble Lords, through the better care fund, local areas voluntarily pooled more than the minimum required in both 2015-16 and 2016-17, taking the total to £5.3 billion and £5.9 billion respectively. In 2015-16, 90% of local area leaders said the better care fund had already had a positive impact on local integration. I agree with the noble Baronesses, Lady Jolly and Lady Brinton, that people with disabilities and people of working age with care needs face a number of challenges. As indicated by the noble Baroness, Lady Jolly, we are taking forward a piece of work—led by the Department of Health and Social Care and the Ministry of Housing, Communities and Local Government—that will consider any issues specific to working-age adults and therefore not covered in the Green Paper. We will set out the results of this work in due course. I will write to the noble Baroness, Lady Jolly, to answer her specific questions on impact assessments and the consultations that have taken place, and place a copy in the Library.
As mentioned by a number of noble Lords, the recent Select Committee report, Long-term Funding of Adult Social Care, suggests that a tax on the over-40s or a social care premium similar to the German-Japanese model is the right way forward. The Government are committed to ensuring that everyone has access to the care and support they need, but we are clear that people should continue to expect to contribute to their care costs as part of preparing for later life. I can confirm for the noble Baroness, Lady Brinton, that the Green Paper will set out proposals for a sustainable system. Reforms must be affordable and fair across generations, including to working-age taxpayers. As noted by the right reverend Prelate the Bishop of Rochester, the Green Paper will bring forward proposals to build on the seven principles set out by the Secretary of State: quality and safety in service provision; whole-person, integrated care with the NHS and social care systems operating as one; better practical support for families and carers; and a sustainable funding model for social care supported by a diverse, vibrant and stable market. However, we are looking at the exact proposals in the Select Committee’s report and the Government will of course respond in due course.
Noble Lords did not mention the parliamentary commission, but I want to say that we welcome parliamentarians across the House and people in the NHS and social care coming together to look at how we can improve and make a more sustainable system.
The right reverend Prelate commented on informal carers and voluntary work. The Government are committed to continuing to support carers to provide care as they would wish, and to do so in a way that supports their own health and well-being, employment and other life chances. On 5 June, the Government published the Carers Action Plan which sets out a cross-government programme of targeted work to support carers over the next two years. As noble Lords have stated, a sustainable future for social care will simply not be possible without focusing on how our society supports carers. They are vital partners in the health and care system. I would be delighted to look at the Ministry of Justice system and learn from that experience. Indeed, as the Minister is here, I will ensure that that system is also drawn to his attention.
The noble Baronesses, Lady Brinton and Lady Jolly, and the noble Lord, Lord Beecham, also identified NHS mental health services. Of course, mental health services are important and are available for people with poor mental health, including carers. The improving access to psychological therapies programme provides treatment for adult anxiety disorders and depression in England.
My time is nearly up. I think I have answered most questions and as I said, I will write to the noble Baroness, Lady Jolly, about the two questions she asked. If there are any other questions outstanding, I will write to noble Lords and put a copy of my response in the Library. I conclude by thanking all noble Lords for their contributions and I look forward to us working together to find a long-term, sustainable solution—a sustainable way forward—to meet the care needs of some of the most vulnerable people in our society. I end by saying to the noble Baroness, Lady Brinton, that I was very sorry to hear Lucy and her family’s story. Those sorts of issues should not be in the system. I acknowledge that they are and we will try to sort them out. Thank you.
Motion to Take Note
My Lords, in opening this debate, I declare my interest. I am a practising surgeon in the NHS at St Mary’s Hospital, Paddington, and the Royal Marsden and am the chair of surgery at Imperial College. I proudly sit as a non-executive director of NHS Improvement. Over the past 10 months, I have led an independent review of the health and care system with the Institute for Public Policy Research.
As a surgeon and a former Health Minister, it is a great honour to speak in this place to mark the 70th anniversary of the National Health Service. The NHS is this country’s most treasured institution. It touches our lives at times of the most basic human need when care and compassion matter most. This is a time for reflection to celebrate the institution and give thanks to NHS staff for their service to our nation, and to look to the future.
The NHS is the expression of the moral principle that no one should be denied healthcare because of their means—the idea that the provision of healthcare should be based on need and not the ability to pay. Most people alive today cannot recall the time before the health service was created. With each passing year, the number of people who can recall the pre-NHS era recedes, but if we are to secure its future we must never forget what preceded it.
A friend recently told me the story of his family. His parent worked in the textile mills in Lancashire that have long since disappeared. In the simple kitchen there were two sugar bowls. One was for the sugar and the other for the doctor. It was where they would save a penny or two whenever they could so that, if any member of the family got sick, they could pay for a visit to a doctor. Fear of falling sick was a normal part of daily life in Britain. Illness was the surest path to poverty and destitution, not just for the individuals but for whole families. The founding of the NHS took that fear away for millions and it is a fear that those of us born since have never known and can only imagine.
The NHS was the greatest achievement of the post-war Labour Government. We owe an eternal debt of gratitude to Nye Bevan for his vision, passion and determination to establish the health service. He memorably described the NHS as taking the place of fear. It remains one of the most extraordinary achievements of any society anywhere in the world. It is on occasions such as the 70th anniversary that we must make and remake the case for comprehensive, universal healthcare, free at the point of need for all.
Never let anyone tell you that we cannot afford the NHS. The moral principle of universal access to healthcare is shared by all people everywhere. Those countries that have made it a reality have done so in different ways, but by far the most efficient, dignified and lowest cost is to create a universal service free at the point of need funded by taxation. Private insurance and social insurance systems are much more costly. Those who argue that we cannot afford the NHS are seriously wrong. It is a fundamental error of logic to say that something is unaffordable so we should make the move to something more expensive.
The NHS is funded by us all. It serves each of us and it reflects the best of us. The health service employs 1.5 million people across the four nations of the United Kingdom—that is 5% of all working people in our country. The NHS is its people, not only the doctors and nurses but clinicians of all kinds and the porters, cooks, cleaners and, yes, the vital managers and administrators too. Spending a day working as a porter in the NHS was one of the most illuminating moments of my career. Every member of Team NHS matters. Every one has a contribution to make and each is valuable. I pay tribute to the NHS employees of today who are my colleagues, and to the NHS staff of previous generations. On this day of thanksgiving, we owe them a lasting debt of gratitude.
I have worked in the NHS for longer than I have been a citizen of this country. In a time of great anxiety, I pay a special tribute to the citizens of other countries who have helped to build our NHS throughout its existence and remain the backbone of it today. From the Windrush generation to the European citizens and nationals of every race and creed, from every corner of the world today, they have made an immeasurable contribution. Let that never be forgotten.
NHS staff work at the frontiers of innovation because healthcare exists at the limits of science. This country is a scientific superpower with an extraordinary record of discovery and invention, yet in recent years we have fallen behind on investments in R&D. R&D is the engine of innovation yet R&D spending as a share of GDP has been falling while our competitors have invested more. We need a new commitment to be at the top quartile of advanced countries for R&D investment. The future prosperity of our country depends on it.
Many of the most important medical discoveries took place in this country, often through partnership between the NHS and the universities. No matter the challenges, we are constantly finding new ways to treat disease and soothe pain and suffering. That means that high-quality care is constantly a moving target: to stand still is to fall back. What energises NHS staff is relentlessly improving the quality of care they deliver to their patients. In my review of the NHS with the IPPR we found that, on a wide range of measures, the NHS has maintained and improved the quality of care it provides. Fewer people are harmed and more people are cured than ever before. There is a huge amount to celebrate and to be proud of, yet we should frankly acknowledge the difficulties the health service has faced. The past decade has been the most austere since the health service was founded. Waiting times have risen considerably and the system has been subject to needless destructive reforms. The NHS is not failing, but it is fragile.
A properly funded NHS is the foundation on which a fair, cohesive and inclusive society is built, so the new funding settlement announced by the Prime Minister, the Chancellor and the Secretary of State for Health is very welcome. My friend the noble Lord, Lord Prior, and I, together with the IPPR, recommended a 3.5% annual funding increase: the Government came close, with 3.4%. However, the settlement did not include public health, capital investment or education and training. Each of these is vital and the Government must now deliver on them too.
Securing the NHS is an eternal task. It is no more perfect than life itself. That is why new investment must be joined with reform. Together with the noble Lord, Lord Prior, and the IPPR, I set out a 10-point plan for a 21st-century NHS. At its heart is a new vision, what we call “neighbourhood NHS”, where services are organised around groups of patients with broadly similar needs, rather than groups of professionals with broadly similar skills. We argue that there should be a new option for single integrated care trusts, able to take responsibility for all the health and care needs of a population.
Warm words on mental health must be followed by bold actions. Parity of esteem should mean parity of service. Bringing care closer to people is a crucial principle for a modern NHS, yet for too long the NHS has said it would invest more in care closer to people yet continues to do the inverse of its stated strategy. Each year we say that resources will shift and each year they flow upwards towards hospitals rather than outwards towards communities. That is why we must lock in more spending on primary, community and mental health services each year in the decade ahead.
As we celebrate the past on this anniversary day, we must also look to the future. It is our duty to seize all the technological opportunities that this new era offers. There must be a tilt towards tech to create a digital-first health and care system. That will demand investment in digital infrastructure, improved data sharing and embracing full automation. Many people fear that automation will destroy jobs, but it is much more likely to reshape them by taking away mundane tasks that fill most of our time working in the NHS. This will release more time to care and give more space for clinical reasoning, for research and for innovation.
I have spent decades developing robotic surgery. The robots have yet to replace me, but they have helped me deliver higher-quality care to my patients. For all these improvements to happen, we need a radical simplification of the system. It has become impossibly complicated and is in desperate need of change. I therefore welcome the Prime Minister’s commitment to bring forward legislative change. Tinkering at the edges will not be enough: we need fundamental reform. Above all else, we need to confront the great social challenge of today, which is social care, as we heard earlier.
When the NHS was founded, life expectancy for men was 66 and for women it was just 71. Today, it is 79 and 83 respectively. Today, one-quarter of NHS beds are occupied by patients who are medically fit to go home, if there were good enough support for them. More than £3 billion a year of NHS money is wasted by delayed transfers or transitions of care. If Bevan were designing the health service today, it is unimaginable that he would have excluded social care. We must now extend that simple, noble, brilliant principle of care based on need rather than the ability to pay from the NHS and apply it to social care.
Social care reform has become the third rail of British politics: any politician touching it swiftly expires. Between now and 2030 the number of people over the age of 65 will increase by about one-third and the number of those over 85 will nearly double. At the same time, the working-age population will increase by just about 3%. If we do not act now, a heavy burden will fall on families to take care of their relatives. Since 2010, social care has been slashed. Despite rising demand, state social care has plummeted by 27%. That does not mean that less care has been provided. There has been a dramatic rise in informal care. Critics will argue that the older generation should contribute more of their wealth to pay for social care, particularly the wealth locked up in housing, but tying social care reform to the thorny issue of wealth inequality and taxation is wrong. If we make that hurdle for social care reform, there will be no progress at all. Surely, the level of personal wealth is a better basis for wealth taxation than the need for social care.
Better social care means that families spend less time on functional tasks and more time on relationships. If we want a less lonely and more dignified future for our ageing society, now is the time to act. There could be no better birthday present for the health service. It has been a privilege for me to open this debate, but it has been the greatest honour of my life serving the National Health Service for nearly 30 years. In 30 years from today I hope to see the NHS’s centenary. It is a great comfort to know, for me just as for all of us, that the NHS will be there to provide care and compassion when it matters most.
My Lords, I thank the noble Lord, Lord Darzi, for introducing this important debate. It is a privilege to follow him, as a fellow surgeon. The debate marks the 70th birthday of the NHS and the social care system, and the role that Aneurin Bevan played in it. Making our health service free at the point of need and use while social care remains means-tested has created an unfair system. Equal opportunities and the emancipation of the workforce has meant that an army of carers which used to exist to look after one’s own is no longer there, and increasingly we turn to care homes for our elderly.
The noble Lords, Lord Darzi and Lord Prior, in their excellent report Better Health and Care for All, published in June, focused on social care, public health and life sciences. This debate makes the case for integrated health, mental health, social care and community care. The creation of a Department of Health and Social Care this year is a welcome first step in recognising the importance of integration. This report makes the case for releasing time for health professionals to care and makes a plea to trust the judgment of professionals. These words are welcome in a health service where professionals feel that top-down management calls the shots, rather than those at the coalface—that is not meant to be a reference to Tredegar.
The challenge for government is to extend the principle of need and not the ability to pay to social care and to fully fund the service as part of a new social contract between citizen and state. We await the Government’s Green Paper on social care, alongside the NHS plan, in the autumn with keen interest, mindful that in the past 20 years, with 12 Green Papers and White Papers and five independent commissions, successive Governments have kicked the can down the road when social care reform is considered. The Government accepted the proposals in the Dilnot report of 2011, albeit with a different cap, yet in 2018 we do not have any action on them. I am sure that my friend, the noble Lord, Lord Warner, will say something about that in his speech. Can we expect a definitive statement on this, along with the Green Paper, in the autumn?
There also needs to be a paradigm shift in the model of urgent and emergency care, the workforce to deliver it and the contribution of patients to manage their own health. The days of “doctor knows best”—let alone politicians or managers—are over. As chairman of the Independent Reconfiguration Panel, which advises the Secretary of State for Health on contested service change, I know that a sound clinical case for change is necessary but not sufficient to achieve change. For that to happen in the future, the views of patients and the public must lead the decisions about their health and healthcare. The challenge, as always, is how to achieve that in a meaningful and effective way.
My Lords, it is a great pleasure to congratulate my noble friend—and respected colleague at Imperial College—Lord Darzi on the outstanding way he introduced the debate. I was just talking to the noble Lord, Lord Reid, in the Bar and he said that sometimes you tear up the speech that you have written. This is one of those occasions.
At 8.40 am today, my grandson was born at Queen Charlotte’s and Chelsea Hospital under the National Health Service. My daughter had a horrendous pregnancy four years ago. I went through every single red light in London, I think, on my way to Queen Charlotte’s, when she had the most serious obstetric emergency and could have died. In fact, both she and the baby, Ellie, survived and are well, and she had this last pregnancy by elective caesarean section. It is striking that the National Health Service has been an example of the most amazing care. When I took her into Queen Charlotte’s the first time, she was delivered within 13 minutes of arrival on site and they did not even recognise me, even though I had helped design the building in which she was being delivered. That is a great credit to the health service.
Today there was a slightly different welcome when I drove up to the car park. It was completely blocked by television cameras, with various news media filming Queen Charlotte’s in all its panoply of glory, accompanied by wonderful, syrupy comments about the National Health Service. While I was hoping to hear a baby cry in the operating theatre next door, I was watching the coverage on television as an example of exactly what we do not need. My noble friend Lord Darzi was completely right, in the humble way he introduced the debate, to point out how magnificent the health service has been, but it is also important for us to be realistic. There is a major problem that we have to face and it is often easy to be really quite untruthful about the impact.
We are not having a proper debate about the health service in this country. I mean no disrespect to the Prime Minister or anybody else but we cannot continue on handouts. Both parties have been equally responsible. We always claim on this side that we invented the health service. I remember that when the dreadful internal market was brought in by Margaret Thatcher, Frank Dobson, the shadow Health Minister, promised he would abolish it. He did not when we came into power. We still have that iniquitous system, which is costing the National Health Service millions in bureaucracy and all sorts of other things, and of course resulting in health inequality, with the postcode lottery and many other examples.
We have to recognise that we need to have an honest debate and the only way we can do this is to depoliticise the system and the argument. We have to recognise that on all sides of this House we agree about the value of the National Health Service. We all realise that it is a remarkable and unique but fragile organisation. We need to do something about recognising that first we have to agree on a proportion of gross domestic product to understand how we are going to fund it before we consider taxation or any other form of spending. We have to understand how much it actually costs and at the moment, with that internal market, sadly, we do not know that. That is a major problem for us and something that I hope we will look at.
My noble friend Lord Darzi reiterated a very important point that I made in a debate about a month ago when I pointed out the importance of academic healthcare and the academic science centres. This is something which really is unique in the health service and unless we continue with that aspect of science, there will be a problem. So we have to weigh that in the balance of how we fund the health service in the future.
My Lords, I congratulate the noble Lord, Lord Darzi, on securing this extremely timely debate, and pay tribute to the wonderful work and care of all staff in both the health and social care sectors. I will start with my favourite Bevan quote before someone else gets it in. Back in 1948 he said:
“Illness is neither an indulgence for which people have to pay nor an offence for which they should be penalised, but a misfortune the cost of which should be shared by the community”.
How do we reinterpret this incredibly important founding sentiment of the NHS in the modern age and over the next 70 years?
Recent polling by the King’s Fund shows that the British people have a great deal and pride in and good will towards the NHS. Despite this, securing proper long-term investment to achieve a fully integrated health and care service has sometimes felt like pulling teeth. Yes, the Prime Minister announced that the NHS would get a 3.4% yearly rise for its birthday and of course that is to be welcomed, but we cannot ignore the fact that the often-cited 4% necessary to even maintain existing standards, let alone improve and transform services, is still some way off. Sadly, as others have said, this new long-term funding settlement has so far ignored social care and public health and there is no clarity on what proportion of this money will go into mental health care—something I hope the Minister will be able to help us with this afternoon.
To meet increasing demand, the NHS will need more than just money: it will need a wholesale shift to promoting health as well as healthcare, to ensuring wellness rather than just treating illness, and to integrating health services so that they can be centred around the individual and the holistic needs of each patient. It came as no surprise to read in the Guardian last week that keeping the same doctor improves a patient’s life expectancy. This is great news so why is it so often not the case?
Turning briefly to social care, as we have just heard, continuous cuts, coupled with chronic long-term underinvestment, have left social care in a dire state. In their recent report, What’s the Problem with Social Care, and Why Do We Need to Do Better?, four leading health and social care bodies reported that to qualify for publicly funded social care, someone now needs to be 12% poorer than eight years ago. Meanwhile, informal carers continue to carry the bulk of the burden. The IPPR estimates that insufficient social care costs the NHS £3 billion a year, and with an ageing population these costs are bound to increase. If we are serious about safeguarding the NHS and its future, social care needs its birthday cake, too, and it needs to be a big one.
Turning to public health, in their recent report, The NHS at 70: Are We Expecting Too Much from the NHS?, those same four health bodies again emphasised that the most important factors in people’s health and life expectancy relate to the economic, physical and social environment in which they live. Therefore, public health must be made a priority if we are to have a healthier population.
Mental health is starting to get the public attention that it deserves. A recent Ipsos MORI poll found that the public rate it as their second-to-top health priority, which is great—but it is critical that those money increases are accompanied by mental health services that are much better integrated with physical health, community care and social care. So when the Minister winds up, perhaps he will tell us whether he feels that it is acceptable that currently only some one in four people with a mental health problem is able to access treatment, and what plans the Government have to increase this—and, specifically, what percentage of the new money announced for the NHS will go to mental health.
I conclude by saying that a good way of addressing all the issues that I and others have raised today will be to reframe the way we talk about the NHS as a national wellness service rather than one that just treats illness. I like to think that Aneurin Bevan and Beveridge would approve of that sentiment.
My Lords, I thank the noble Lord, Lord Darzi, for introducing this important debate. My colleagues and I have been at the cutting edge of the integration agenda for 35 years now. We are today generating a national and international movement and infecting the NHS culture. This year we have welcomed leaders from 23 countries across the world to see our work. Today I am taking our experience to 10 cities and towns in the north of England, through the Well North programme, which I have been asked to lead by the CEO of Public Health England. I declare my interests.
If we are to have an NHS in 70 years’ time, we suggest the following steps, based on hard-won practical experience. First, we must return to the fundamental question raised by the Peckham experiment in 1948, “What is health?”. The NHS closed this project in 1952, saying that its services would now be delivered by the NHS. It was wrong. Some 50% of our patients today do not have a biomedical problem: they have a housing, education or employment problem, or they are lonely. I am finding similar numbers in communities in the north of England. The Bromley by Bow Centre is Peckham mark II, but this time with a business plan.
Secondly, we should stop building health centres. Today we offer a vast array of services to our local community and our 40,000 patients. They stretch from conventional healthcare for local residents to opportunities to set up your own business, from support with tackling credit card debts to help with learning to read and write and help up the career ladder. We should stop building health centres, but that is not to denigrate clinical health. On the contrary, we need to position clinical health within a broad range of services to drive well-being in communities.
The list in this debate question is far too limited. We need to create a locally blended offer, where doctors sit alongside others, including patients and local residents, to provide what people need. It is healthier for doctors. Our health centres are more like a John Lewis store, where the customer is welcomed in and a host of choices are laid before them. The people who run successful department stores know that a diverse product range makes complete sense for the customer and financial sense for the business. You can capture the customer and have an opportunity to offer myriad products and services. It is the same principle in integrated holistic centres, where health is about life and living, not just disease and illness. It is about sweating our community assets. This approach would create benefits and savings across a range of Whitehall departments, not just the Department of Health.
We are working with our partners to build two new town centres in Rotherham and Stocksbridge, just outside Sheffield. The retail sector is challenged at the moment by the internet, but there is a real opportunity to rethink what a town centre is and to put the heart back into it. We will require flexibility and imagination from the NHS and other government departments.
Thirdly, over the years we have developed many innovations that have quietly gone national. The latest is the social prescribing movement which we founded in Bromley. It is now in 20% of GP practices nationally and 80% in Tower Hamlets; there is a network of 2,000 social prescribers across the country. Social prescribing should be the norm in every practice, because it focuses on what matters to patients rather than what is the matter with them. It also ensures maximum engagement with patients in managing their own health. Let us unleash healthy communities.
Finally, there is too much focus on beds and hospitals rather than on early intervention. People believe that the NHS will solve their health problems; often it will not. We are breeding a massive dependency culture through an institution that I would suggest is far from well. Let us be honest. It is not lack of resources that is the problem, but what we have chosen to focus on. I fear more of the same. What happened to the five-year plan? It is time to be more radical. Let us drop the sentimentality about the NHS and return to the fundamental question: what is health in the modern world for our children, in a society that is increasingly atomising? I agree with the noble Lord, Lord Darzi. It is time for fundamental reform, based not on sentiment, theories or ideology but on practical innovation and experience on the ground—and it cannot be led simply by the vested interests of the medical profession.
My Lords, I am delighted that the noble Lord, Lord Darzi, has not been replaced by a robot, and I thank him for the wonderful way in which he introduced an important debate on an important day. Like many people in our country, I owe a huge debt of gratitude to the NHS. It nursed me back to health when I broke my back in a riding accident at the age of 17, and today the brilliant rheumatology and orthopaedic departments at Guy’s and St Thomas’, along with my exceptional GP Stephen Liversedge, literally hold me together and keep me physically and economically active. I congratulate the noble Lord, Lord Winston, on the birth of his new grandchild. Three weeks ago my daughter gave birth to my grandson at St Thomas’. I cannot praise the community midwives and the staff of St Thomas’ who looked after her highly enough.
It is hard work not being well, especially as you get older or suffer economic hardship alongside being poorly. In the mid-1990s, when I was deputy chairman of the then Salford Royal Hospital NHS Trust, I would regularly pop into the hospital at weekends to speak to visitors, patients and staff when they had a bit more time to talk and were less stressed. Invariably, at the top of their health concerns would be worries about not being able to park, difficulty getting transport to hospital, childcare while they were in hospital or visiting, weariness at constantly having to explain their symptoms and their circumstances, fear of losing their independence and their job and fear of not being able to cope with the financial burden of recuperation or to care for themselves or their relatives when they returned home. Much of this is beyond the control of the NHS, but all of it is an important ingredient in the recovery and well-being of patients and their families. That is why it is crucial that we bring together as many services and patients as possible, taking a holistic view that puts people at the centre of decision-making.
In 2015 the 37 NHS organisations and local authorities in Greater Manchester came together to form the Greater Manchester Health and Social Care Partnership and signed a ground-breaking agreement with the Government to transfer the management of these services to Greater Manchester. The Government’s enabling legislation, the Cities and Local Government Devolution Act 2016, made this a reality. In one of its documents, the partnership said:
“Our health and social care reform is built on the need to reimagine services across our whole care system”.
I am delighted to say that, in my home town of Bolton, which is one of the 10 metropolitan and city councils that make up Greater Manchester, reimagining began on Tuesday with a decision by the council and the NHS to work together to take steps to join up health and care. I wish them well.
This builds on an already established and visionary partnership between the council, the NHS and the University of Bolton, which in 2012 saw the opening of Bolton One, a £31 million health, leisure and research centre. Our universities, with their research facilities and training in new ways of working, are vital in this mix of integrated care—and it is not just universities with medical schools but all universities across the country that are delivering excellent work in health and social care. I hope noble Lords will indulge me if I single out the University of Bolton, where I served as the first chancellor, for being ranked number one in England for teaching quality across its nursing courses in the Times and Sunday Times Good University Guide 2018.
I cannot begin to imagine what the future of the NHS will look like, with new technologies and redesigned services. But the one constant will be the dedication and experience of the people on the ground, doing the job and working so hard to look after us and keep us well. I pay tribute to them and wish the NHS a very happy 70th birthday.
My Lords, I, too, congratulate my noble friend on initiating this important debate. It is true that the National Health Service has grown under successive Governments, but currently the growth is slower than at any time in its history. Even the latest cash injection, recently announced, will, in the view of many health service organisations and influential experts, including the Association of Directors of Adult Social Services, the MS Society and the local government society are saying that it is clearly disappointing, that funding is at a standstill and that it is a sticking plaster at best.
The statement from the Prime Minister that social care must wait until 2020 for extra funds—which will not be additional to the £20 billion injection—beggars belief. Where, however, does that leave the Secretary of State? During the debate of 25 January I congratulated him on standing up to the Prime Minister with his implied resignation threat. However, when he was appeased with another string to his bow—the addition of social care to his title—he backtracked. I, and no doubt he, along with others, believed that that would bring extra cash on top of what came with his previous title. Since then, the Prime Minister has made it absolutely clear—Green Paper or not—that no extra money will be forthcoming. Surely Mr Hunt expected more money—for mental health issues, obesity, carers and the vulnerable in our society—when he threatened resignation.
The honourable thing to do, surely, is to adhere to his earlier threat and resign. Ruling out any increase in social care until 2020 makes a nonsense of giving the Secretary of State the additional handle of social care. By definition, that means extra responsibilities and funding now. That is what I thought when we debated the National Health Service and social care in January and I said that the Secretary of State had a golden opportunity—when the Green Paper comes to light—to prove his critics wrong and produce a meaningful improvement in social care provision. Unhappily, however, the Prime Minister has done it again: another promise not kept.
As the noble Lord who introduced this debate said, in a debate of this kind it is important to remind the nation—especially on the 70th birthday of the NHS—that it was Clement Attlee’s Government, and no other, that brought to life the National Health Service, and hopefully to end for all time the lie espoused by Jeremy Hunt at the last Tory party conference, when he claimed that the Tories, and not the Labour Government, invented the National Health Service. History books, and Hansard, clearly show that it was Aneurin Bevan who introduced the first comprehensive national scheme in 1948, when Tory luminaries Winston Churchill, Anthony Eden and Harold Macmillan—all former Tory Prime Ministers—were among other Tories who voted against the implementation of this bold policy. The result of that vote was an enormous victory for the Labour Party and for the nation. I hope that this gigantic lie by the Secretary of State will be laid to rest for ever.
My Lords, I too am most grateful to the noble Lord, Lord Darzi, for securing this timely debate. On the one hand, I am grateful because it is an opportunity to recall and be thankful for the establishment of the NHS in 1948 as one part of a comprehensive vision of social welfare—which, incidentally, owed much to the insight and energy of Archbishop William Temple and other Christian thinkers and activists. Temple and Beveridge were close friends, and much of the post-World War II vision that led to the creation of the welfare state by Bevan and others emerged from church-led consultations.
On the other hand, I am grateful for the clear emphasis in this debate on integration. Our word “health” comes from an Old English word meaning “wholeness”, and the Old Norse version of that word meant “holy” or “sacred”. From the start, when churches and monasteries founded our first hospitals, healthcare has been understood holistically. There is a real sense in which our National Health Service should include caring for all aspects of well-being in all our people. Certainly, in the Select Committee report on the long-term sustainability of the NHS the word “integration” appeared several times.
In the brief time available, I will suggest two aspects of healthcare that fall into the community care category, and which, like mental health and social care, urgently need integrating with other parts of the NHS. The first and most obvious is public health. Here I declare an interest as an associate of the Faculty of Public Health. Other noble Lords have raised this and I am sure others will. I will not, therefore, dwell on it, but from a purely financial point of view money spent on prevention bears obvious dividends: it is never wasted. From a well-being angle, furthermore, prevention has always been better than cure and always will be, especially in relation to our consumption of food and alcohol and our commitment to taking exercise.
The second aspect is spiritual well-being. The World Health Organization understands spirituality as,
“an integrating component, holding together the physical, psychological and social components of a person’s life”.
It is often perceived as concerned with meaning and purpose. For those nearing the end of life, this is commonly associated with a need for forgiveness, reconciliation and affirmation of worth.
Delivery of spiritual care is the responsibility of all professionals in the multidisciplinary healthcare team. This debate, however, provides the opportunity to affirm the vital role of healthcare chaplains, who minister to the spiritual needs of those from all religions and none.
Underlying all this is a significant question of responsibility. Who is responsible for making all this integration happen? We ourselves have an obvious responsibility, as every citizen does, when it comes to prevention but with regard to the integration of physical and mental health with social and community care, do we look primarily to NHS England, regional STPs, local trusts or Parliament to take a lead? I would be most grateful for the Minister’s view on this. There is also the question of consultation. The foundation of the NHS followed a comprehensive and inclusive debate in UK society. Are there any plans for a similar process of inclusive debate, in which all voices are heard and all concerns addressed, as we look forward to the next 70 years of our invaluable National Health Service?
It is an immense pleasure to follow my favourite Bishop. Fortunately, none of the others are here to learn that I care for them less.
I would like to offer a few reflections on the historical background to this important debate, introduced so memorably by the noble Lord, Lord Darzi. I am a historian and a few words about what happened in the 1940s would perhaps not come amiss. I should say at the outset that I take a view very different from that of the noble Lord, Lord Pendry.
In this very month 74 years ago, the then Minister of Health broadcast a message of historic importance to the nation about the Government’s plans for a national health service. He said:
“Whatever your income, if you want to use the service … there’ll be no charge for treatment. The National Health Service will include family doctors whom you choose for yourselves, and who will attend you in your … homes when this is necessary. It’ll cover any medicines you may need, specialist advice, and of course hospital treatment whatever the illness”.
It was with these words in July 1944 that Henry Willink, the Conservative Minister of Health in Churchill’s wartime coalition, heralded a new era in which comprehensive health services would be available to all, free at the point of use. It would be the fulfilment of the vision that Neville Chamberlain, a formidable Health Minister in the 1920s and the greatest of all Tory social reformers, had hoped would one day be accomplished.
Willink set to work. The British Medical Association swiftly assumed the role that was to become so familiar to British politicians over the years, putting the self-interest of its members before all other considerations. Willink was an able but emollient man. He made many concessions to the BMA, though without weakening the Tory commitment to the principles of universality and free delivery of services underlined in the 1945 Conservative election manifesto.
Today, no one remembers Henry Willink, who gave up politics in 1948 to become the master of a Cambridge college, while enduring fame is attached to his successor. Nye Bevan fought the BMA with vigour and panache, which Willink would never have done. He too made significant concessions but his ferocious public rows with the BMA dominated the headlines, while his concessions attracted much less notice. This worked hugely to Bevan’s advantage. As his perceptive biographer, the leading historian Dr John Campbell, has observed,
“it was politically useful to Bevan that the BMA made such a fuss. It seems clear that Bevan privately welcomed, if he did not positively encourage, the BMA’s help in making the NHS appear a more socialist measure than it really was”.
There was not a great deal in Bevan’s plans that the Tories found wholly objectionable; after all, they shared the same objectives. But Bevan, consummate party politician that he was, exploited the Tories’ decision to oppose the complete nationalisation of hospitals. He relished blackening their name as the enemies of a great national reform. It was on the evening before the NHS came into operation that he made his notorious speech denouncing them as “lower than vermin”.
One of the great tragedies, perhaps, of the fierce partisan wrangling that took place over the structure of the NHS is that no one thought about its cost, even in Whitehall. Finance was not discussed as the legislation went through Parliament. As a result of this omission, politicians of both parties would be plunged into recurrent funding crises over the next 70 years. Bevan’s achievement was prodigious. Nevertheless, as John Campbell has pointed out,
“it must be said that too much can be claimed for him, and in Labour mythology often is”.
There was wide cross-party support for the NHS at its inception, just as there is today on its 70th birthday. It is perhaps a time for remembering Sir Henry Willink, as well as the great Nye Bevan.
I thank my noble friend Lord Darzi for initiating this debate and I thank Nye Bevan for his towering achievement in setting up the NHS against concerted opposition—a miracle for those who had no money.
We still expect the NHS to cure all our social ills while tackling permanent supply and demand challenges. Government-imposed changes in legislation, reorganisation and financial stop/start policies make it difficult to plan for the long term and apply consistent recruitment and training policies.
If there is a chronic shortage of doctors, we import them. The Royal College of Physicians says that we are currently training only half the number of doctors required by 2030 and the cap on medical school places means that we reject half of all eligible applicants— 770 of them with at least three straight grade A’s at A-level. While I am not trying to correlate the possession of three A-levels with suitability, we should be training more in the UK. Instead, 700 rejected medical student applicants a year are studying to be doctors in the eight English-language medical institutions set up in former eastern bloc countries. This is crazy, and it is the responsibility of the Government. The recent announcement of more places is too little, too late.
The NHS cannot solve all our social ills. We do not have a proper social care system, and that has an immediate impact on hospital beds. Our GP system has been weakened to the extent that many patients do not have a hope of seeing their local doctor when they need to. There were 1 million hospital visits last year because of drug or alcohol usage. The human cost of obesity is appalling, but so is the cost to the health service, which has to pay for larger stretchers, beds and mortuary places.
It is vital that we improve transparency and accountability in our NHS. The Government abolished the independent review panels in 2004 and the recently established Healthcare Safety Investigation Branch plans to cover only 30 cases a year. Will the Minister say how the Government intend to invest in independent reviews, deal with complaints and protect whistleblowers?
The advances in medicine in the past 70 years are almost beyond belief. Some of the potential breakthroughs are exciting. One drug is being made from the strain of cannabis grown legally under Home Office licence. It has a high concentration of anti-convulsant and very low content of THC, the psychoactive compound. If approved, it could help up to 5,000 people with epilepsy. Research has shown that metformin, an anti-diabetes pill, also cuts the number of heart attacks, strokes and heart failures. Researchers call that repurposing.
Finally, I thank the BBC and ITV for their coverage of the 70th birthday of the NHS and for all the programmes that have been enjoyable, historical and absorbing. They have been inspiring and have made me realise that any future attacks on the health service will be met by an army of fierce defenders, all of whom have a story to tell.
My Lords, I was in this Chamber when the noble Lord, Lord Darzi, then Minister of Health, saved the life of a noble Lord who collapsed in the debate. I congratulate him on all his wonderful and inspiring work. I declare an interest, as the National Health Service saved my life when I broke my back in 1958.
I celebrate the 70 years of the NHS, but I feel that safety in medicine should be the top priority. Without good communication and leadership, the patient can be left in limbo. Last week, I spent two-and-a-half days in St Thomas’ Hospital with an infection. It brought home to me the hugeness of the NHS and the pressure that it is under. The nurses I met were all agency nurses, and I understood their reasons for that, but I never saw a sister, so answers were not forthcoming. I left wondering what Florence Nightingale would have thought. There were some charming young doctors. One of them told me she had had problems since Brexit and was thinking of leaving. This is tragic when they are so badly needed. The Government need to work very hard on providing a competent NHS workforce across the UK, with good communication between hospitals and the community.
When injuries were expected from Normandy, a specialised spinal unit for the military was set up at Stoke Mandeville Hospital. In 1948 when the National Health Service was born, civilians with spinal injuries were admitted, and having specialised treatment and rehabilitation free at the point of need made all the difference for them. Stoke Mandeville is also celebrating the 70th anniversary of the paraplegic games this year. They were founded by Sir Ludwig Guttmann, who said that sport helped to rehabilitate patients. The games became the Paralympics of today. I cannot stress enough the importance of specialised treatment centres for many rare conditions. Their specialised teams of staff and drugs can save and extend life.
Our NHS must find watertight systems to safeguard patients and protect whistleblowers who may suspect and expose dangerous procedures. Safety is of the utmost importance. The duty of candour should become part of our health and social care culture.
My Lords, I thank the noble Lord, Lord Darzi, for introducing so beautifully this important debate. In an age where some view suggestions of NHS reform as heretical, I welcome the opportunity to put down ideological swords and approach the NHS and the issue of social care with the clarity of debate that our healthcare system so desperately needs.
Lots of people, including my family and close friends, rightly testify to the wonderful care that they have received from the NHS. I do not yet have grandchildren and congratulate the noble Lord, Lord Winston, and my noble friend Lady Morris on their recent arrivals, but St Mary’s in Paddington looked after me very well when I had both my children on the NHS, so I understand the emotional attachment that we have to the noble ideal of the NHS and the numerous examples of superlative care experienced.
However, although we are often told that the NHS is the envy of the world, it is not the envy of the developed world. The UK healthcare system consistently receives mediocre rankings in international reports. Even the Commonwealth Fund report ranked us last but one for healthcare outcomes. We need outcome-driven improvements to our National Health Service, as those matter most to patients.
There have been and will be many important contributions today from those with direct experience of the NHS. I shall therefore limit myself to three short observations. We must invest in early diagnosis. The UK has lower cancer survival rates than comparable health systems. The cost of late diagnosis can be up to four times that of early diagnosis, which in turn dramatically improves the chance of cure and survival.
Secondly, we need to help to transform a culture in the NHS that can be resistant to innovation. Without this, reform will prove ineffective. Healthcare professionals must absolutely be able to speak up for the benefit of patients without the risk of victimisation. The national guardian, Dr Henrietta Hughes, is leading a positive culture change by publishing case reviews to support the proper treatment of whistleblowers. Our remarkable NHS staff are our greatest asset and a rich source of knowledge. They must be empowered to identify concerns and provide solutions.
Finally, we must have a proper debate about the funding of the NHS. It is simply wrong to perpetuate the myth that any alternative to the current system is a malicious attempt at privatisation. It is not a binary choice. We all agree that healthcare in this country should be universally accessible. This was the original and great gift when the NHS was created. Although every developed economy now provides its citizens with universal access to healthcare, none has copied the UK model. Other healthcare systems—in Germany, the Netherlands and Switzerland—offer feasible alternatives that deliver not only better value for money but better outcomes for patients. We know that the NHS needs more money, but we should not presume to know how to get it.
I welcome the proposal of a cross-party commission, but if we seek a sustainable future, we must keep an open mind, fairly evaluate alternative regimes and resist the narrow dogma that hampers rather than protects the NHS.
My Lords, I, too, congratulate the noble Lord, Lord Darzi, on opening the debate and thank him for being such a breath of fresh air, as he always is when he speaks in this House. I also thank the right reverend Prelate the Bishop of Carlisle for his words. It reminds me to confess my qualifications in the register as a retired nurse and midwife who started 65 years ago. I started in 1946 as a volunteer in the order of St John as a cadet, and learned the basics of life-saving and care. I have always been grateful for that background and the privilege that I had as a registered nurse.
In one of my jobs, as the youngest member of a consensus management team, I was asked to close two large hospitals and move mentally handicapped patients into the community. The first hospital had 1,500 patients and the second had 1,200 patients. It was my job to find a team that would work with me, with the money coming from the health service. I learned a tremendous amount about social services, working with two county councils and five London districts. It taught me one very large lesson: we have tremendous barriers that have to be broken down when we are concerned with delivering care. It is not a question of care in hospital and care in the community being different; we are looking at the whole person and their whole life. One thing I hoped, as I travelled through this task of 10 years, was that we were on the verge of reaching where we are today: considering bringing together health and social care.
I have always valued that experience, because I learned three things. One was that we needed the money, but that it needed to be spent cost-effectively and that we had to look at the way in which people were trained for this new model of care. The second was the high quality of care, which was different from that in an institution. The last was the culture in which people were cared for. I hope that, as a result of today’s debate and all that we have heard from the Government, we will be able to move forward, get rid of the barriers between health and social care and become one caring service.
My Lords, I welcome the debate of the noble Lord, Lord Darzi. I must also declare my 40 years in the NHS and that I am a fellow of the British Dental Association.
In 1948, the nation’s dental health was in a worse state than that of defeated and occupied Germany; decay and gum disease were rife and more than three-quarters of the adult population had complete dentures. The creation of the NHS meant that, for the very first time, dental care was free at the point of use and the demand was overwhelming. By late 1948, more than 80% of practising dentists had signed up to work in the NHS and, in the first nine months of its existence, NHS dentists provided over 33 million artificial teeth, performed 4.5 million extractions and put in 4.2 million fillings. By 1951, the NHS started running out of money and so charges for dentures were introduced—the first charges of any kind for NHS treatment. This controversial move caused much debate and led to the resignation of Aneurin Bevan. Charges for other types of dental treatment soon followed and, to this day, dentistry remains the only part of the NHS that is not free at the point of use.
NHS dentistry today looks very different from the way it did 70 years ago. Modern technology means that dentistry today is relatively pain free compared with the dentistry of the past. Our nation’s oral health continues to improve and most of us keep at least some of our own teeth past the age of 85. Satisfaction with NHS dentistry is at a record high. Despite an estimated 10 million adults in the UK reporting dental anxiety and 6 million experiencing dental phobia, 85% of patients rate their NHS dental experience as positive.
We cannot, however, afford to be complacent. Although oral health on average is steadily improving for the general population, there are still unacceptable variations in outcomes, depending on where you live. Almost half of five-year-old children living in places such as Pendle, Rochdale or Burnley have tooth decay, but a mere 5% are affected in Waverley or Guildford. Tooth decay remains the leading reason for hospital admissions among young children, despite being almost entirely preventable—a scandal in 21st-century Britain. Increasingly, there are also problems with access to NHS dentistry in many areas. A recent BBC investigation revealed that only 52% of dental practices were able to accept new NHS patients. Almost half of all adults in England—a total of 21 million people—have not seen an NHS dentist for over two years.
The reasons for that can be traced back to two main problems: the lack of funding and a failed dental contract. NHS dentistry has been chronically underfunded in recent years. Nominal spending on dental services per capita fell from £41 in 2013 to £36 in 2017. This drop is even greater if we take into consideration inflation and the rising cost of dental materials. At the same time, patient charges in England have increased at an unprecedented pace—a 5% rise each year for the past three years. Data shows clearly that this fee makes many people delay going to the dentist until the problem has escalated, ultimately requiring more expensive treatment.
The second reason for problems with dental access and rising inequalities in England is the way that dentistry is commissioned. The failed NHS dental contract effectively sets quotas on the number of patients a dentist is able to see on the NHS.
My Lords, I am prepared to loan the noble Lord a second of my time.
I thank and congratulate my noble friend Lord Darzi on introducing this debate so beautifully. Having only three and a half minutes to talk about the NHS, I shall simply say that the NHS is a product of its time. That is very important to bear in mind, because the fact that it was born in 1947-48 penetrates its inspirational principles as well as its structure.
On the division between healthcare and social care, healthcare is free at the point of delivery, whereas social care is means tested, and that binary division is itself a product of its time and was introduced into the structure. There is also a distinction between physical and mental health. When the National Health Service was created, it should have meant the national physical and mental health service, but it tended to mean physical health. Mental health was added later and has enjoyed a Cinderella status; it has not enjoyed parity of esteem in the National Health Service.
My first point is that these various strands that the NHS has inherited have to be integrated, but the question is about how you do that when they are moving in different directions. We need to integrate but in a manner that respects the differences between the strands.
The second way in which the NHS has historicity is in the role of the GP. The GP began as a family doctor—an old tradition in this country—but he is now a gatekeeper. There is a division between the GP and the hospital, and that division also affects the relationship between the GP and his patients.
The third important feature of the NHS that is worth noting is that it began as a highly centralised institution. Those were the days of centralisation, with everything done from the centre. Now, there is an increasing realisation that that is not the way to deal with many of the problems, because problems are localised and so are the solutions. How do we move from a centralised to a decentralised structure? It is not just a question of decentralising an already centralised structure; it is a question of designing it from below and asking fundamental questions.
Here, I want to emphasise the important distinction between the way in which the NHS was conceived, based on excellent principles, and the way in which it has developed certain flaws. Some flaws are adventitious; others are structural, and the structural flaws need to be addressed very carefully—the fact that many of our doctors leave the NHS and leave the country rather than stay here; the fact that there is low morale; and the fact that hospitals are structured in such a way that the management takes over and the doctors count for very little. Those are some of the flaws. Therefore, while we celebrate the achievements of the NHS, we will celebrate them more sincerely and honourably if we are also alert to the weaknesses that it has developed.
When we talk about what we should do for the next 70 years, I simply urge a note of caution. Given the way we have tried to change it over the years, if we can get it right for the next 20 years, I shall be more than happy. Due to the way in which mental and physical health problems are distinguished and new insights into medicine and human health appear, there will be new questions, new divisions and new ways of organising our hospitals. In the light of that, let us think of the next 20 years, rather than the next 70.
My Lords, it is fitting and symbolic that the debate was opened by three of the foremost medical experts in this House. We thank the noble Lord, Lord Darzi, for initiating the debate. He was followed by the noble Lord, Lord Ribeiro, and the noble Lord, Lord Winston, who, although not a surgeon himself, is a great expert on his own subject in the medical field. We thank them for their remarks. I must give a strong word of thanks to the noble Lord, Lord Darzi, for his inspiring introduction. He covered a lot of ground and dealt with a lot of things. I agree with his implication—possibly it was even stronger than that and was a full expression—that we can all be proud and sentimental about the amazing National Health Service and what it has achieved but, at the same time, call for modernisation, efficiency and so on. I hope and pray, however, that we will avoid yet another upheaval of the administrative structures, which would drive people mad. That all comes together, and there is no sense of shame in saying that this taxpayer-funded service should receive more funds in the future. The period of austerity from this Government has been very painful for the National Health Service and we need to get over that now.
The noble Lord, Lord Darzi, mentioned his connection with the Royal Marsden. In 2003, for very sad family reasons, I had occasion to experience the Royal Marsden Hospital and its superb and wonderful treatment of people facing cancer. To a lay man like me, an example such as that remains in your memory for ever. I have always tried to avoid private healthcare, although I suppose that on occasion there is an emergency or one needs something quickly and therefore has to agree to a date being fixed if the NHS asks you to wait a bit longer. However, the service provided by the NHS is superlative. Even private medical companies often use its facilities and equipment because they do not have the same range of skills, equipment and expertise.
I commend the very good briefing note by the Library. It reminded us that the cost of the NHS as a percentage of GDP is similar to the EU average and very similar therefore to other leading countries. The cost of private healthcare is much more expensive for self-evident reasons, and I do not think it can ever match the efficiency of the NHS, despite it being funded in the way that it is. It is an amazing achievement.
I conclude not by trying to be clever for its own facile reason but by genuinely linking the dangers of Brexit with the National Health Service. Although there is no obvious connection at all between them, I was very grateful to the noble Lord, Lord Kinnock, for his letter to the Guardian today referring to these problems. He talked about the degradation of the physical economy and GDP as a result of the falling size of the economy already because of Brexit—it has already started and it is going to get worse if Brexit is to occur—and the departure of nurses and doctors from this country back to where they came from or elsewhere because they fear there will not be a positive future for them if we are not members of the EU. He quite rightly concludes by saying:
“Of the 52% who voted leave, few, if any, voted to sabotage the NHS”.
I am sure that is right. Therefore, that must be yet another collection of reasons why we have to think about the future of the NHS but also the future of the country.
My Lords, I am delighted to speak in this debate celebrating the 70th anniversary of the National Health Service. I join all noble Lords in congratulating the noble Lord, Lord Darzi, on opening the debate. The NHS is proudly the envy of the world but, with the increase in population and the discovery of new illnesses and diseases over time, we need a fresh way of looking at how it will function in the next 70 years. In saying this, I would like to speak about a part of the health service that is often seen as a separate arm but really should be an integrated and well-bedded key component of the delivery of care that the NHS must provide.
I declare an interest as a provider of adult social care, through a business I started 18 years ago. Since that time, we have seen huge changes both to the National Health Service and to social care. In my opinion, we should see them as two parts of the same ecosystem. Instead, they have had to fight for budgets and space within the political debate.
There seems to be a huge deficit in the understanding of how social care is delivered and how well funded the social care system should be to support the NHS. Every day, we hear politicians saying how much they love the NHS. It does not matter from which part of the political spectrum they come, but this mantra never includes the words that they also love social care. Until we have a radical change in our thinking about social care, understanding that it is part and parcel of the delivery of support in the health systems, the burdens on the health service will continue to increase and the funding of social care will continue to decrease.
An easy example to illustrate this is that, if you suffer from cancer, you would expect the health service to provide medical care and support to you free. Why then should someone who has dementia not have the same support at the point of need, just because they are being cared for in a residential setting? It is unjust to pit one type of illness against another, and it needs to be addressed, if we are to be a community that values justice and respect for everyone. With age come new challenges of illness specific to growing older. Does that mean that because we want people to live in their own homes we ignore their needs?
Social care is not just for the elderly; it also supports those with disabilities across the whole age spectrum, so it is high time to rethink how our health service and social care work are made to work as one. Social care has always been the poor relative of our healthcare systems yet, as we become more and more dependent on treating people at home, there is a large recognition that we are fast running short of adequately trained care workers to support people in their communities. The fact that funding for social care is delivered through local authorities and is never ring-fenced means that often any extra funding from government may be used for other immediate pressures faced by local authorities. That cannot be right.
If adequate resources were put into providing people with access to well-trained and better paid care workers, it would have an immediate and huge positive financial impact on the NHS, in terms of improved exercise, dietary plans and mental well-being. How does the input of social care providers get integrated into Ministers’ wider thinking about policy? I urge the Minister not to call just on the work of clinical commissioning groups. We know that there are huge gaps in social care provision; trying to find people to work in the social care sector is getting ever harder. How does the Minister feel we are going to fill the gaps of doctors, nurses, therapists, cleaners and carers once we leave the EU? The NHS cannot change for the sake of change; the Government must understand that you cannot fix a problem unless you fully understand what all the solutions are.
My Lords, I am grateful to my noble friend Lord Darzi for a towering speech, made with spirit and committed to the fundamentals of the health service. We are extremely grateful to him. I express my gratitude to all who work in the NHS for all the outstanding work that they continue to do, often in difficult circumstances. I wear no badge today, but I have a kind of badge on my head, as I am wearing an NHS bandage from treatment I had this week. I shall be going to my doctor’s surgery tomorrow morning.
It is all part of my life. I was born before the health service was created, but I have had two near misses with my life. When I was 55, I had bowel cancer and was saved by the Royal Marsden. I was quite close to death, and here I am, 20 years on and still enjoying a fruitful life, for which I am eternally grateful to the health service and the people who work in it.
I shall take a different approach from anyone else. I have a different concern about the extent to which the public and I are responsible for the care of the NHS and how we deal with it. People can take it for granted in many instances and, as a consequence, the health service suffers. We do not get efficiency and effectiveness from it because of that—people not turning up for appointments and so on. It is important to continue to look at what we as individuals can do to make the health service even healthier.
I have suggested, and raised previously with the Minister, that one way in which we might bring about a change in attitude is to know what the cost of our health services is; after all, there is not much that we get in life whose cost we do not know, but that is not so with the health service.
The Government do not like this idea because they say that it might discourage people from taking up services. That is questionable. I have suggested in turn that those who would like to know the cost should be told, so that, if they feel gratitude to the NHS, they could make a charitable contribution towards a fund. It would be a fund that not just went towards the hospital where they had been treated or given the service but would be redirected to those areas in the country where we see the most ill health and the greatest deprivation in terms of health services.
The Minister has not responded very positively to these suggestions on previous occasions, so my appeal today is not to the Government but to my fellow Peers and to MPs: we should come together and, instead of words, words, words with nothing happening, we set up an all-party parliamentary group to look at how we might establish a charity that commemorated the 70 years of service that we have had from the NHS but in turn found ways of taking in contributions from those who were able to make them and wanted to express their gratitude for the services or operations that they had had from the NHS. I would certainly be prepared to do that. We would have a group of qualified people—maybe Peers or surgeons—who redirected the funds or gave advice on where they should go in the NHS. We should do it ourselves. If the Government will not do it, this is a source of considerable money among the public at large to which the NHS fails to respond. There is great feeling for the service. I believe that people would make bequests or offerings after they had had operations. It is time that we took advantage of what is there for us. I hope the Minister will respond that when he replies.
I thank the noble Lord, Lord Darzi of Denham, for introducing this debate and for his excellent speech. I also thank the noble Baroness, Lady Verma, whose eloquence on social care and the need for investment in it I wholeheartedly support. I declare my interests as in the register, most specifically as a mental health nurse of some 40 years’ standing.
There is a clear case for further integration of physical and mental health and community and social care provision if we are to meet the needs of our citizens and promote healthy living and, where necessary, treatment intervention. I am involved with the social movement Nursing Now, working with policymakers and senior nurses from several continents.
In Africa, a phrase is used: “Health is made in the home and communities and hospitals are for repairs”. We need to adopt this approach in our communities to serve our citizens as cost-effectively as is feasible. We are celebrating our investment in 70 years of the NHS, which has resulted in people living longer and healthier lives. However, this has brought the challenges associated with many older people having several complex health and social needs, a situation that was not fully anticipated in 1948. The challenges facing our young people in terms of mental problems and the increasing prevalence of non-communicable diseases associated with lifestyle are resulting in higher demand for healthcare intervention.
The demands on the NHS will continue to rise unless we focus on public health policies that encourage citizens to become more responsible for their own health. With the access we all now have to digital data, why should we not be more responsible for our own health records and monitor our responses to exercise, diet and medication? If our citizens are to be more accountable for their own health and well-being, they will still need health education, support and guidance to do so. Families need help in the early years of their children’s lives through effective health visitor interventions combined, where necessary, with structured support from social services and mental health interventions for families with experience of anxiety, depression or severe and enduring mental health conditions. Yet we know that these services are under considerable strain and that, even when sufficient resources are available, families and individual citizens complain that different workers often fail to work collegiately to provide coherent packages of care. If community-based health and social services were better integrated, it would be easier for individual providers of care to deliver appropriate services, as indicated in some of the vanguard sites. This also includes successfully reducing delayed transfers of care.
I have two further suggestions that I would like the Minister to consider. First, there should be a move towards more clinical treatments for people in their own homes, care homes and nursing homes. In Spain, it is not uncommon for a person with pneumonia to be treated with intravenous fluids and antibiotics in a nursing home, and even occasionally in their own home, without the need for hospital admission. Serious consideration of more simple treatments being given outside acute hospitals needs to be undertaken. This would reduce the need for more hospital beds and allow a redistribution of resources towards community-based interventions.
Secondly, all healthcare workers should be expected to be proficient in coronary pulmonary resuscitation and physical first aid. The APPG recently heard, when reviewing progress against the five-year mental health strategy, that there is a real need to increase training in acute in-patient first aid across society. I very much hope that we will do this.
My Lords, I begin by declaring my interest as the chair of NHS Improvement and thanking the noble Lord, Lord Darzi—my esteemed colleague on the NHS Improvement board—for his masterful introduction to the debate. After listening to various noble Lords who have contributed their whole working lives to the NHS, and thinking about the more than 5,000 NHS staff members who are still working there after more than 40 years’ service, I have to say that I feel like a bit of an impostor in this debate, having all of seven months’ experience of working in the NHS, in NHS Improvement. I have tried to hold three things in my head as an employee of the NHS who is still learning. The first is that the NHS is undoubtedly the best health service in the world. In the round, taking everything into account, it is the fairest service and is definitely the most efficient one. As my noble friend Lady Finn said, clearly there is room for improvement, but I would contend that it is one of the most cherished institutions in the land. While we look at how to improve it, it is really important to remember, in everything that we say and do, how brilliant it is.
Secondly, it could be so much better. The variation in outcomes for patients across the country is just not acceptable. You only have to be a patient or the carer of a patient for 10 minutes to see how money is being wasted. We could be more efficient and at the same time deliver better outcomes. Thirdly, we are all living longer. Technology is enabling us to live well for longer, which is a good thing. It is a problem of success, not failure, but it is none the less a problem that must be faced, and in reality it is one that will require more money for the health and social care system.
What should we do? Many noble Lords have talked about the important need to integrate care in the health and social care system: the governance, the structures and the money flows. I would like to focus on the people: the 1.7 million people across the United Kingdom who are working for the NHS. They are our greatest asset and it is really important that we help and support them by preparing them for the future. If we are to deliver integrated services, we will need to drive considerable change in the NHS. That will include organisational change, process change and technology change. Change is hard for everyone, however clever and experienced they are. It means that the NHS needs to improve significantly the way in which we manage and lead.
Just as there is variation in clinical practice and operational processes, there is enormous variation in management and leadership capability in the NHS. I have met some of the very best managers I have ever seen in any walk of life in the last seven months, but unfortunately our NHS staff tell us very clearly in their staff survey that that is not uniformly the case. I have been shocked by the results of the NHS staff survey, first by how small a percentage of staff actually fill it in—50% to 60% filling it in is deemed as a huge success in the NHS. Best practice in industry would tell you that 80% to 90% just filling the survey in is a measure of real engagement. The percentage of people who say that they have been witness to or have experienced bullying is terrifying. On average it is 24% of staff and at the worst trust it is 41%. All this points to a management and leadership culture that needs to change to prepare us for the future.
We need to instil a consistently just and learning culture. We need to root out bullying and replace it with honest and open management, and to encourage much more flexible working and the greater diversity in leadership styles that reflect the way our society is changing. These are not “nice to dos”; these are the essential building blocks if we are to transform the NHS to meet the challenges that various of your Lordships have set out. I know that it is tempting at this national political level to focus on money, organisational structures, regulatory levers and command and control, but it is the people of the NHS who have made it the national treasure that it is today. Focusing a bit more on supporting and developing the people in the NHS, their culture and ways of working will be the essential ingredient for success in the next 70 years.
My Lords, like every other speaker I am delighted to congratulate my noble friend Lord Darzi on the brilliant way that he introduced the debate. I thank him for the hundreds—probably thousands—of lives he has saved during his very distinguished career as a surgeon. My contribution will focus on why treating tobacco dependency must be embedded throughout the plan that NHS England has committed to delivering in return for the additional £20 billion it has been allocated. The evidence for this is set out in a major new report published just last week by the Royal College of Physicians. I declare an interest as a long-standing officer of the All-Party Group on Smoking and Health.
Helping smokers quit is not just about prevention. It improves treatment outcomes and helps poorer people in particular to live longer. Take lung cancer. Currently, at diagnosis one-third of lung cancer patients still smoke and their average life expectancy is nearly doubled if they quit, yet fewer than a quarter get advice to quit from their GP and only 13% are prescribed stop smoking medications. Helping to quit smoking costs hundreds of pounds and has a similar impact on life expectancy as the latest lung cancer drugs, which cost tens of thousands of pounds per course of treatment. So why are lung cancer patients not being given the help to quit that they need?
Tobacco dependency treatment is cheap and saves the NHS money. The RCP has calculated that if all smokers were provided with help to quit the NHS could save £60 million annually in hospital admission costs and A&E attendances alone from year one onwards. This includes the cost of the treatment, which is only £182 per quitter. By freeing up beds and saving money, it would ensure the additional £20 billion can be used more cost effectively.
We need only look to Greater Manchester, where the CURE programme will start to deliver treatment for all smokers from September, to see the potential gains. Manchester has almost 53,000 hospital admissions of active smokers every year. Smokers are admitted with cancer, heart disease, mental health conditions, HIV/AIDS—the list goes on. It has been calculated that providing patients with tobacco dependency treatment will save the equivalent of 250 additional beds per day. This will help to tackle the winter bed crisis in Manchester. Smokers are five times more likely to have micro-biologically confirmed influenza. When combined with other smoking-related respiratory diseases, such as chronic obstructive pulmonary disease, this can lead to their admission to hospital at the worst time of the year.
Supporting smokers to quit will also deliver improved maternity outcomes. Every year, maternal smoking in the UK causes 5,000 miscarriages, 300 perinatal deaths and 2,200 premature births. Younger mothers in disadvantaged circumstances who have never worked are more likely to smoke throughout their pregnancy. These are the immediate savings; the benefits in the longer term are even greater, as current smoking costs hospitals almost £1 billion a year, most of which is avoidable.
It is not that smokers do not want to quit—over 60% say that they do—but our hospitals are not providing the help that the most addicted need if they are to succeed. Will the Minister ensure that NHS England takes into account the evidence and recommendations set out in the recent RCP report on treating tobacco dependency as it develops the new plan for the NHS?
I add my congratulations to the noble Lord, Lord Darzi, on an inspiring opening speech.
In the life of a nation, there occur a few ripe, golden days—the kind of day that you want to “bite to the core”, to borrow a line from the poet Edward Thomas. Undoubtedly, 5 July 1948 was such a day. The British state came as close as it ever has to institutionalising altruism when the Attlee Government created the National Health Service. As we have heard already, it was shaped by that man of genius and brilliant word power, Aneurin Bevan, who the noble Lord, Lord Morgan, once aptly described as “an artist in the use of power”. Its core principle was the pooling of human risk and financial resource—that the National Health Service should be taxpayer funded and free at the point of delivery—which has been sustained by every Government since.
The National Health Service was, and is, one of those national banners around which my generation rallied, as it has served us since we were in our cradles. No doubt we will still laud it as it eases us towards our graves. Talking about the welfare state in 1948, Nye Bevan said to his Parliamentary Private Secretary, Barbara Castle, who recorded it for me in a television interview 20 years ago:
“Barbara, if you want to know what all this is about, look in the perambulators”.
Given our average age, that encompasses many of us in the Chamber—we very fortunate children of the early post-war period.
Let us go back to vesting day 70 years ago. More anxiety was lifted off more shoulders on 5 July 1948 than possibly any other single day in British history. It was an extraordinary day. The creation of the NHS was a declaration of great national purpose. Achieving it over seven decades has been freighted from the beginning by the core problem that we have heard much about this afternoon: demand has always outrun the funds available to meet it. We now have a golden chance to tackle that. Let us rally once again around the banner of the NHS, the flag that we have rallied around all our lives.
In this vexing era, when we torture ourselves daily with our differences over Brexit, perhaps here at last is a consensus that is there for the taking. I dearly hope that it will be taken, shaped by that rigorous, realistic national debate of which the noble Lord, Lord Winston, spoke so forcefully. We owe it to the founders of 1948 and the generations who have devoted their professional lives to this extraordinary institution over the past 70 years. This is an hour for seizing.
My Lords, I emphasise that I have worked in the health service for well over 60 years, but there is still such a lot to learn about it. Something important to have come out of today’s debate is that we should look at a lot of things again.
I know that the noble Lord, Lord Mawson, spoke about doing away with health centres. I do not agree at all with that. As a dentist, I found that health centres were a very effective way of giving treatment to children. Parents, especially now that you have to pay for dental examinations, no longer take their children to their own dentist twice a year, which is what used to be the practice. Now, children are lucky if they are seen before they are in pain, which is a most awful reason for anyone to go for treatment: you are automatically very worried and unhappy from the start.
I congratulate the noble Lord, Lord Darzi, on securing this debate. It is very far-reaching and should be considered in detail. Certainly we should use more of those health centres, as we did in the past, and more respite care, or cottage hospital-type recovery after hospital. We are using a very expensive facility to keep people in hospital during their recovery when they would probably much rather be in slightly more homely surroundings. Of course, they would have to be adequate for the treatment that they were recovering from, but all these things are possible if enough thought is applied to them: that is what I believe should happen.
In these couple of minutes which is all we have, I pay tribute to the very many dentists and doctors—huge numbers of them—who came from the Commonwealth in the early days of the National Health Service. In Australia, where I graduated, anyone who had been in the forces was allowed to go to university if they had enough qualifications. As a result, 150 dentists a year qualified in Sydney and there was no work for them; they were just out digging the roads or working on the Snowy River scheme; anything to be earning a crust. Then someone discovered that, yes, there were jobs over here. The first ones came and they passed the word on to all the others. In the early years, in this country, the big thing was that people looked to full clearance of teeth at the age of 21 as the desirable situation in dentistry, which was unbelievable. When we arrived, children’s teeth were in a terrible condition.
Commonwealth dentists, in particular from Australia, New Zealand and South Africa, all of whom had a higher degree, which was acceptable here, did a huge amount. We almost got the situation completely under control, but now it is as bad as it ever was. In Manchester, we find that children cannot have ordinary operations under general anaesthetic because every slot is taken with clearance of baby teeth: that is just hard to believe. I have almost run out of time so I will not go on further, but I think we have a lot to think about and a lot to aim at. I want to pay tribute also to Lord Pitt, David Pitt, who did a marvellous amount here, coming from quite a different part of the Commonwealth. He was a hospital patient in the hospital I was chairman of and was so undemanding it was just hard to believe. There is still a great deal for us to do.
My Lords, I thank my noble friend Lord Darzi for bringing this important debate before us today and for the wonderful story he told, making us realise how much we must cherish this precious asset we have. The improvement in women’s health since 1948 has been absolutely amazing. I have the time to mention just three measures: the oral contraceptive pill, the Abortion Act 1967, and the improvements in the treatment of breast cancer.
The pill was introduced in the UK and became available on the NHS in 1961, but it was for married women only at that time. That all changed in 1974, when family planning clinics could prescribe single women the pill: it was a very a controversial decision. Now it is taken by 3.5 million women in Britain between the ages of 16 and 49. It gave women, for the first time, the freedom to control their own fertility and it was a great liberation for them. It avoided unwanted pregnancies and a woman could decide when to have children. It proved to be a great advantage in so many ways. Women could now plan their lives, in terms of their education and their job development, and could choose when and if they wished to get married. It changed our society and allowed women the freedom that women of earlier generations could not have dreamt of; that was all because of the National Health Service.
The Abortion Act 1967 allowed women to have safe, legal abortions under the NHS and did away with the illegal back-street abortions that many desperate women turned to because there was no alternative. In 1990 the time limits were lowered from 28 weeks to 24 weeks for most cases because medical technology had advanced sufficiently to justify the change. The Act does not apply to Northern Ireland, but at the last general election the Labour Party manifesto said:
“Labour will continue to ensure a woman’s right to choose a safe, legal abortion—and we will work with the Assembly to extend that right to women in Northern Ireland”.
We are committed to ensuring that women in Northern Ireland will have the same rights as women in the rest of the UK. I trust the Government are equally committed.
Screening was introduced for breast cancer in 1988 in the United Kingdom and now women aged 50 to 70 are offered tests every three years; older women can ask for one. More than 55,000 women are diagnosed with breast cancer each year in the United Kingdom, but the good news is that more women than ever are surviving breast cancer thanks to better awareness, better screening and better treatments. Around five out of six women diagnosed in the United Kingdom today will be alive in five years’ time, compared with three out of six 40 years ago. The charity Breast Cancer Now has an ambition that by 2050 everyone who develops breast cancer will live. It believes that its research will allow it to achieve its ambition to stop breast cancer taking lives. Combined with the work that the National Health Service is carrying out in research and medical advancements, I think this is possible.
Everyone in this country can give thanks to the National Health Service, especially for the advancements in women’s health. I give thanks to the National Health Service for bringing about such a great improvement in women’s health.
I am really pleased to be talking in this debate about the National Health Service. I started life in St Mary’s Hospital. My mother, a lovely Irish lady, said that I was the most difficult birth because instead of it taking 10 Woodbines to birth me, it took 20. I should not really be here: I should be dead, because I come from poverty. I am in the House of Lords because of poverty, to try to dismantle poverty and to prevent poverty happening.
I do not want to sound like Mark Antony at Caesar’s funeral, but talking about the National Health Service raises a number of questions for me. One is: are we talking about the National Health Service or the “I will get you back to health” service? My problem is that when I look around, I look at the big, ugly sun that sets and rises over all of us, which is poverty. According to a friend of mine who worked at St Thomas’ Hospital, 60% to 70% of the people the NHS has to deal with come from poverty. Because they come from poverty, they present their poverty in many ways and one of the big ways is in their health.
I will quote two human beings. One, John Newton, is the director of Public Health England, who makes the point that 40% of all illnesses that present in hospitals and the National Health Service are preventable and 23% of deaths need never have happened.
I have a quotation from 1944, from the MP for Rochdale, Dr Hyacinth Morgan, who said:
“The whole question of social medicine, with the questions of good milk supply, prevention of disease, good food and nutrition, good housing, good recreational facilities, prevention of mental disability in its early stages—all this has been left out of the White Paper”.—[Official Report, Commons, 16/3/1944; col. 494.]
Looking at the National Health Service over the past 70 years, I would say that it is an absolutely wonderful invention that has saved many members of my family. I have yet to use it, but, when it does come along, I am sure you will give me a brilliant send-off.
The point is that, unless we find a way, instead of spending 5% of the national health budget on prevention, to move it mainstream, we will always be worshipping at the altar of the accomplished fact. We will always be dealing with health rather than the terrible reality that exists behind it, which is the fact that we live in a poverty culture; we have poverty capitalism, where the poorest among us have to resort to the kind of food that can lead only to bad health. Until we get rid of poverty capitalism, we are not really going anywhere, and we will be talking about more and more needs for the National Health Service. The National Health Service will become even bigger unless we tackle the elephant in the room, which is poverty.
My Lords, I thank my noble friend, Lord Darzi, for securing this debate, which has demonstrated how important our National Health Service is to the lives of so many in this House. I was very proud of the IPPR report—I was a long-standing trustee of the IPPR. I am an engineer; I am not a doctor. I design cars. However, I am married to a midwife, as well as the proud father of both a dietician and a recently qualified junior doctor; I have taken a great interest in this area. On that note, I should draw attention to my interests in the register.
This debate asks how the National Health Service can serve our nation in future. I want to raise two examples of how digital technology can improve our national health. Today the National Health Service is far from being a digital organisation. In fact, it is the world’s largest purchaser of fax machines. However, current digital resources can be used to improve future NHS services. In radiology, the NHS has held images and reports for a decade: millions of X-rays, scans and diagnoses. At the same time, radiologists face ever greater time pressure. Only seconds can be given to reviewing each new X-ray. This leads to outsourcing to expensive tele-radiology firms, which then make a lot of mistakes that cause a lot of errors.
We have an opportunity to build artificial intelligence systems that use the NHS’s historical data to identify which new X-rays radiologists should examine first. It is a form of digital triage. At my place we are developing such a system for chest X-rays. In future, the same principles could be applied to CT scans and MRIs.
Data anonymisation is essential, but, as my very good friend Dame Julie Moore of Queen Elizabeth Hospital in Birmingham, with which we are co-operating, said, no patients have refused consent to her trust collecting outpatient data.
Another way we can improve the use of current data by the NHS is with patients who have multiple chronic conditions. These cases are so complex that the causes of worsening symptoms may not be apparent even to experienced healthcare professionals. Furthermore, when multiple treatments are prescribed the patient can be overwhelmed. These patients do not need to present to a GP or an A&E as often as they do. A digital care planning programme could intelligently understand how treatments interact, prompt patients to medicate correctly and allow healthcare professionals to monitor patients remotely. Such technology and devices are available now. This would reduce the pressure on front-line NHS providers and provide better care to patients at home or in social care.
We desperately need to support innovation if the NHS is to succeed for the next 70 years. Sadly, as the Science and Technology Committee report on life sciences has said, the structure of the NHS stifles innovation. Innovation is a topic I am familiar with. We have been innovating in British manufacturing industry for a long time. We need to transform the way the NHS applies new technologies. To achieve this we need strong leadership on innovation in the National Health Service. Innovation is simply essential and is very easy to use. However it is important that we have the skills base to use it.
My Lords, the noble Lord, Lord Darzi, in his superb opening speech, reminded us that we must not forget what the alternatives to the NHS look like, when whole tranches of the population cannot pay for care. As Bevan said:
“The field in which the claims of individual commercialism come into most immediate conflict with reputable notions of social values is that of health”.
It is said that you cannot know where you are going unless you know where you have come from. Our roots go back far. Lady Beatrice Webb led the 1909 minority report of the Royal Commission on the Poor Law, which called for a unified medical service. Beveridge, himself a researcher for the minority report, recognised the influence of that on himself. Then Bevan, in an inspired political appointment, took on the medical resisters, and we all celebrate the benefit from their defeat.
My interests go back more than four and a half decades, working fully in the NHS. I am grateful to all the patients I have looked after, who have taught me so much and enriched my life. It is a two-way process, and it is has been an honour and privilege to work with them.
In Bevan’s book In Place of Fear, he wrote:
“Preventable pain is a blot on any society. Much sickness and often permanent disability arise from a failure to take early action”.
By embracing artificial intelligence, we now have amazing opportunities for early action: we can decrease error, diagnose sepsis, acute kidney injury and melanomas, use CT and MRI to diagnose cancers, and so much more. The horizons are expanding before us. In my own cancer centre we are using virtual reality to help patients understand what is happening to them. Yesterday, at the Bevan Commission international conference—I declare my interest as a commissioner—artificial intelligence was seen as key to reducing error but was not expected to replace clinical roles in the next 10 years.
The latest paper from the Bevan Commission stresses the need for social support and social change. This week, Vaughan Gething, the Minister in the Welsh Assembly, has announced plans for Wales to be the first “compassionate country”. Across society, we must all take responsibility. Loneliness is a killer.
We must recognise the unique value in each individual and harvest it, recognising that adverse childhood experiences result in poor physical and mental health in adulthood, and take responsibility. For these children, the most important factor in their future is a stable adult in their lives.
Social care prevents some problems and delays others. It does not substitute for, or replace, life-saving technology or highly complex interventions when we need them.
We need a huge shift in controlling data. Patients should be able to access all their data. The OpenNotes trial found that 99% of patients and 75% of doctors want to continue with open access.
Bevan said that we would be in a state of constant change, and we are. We must look forward. We must not carry on squeezing until the pips squeak, but we must value care, science and vocation in our staff, so that in 70 years’ time we can meet the greatest need without the threat of somehow having to find money to pay—perhaps even millions of pounds if it is life-saving.
My Lords, it is an honour for all of us in this place to speak in this debate on the 70th year of the NHS. We owe a great thanks to the noble Lord, Lord Darzi, for showing the initiative. We also owe him a thank you for when he was the Minister on the Benches for the Government, over a number of years, because he certainly got a grip of things when he was there. I also pay tribute to my noble friend sitting on the Front Bench, as it is a long time since we have had a Conservative Member sitting there who has tried really hard to get a grip of the issue.
I am a marketing man by profession and I am looking at the things on which we need action on a practical basis. I start with the GPs; I am married to a retired one. It is not working at GP level today, on the whole. I exempt the GP practice where I am a patient at Greensands in Potton, which is pretty good, but it is not working because there are not enough GPs. There are also not enough district nurses. Those are the two key areas. Just look at the figures for district nurses. The graph has gone down for the last X number of years, certainly the last 10 years. We have to double the number of district nurses, because they are the people who visit patients at home and keep them out of hospital and the GPs’ surgeries. That is point number one.
Secondly, my wife was a full-time GP and she looked after me and three children in our constituency, and all the rest. Initially, she had a small practice and she built up to a very large practice in Bedfordshire. There were night calls and weekend calls. One of the doctors did minor surgery and it worked well. None of that happens today. Why do we not have minor surgery from our GPs? That would relieve our hospitals a little. Why do we not have more GP hub units like the one in Biggleswade today, which works at weekends? It is looked after not by doctors who are running their normal practices, but other doctors do the work and that unit works well.
Thirdly, we need to look at the number of doctors. We have about 50% of what we need. I hope nobody thinks that I am biased, but there is something wrong with the gender balance. Nearly 60% of the medical school intake is female now. The net result, as ladies across the medical profession will know, is that 5% never work, 80% work half-time and about 15% work full-time. Against that background we need two women for every man, so that is a challenge. Moreover, my son works as an Army doctor and he had it in his contract to work for five years. In Singapore, if you take a medical degree you have to work full-time for five years. Not surprisingly, if you leave early you have to pay back the money that has been spent on you.
As a further point, in Bedfordshire there is the Luton and Dunstable Hospital. It has a unit where, when you arrive, they assess you and you go either to its GP unit or to A&E. Seventy per cent go to the GP unit. That is the situation.
Finally, on payments, I am fed up with looking in my surgery at the number of people who do not turn up. Somehow, we have to find an answer to that. Personally, I think we should trial a £10 fee for those who fail to turn up.
My Lords, I congratulate my noble friend Lord Darzi on initiating the debate and on his speech.
Exactly 70 years ago today, I was a patient in Stockport Infirmary. I was quite ill. In those days, when the consultant did his rounds it was like God visiting, with a team of doctors, matron and so and, if I remember rightly, one was supposed either to stand to attention if one was well enough or lie to attention if one was not. I was lying to attention. The consultant came by and I said, “Just a minute. I have a question to ask you”. One did not ask consultants questions like that, so he turned around and said, “What is it?”, and I said, “Are we having a party today?”. He said, “What for?”, and I said, “The hospital’s ours. Isn’t it terrific?”. He walked on. I was the only child in the ward and the other patients asked me what was going on. I explained and I think I got a few Labour supporters out of that.
I should declare that, more recently, I was a member of an area health authority and, even more recently, I was a member of a mental health trust, and I found it a privilege to serve on both those bodies.
I welcome the Government’s recent announcement of a bit of an increase, although it is only a standstill increase and does not increase the resources going into the health service. For all the criticism of the health service, I think we get fantastically good value for money out of it. If we look at the percentage of GDP spent on health, we compare extremely well with many other countries. Most of the major European countries spend more of their GDP on health than we do, and the Americans are way ahead. The trouble is that we get all this on the cheap. It is to the detriment of the health service that it is too easy for the Government to turn off the financial tap for reasons of austerity, and there are no safeguards to protect the health service against a Government’s short-term need to save money. My noble friend Lord Winston made that point earlier. I believe the value for money is incredibly good.
I hope that the Government will tackle the problem of social care. It is all too clear that so much bed-blocking takes place and that the health service would benefit if people could be moved out of hospital when they are well enough into their home with support or into other forms of residential support. It is to the detriment of the health service that we allow this to continue. We have to tackle it.
At a local level, Charing Cross Hospital in West London, which is much loved and much appreciated, is still under threat. There has been a big campaign to save it. The local health authorities wanted to close it down. At the moment, it is still there, at least until 2021. In the meantime, the Government have added £7 million to the A&E services, which are very important, but there is no point in putting money into A&E in the short term unless we have some assurance that the hospital will continue. The trouble is that we have to get out of the position in which the Government can too easily cut off the money so we do not have any long-term assurance about the health service.
Finally, I believe this most sincerely: the British people would accept an increase in taxation in order to fund the health service more securely. They would accept that, provided it was hypothecated for the health service. I know the Treasury does not like that, but I believe that if the people of Britain were told that more money from taxation would be used directly for health and social care, they would accept that.
My Lords, I, too, add my congratulations to the noble Lord, Lord Darzi, on his excellent speech and his constructive IPPR report. He and I have both had a go at reforming the NHS, and I think we can at least congratulate ourselves on not creating a mess on the scale of the Health and Social Care Act 2012, from which the NHS still suffers.
The NHS has been a key part of our welfare state and a great piece of communal risk pooling and social cohesion. It has survived some difficult years with its funding veering around from famine to feast and back again. It has become like David Attenborough and Judi Dench: a national treasure. However, the trouble with national treasures is that they can end up like Danny Boyle at the 2012 Olympics, engaging in a fantasy view of something that badly needs to change but gets frozen in the national psyche.
The NHS and its staff are tired in part because its business model and operations badly need a major overhaul. The NHS still operates the organisational silos created 70 years ago. It has not integrated its own services very well, let alone integrated with social care. It is still largely a sickness service rather than a health service. Public health, mental health and adult social care remain Cinderella services financially, while the acute hospitals remain the financial preoccupation of most elected politicians. The patient base of the NHS now lives much longer than in 1948, with a set of comorbidities that come largely from lifestyle choices, but the service delivery system has changed little, despite countless reorganisations. It certainly does not deliver consistent quality across the country.
The way services are delivered needs to change radically and swiftly. Simply giving giving the NHS shedloads of new money without a credible and enforceable long-term reform plan would be a waste of taxpayers’ money. The NHS England long-term plan promised for this autumn needs to provide for a radical shake-up of the way in which services are delivered outside hospital, the way in which staff are trained, treated and deployed, and the way in which technology and regulatory change are to be implemented. There needs to be a sweeping away of the 2012 governance and accountability arrangements. This plan must lock funding into reformed services outside hospitals and will need regular parliamentary scrutiny on its delivery. It must also be supported by a new, credible and sustainable funding system for adult social care, which remains in a parlous state both financially and through the growing collapse of the publicly funded social care provider market. Unless the Government show a greater sense of urgency about a new funding system for social care, they are setting up the NHS to fail.
Let us be clear. There is no Brexit dividend for the NHS. The OBR forecasts show the UK economy flattening out, flatlining at about 1.5% growth a year after Brexit. This will make it very difficult to sustain a 3.4% real-terms annual increase for the NHS over a long period. So the NHS had better get on and reform itself quickly while the financial sun shines briefly for a moment.
My Lords, I, too, congratulate the noble Lord, Lord Darzi. I was in the Chamber when he leapt across that Bench to save the life of a noble Lord who had had a heart attack, and a very impressive sight it was. I, too, have suffered a cardiac arrest and I received life-saving care from two wonderful paramedics from the South East Coast Ambulance Service.
My personal experience, not in a way that I would have chosen, was of the NHS at its very best. Everything at every stage, from the moment the cool-headed handler took the 999 call, the paramedics who got my heart going, the surgery, to the kindnesses and the professional aftercare that I received in East Surrey Hospital, could not be faulted. I was honoured when the hospital asked me to open its wonderful new cardio wing and meet the staff. It was an emotional event for me to stand in front of the very people who had saved my life, giving me an opportunity to join this debate today.
I declare an interest, in that my sister was a state registered nurse, my brother-in-law is a retired senior surgeon with the NHS and my niece is a junior doctor training in infectious diseases. She is extremely proud to be part of the NHS and very optimistic for the future.
While we bask in the reflected glory of all that the NHS has achieved in the past 70 years, I agree with the noble Lord, Lord Winston, that we must be realistic. We need to remember the winter pressures and looming targets that put the NHS under immeasurable pressure and result in less than optimal patient care.
At this late stage of the debate, I will touch on just one challenge facing the NHS, which has been mentioned by many noble Lords: creating a sustainable workforce moving forward, particularly as we rely so heavily on European and overseas staff. Since we voted to leave the EU, there has been a dramatic reduction in the number of staff coming from Europe. Although immigration restrictions have been lifted, it is going to take time to recruit staff. The NHS must be able to offer a long-term future, or why would they come? The focus should be on making medicine and nursing attractive again and developing a long-term plan that meets workforce challenges. There is much bridge-building to do after last year’s junior doctors’ strikes if the NHS is to keep them once they have completed their training. Junior doctors welcome Jeremy Hunt’s pledge for more medical school places, but there are ongoing concerns about low morale and rota gaps in the workforce causing significant issues with retention of staff. Worryingly, junior doctors are leaving not only the NHS but the profession altogether.
With regard to nurses, this is the last year that those in training are entitled to receive a bursary and will not have to pay university fees. They will then have to pay £29,000, plus living costs, for a three-year period. This means that most nursing graduates will leave university with debts of around £54,000. I would be interested to hear whether the Minister is concerned that this issue will have a negative impact on nurses’ recruitment.
My Lords, I was born in 1948, five months after the maternity unit in which I was born was taken over by the National Health Service—that was 70 years ago today and we are debating that anniversary.
Yesterday, in the House of Commons, my successor as Member of Parliament for Torfaen, Nick Thomas-Symonds, gave a lecture on Nye Bevan—on whom he has written a wonderful biography—and the National Health Service. In it, he referred to the Tredegar Medical Aid Society, which was an embryonic version of the National Health Service, based as it was on the spirit of community and solidarity of the people in south Wales. It was Nye’s intention then, as he put it, to “Tredegarise” the rest of the United Kingdom, which he successfully did. We have heard—particularly of course in my noble friend’s brilliant opening speech—of the three principles of that service: it is free at the point of use; it is financed from central government; and everybody is eligible to use it. In Nye’s words, he believed that it would,
“lift the shadow from millions of homes”.
Since Nye’s day, the NHS has of course been devolved. He was not too keen on devolution but I think that he might have changed his mind as the years have gone by. In Wales today, a country of 3 million people, we have 20 million patient contacts a year, 1 million seen in A&E, £7 billion spent on health and social services—in Wales, the two are put together—and 100,000 staff. It has been the fashion over the past few years for Prime Ministers, when they face criticism of the English health service, to say that the Welsh health service is not up to much. Far from it. In fact, it is an unfair comparison. The people of Wales worked mainly in coal, steel and heavy industry and, in consequence, there was a much greater need for health services than in parts of England. Nor was the comparison necessarily like for like because, as I said, health and social services in Wales are combined, which is not the case in England.
Over 90% of Welsh people are well satisfied with the National Health Service. More is spent per person on health in Wales than in England. Wales was the first of the home nations to ban smoking in public places, to ensure that parking in hospitals is free and to introduce free prescriptions. I certainly want to celebrate our National Health Service today by thanking all those 100,000 people who work in the health service in Wales and, of course, all those hundreds of thousands of others who work in the United Kingdom.
Finally, to quote Nye:
“Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can deliver”.