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NHS Long-term Plan

Volume 798: debated on Monday 1 July 2019


My Lords, with permission, I will now read a Statement made by my right honourable friend the Secretary of State for Health and Social Care in the other place on the implementation of the NHS long-term plan. The Statement is as follows:

“Mr Speaker, I would like to update the House on the implementation of the NHS long-term plan and the delivery of improvements to the health service. Today marks the 100th anniversary of the Ministry of Health under the Liberal and Conservative coalition of Lloyd George. I can tell the House that on Thursday, the boards of NHS England and NHS Improvement agreed the long-term plan implementation framework.

Alongside the clinical review of standards, and the interim workforce plan, published last month, this framework is a critical step in delivering on our 10-year vision for the NHS and in transforming our health service with the record funding the Government are putting in. The document sets out the framework in which each of the 300 commitments in the long-term plan will be delivered, the 20 headline commitments and how we will monitor delivery of the plan. In the past, there have been criticisms that NHS plans have not led to full delivery, and we are determined to ensure that the LTP fulfils its potential to transform the health service. I am placing a copy of the implementation framework in the House Libraries.

I would like to draw attention to three areas, the first of which is cancer care. I would like to thank my honourable friend the Member for Basildon for his efforts in ensuring our focus on the vital indicator of cancer survival. The Prime Minister set out the ambition that three-quarters of all stageable cancers are detected at stage one or two by 2028. Early detection and diagnosis are essential to enhancing people’s chance of survival. Since 2010, rates of cancer survival have increased year on year. However, historically our survival rates have lagged behind the best-performing countries in Europe.

The implementation framework sets out our goal of measuring the one-year cancer survival rates as one of the core metrics. The one-year survival rate is how we measure our progress in achieving the ambitions set out in the NHS Long Term Plan. To realise these ambitions and ensure that we do everything we can to give people diagnosed with cancer the best chance of survival, these are the steps that the framework sets out: first, a radical overhaul of screening programmes; secondly, new state-of-the-art technology to make diagnosis faster and more accurate; thirdly, more investment in research and innovation.

From this year, we will start the rollout of new rapid diagnostic centres across the country, building on the success of a pilot scheme with Cancer Research UK, so that we can catch cancer much earlier. NHS England is further extending lung health checks, targeting areas with the lowest survival rates. Health Education England is increasing the cancer workforce, which will lead to 400 more clinical endoscopists and 300 more reporting radiographers by 2021. Because of these steps, our ambition is that 55,000 more people will survive cancer for five years, each year, from 2028. Improving the one-year survival rate is how we ensure that the NHS remains at the forefront of cancer diagnosis and treatment and continues to deliver world-class care.

The next area is mental health. The Prime Minister and her predecessor have rightly prioritised the treatment of mental health so that we can ensure that it finally gets parity with physical health. The £33.9 billion cash-terms settlement—the longest and largest cash settlement in the history of the NHS—includes a record £2.3 billion extra for the expansion of mental health services. The framework sets out how 380,000 more adults and 345,000 more children and young people will get access to mental health support. We are also introducing four-week waiting-time targets for children and young people, and testing four-week community mental health targets for adults.

The implementation framework specifically references the vital improvements to community mental health services that we all know are needed. These are adults living with serious mental disorders, including eating disorders, and those coping with substance misuse. The framework sets out how we will create a new workforce of mental health support teams to work with schools and colleges to help identify young people who need help and reach them faster. In all, it is a fundamental shift in how we treat mental illness and how the NHS will prioritise mental health services.

The third area I want to draw out is people. Three-quarters of the NHS budget goes on staff because people are the most valuable resource that we have in the NHS. We need not only the right numbers but to ensure that we have the right support for our staff. The long-term plan sets out our ambition to recruit, train and retain the right numbers of staff over the next decade. Last month, Baroness Dido Harding published her interim people plan, setting out how we will build the workforce we need and create the right culture so that doctors, nurses and other NHS staff have the time to care for patients and for themselves.

Last week, the BMA accepted, in a referendum, the new agreement with junior doctors that will improve both pay and working conditions. Thanks to the hard work of my predecessor, we are already taking steps to increase the number of clinical training places by opening five new medical schools and increasing the number of routes into nursing through apprenticeships and nursing associates. Last year, more than 5,000 nursing associates started training through apprenticeships, and this year the figure will be up to 7,500.

Those are just three of the most vital areas from a 10-year vision for the NHS. Across England, based on the implementation framework, local strategic plans are now being developed and will be brought together as part of a national implementation plan by the end of the year. All of this will be underpinned by technology.

Today sees the official opening of NHSX, the new part of the NHS which will drive digital transformation to give citizens and clinicians the technology that they need. I am delighted that NHSX has received such a warm welcome across the NHS, because it has so much potential to transform every part of health and social care for patients and for staff.

The forthcoming government spending review will settle the budgets for health education, public health and NHS capital investment, and these settlements will feed into the final implementation of this plan. As part of the SR, we will also review the current functioning and structure of the better care fund, which is rising in line with NHS revenue growth.

On this the 100th anniversary of the foundation of the Ministry of Health, this framework sets out how we will go about securing the foundations of the National Health Service into the next century and the creation of an NHS that delivers world-class care for generations to come. I commend this Statement to the House”.

I thank the Minister for repeating the Statement and refer the House to my interests as listed in the register.

It is 71 years this week since the Labour Party created the NHS in 1948; it will also be a Labour Government who will turn around the NHS again, as we did from 1997. As the Minister will know, I welcome the things we agree on: alcohol care teams, perinatal mental health services, a greater focus on health inequalities and enabling gambling addiction services; all Labour ideas, of course. Even today the Minister—or rather, her right honourable friend—talked about bringing hospital catering in-house, which is another Labour idea.

The Minister has focused on three important matters in this Statement, but I have some questions about other matters that it contains. I want particularly to raise the question of support for local systems. Increasing the focus on population health in the long-term plan is of course very welcome. Can the Minister explain how STPs will become ICSs by April 2021, with all ICSs—I apologise to the House for using all these acronyms—reaching “mature” status, as described in the recently published ICS maturity matrix? Will the Minister also explain how the provider and commissioner landscape will develop, with a new integrated care provider contract due to be published this summer to provide guidance on how primary care can be integrated with secondary and community services?

The long-term plan rightly has prevention at its heart. Will the Minister set out how the Government will work with local authority partners to take forward prevention activities on obesity, smoking, alcohol, sexual health, antimicrobial resistance and air pollution, including how they will use the additional targeted funding being made available to support this series of activities?

At a time when life expectancy is stalling and infant mortality rates—the rate of children not making it to their first birthday—have risen three years in a row for the first time since World War II, vital public health services that tackle inequalities have been cut by £700 million. We all know that the NHS’s ability to plan for coming years is dependent upon a well-resourced adult social care system; of course, adult social care budgets have been cut by £7 billion. Also, we still await the social care Green paper. Will the arrival of a new Prime Minister hasten or further delay further its arrival? How can system-wide reform be delivered, as aspired to in the long-term plan, under these circumstances?

On staffing issues, we have 100,000 vacancies and are short of 40,000 nurses; at the same time, bursaries have been scrapped, CPD budgets cut and the no-deal Brexit we seem to be preparing for will exacerbate the staffing crisis. I noted and welcomed the interim NHS People Plan published by the noble Baroness, Lady Harding, but when will we see a workforce plan backed up by actual cash? It cannot be delivered unless this happens. The Government talk about IT systems but give no certainty on capital investment. Hospitals are facing £6 billion-worth of repairs, with walls crumbling, ceilings falling in, pipes bursting and outdated equipment stalling. Maintenance designated to address “serious risk” has doubled to £3 billion. Will this backlog also be tackled?

I turn briefly to mental health. We know that more than 100,000 children are denied mental health treatment each year because their problems are not judged “serious” enough. Over 500 children wait more than one year for specialist mental health treatment. When the Minister talks of a fundamental shift, does she mean that the Government will ring-fence funding? Given that just 1.6% of the public health budget is spent on mental health, will the Government insist that more is spent on mental health resilience and prevention?

Finally, I want to ask about next steps. It is my understanding from the Statement that a national implementation plan to be published by the end of the year will bring together the aggregated ICS/STP plans and national activities with performance trajectories and milestones to deliver the long-term plan commitments. However, it notes that the development of the national plan is contingent on the spending review, due to the need to account for decisions on workforce, social care, public health and capital budgets. Due to the uncertainty in the current political environment, will the spending review be delayed, and will that set back the development of the national plan beyond November?

The national plan states that the NHS needs to,

“remove the counterproductive effect that general competition rules and powers can have on the integration of NHS care”.

I say Amen to that. But are the Government now willing to admit that the Health and Social Care Act of the noble Lord, Lord Lansley, has had a devastating effect on the NHS? Will the Government bring forward primary legislation to achieve the objectives set out in the long-term plan?

My Lords, I too thank the Minister for reading the Statement. I feel I should get out an orange flag—I am probably wearing the right colour—because, in the 1940s, Liberals were orange, not a yellowish colour. Beveridge, whose paper proposed the National Health Service, was indeed a Liberal and his proposal was for a service,

“free at the point of need”.

Anyway, I will get back to the Statement. I welcome the Secretary of State’s commitment to cancer and mental health services and workforce growth—who would not? But the Statement does not refer to the local five-year strategic plans to be completed by mid-November and rolled out thereafter. These will involve local consultation and incorporate performance trajectories and milestones across health and social care; they are truly the plans to implement the Secretary of State’s plan. The Statement mentions funding but is quiet about how much. I guess that is quite understandable given the position of the Government, who do not know who the new leader will be let alone his priorities.

The NHS is crying out for more capital: diagnostic and treatment equipment these days is big and very expensive; those of us who have been into English hospitals recently will notice that the buildings are looking sadder than they did 10, 15 or 20 years ago; and workforce shortages are mentioned. Will the Minister tell us when we can expect the NHS to be fully staffed and appropriately equipped? There is no mention of widespread regional variation in outcomes: by when will these be no more? Can the Minister explain how the areas for concentration will be managed? Will management be top-down or bottom-up, reflecting local needs?

Will the Minister also tell the House about any conversations regarding more funding for adult social care? I shall not say any more about the Green Paper. Public health services are critical to help people deal with obesity, stop smoking and become fit, so living longer, healthier lives. All these are critical matters for local authorities. The Statement barely mentions social care but, without an injection of staff and funding, it will fall, and with it the Secretary of State’s laudable visions for cancer treatment and mental health.

I thank the noble Baronesses for their contributions. I think the most helpful thing would be for me to talk a little about the next steps in the development of the local plans, which answer a lot of the points that have been raised.

A significant engagement exercise went into the development of the implementation framework as it stands. It identified a real desire to deliver on the total breadth of the long-term plan rather than to pick and choose, a request for systems to take into account local needs and the different starting points in order to deal with variability, and a request for help on sequencing: what they should prioritise and where they should start from.

The framework seeks to address these issues and asks the systems to develop the five-year plans, which they will implement over this period. It also sets out the approach to STPs and ICSs, which are asked to develop their strategic plans by November, covering the period from now until 2023. By the end of the year they will be aggregated as part of the national implementation plan. As has been noted, that will take into account the Government’s spending review decisions on workforce education training. Social care will be part of it, and it will also play into the upcoming publication of the prevention Green Paper and the social care Green Paper. Relevant decisions will also need to be made about public health and capital investment, as set out in the Statement.

There are key points that need to be taken into account. The NHS has been asked to ensure that these are clinically-led plans and that they are locally owned, so that communities can have meaningful input; that there is realistic workforce planning—the people plan will be part of that process; and that the plans are financially balanced, because that is the only way we can ensure genuine delivery of the long-term plan and that the concerns raised by both noble Baronesses are taken into account.

My Lords, I declare my interest as a past president of the BMA. It will take some years for the new workforce plan to come through. Given that the current NHS medical workforce crisis involves consultant and GP staff having to drop clinical sessions to avoid huge tax bills, what consideration is being given to abandoning the concept of annual allowance in relation to defined benefit pension schemes, and allowing tax relief to be limited by the lifetime allowance? The current situation means that people are dropping sessions. Combined with the GMC regulations around retirement and revalidation, this is forcing clinicians into permanent retirement, rather than coming back to work additional sessions, which would relieve the pressure on waiting lists in clinics, would help with teaching and supervision, and would offer experienced surgical hands in operating theatres to assist in complex operations.

The noble Baroness, as ever, asks a very perspicacious question. She will know that as part of the GP contract negotiations, pensions and other issues were raised, and are still under discussion. Similarly, issues around secondary care doctors are in discussions with the Treasury. These discussions are quite technical but the issues are under consideration. I am unable to give her a complete answer now, only to tell her that we are very alive to the issue and trying to find a way through.

We are very keen that the Government’s attempt to have a proper plan should work. The Minister knows that the staff are working under shortages of numbers and terrible shortages of finance. The Government go on and on about promised increased finance. According to the Health Foundation, funding for the wider health budget, which includes public health, will in real terms be £1 billion less in the next financial year. Are they right?

It is very important to pay tribute to the extraordinary work that NHS staff are doing across the system and in the wider healthcare system—we should thank them for that. The noble Lord is right that there is great financial stress in the system. A lot of work has gone into trying to alleviate it. That is why the NHS is one of the few parts of the public health system which received a significant increase in the £22 billion increase.

As for the public health system, training and the capital and social care investment, this will be part of the SR negotiations. I am sure the noble Lord will be aware that the Department of Health and Social Care will be making a strong case for increasing those parts of the system, because we believe it needs to increase just as much as he does.

My Lords, I have two questions for my noble friend. First, I very much welcome the inclusion in the plan of a section on improving productivity. My experience is that the best way to improve productivity is the intelligent application of additional capital, and not just, to quote from page 29, “its better use”. Picking up on some of the comments already made, may I ask the Minister how the NHS will make a step change in providing or attracting, and using, capital within the system?

Secondly, a huge medium-term threat is antibiotic resistance, which gets the briefest mention on page 15. Is there a plan to nail this as part of the approach to improving the NHS?

I thank my noble friend for a very important question. We have just published our new plan to tackle antibiotic resistance; it is an incredibly sophisticated proposal. We have already had some success in bringing down antibiotic use in humans and animals, but there is still a significant way to go, as antibiotic-resistant infections within the system are still rising. That is why we cannot relent in our ambitions, and why it is so important that the commitment to implement that strategy is in the long-term plan and the implementation plan. Although it has a brief mention, there is a whole strategy that it refers to, and it is comprehensive, so I am optimistic about that part.

On intelligent application of capital and ensuring that it increases productivity, my noble friend is right. That is partly why there is such a focus on ensuring that there is a radical reshaping of how the NHS delivers health and care using technology: so that services and users can benefit from the advances, and so that we can have a democratisation of information, which will be one of the key ways that we will manage demand and ensure that the NHS is sustainable.

My Lords, as a former member of the Long-Term Sustainability of the NHS Committee, I welcome the long-term plan and the Government’s response to it. I am especially glad that mental health issues will achieve financial parity with physical health issues. Does the Minister agree that research into and attention to the causes of these ever-increasing issues is as important as more spending on their treatment?

As ever, the right reverend Prelate is insightful in his question. He is right that although we have made a lot of progress in improving services, we were coming from a low base. One of the challenges is not understanding why there is such an increase in the challenges we face. This is why the NIHR has dramatically increased the amount of funding it provides to mental health research, and why other important organisations, such as the Wellcome Trust, are prioritising mental health research as a matter of urgency.

My Lords, does the Minister recognise that while welcoming the emphasis on mental health—as the right reverend Prelate did—the Women’s Mental Health Taskforce, which reported in December 2018, recognised that more women are becoming the real issue in mental health work, that many more women are presenting, and that many of them, particularly those who have suffered abuse and trauma, require a gendered approached? The Women’s Mental Health Taskforce recognised this as an issue for the workforce and the way women engaged with treatment, particularly that group of women. I recognise that not everything can be reflected in plans, but it would be a tragedy if that message was not communicated to localities and to those providing mental health services. Unless that happens, many women will simply be let down.

The noble Baroness has communicated an important message and it is one reason why we have prioritised perinatal mental healthcare. Specifically, services for young girls, who are particularly at risk of self-harm and suicide, recognise this risk. I would be interested to see the findings of the task force she mentions to ensure that those concerns are communicated.

My Lords, the Statement puts importance on technology. Will the Government speed up NICE in its assessments of technology? I hear that it is taking too long.

The noble Baroness, Lady Masham, is right to raise the importance of this. If we want to get innovative technologies and treatments to patients as soon as possible, we must ensure that we are one of the fastest in the world at regulating and assessing those technologies. However, it is also a matter of uptake. We have dramatically improved that process but we can and must always strive to do better. This is part of my job and I will make sure that I keep working harder at it.

My Lords, I welcome the development of the five new medical schools that are going onstream. Two weeks ago, I was fortunate to be at Chelmsford when the Duke of Kent opened the Anglia Ruskin University medical school. But it is quite clear that a lot of medical graduates are leaving the profession, for whatever reason. There is also good evidence that those who come in at graduate entry last the distance a lot better than those who perhaps come in much younger. Your Lordships may ask, “Where is the evidence for that?” What efforts are being made to look into why people are giving up medicine early, and what is the possibility of increasing the number of graduate entries?

I thank my noble friend for his question. The core of the work my noble friend Lady Harding is doing is to analyse recruitment and retention patterns in the health service, obviously not just among core clinicians but across the whole system, to identify best practice for improving the workplace environment to recruit and retain. I am not sure whether she has done specific work on the difference between direct entry and graduate entry but I will be happy to find out for my noble friend.

My Lords, with longevity still at record levels, is the Minister satisfied that in the plan for the future new doctors coming into the service get sufficient support in their training on dealing with the dying and their families, or is it often just left to them to pick it up in their professional work? The same sorts of issues arise in mental health. If you are treating mental health, of course there is often a great deal of stress within families. How far do these plans take into account family support, at the same time as the treatment of those with mental illness?

The noble Lord raises two hugely significant issues, which probably deserve a full debate. On clinicians and NHS systems being prepared to respond most effectively to those facing terminal illness, and their families, we have improved but there is much more to do—not just for the health service but for us all as a society. We need to become more open and comfortable with discussing that; some work has been done but more is needed. On mental health services providing support for families as well as individuals, we are still some way from where we would like to be but it is recognised as something that needs to be done.

My Lords, I want to ask my noble friend the Minister about GPs’ training in mental health. I think it has been acknowledged that when parents take their children to the GP, quite often that is for a physical ailment but it turns out that the child could have a mental problem. It is difficult for GPs to pick that up, perhaps partly because of a lack of training and partly because they have only 10 minutes to see the child.

My noble friend raises a hugely important issue. We are seeing an improvement in the quality of training for GPs; the RCGP has been playing an important role in this, especially in raising specialist areas such as perinatal mental healthcare through the champions that it spreads through its system. We are seeing the impact on the ground, with CCGs meeting the mental health investment standard and rolling out specific access waiting times, so it is having an impact. But there is always more to do and the royal colleges have a specific role to play in raising awareness and the quality of training.

My Lords, I declare an interest as chairman of the Greater Manchester Health and Social Care Partnership. There is much to welcome in this White Paper’s implementation—after all, a lot of the ideas were taken from Greater Manchester in the first place so we are pleased about that. We are particularly pleased about population health being a major factor now within government. I want to raise again two of the main issues that noble Lords have already raised. First, in deciding on local needs, if we think about only health we are missing a lot. Many times when people present with health symptoms, other social and economic issues are causing them to present. It could be loneliness or unemployment, but all these things create ill health in people and we need to think of things in the round rather than just about health. Secondly, I have a local government background, as Members know, but I must emphasise that unless we get social care right the NHS will grind to a halt. There is a real crisis in social care at the moment; it needs more money and there is no flexibility. We cannot solve the issues in the NHS unless we resolve care as well.

I thank the noble Lord and he is absolutely right, which is exactly why one of the core priorities in the long-term plan is the creation of integrated care systems, so that there can be a holistic approach to health while recognising that a lot of ill health is driven by social determinants. If we do not address what are often perverse incentives within healthcare systems, we will not be able to address the problems that we all know have been experienced through multiple Governments and generations. In addition, in the prevention Green Paper we have already announced a desire to bring in much more social prescribing, making it much easier for general practitioners and others within the system to address some of those wider challenges that lead to ill health and transform the system. We have already seen some fantastic pioneers of social prescribing transform the healthcare in their area, such as those in Tower Hamlets, and we want to see that thriving across the country.