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NHS: Targets

Volume 801: debated on Thursday 6 February 2020

Motion to Take Note

Moved by

That this House takes note of the National Health Service’s performance in relation to its priority area targets; and the impact of adult social care pressures on patients of the National Health Service, and their safety.

My Lords, I welcome this opportunity to debate the current performance of the National Health Service. I declare my membership of the GMC board, my trusteeship of the Royal College of Ophthalmologists and my presidency of GS1, the organisation responsible for the “scan for safety” programme. I am very pleased that my noble friend Lady Wilcox will be making her maiden speech in this debate.

I have instituted this debate because I am increasingly worried about the performance of our National Health Service. Despite the heroic efforts of many staff, every key indicator is being missed. Last November saw the worst four-hour wait performance in A&E since figures were first collected in 2010. Two-week waits for GP appointments rose by 13% last year. The target of a maximum wait of 18 weeks for hospital treatment has not been met since 2016. The cancer target of 62 days between urgent referral and first treatment was last met in 2013-14.

I fully accept that these targets are not the only way to judge the NHS, but they reflect overall performance. At the same time, we have seen an increase in the rationing of medicines, and failings in ambulance services and services for people with learning disabilities or mental health issues. The CQC’s review of the Mental Health Act today refers to a number of very worrying problems in that area.

Given this, it is a huge tribute to NHS staff that so much care remains of a very high quality. I absolutely acknowledge that. However, the calamitous drop in performance over the past decade is clearly having an impact on patient safety and leading to those longer waits.

I was very struck just before Christmas by the Norfolk and Norwich University Hospitals NHS Foundation Trust advising staff to make “the least unsafe decision” following a huge rise in admissions. Over the new year, the Royal Cornwall Hospitals NHS Trust told its staff to reduce severe overcrowding by discharging patients, despite the obvious risks involved. These are not isolated incidents. What has caused this? Many factors and pressures are at play. The alignment of austerity with workforce shortages, inadequacies of adult social care and a complete failure to factor in the growing older population mean it is little surprise that the NHS is reeling.

If we look at funding, the lowest five-year period of funding growth was between 2010 and 2014, and the past five years have seen little improvement. It is no wonder that the NHS is cash-strapped, in deficit and finding it very hard to invest the resources necessary to prevent hospital admissions. We can see similar trends in the workforce. In March, the Health Foundation highlighted a shortage of more than 100,000 full-time equivalent staff, including more than 40,000 nurses. The GP workforce has continued to stagnate, despite government promises to increase the numbers, and the GMC’s 2019 workforce survey showed that one-third of doctors have refused requests to take on additional workloads and one-fifth have reduced their hours. It is part of a vicious cycle in the workforce. Fewer doctors and more patients means that doctors are overworked. They get ill from stress and exhaustion. They decide to cut their hours or just leave the profession, and the remaining workforce feels under even greater pressure.

All of this is happening when social care is in meltdown. In 2018, the House of Lords Economic Affairs Select Committee reported that 1.4 million older people in England had an unmet care need. We know that the number of older people and working-age adults requiring such care is increasing rapidly, yet public funding declined in real terms by 13% between 2001 and 2015. We see a second vicious cycle. The level of unmet need in the system increases, the pressure on unpaid carers grows stronger, the supply of care providers diminishes, the strain on the care workforce continues and the stability of the adult social care market worsens.

What is the Government’s response? It seems to be twofold. The attitude of the Secretary of State appears to be to get rid of any target on which the NHS is not delivering, but I remind the Minister that the Royal College of Emergency Medicine has said of A&E that there is

“nothing to indicate that a viable replacement for the four-hour target exists”.

I strongly encourage the Government to think again before they agree to change that target.

The second line of the Government’s defence is essentially to argue that they are dealing with an unprecedented increase in demand. I am the first to acknowledge that the drivers of change are intensifying and that the NHS is clearly caring for a patient population with more long-term conditions, more comorbidities and increasingly complex needs, but this is not a new problem. The Labour Government of 1997 faced the same demographic challenge, but turned it around through investment in 300,000 more staff, 100 new hospitals and new services such as NHS Direct and walk-in centres. Waiting times came down as dramatically as public satisfaction went up. It can be done.

The Government have their own long-term plan with a new five-year settlement of around 3.4% per annum. However, as the right reverend Prelate the Bishop of London said in the debate on the Queen’s Speech, the additional funding is not a bonanza; it will serve only to stabilise NHS services, and the right reverend Prelate knows what she is talking about when it comes to the NHS. Yesterday, the NAO warned that NHS trusts reported a combined deficit of £827 million and clinical commissioning groups reported a £150 million deficit in the financial year ending 31 March 2019. The NAO said that short-term fixes have made some parts of the NHS seriously financially unstable, with trusts in financial difficulty increasingly relying on short-term loans from the Minister’s department.

As we look at the funding promised—we will have a Bill on it in your Lordships’ House soon—I refer noble Lords to a letter written by NHS leaders to the Times on Tuesday, which pointed out that this funding does not include areas crucial to the Government’s election promise to provide more hospitals, nurses and GP appointments. The additional funding does not cover investment in buildings and equipment, so there is very little relief for our crumbling infrastructure or money to fund new technology to improve care. We know that the NHS is facing a workforce crisis but the funding does not cover education and training budgets to help with recruitment and retention. Nor does it offer any relief for public health and social care services, which would, I hope, if properly invested in, keep more people healthy and independent.

Therefore, the question before us is how to turn this around. I am sure that noble Lords will come forward with many ideas in this debate but I would like to propose four key measures. First, we have to plan for the long term—not five but 20 or 30 years ahead. I want to come back to the House of Lords Select Committee report on the long-term sustainability of healthcare. It was published three years ago and chaired by the noble Lord, Lord Patel. The committee said that we have to get away from the short-term fixes that we currently see and have seen in the past. It suggested that we set up an office for health and care sustainability to look at the likely funding and workforce requirements for up to 20 years ahead. Like the Office for Budget Responsibility, which has now been well accepted as giving authoritative, independent advice to government, this body could give advice to government, Ministers and parliamentarians on the likely demands on health and social care over the next 20 years. I believe that would be the start of a much more fundamental way of ensuring that we have a high-quality healthcare service in the future.

Secondly, alongside those kinds of projections, of course we need the commensurate funding. The funding challenge is immense. No one in the health service believes, for instance, that the 3.4% being given will allow them to invest in services for the long-term five- year plan. The money is not there to invest in services to keep people out of hospital; we have a crumbling primary care service because of the pressure from patients coming through the door; and people who work in the health service regard the local plans—the STPs—as a flight of fancy. They have had to publish them and have had to agree the figures with the Government because, if they do not, they will get their heads chopped off. However, Ministers are living in a dream world if they think that these plans will be delivered. Therefore, we have to find a way of funding the health service seriously in the future, but at the moment I see no indication that the Government recognise the scale of the challenge they face.

Thirdly, on the workforce, we need better recruitment and retention, and we need to increase our training numbers, but much of the problem is due to what I am afraid I have come across many times—a bullying and blame culture. It is very off-putting for many staff in the health service. I know that Ministers are concerned about this but it starts with them, their attitude and the way they deal with the health service and the bodies responsible for it. They have to lead from the centre.

Fourthly, we have to find a solution to social care. The Government have promised to come forward with one but, as we know, the last 20 years have seen a failure of nerve and an absence of political consensus. Frankly, at the moment we seem no nearer to a solution. I must acknowledge that it is a wicked problem. However, can we really wash our hands of the pernicious situation in which many people receive no care at all and many face the loss of not just their homes but their savings as the price of their long-term care?

In this debate noble Lords will raise many other issues, including improving outcomes, developing a more robust approach to public health, targeting health inequalities, and prioritising mental health and learning disability services. However, at heart, I hope the debate will come back to the issue of performance. The targets were not plucked out of the air. They were chosen because they were a very good proxy for the overall quality and performance of the NHS as a whole. In 1997, we inherited something called the Patient’s Charter, which said that there should be a maximum waiting time of 18 months for hospital treatment. The Conservative Government at that point had come nowhere near meeting that target. We turned that around and delivered an 18-week maximum wait. We hit other targets as well. I fear that it will not be too long before we go back to those bad old days if we carry on as we are at the moment. I ask the Government to think seriously about the kind of health service that they want for the public in the future. Based on current trends, I am afraid the situation is deteriorating. I beg to move.

My Lords, I draw the House’s attention to my registered interests as a councillor and a vice-president of the Local Government Association. I thank the noble Lord, Lord Hunt, for instigating this important debate. As this is such a wide-ranging issue, I want to concentrate my contribution on adult social care. As the wording of the debate indicates, a significant part of the increasing pressure on the NHS is a direct consequence of the Government’s failure to find a solution to the social care funding crisis.

Two years ago, the House of Commons Library produced an excellent briefing paper on adult social care funding in England. The report stated:

“A lack of suitable care services can delay hospital discharge, putting pressure on acute NHS services. Between 2014 and 2016, delays in discharging patients from hospital increased by 37%.”

The two main reasons given for this increase—not a surprise to any of us here—were patients waiting for care packages at home or in residential care. The report went on to say that

“the National Audit Office estimates that the gross annual cost to the NHS of treating older patients in hospital who no longer need to receive acute clinical care is in the region of £820 million.”

I have no doubt that both of those figures have risen substantially, as so little has been done to alleviate the pressures.

In December last year, Age UK updated its Care in Crisis figures for older people and reported that, in the last five years, there has been a £160 million cut in total public spending on older people’s social care, despite rapidly increasing demand; 1.5 million people aged 65 and over do not receive the care and support that they need; and cuts in local authority care services have placed increasing pressure on unpaid carers. Of course, there is also a growing number of young adults with severe disabilities for whom long-term care is provided by local authorities, hence the estimate from the Local Government Association that there will be a £3.6 billion funding gap in four years’ time unless there is an immediate and substantial increase in funding.

In summary, we therefore have what is currently described as a perfect storm, although I see nothing at all perfect in this crisis. People are becoming less independent and not receiving the support that they need to retain their independence. When they reach a crisis point—for example, following a preventable fall—and are admitted to hospital, where their care needs are assessed after treatment, there is often no residential care package or home care team to meet their new need. This is a situation where nobody wins: not the elderly person, who has unnecessarily lost a degree of independence; not the NHS, which is unable to transfer such patients to home or community settings; and not public services, whose funding is not being used efficiently and effectively.

What then are the potential changes that could help resolve this? There have been numerous reports and commissions to seek answers to the funding of adult social care. The Prime Minister declared himself committed to solving the problem, yet there were no proposals for reform in the latest Queen’s Speech. All we have is a relatively small amount of additional funding and a requirement for council tax payers to find an extra 8% on top of the capped limit over the last four years. This is no more than chicken feed in the face of the challenge.

The human cost is unacceptable; the additional, preventable pressures that are piled on to the NHS are unacceptable; the inability of the Government to propose a solution is unacceptable. The options for the future are clear. The Government have a duty and an electoral mandate to act—and act they must.

My Lords, I thank the noble Lord, Lord Hunt, for securing this debate and look forward to hearing the maiden speech of the noble Baroness, Lady Wilcox.

My proposition is that, all things considered, the performance of the NHS in delivering free-at-the-point-of-need healthcare to the people of the United Kingdom is utterly outstanding, and that the credit for that should go to the 1.5 million people who give of their all every day to make it so. Each year in England, 300 million GP appointments, 23 million attendances at A&E and over 10 million operations take place. The NHS in England treats 1 million patients every 36 hours, yet, according to the 2018-19 NHS England annual report, of these hundreds of millions of engagements, just 6,395 complaints and 7,967 concerns were raised by the public through the Parliamentary and Health Service Ombudsman. Most find their treatment to be good or outstanding.

Opinion surveys agree. The NHS comes top of Mintel’s list of things about Britain that make us most proud. In 2018, a YouGov poll found that 87% of people were very or fairly proud of the NHS. And it is not just at home: the Commonwealth Fund’s latest survey ranked the UK as the best healthcare system in the world for the second successive time, with Sweden ranked sixth and France 10th.

The NHS has come a long way since its formation in 1948. At that time, total government spending on health was £11.4 billion in today’s prices; today the budget stands at £134 billion—12 times higher in real terms. Staffing in 1948 was 144,000; today it is over 1.5 million, a figure which does not include 369,00 GPs, dentists, opticians and temporary staff. The demands on NHS services have changed too, with breakthrough surgical procedures and new drugs. Life expectancy has risen from 68 in 1948 to 80 now. Age is a principal driver of demand for the NHS. Those over 65 require, on average, 2.5 times the NHS resource needed for the average 30 year-old, and those over 85 an average of five times more. The over-85 age group is the fastest-growing age group in the UK and is set to double in size over the next 25 years, hopefully with my help.

All things considered, the NHS is performing extraordinary well, with its productivity growth running at three times that of the rest of the economy, which means that staff are working harder and smarter. Cancer detection and survival rates are increasing while deaths from heart disease are falling, but we cannot expect them to take all the strain. This, after all, is our NHS and we need to work together to ensure that it can meet the challenges of the future. I will make three quick suggestions as to how it can.

First, the NHS should not be used as a political football. The NHS is currently under the stewardship of the Conservatives in England, Labour in Wales, the SNP in Scotland and the power-sharing Executive in Northern Ireland. It has prospered and struggled under Governments of all political parties. Every healthcare system in the world is struggling with advancing science and advancing ages. It would be true political leadership if we could work together to find solutions, rather than blaming each other for mistakes.

Secondly, we need to treat staff in the NHS much better. They are not a vending machine delivering care packages but human beings putting their heart and soul into it. That makes all the difference. Yet clinical negligence claims have increased by 200% over the past 10 years, reaching £2.4 billion of claims in 2018—enough to train 10,000 doctors. Most worryingly, the number of attacks on NHS staff is increasing at an alarming rate, as pointed out by Unison and the Nursing Times. They have estimated that the number of violent incidents could be as high as 75,000, or 200 per day.

Thirdly, we all need to take greater personal responsibility for our own health and our use of precious NHS services. Fifteen million GP appointments are missed each year, while hospital admissions for obesity have doubled in just five years. Our NHS is our shared responsibility. If politicians and the public can all play their part to the same standard as our NHS staff demonstrate every single day, our beloved NHS can not only survive but thrive in the future.

My Lords, this is a very timely debate. I am most grateful to the noble Lord, Lord Hunt of Kings Heath, for securing it. I also look forward very much to the maiden speech of the noble Baroness, Lady Wilcox. We have already heard many statistics with regard to NHS targets and shall no doubt hear many more. But there seems to be general agreement that one of the biggest problems facing the NHS is what many now call a crisis in social care, which has been highlighted by this debate and emphasised by the noble Baroness, Lady Pinnock, and to which I will address this contribution.

The crisis consists of several factors—most already mentioned, so I will not repeat them—that lead to delays in discharge, the cancellation of elective operations due to lack of beds and an increase in A&E admissions, including elderly people whose health has suffered as a result of a lack of adequate care. All this is of course immensely costly in time, money and misery, as well as immensely disruptive for an NHS desperately trying to meet its targets. Given that the laudable aims of the NHS long-term plan will never be realised unless we sort out social care, what needs to be done?

I suggest that in the first place we remind ourselves just why this is so important. It is not only because it is vital for an effective NHS but primarily because the hallmark of a civilised society is the way in which it treats its vulnerable members. Recognising the intrinsic value and dignity of every member of our society, we want to offer care and respect to all, and aspire to the best by enhancing rather than just maintaining people’s lives. That will involve three fundamental changes. First, and most important, is the proper integration of health and social care. This was one of the main recommendations of the ad hoc Select Committee on the Long-term Sustainability of the NHS, mentioned by the noble Lord, Lord Hunt, of which I had the privilege to be a member. Although we now have a Department of Health and Social Care, there is still a very long way to go. The root of today’s problem was the separation of health and social care and their means of funding, even though they are linked aspects of health and well-being. Secondly, we need proper training, care and status of care workers. We need a professional, motivated and committed workforce who enjoy high esteem, which is not always the case at present. We also need to acknowledge the immense and invaluable contribution of unpaid carers.

Thirdly, social care in this country needs adequate funding. Noble Lords will have seen the seven key principles for that offered by the Health for Care coalition in our briefing note from the NHS Confederation. The need is estimated at an extra £8 billion per annum, which obviously has to come from somewhere. That somewhere is presumably our pockets. Of course, that is one reason why this subject is so politically sensitive. It is also one of the many reasons why we so urgently need the sort of cross-party consensus to which this Government have declared their commitment.

I support calls that have been made for a Select Committee or cross-party group of some kind to be established immediately to produce specific long-term proposals—that expression, “long-term”, has been used several times already in this debate—to break the current deadlock. There are plenty of previous reports on which to draw and although this might look like yet another delay to the long-awaited Green Paper, if it results in decisions and actions, that brief delay will be well worth it. Without it, the situation will only get worse to the detriment of all concerned. As we have already been eloquently reminded, a well-funded and good-quality social care sector is fundamental to a well-performing NHS.

My Lords, to begin at the beginning, I thank the doorkeepers who have guided me more than once along different corridors, parliamentary staff who supported my induction, my party colleagues and the Front-Bench team who patiently explained the rules and regulations of this House. I have been shown great kindness and I appreciate the privilege that it is to be here. My parents are no longer here to share this day, but I have a wonderful partner who has always made sure that our life together over 30 years has allowed me the freedom to pursue a political career, which is not always conducive to family life. I will always be grateful to her for her love and support.

A girl from the Rhondda, I attended the Central School of Speech and Drama and then had a teaching career in London and south Wales that lasted almost 35 years. I was an elected member of Newport City Council from 2004, the first woman to lead that council and subsequently the first woman to lead the Welsh Local Government Association. I am immensely proud of the work of local government, running public services day in and day out despite all the difficulties, and working in such ventures as city deals. I now look forward to the future of the ground-breaking collaboration across both countries and both Governments, with the innovative Western Gateway project that stretches from Swindon in the east to Swansea in the west, bringing breadth and depth to the model of economic growth.

I thank my noble friends Lord Hain and Lady Morgan of Ely for supporting me through my introduction on 4 November, the day that marked the 180th anniversary of the Newport Rising at the Westgate Hotel. We owe the Chartists an enormous group debt of gratitude for their immense bravery and sacrifice in fighting for the vote for ordinary people. I was keen to have my introduction on that day and to remember that Newport is indeed the UK’s city of democracy.

I am pleased to make my first contribution to the House on the NHS. Wales is the inspirational source for this great institution and I feel entirely comfortable offering personal reflections. But I intend to do this through the prism of well-being and, in particular, as the former leader of Newport City Council, I will concentrate on the crucial impact of social care. Noble Lords will know that the additional NHS funding will be wasted if we do not deal with the continuing and growing problem of social care. I am from that tradition of socialism that seeks workable answers to people’s problems. Social care has been subject to a plethora of reports, commissions and solutions. The promised government Green Paper was postponed at least six times and Simon Bottery, a senior fellow at the King’s Fund, has described it as the

“zombie of modern policy debate, stumbling unsteadily around in circles.”

All Governments of various hues and all political parties have failed our communities on this issue. If we are to solve the problem of what amounts to the most pernicious means test in the welfare state, a new political consensus is required. Genuine attempts by recent political leaders of all hues to do something different blew up in the face of blunt political onslaughts.

The Prime Minister announced in his first speech last August that

“we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve”.

A fully worked-up plan is desperately needed, not another rough draft. No one doubts the difficulty of delivering a solution. Contextually, those in local government have had to deal with a decade of austerity. I can testify to the day-to-day grind of trying to protect the public realm—which libraries and leisure centres do I cut to protect the looked-after children’s budgets? Can we afford to maintain those CCTV cameras and at the same time sustain direct payments for disabled adults and young people?

In Wales, our Welsh Government and Welsh councils resolved to protect social care. We put in place the Social Services and Well-being (Wales) Act 2014 with all attention aimed at supporting those who rightly desire independent living. Furthermore, in Wales, no one who is eligible for care at home is expected to pay more than £90 a week towards it. But I am not claiming that we have solved the problem. Huge efforts are under way to find new funding models, including a common social insurance scheme. A report by the economist Gerry Holtham is looking at an emerging preference from that work for a simpler social care tax in Wales to pay for social care. Indeed, the idea that there is a magic solution that does not involve paying more tax is disingenuous. In a statement to the Assembly just this week, the Health Minister told Assembly Members that the cost of care is expected to grow between £30 million and £300 million by 2023. If the Government seriously want to improve the quality and reach of care, it will require more funding. If Members say they do not want to raise more taxes, they have to identify where the money will come from. Raising money from elsewhere will target other areas for cuts. After a decade of austerity, there is little more that public services can absorb.

Our responsibility as politicians is to tell the truth on this. My plea is simple: let us work together to find a solution. It will not happen overnight and it will cost billions, but it is the greatest political imperative we face since the founding of the NHS over 70 years ago. More delay or failure is not an option for those who need that care.

My Lords, it is a great pleasure and privilege to follow my noble friend’s maiden speech and I congratulate her on it. It will be the first of many such speeches in your Lordships’ House that we will all have the pleasure of hearing.

I have followed my noble friend’s career over many years and watched her progress both in the Labour Party and in local government. She is a formidable campaigner and a straight talker. She has a no-nonsense approach to whatever she undertakes, as I am sure noble Lords will have noticed in her maiden speech.

Like me, she was born and brought up in the Rhondda Valley, which no doubt gave her a good grounding in local politics. She has a keen interest in education and worked as a teacher in Brixton in south London, was head of drama and media studies at Hartridge High School in Newport, and head of the performing arts faculty at Hawthorn High School in Pontypridd, with over 35 years’ experience in front-line education. She was an external examiner for the WJEC and AQA examination boards for over 25 years and became principal examiner for A-level theatre studies.

She also has an interest in local government, as she mentioned. She has served as a Newport councillor since 2004 and by 2016 she was elected leader of Newport Council—the first woman to hold such a post. Those of us who are involved in Welsh politics will appreciate what an achievement that was: for a woman to be elected leader of a local council.

But it did not stop there. By 2017, my noble friend had been elected leader of the Welsh Local Government Association—again, the first woman to hold such a post. That was even more of an achievement, as the Welsh Local Government Association has been dominated by men for so long—I could say “centuries”, because it feels like that; we waited for so long to get a woman in post. In 2018, my noble friend was invited to become a Fellow of the Royal Society of Arts, an award granted to individuals whom the RSA judges to have made outstanding achievements in social progress and development.

My noble friend has certainly smashed her way through the glass ceiling of Welsh politics and has been an example and an encouragement to women in Wales. I know that she will continue to be so as she begins her life in your Lordships’ House.

I thank my noble friend Lord Hunt for bringing this important debate before us today. I intend to focus on two NHS priority areas that impact people with Parkinson’s: mental health and dementia. I declare an interest, as I co-chair the All-Party Parliamentary Group on Parkinson’s.

Up to 40% of people with Parkinson’s will have depression, and up to 31% of people with the condition will experience anxiety. In 2017, in response to reports from Parkinson’s UK information and support staff, the APPG on Parkinson’s held an inquiry into the experiences of people with the condition who have anxiety and depression. The inquiry and subsequent report, published in 2018, found that people with Parkinson’s wait months, and sometimes years, to see a mental health professional once a problem has been identified; that the difficulty of diagnosing a mental health problem in someone with Parkinson’s is compounded by a lack of guidance for health professionals; and that there are complexities in the referral process, as a Parkinson’s professional must send an individual back to their GP so that they can refer them on to a mental health professional, which creates further, unnecessary delays. Professionals who presented evidence to the inquiry described communication barriers between departments, difficulties accessing patient notes, and a shortage of mental health professionals with the knowledge and skills to meet the specific needs of people with Parkinson’s. The mental health support received through improving access to psychological therapies, or IAPT, is not tailored to the needs of people living with Parkinson’s, and specialists such as neuropsychologists and neuro- psychiatrists are in short supply, leaving many people with Parkinson’s accessing IAPT services that are not tailored to their needs.

It is almost two years since the release of our report, and we are yet to see progress on several of the recommendations, which included funding research on effective mental health interventions for people with Parkinson’s, training in Parkinson’s for talking therapists working in IAPT services, and the publication of data on how mental health services for people with Parkinson’s are performing.

Every two years, the UK Parkinson’s Excellence Network, started by Parkinson’s UK to link up professionals who treat people with the condition, conducts an audit on the quality of Parkinson’s services. While the audit is not mandatory, an increasing number of services are taking part to track how they are improving. The results of the 2019 audit were released last week. They showed that, from 2017 to 2019, there was a reduction in the number of people with Parkinson’s being reviewed each year by their neurologist or elderly-care consultant, and less than 20% of these services were offering multidisciplinary clinics.

The results around mental health show how improvements are needed in screening and access to referrals. Almost a fifth of Parkinson’s services across the UK could not refer psychiatric services. The Excellence Network will now support Parkinson’s professionals to deliver an action plan to improve their services ahead of the next audit cycle, which will happen next year. Parkinson’s UK is currently interviewing people with Parkinson’s-related dementia and their carers about their experience of the health and social care system. Initial findings show that carers are struggling with some of the more distressing symptoms of Parkinson’s-related dementia, such as challenging and aggressive behaviour. They also show that NHS support for people with Parkinson’s-related dementia drastically reduces after entering a care home, and that social care staff do not generally understand the condition, leaving families and carers to step in and explain how they should provide care.

Acknowledging the importance of social care to an effective NHS, can the Minister say what progress the Government have made towards a future funding solution for social care, so that people with Parkinson’s dementia are not continually let down?

My Lords, I thank the noble Lord, Lord Hunt, for this debate, which is of the utmost importance. There is nothing more important than the safety of patients. It is thanks to the press and relatives that some of the neglect and horrifying bullying of patients in some hospitals has been highlighted over the years. I hope that the Government agree with me that we need a transparent and open way of reporting concerns. Members of staff, friends and relatives should not be punished and penalised for doing this; perhaps we need another word to replace “whistleblowing”.

It is of great concern that some ambulances have not been able to meet their targets. It is not acceptable that patients have to wait for hours on trollies in corridors. This illustrates the pressure on beds and staff. Recently, a member of my household was admitted to Harrogate District Hospital. One night, a nurse came to him in tears, saying she had 12 patients to look after. She could not give them enough of the care they needed. Well-trained nurses should be a priority if patient safety is to be safeguarded. In Birmingham, some cancer patients having treatment, such as radiotherapy, for their conditions, and who have to travel many miles, can stay free and look after themselves in a hostel—part of the hospital—during the week while having treatment. This alleviates them of the stress and exhaustion of travelling. I hope that this excellent plan can be extended across the country.

I belong to several all-party parliamentary health groups. When taking evidence, there is one overriding similarity: late diagnosis. Many people are told to go home and take paracetamol. This can happen several times. In the end, it can turn out that they have a serious long-term condition. What can the Government do to improve this dangerous problem?

I am president of the Spinal Injuries Association. Many of our members who are patients of the spinal unit at Stoke Mandeville Hospital cannot get appointments or new patients cannot be admitted because non-spinal patients are being placed in the allocated spinal beds. This illustrates the pressure on beds in a busy hospital. It also means that patients with life-threatening injuries, resulting in paralysis, are treated in intensive care beds without specially trained spinal nurses in general hospitals—blocking these beds while waiting for a transfer to a spinal unit.

I end by paying tribute to Brian Gardner, who was a spinal injuries surgeon at Stoke Mandeville. He was an outstanding doctor and always had time for patients and advised GPs on their needs. He died of cancer a few weeks ago. We need more doctors like Brian. He was one of the SIA’s advisers and is missed by very many people. He was an excellent communicator. Better communication throughout the NHS is what is needed. If public health, NHS England, social services and voluntary bodies do not work in co-operation, patients will not be safe. I add my congratulations to the maiden speaker for her passionate speech.

My Lords, do not be confused, I am not my noble friend Lord Brooke; I am grateful to him for swapping places with me—noble Lords will be hearing from him later.

I am grateful to my noble friend Lord Hunt for securing this debate; nobody knows more about this than he does. I am particularly pleased with the wide range of his topic: we can focus on the performance of the NHS in relation to its targets but also recognise the impact of adult social care pressures on those targets and that performance—I am glad that so many noble Lords who have spoken realise this.

My noble friend draws attention to a whole-system failure, and we can see evidence of that in the shocking statistic that shows how life expectancy in the United Kingdom is falling, contrary to what the noble Lord, Lord Bates, said to us. Life expectancy had been rising for decades, but has now started to decline, with the elderly, poor and newborn worst affected. Life expectancy for those over 65 has dropped by more than six months. Why? Academics have said that it is a direct result of the austerity measures imposed by the coalition Government in 2010. These cuts, which removed more than £30 billion from welfare payments, housing subsidies and social services, were some of the severest made by any nation after the 2008 financial crisis. They triggered dramatic reductions in social care, meals on wheels, rural transport, health visitors and district nursing services.

Community and voluntary services, which have always been so important in the care of the elderly and isolated especially, suffered similar reductions. If no one visits an isolated older person, no one notices if they have stopped eating or are having trouble moving about. They fall over, are finally discovered, and are then admitted to hospital where they have to be given more serious interventions than would have been the case if services had been available earlier. Then there is difficulty in discharging them because social care services are not available or are inadequate, and so the whole sorry cycle starts again, inevitably leading to shorter lives.

The cancelled operations, the ambulances queueing outside A&E and the patients dying in corridors are in fact a crisis in social care. NHS budgets may have been ring-fenced, but social care has lost £6 billion from its total spend and the 50% rise in elderly people and others stuck in hospital is because there is nowhere for them to go in the community. Thousands of care homes have closed and more than 30,000 places have been lost because providers can no longer afford to operate on the money they receive from the state. Even those homes that keep going—and there are many of high quality—face a constant battle to keep staff, since the starting wage for a care assistant is about £2,000 a year less than you could earn if you went to work in Asda or Aldi.

I mentioned a whole-system failure, and part of that whole system is of course the huge contribution of unpaid carers to our health and social care system—many noble Lords have mentioned this. Noble Lords would expect me to remind them that this contribution is worth £132 billion a year, or the cost of another whole NHS. But let us not forget the cost to the carers themselves, in terms of their own physical and mental health and the financial strain on them, which is not just the extra costs associated with providing care but the loss of future income because of lost earnings and pension provisions. I acknowledge with pleasure the commitment to carers’ leave in the gracious Speech, but it is to be unpaid so, frankly, it will not help much.

Your Lordships will be familiar with all the arguments about social care that some of us have been making ad nauseam for many years. I will not call that group the “usual suspects”, but after her wonderful maiden speech today I am delighted to welcome my noble friend Lady Wilcox to that group. We are familiar with reports followed by endless delay and indecision about how to tackle the complete unpredictability of the cost of care so that we pray we will die of cancer quickly rather than dementia slowly.

The Minister will quote the £1.5 billion given to local authorities for adult social care. That is a sticking plaster on an open wound, as I have said before in this House. I urge political consensus, as others have done, but we cannot get away from the fact that a very large chunk of money is required immediately to prevent more deaths in a situation which is surely the most pressing problem facing our nation. I have urged the Government before to be honest and bold about tackling this problem. I do so again. I ask the Minister to confirm that we will have an honest and bold proposal before the end of this year.

My Lords, I am grateful for this opportunity to consider opportunities to improve the NHS and get waiting times down. I thank the noble Lord, Lord Hunt, for securing the time for us to discuss these issues.

There is little doubt that outcomes in the NHS have been slipping. In particular, NHS England has under- performed on the four-hour accident and emergency waiting time target for some time and November saw the worst performance since records began. Some of the issues driving this are essentially secular and will not simply dissipate. This is in no way due to the NHS staff, who always impress me with their attention and care.

There is a general understanding that the greatest pressure on the NHS is the increased care burden of an ageing society. This comes across in higher numbers of operations, but nowhere more so than in adult social care. Without better social care provision, the elderly will continue to recover in hospital rather than in the community and waiting lists will increase. Adult social care has become a lingering issue that previous Governments have been unwilling or unable to address. When a new funding system was proposed in 2017, the policy had to be walked back within a few days. This underlines the weakness of creating a lasting settlement without some sense of cross-party approach. Indeed, to create institutions that last there needs to be an understanding by all parties that the need must be met, as occurred at the founding of the NHS itself.

It is for this reason that I welcome the second of the Government’s points for the forthcoming social care proposals, to

“urgently seek a cross-party consensus in order to bring forward the necessary proposals and legislation”.

I hope that all English opposition parties will recognise that this is an existential issue and play a constructive role in shaping a lasting consensus. For many in opposition, this is a real chance to leave a legacy not normally achievable for parties out of power.

The real issue to resolve will be funding a more extensive care system. The sums involved are substantial but the gains must be remembered. Shorter waiting lists, more available beds and fewer unpaid carers will make a large combined contribution and free up some capacity in the public and private sectors. The Government have committed to making sure that nobody will have to sell their home to afford care. This is a sensible first step, but there must be an equitable element to the system.

The Barker commission gave serious thought to making those above pension age pay national insurance contributions and Sir Andrew Dilnot suggested to the Economic Affairs Committee of this House that the current exemption was a “major distortion” in the tax system. The exemption should be reviewed, alongside the current range of pension benefits, which may need to be means tested to deliver additional savings, including the winter fuel allowance.

Ultimately, without increased contributions from the elderly, any new system will be doomed to unsustainability as the proportion of working-age citizens to retirees increases. Other forms of wealth taxation will also need to be explored, including higher capital gains taxes on transfers of wealth. It will not be easy, but I am convinced that with a collegiate attitude and a real effort, a path forward is possible.

My Lords, it is good to take part in this debate secured by my noble friend Lord Hunt of Kings Heath, whose commitment to and leadership in the NHS is known to us all. I am also delighted to follow the inspirational maiden speech of my noble friend Lady Wilcox, who I think has cheered us all up.

Speeches about the NHS are inevitably a cross between a love letter and a post-it note. The love letter bit is revisiting everything in one’s life that makes one grateful to the NHS, despite all its faults. For me, it is the safe birth of my three beautiful children, two of them twins, born in the brand new John Radcliffe Hospital in Oxford in the 1970s, the restoration to rude health of my husband from leukaemia 10 years ago and my mother’s care in her final years of dementia.

We all have our personal love letter to the NHS, but we also have the post-it note reminder: never to be complacent about this amazing national service; always to hold the Government to account; and to ask the awkward questions, as my noble friend has asked in his debate today, on performance, safe staffing, budgets and future prospects.

This year, 2020, is Florence Nightingale’s bicentenary and has been designated the Year of the Nurse and Midwife by the World Health Organization. In this year, it is right that, in response to the NHS long-term plan, we highlight, as has the Health Foundation, the real difficulty of growing pressure on our services and the widespread pressure of staff shortages.

In our local campaign in Banbury, Oxfordshire, which has been going on for years now, to keep the Horton hospital general and functioning across many departments, time and again the question of not being able to recruit staff—from the UK, Europe or the Commonwealth—has been cited for closing services. How will workplace shortages in both the NHS and the social care system be handled post Brexit under the Government’s new immigration strategy?

When it comes to staff pay, the social care sector in this country, in particular, as noble Lords have said, has nothing to be proud of. We cannot continue to run a care system on the cheap with an ageing population, the rising incidence of dementia and the prospect of AI just around the corner—benign or otherwise.

The excellent House of Lords Library briefing for this debate reminds us of the facts when it comes to the targets spoken of by my noble friend. NHS England’s performance against the four-hour A&E waiting time target in November 2019 was the worst since the figures started being collected in 2010. The 62-day maximum waiting time target between an urgent GP referral and the first cancer treatment was last met, astonishingly, in 2013-14. Also in November 2019, NHS England was below its operational standards for elective referrals, cancer referrals and treatment waiting times. Had those figures been owned by a Labour Government over the past 10 years, the media would have hounded us out of office. All those targets are now under review, and in that review, the House of Commons Public Accounts Committee has called on NHS England not to reduce current standards to make them easier to meet. That is a forlorn hope, I fear, but again we call for it today.

I was proud to be a member of a Labour Government who invested record sums in our NHS and the social care system. However, we did not grasp the issue of long-term social care funding and it is now for the Government to step up and turn the Prime Minister’s rhetoric into the reality of a properly funded NHS and social care system for the future, free from the threat of a trade deal with the United States and free at the point of use well into this century.

My Lords, much of the context for this debate is set by the targets that NHS England has laid down for the delivery of its services. There has been much discussion of the appropriateness of these targets, but we can draw some general conclusions from the persistent failure of the NHS to meet them. I suggest that the most important conclusion is that we are looking at a system stressed beyond its capacity to adapt and at serious risk of catastrophic failure. One can cite specific weaknesses and institutional failings, an inadequacy of funding and the need for coherence across the care sector. All are valid points, but they miss the root cause of the extreme stresses in the NHS: there is no proper strategy for the provision of healthcare in England.

I say that because a proper strategy is not just about plans, nor just about resources; it is about balancing ends, ways and means. Part of that balancing act involves deciding on the ends that are achievable within the means available. That is the calculation missing today. We are simply asking too much of the NHS. This is not a problem that can be solved just by looking at the inputs. Healthcare is an inherently ungoverned system of ever-increasing demand and ever-increasing technological opportunities. The recent growth in pressure has already outstripped the new resources promised, but that is not surprising. Left to itself, demand will always exceed supply, wherever we set the level of funding. We have to exercise control over the outputs as well as the inputs. That involves making hard choices and taking political risks, which is why I am rather pessimistic about the likelihood of our grasping this nettle. I do not believe that any of the main political parties is courageous enough, but we should be under no illusion about the consequences if we fail to rise to the challenge.

The Government will point to their long-term plan and the proposed increases in the numbers of clinical staff. These are indeed welcome, but they are insufficient. The Minister will be aware that morale within the NHS is in a parlous state. Many clinical staff are exhausted, physically by the unrelenting demands placed on them but also, and perhaps more importantly, exhausted mentally because they see no light at the end of the tunnel; indeed, they see no end to the tunnel. They need some sense that the system will be brought into sustainable balance in the reasonably near future, but I fear they are unlikely to receive such reassurance. If that is so, I ask the Minister to respond to some more detailed concerns, which, if addressed, might at least help to stave off an impending collapse of the service.

NHS staff clearly need some immediate relief from the pressures under which they labour today. The Interim NHS People Plan has made some proposals in this regard, but a number are as yet neither specific nor quantifiable, so when will a comprehensive and detailed plan of action, with milestones and accountable persons, be available? How will progress on these measures and their impact on NHS morale be assessed and reported?

At present there is a clear lack of adequate or timely maintenance of the NHS infrastructure, which—as we know only too well in this place—only builds up even greater and more expensive problems for the future. What steps are being taken to improve and sustain the fabric of the NHS estate, and how are capital investment and maintenance needs being measured, funded and reported?

The pressures on GPs mean that all too often they are unable to investigate the condition of their patients as thoroughly or deeply as they would like. This can result in them making more referrals than necessary to a secondary care specialist, leading to longer waiting times for all. A little more investment in the primary care end of the spectrum might result in an overall saving of time, money and staff morale, as well as a better service to the patient. Can the Minister say who, if anybody, is making such risk/benefit judgments, especially across the boundaries in the care system, and what power they have to allocate resources in ways that would give effect to such judgments?

The Prime Minister has indicated his intention to seek a consensual way forward on adult social care. My plea, echoing the noble Lord, Lord Bates, is that this be extended to the provision of care more widely, to include the NHS. The Beveridge report and the ensuing legislation to give effect to it were made possible perhaps only by the upheaval and dislocation of a catastrophic world war. I hope we do not have to experience similar turmoil before we can make Beveridge’s legacy fit to survive the challenges of the 21st century.

My Lords, I am grateful to my noble friend Lord Hunt for getting this debate and setting out the facts in such a devastating way. I heartily endorse his words. May I also say how much I appreciated the maiden speech of my noble friend Lady Wilcox? It was a breath of fresh air.

When I saw the announcement about this debate, I thought: “Here we go again. We will go around the well-worn track of rising demands from an increasingly ageing population needing more and more expensive treatments, while at the same time we suffer from inadequate staffing levels, poor buildings falling to pieces, lower morale and barely enough money to keep our heads above water.” While many patients seem satisfied, and indeed many—as we have heard—praise the services for acute, one-off care, the long-term sick and disabled are poorly cared for, especially by community services.

Of course, both the NHS and social services need more money. We are still way behind the level of 10 years ago and have some way to go to catch up, but we have to face the fact that if we are to match demand to resources, we will have to be much cleverer and more efficient in how we provide care.

I will talk about just two things that we must do, with or without the additional funding that we desperately need. First, we must find a way of bridging the gap between the way we fund the NHS and the way we fund social care. The current divide is a nightmare of inefficiency.

I will give noble Lords an example. Imagine an elderly gentleman sitting in a bed in a crowded NHS hospital, having been brought in following a fall in which he injured himself. He has been repaired and is ready for home, but he lives alone. There is no one there to look after him as he recovers and no obvious places available in the local care home. It is a weekend, and no one is available in the social care department until Monday. Meanwhile, patients are piling up in the A&E department, waiting for the bed that the current occupant is keen to leave. That is the normal Catch-22 situation in far too many places.

Now imagine another situation in which the hospital trust itself has the budget for social care, employs its own social care staff in the community and funds its own care homes. It does not have to negotiate with any other organisation when it wants to bring in or discharge any of the patients in its community. It simply uses its own resources. It is the integrated, undivided care system that we have long been talking about. I fear it is the one I have been banging on about for ever.

That system has been in operation for some years now in Salford, in the hospital where I happily spent most of my working life, Salford Royal. David Dalton, the then chief executive, gained the confidence of the local authority so that it was happy to hand over the social care budget for the common good of the whole population of Salford—250,000 people. He used it very well. Indeed, the hospital trust now runs Salford’s mental health services and employs a number of GP practices, so that the whole care system works as one. Staff morale is high, as they recognise that they are all involved in providing high-quality, efficient care. I should say that David Dalton took advantage of my having left Salford to undertake all these changes.

So it is possible to run an effective and efficient combined NHS and social care service that works and saves money, but why have we not been able to spread that system more widely? Of course, much depends on the personalities locally and the confidence they can gain to trust each other, but should the Government not be providing the push and stimulus to combine these services, inadequately funded though they both are? There are likely to be many variations on the theme of integrated services. For really radical change, the Treasury should be changing its funding model and merging these two streams. Meanwhile, will the Minister spend a little time examining what can be done short of that, perhaps even by visiting Salford, where a number of previous Health Secretaries have already been, to see how it can be done and then persuade her colleagues in the department to bestir themselves?

Briefly, my second concern is the care and support of our staff in the community and in care homes. It is no secret that these workers are the lifeblood of care in the community and we rely on them absolutely to look after the huge number of people that I fear society has tended to ignore. Yet these critically important staff are vastly underrated, underappreciated and underpaid. It is a scandal. Of course we should pay them more—at the moment, they would not even reach the lower cap that would allow them entry from the EU—but equally importantly we should provide them with not a voluntary but an obligatory training programme, give them a qualification and offer the possibility of career progression. We certainly need to do more to give them the respect and recognition that they rightly deserve.

My Lords, I am most grateful to my noble friend Lord Hunt for such a great and devastating speech. He has great experience in and insight into the NHS, and he does not lightly make attacks without good foundation behind them.

To the noble and gallant Lord, Lord Stirrup, I say that we have been here before. In 1997, the health service was in a hell of a mess and the Labour Government were elected to try to put right some of the problems we had with declining public services. It was done. The Blair and Brown Governments reversed the decline, in part by introducing targets, which were very successful indeed in many areas. Regrettably, since 2010, both the coalition Government and the Tory Government, for a variety of reasons, have dismantled some of those targets and we have suffered as a consequence. We argued that it was the wrong thing to do when they took away the target for the time that doctors should see patients. The Government’s cover was that they wanted to extend the availability of surgery from five days to seven days, but of course there were no extra staff to do that. In turn, we said that people would wait longer to see their GPs than they had in the past. Is that true? Yes: everybody is now complaining about the difficulty of accessing a GP of their choice.

We now have the argument about A&E targets. The Government want to abandon them. Why? It is a bit like the five people who have been sent to prison giving the Government cause for a major examination of the funding of the BBC. Whenever we see these changes coming, there is an ulterior agenda behind them. I hope that I am wrong on this and that the Minister will put me right, as I am sure she will.

Problems have been arising in A&E where the Government could have taken action. Yes, they are trying to deal with more people and yes, more patients are going there who should be going to their GPs rather than to A&E, but also—here I am banging on about my favourite subject, as noble Lords will know—more and more people are going there with alcohol problems. This causes great stress and strain to the staff involved and, in turn, great pressure on the number of beds that they go to afterwards. All the statistics indicate that the issue has got worse since 2010. Only yesterday in the Times, there was a report about the rising number of people who have been taken in, particularly from age 45 upwards, who are drinking too much and then putting pressure on the service.

When we look at what the Government have done in this area, it can be argued that they have taken steps that have made matters worse. A regulator was introduced in 2008 to ensure that duties on alcohol went up on an annual basis linked to RPI. What did the next Government do? In 2012, they abandoned that. Year on year, the Government have in fact been freezing duties or, in some cases, even reducing them. Has that helped the case and the numbers of people who are being affected by alcohol? No, it has made matters worse. Statistics show that beer duty has been cut by 18%, spirits and cider duty by 10% and wine duty by the low figure of 2%, so overall, we have lost £1.2 billion a year in income for the Government that could have been going into the NHS because of those changes. So who are the beneficiaries, and why? At the end of the day, the public have to pay for the people who end up in A&E and in hospital.

I hope that the Minister will be prepared to say something about this and the importance of campaigning on the public health side, which we have not mentioned greatly. I believe that changes in lifestyle need to be addressed more seriously than we have done in the past. I know that there is a Green Paper coming on that and I look forward to having a debate on it. In the meantime, urgent action can be taken. Can she persuade the Chancellor in the forthcoming Budget not only to restore the duty calculator linked to RPI but to add 2% to that figure? If she does that, we will start to see fewer people ending up in A&E and fewer people who work in the health service being unhappy, and we will have a healthier and happier community.

My Lords, I thank the noble Lord, Lord Hunt, for securing this debate. It is a pleasure to follow other noble Lords, who have made very cogent arguments for change, and in particular the maiden speech of the noble Baroness, Lady Wilcox of Newport; it seems like nirvana to think we might have to pay only £90 a week to many people in England.

Clearly we want to reform health and social care to best serve the health and well-being of people in England. I declare my interests as outlined in the register, particularly as a registered nurse, president of the Florence Nightingale Foundation and a former sister in accident and emergency.

At the heart of the issue is whether the NHS should reform the A&E four-hour waiting target a decade after its inception. The national medical director of the NHS considers that a change to the four-hour target and some cancer treatment targets may, based on sound data, serve the population more effectively. I will concentrate on the A&E target and delays to patients’ transfer of care from acute hospitals to their own homes, nursing homes and registered care facilities.

The NHS is piloting a new A&E scheme entitled “rapid care measures” with 14 trusts. The new standards include the rapid assessment of all patients in A&E, coupled with faster life-saving treatments for those with the most critical conditions, including sepsis, heart attacks, strokes and acute psychotic episodes. The initial results are promising, with the number of patients spending over 12 hours in A&E falling faster than in control groups. There appears to be broad public support for these measures. It is vital that any change to targets are clinically appropriate and supported by evidence-based healthcare interventions, which the proposed changes reflect.

Therefore, unlike many in this House, I urge the Government to revise the A&E targets in this way and set clinical teams free to work in a more independent, evidence-based approach focused on individual patient need rather than keeping to a four-hour target set in stone. This is likely to enhance staff morale and improve time from attendance to treatment for those most critically ill. It may also reduce the number of people attending A&E for very minor problems as they may have to wait longer than four hours. We know that many people go to A&E for health problems much better suited to community-based services because they have difficulty accessing a GP or community nurse. The need to increase the number of GPs is essential, but so too is developing and enhancing the role of other healthcare practitioners in the community if we are really serious about system redesign in the NHS and social care.

In the US there has been an increasing focus on systematic change associated with the affordable health care Act, which elevated the role of both physicians’ assistants and nurse practitioners. I have witnessed the positive effects of the introduction of these roles in Washington State, particularly in supporting people with multiple physical and mental chronic health conditions in community settings. An analysis of US census data published this week shows that the number of nurse practitioners has grown at an unprecedented rate across the USA, from around 91,000 in 2010 to 190,000 in 2019. These practitioners are filling a primary care void, particularly in rural areas. A professor of nursing at Montana State University estimates that there will be two nurse practitioners for every five physicians by 2030, compared to one in five in 2016. Will the Government look at this research and investigate whether one way of improving primary care and reducing A&E visits would be to invest more significantly in a range of advanced roles for community healthcare practitioners?

The Government intend to publish plans to reform the social care system this year. That is essential because it will improve people’s lives and, we hope, reduce delayed transfers of care from hospital to the community. Will the Minister please note my support for altering the four-hour A&E targets in the light of the results from the pilot sites? I urge her to ask the noble Baroness, Lady Harding, to work further on the NHS people plan in the way outlined by the noble and gallant Lord, Lord Stirrup, and to consider piloting the NHS funding care packages for a fixed period on discharge for those due to leave hospital, in the way so ably outlined by the noble Lord, Lord Turnberg.

My Lords, I congratulate my noble friend Lord Hunt on giving us the opportunity to debate this issue and on his tour de force contribution, giving us the benefit of all his vast experience.

I declare an interest: like many, I am a frequent user of the NHS, which gives you an opportunity to observe first-hand the range and quality of service that you get. I echo my noble friend Lady Crawley in saying that in most cases it is very good. I am also a member of my GP’s patient care committee. The practice has nearly 8,000 patients but operates in what is an extended semi-detached house. For the past five years or more we have had plans for a nice brand new medical centre offering a good range of services, but that was suddenly scrapped. Quite apart from the £1 million or so wasted in the planning, you can imagine the frustration and demoralisation in our practice as well as the impact on the local A&E. I would welcome a comment from the Minister on why essential schemes such as this are suddenly scrapped.

I declare another interest: our daughter Laura, an ex-paramedic, is now a trainee advanced clinical practitioner in A&E, working at a local hospital, so I hear some of her first-hand experiences.

I, too, congratulate my noble friend Lady Wilcox on a superb maiden speech that drew on her vast experience in local government. I am sure it was the first of many great contributions.

It is national apprenticeship week. Your Lordships will not be surprised that, as an apprentice ambassador, I will refer to staffing and skills, of which we all know there are vast shortages in the NHS. We should be ashamed of our need to poach highly trained medical staff from countries that desperately need their services. Year after year we fail to train enough people. Worse still, and a great example of the law of unintended consequences, the Government previously decided that they would scrap free training for nurses and introduce a bursary—a really smart idea. That is irony on my part. I am glad to say that they have restored it, but it did not help.

Unfortunately, the NHS cannot make full use of the apprenticeship levy because of the need to find replacement staff for apprentices’ study time. Again, I hope the Minister will take away that point to see how to improve that situation. If she wants some good advice, may I suggest that she goes to the Open University, which is heavily involved in nursing apprenticeships?

We are supposedly in the middle of the fourth industrial revolution, yet the use of new technology in the health service is patchy, to say the least. Recently, somebody told me, “We can’t even transfer patient details electronically between hospitals.” This is in theory the 21st century, yet we still cannot make use of that technology.

I enjoyed the Panglossian contribution to the debate made by the noble Lord, Lord Bates. We should pay tribute to the good work done by NHS staff in a very challenging day-to-day situation, as he acknowledged. However, all is not for the best in the NHS world, as the Government acknowledge in their funding proposals. May I suggest that the Minister looks across the NHS for examples of best practice? My noble friend Lord Turnberg gave us an example. That is not the only hospital trust that is using that, but why does it not spread? It takes far too long. I predict that a lot of the Government’s proposed funding increases will be wasted unless best practice of providing good services and keeping to budgets is looked at. I hope that the Minister will take that as a constructive contribution. It takes far too long for best practice to permeate through the NHS, and unfortunately bad practice can be tolerated with disastrous consequences for far too long, as we heard on the Paterson report. Paying billions in compensation is disastrous. There are examples of no-fault liability schemes that would encourage responsible whistleblowing and save that huge waste of NHS money.

I have come to the end of my time. Again, I thank my noble friend Lord Hunt for the opportunity to contribute to this debate.

My Lords, I add my thanks and congratulations to the noble Lord, Lord Hunt, for instigating this important debate and, as ever, to noble Lords for their stimulating and informative contributions. I also thank the many organisations that have sent us briefings, starting with the Library. I found the NHS Providers briefings especially helpful. It is instructive how many of those briefings cover the same concerns about the NHS and social care in England that we have reflected upon in this debate.

I echo the comment made by the noble Lord, Lord Bates, about the brilliant staff in the NHS. I want to extend that to staff in the social care sector and its volunteers, carers and patients. In recent years we have asked patients to change how they receive their healthcare, and many have adapted and responded to that well.

When I was chair of education in Cambridgeshire, I was told very clearly by my director that free school meals were a proxy indicator for children in poverty, and this House has on many occasions debated whether it is appropriate to do that and whether it is an effective proxy. As the noble Lord, Lord Hunt, said, NHS targets are a proxy for the NHS and social care performance. Whether we call them targets, access standards or some new fancy name in any government review, the most important thing from the perspective of these Benches is that they should not be scrapped. They act to make our NHS and social care sector think about and change what it is doing to achieve a better outcome.

The 3.6% increase in the NHS is welcome from the Government, but as so many have said, it is not enough. I am pleased that the Secretary of State, in another place last week at the Second Reading of the healthcare funding Bill, kept saying that this is a floor, not a cap—we will hold the Government to that. It is only a sticking plaster to get us from total emergency to perhaps being able to manage services. It provides no scope for improvement or for the large changes in technology that I know the current Secretary of State is looking for. Unless the long-term underlying problems are addressed in our health system, we will remain in crisis.

I reflect on why the Conservatives introduced the Patient’s Charter in the 1990s. As other noble Lords have said, the NHS was, frankly, in total crisis, with a lack of funding, buildings completely unfit for purpose and a burgeoning crisis in social care, with too many delayed discharges. I remember a story in Cambridgeshire of a woman being taken to Addenbrooke’s Hospital in a horse-box after a three-hour wait for an ambulance. The Patient's Charter worked. The Labour Government adapted and developed it further. I echo the many points made from the Labour Benches about the strength of those targets. Although politicians and media hold every Government to account for those targets, I do not believe that anyone thinks that they are simplistic. We understand the complexity of performance that goes on behind that. The problem is that they are consistently being missed. It is not just about lack of performance; it is about lack of resource—not only money but resource.

I really liked the four key points made by the noble Lord, Lord Hunt. I am going to focus my remarks and try to bring in what other noble Lords have said under them. Long-term planning is right. Woe betide us if we think that five years is long-term planning. It needs to be at least 20 years, and probably a quarter of a century. There is so much changing in care. The way that consultants treat people with a long-term condition such as mine has completely changed in the last five years, let alone the last 10 years. Are the resources available, whether they are staff funding or technology, to match those changes as they come? We need to ensure that it is completely fit for purpose.

Many people outside politics say that we should take the NHS away from politicians. I say no. The NHS is such a key part of our public life that the public will always come back to politicians to say, “What are you doing about it?” Let us just say that we need to tackle the issues. The noble Lord, Lord Suri, rather plaintively said that he hoped the opposition parties would come together behind the Government. I gently remind him that, in the Dilnot review, all the parties came together but the Conservatives walked away the moment a decision needed to be made. All the opposition parties will support the Government in ensuring that we work together in the future. We look to them to ensure that we have a proposal that will work.

The noble and gallant Lord, Lord Stirrup, talked about having no proper strategy. That is also a problem, but we have covered the myriad areas in the debate this morning. I think that the will is there; I know it is there among the staff, but we need to ensure that this is moved with speed to ensure that everybody understands. When I talk to senior managers in hospitals, I hear about their local strategies. I do not always see the golden thread going back to NHS England.

The noble Baroness, Lady Wilcox, made a wonderful maiden speech. I loved her phrase “not another rough draft”. It is just so pertinent. As someone else who went to the Central School of Speech and Drama—I did stage management; she trained as a teacher— I know that, no matter what you did there, you were taught to speak. Other noble Lords commented on the noble Baroness’s content; I, as a fellow alumna, congratulate her on the style of her delivery.

The funding challenge has already been covered, but it remains a persistent issue. It is vital that the funding challenge in adult social care is also addressed. We have seen the knock-on effect on the NHS of not getting adult social care right for nearly three decades. I was pleased when it was decided to make the Secretary of State the Secretary of State for Health and Social Care, but a title on its own does not do enough. The better care fund started to make progress in these areas, but it was not rolled out and is certainly not consistent.

My noble friend Lady Pinnock, who has considerable expertise in local government, talked about that perfect storm, and she is absolutely right. I welcome the comments from the right reverend Prelate the Bishop of Carlisle, and the noble Baronesses, Lady Gale and Lady Pitkeathley.

Workforce development is vital. I echo the point made by the noble Baroness, Lady Watkins, about nurse practitioners. If I hear another Member of this House say that nurses do not need to be qualified but just need to know how to care, I will grind my teeth so hard I will not have any left. I rely on my advanced nurse practitioner for advice and support in my condition, and I see nods from other noble Lords around this House. We should be developing them further in primary care because we are not going to resolve the shortage of GPs. That brings me to my other workforce point: we are not training enough doctors and other healthcare professionals. Not just this Government but Government after Government have avoided the expense of developing our doctors, in particular. That is why we continue to need people to come in from elsewhere.

We need to change the culture. The noble Lords, Lord Hunt and Lord Young, spoke about that. It is important that we do not have just little pockets of good practice. I do not understand why there is not a culture of continuous improvement in the NHS. One can go into an organisation and tell it about something wonderful that is happening elsewhere, and it is completely missed. It is more than just talking about each other. It is more than workshops. I know that NHS Improvement and NHSX are beginning to change that, but the culture changes too slowly.

Can the Minister confirm that the Government will not impose 5% cuts anywhere in the Department of Health or in local government because, if other parts of those departments are asked to take further cuts, any increase in baseline budget will become meaningless? They are way beyond saving or cutting to the bone. We are in danger of beheading the very thing the Government say they want to protect. Do the Government have any plans for a long-term strategy of at least two decades? In the meantime, a commission on adult social care is essential, as is further integration.

Let us get together, all parties, all stakeholders, to make this a national priority over the next few months. It is time to make it happen.

My Lords, first, I draw the House’s attention to my interests in the register. I thank my noble friend Lord Hunt for initiating this debate and all noble Lords who have participated. I particularly want to welcome and congratulate my noble friend Lady Wilcox on her maiden speech, which was a model of its kind. I was delighted when she joined us and I am very much looking forward to working with her in the future. I would also like to add my thanks to the Library, the Royal College of Surgeons, the Alzheimer’s Society, Independent Age, Age UK, the NHS Confederation, the Independent Healthcare Providers Network and many others that sent us briefings. I agree with the noble Baroness, Lady Brinton, that their analyses of the scale of the challenge and the solutions were remarkably similar.

My noble friend Lord Hunt and other speakers have set the Minister a challenging task in answering this wide-ranging debate, linking as it does priority targets, the impact of failing to deal with adult social care and the implications of that for patients in the context of what happens to primary healthcare, social care, mental health, public health and capital expenditure, which are all linked and interdependent. I agree with my noble friend Lady Crawley about how debates on the health service in the House of Lords are a love letter and a post-it note. My contribution is probably the latter.

The Government must own the effects of 10 years of austerity. They are not a brand new Government, as the Prime Minister would have us believe, but a continuation Conservative Government, and they cannot pretend that that the fact that our social care system is completely failing millions of people is a newly acquired responsibility. It is as a result of a deliberate action to starve this sector that we face NHS buildings and infra- structure which are crumbling and a danger to patient safety, that we are nowhere near parity of esteem in mental health in terms of spend or access, that public health is unable to deliver true prevention because of the cuts to local government spending, that parts of the NHS are, as the NAO reported, “seriously financially unstable” and that trusts and CCGs are building up debt.

Thus it is not surprising that, as my noble friend Lord Hunt tells us, the NHS is simply not able to meet the targets which are enshrined in the NHS constitution. While it is welcome that the long-term plan recognises that health and social care go hand in hand, we have yet to see the action and funding which will address the social care challenge. We will soon be discussing the NHS Funding Bill, which some might call window dressing. It is a testimony to a Government who must put into legislation a promise they have made to ensure that they keep it. That is a matter we will be discussing in a few weeks’ time, when there will be another opportunity for the Minister to address some of these issues.

I shall not repeat the statistics that noble Lords have adequately outlined, but at present it feels as if we are at a tipping point and the NHS is slipping back to the years before the last Labour Government, who of course made the historic investment and basically turned around the NHS to leave it in pretty good shape in 2010. However, I agree that we need to look forward, and the Government must make very good use of the resources they are already committing. Any news from the Minister about the likely outcome of the Budget and the spending review would be welcome, and some expansion on the Prime Minister’s declared intention to sort out social care would also be welcome. What exactly is his plan?

Given that I have served on a CCG for the past three years, noble Lords will not be surprised to hear that I intend to start by focusing on primary health care and its importance in future plans. I can bear witness to the tireless work of GPs and their commitment, and their staff’s commitment, to ensure that all patients receive high-quality care when they need it. I also witness the fact that front-line local healthcare is often under threat from funding being sucked out of the system by huge trusts with the push-me-pull-you funding formula that is still apparent in the system. I am pleased that there is some recognition of that in the long-term plan and that that will be reflected in the next round of NHS England’s planning process.

I echo my noble friend Lord Young’s story about his GP’s surgery. I think the Minister will recognise that, if the workforce and the funding for primary care are not sufficient and stable, the knock-on effect for acute services will be deleterious and significant. Along with the general NHS staffing crisis, there is a GP work- force crisis, and I wonder whether the Minister can update the House on how the delivery of 5,000 additional GPs and 5,000 additional staff in England is going. I am very proud of the work of the past three years in primary care delivery in Camden, with our innovative patient care-led commissioning, and I am very keen for that not to be lost in the latest reorganisation that is now under way. Clinical and lay members on CCGs all over the country are anxious that local primary care should not be lost in the creation of ICSs.

The social care system is broken, as many noble Lords, including my noble friend Lady Pitkeathley, and the noble Lord, Lord Turnberg, said. It is ignoring 1.5 million people with unmet needs, leaving carers to feel alone and unsupported in caring for their loved ones, and it is costing people their life savings. Age UK says that the social care crisis, with delayed discharges from hospital due to a lack of social care, is costing our NHS an eye-watering £500 every minute.

As a Labour and Co-operative Member of your Lordships’ House, I will take this opportunity to urge the Minister to look at a new model of social care that uses the principles of co-operation to build on the first-hand knowledge of those who rely on, receive and provide care. I urge her to read the report of yesterday’s debate in Westminster Hall, which explored this very positive proposition. It requires commissioning authorities and central government to recognise that co-operation and mutuality could provide some answers in this sector.

Thousands of people’s lives have been on pause as a result of underfunded mental health services over the last decade. My noble friend Lady Gale outlined the issues around Parkinson’s. There is a desperate need for the 19,000 new mental health workers promised in the next year. That is important not only because hundreds of thousands of people need care but because continuing not to resolve this problem has a knock-on effect on primary and secondary healthcare and social care. All these issues are interlinked.

On public health, I will say only that it really is time that there was real recognition that investment in prevention saves billions further down the line, so let us see that that actually happens. Let us not leave public health at the whim of the spending regime in local authorities whose funding has already been cut, because that is completely counterproductive.

On targets, I am concerned that the Government’s review of NHS clinical standards, including piloting the introduction of new average waiting times for elective care, is a problem. Does the Minister agree that the introduction of the 18-week target is a worthy achievement that should not be jeopardised by this review? The noble Baroness, Lady Watkins, made some very interesting points about how to reduce the pressures on, and redirect people from, accident and emergency departments through investment in GPs, primary care and minor care. She is absolutely right. However, there also needs to be an incentive to keep accident and emergency departments on their toes. We do not want to slip back to people waiting on trolleys in accident and emergency for 12 hours.

In conclusion, it is completely clear from this debate and from the briefings that we have all received that these wide-ranging issues are interlinked and inter- dependent. You cannot divorce primary care, mental health, the capital investment required, public health and secondary care from one another. That is why the long-term plan needs to be a longer-term plan and why it needs to take all these issues into account. The spending needs to be integrated so that we do not feed one side of the National Health Service while the other side—social care—puts such pressure on the system that it cannot possibly succeed. I look forward to the Minister’s response.

My Lords, I thank all noble Lords for an expert and robust debate on a very important issue. In the time available, I shall do my best to respond to as many of the points raised as possible. I particularly thank the noble Lord, Lord Hunt, for, as ever, a robust contribution on a very important issue and for allowing us to have this debate. I also pay tribute to the noble Baroness, Lady Wilcox, for a formidable maiden speech. It is clear that she has deep personal experience and a straight-talking character, which means that she will make a considerable contribution to this place. I look forward to many future debates and interactions with her on the issues she has raised today and many others.

Like my noble friend Lord Bates, whom I can see in his place and who made an outstanding speech, I start by thanking the hard-working staff in our health and social care services. These services face unprecedented demand, with an ageing population and the challenges of winter placing a particular strain on them. In that context, the staff are doing a quite extraordinary job. As was mentioned by the noble Baroness, Lady Crawley, we all have our love letters that we can speak of, based on our own experiences. They demonstrate when the staff go far above and beyond to make sure that we come out on the other side in one piece.

I have listened very carefully to the concerns raised today about NHS performance, the pressures on our social care system and the impact on patients. Noble Lords are absolutely right to expect the Government to be restless in pursuing higher quality and in supporting the NHS so that it can be there for each and every one of us when we need it most. Today, I will outline the steps that the Government are taking to help address those concerns and will bring noble Lords up to date as much as possible.

I turn, first, to performance. As I have already mentioned, the NHS and social care system faces unprecedented demand. A number of noble Lords mentioned the figures. I will not go into too much detail as I would like to answer as many specific questions as possible. However, I should like to note that the most recent figures available for December 2019 show that there were over 2 million attendances at A&E—6.5% more than in December 2018. That means attendance by over 70,000 people every day—the highest ever for the month of December. Hospitals have also delivered 2.4 million more operations and almost 13 million more consultant-led out-patient appointments than in 2009-10. That is an extraordinary achievement.

However, I recognise, as was mentioned by the noble Lords, Lord Hunt and Lord Turnberg, the noble Baroness, Lady Pinnock, the right reverend Prelate the Bishop of Carlisle and many others, that in addition to the pressures on the health service, we are seeing increased demand in the social care system. We must put social care on a sustainable footing, with everyone being treated with dignity and respect. It is one of the biggest challenges that we face as a society. As my noble friend Lord Bates rightly said, we must resist the temptation to treat it as a political football. The Prime Minister has been clear that this Government will deliver on their promises and bring forward a plan for social care this year, as was specifically requested by the noble Baroness, Lady Brinton. I am quite sure that she will hold us to account very firmly on that commitment.

It is expected that there will be 1.5 million more over-75s in the next 10 years and we have to find a way of caring for them. As the noble Baroness, Lady Wilcox, rightly pointed out, there has also been a significant growth in the number of working-age people with disabilities who need care at a younger age. We need a system that gives every person—old and young—the dignity and security that they deserve.

The noble Baroness, Lady Wilcox, was right that these are complex questions which require not only difficult decisions to be made but the establishment of a sustainable settlement that will provide certainty for generations to come. That is why we will seek to build cross-party consensus, but we have been clear on two points: that everyone will have safety and security, and that nobody will be forced to sell their home to pay for care. The noble Baroness, Lady Thornton, asked me to predict both the Budget and the outcome of these negotiations. I am afraid that I will not be able to do that today but I am very touched by her thought that I would be able to answer those questions immediately at the Dispatch Box. However, I would like to update the House on what we have been doing to try to reduce pressures in the meantime.

To help address the increases in demand, last year we committed to £33.9 billion more funding a year by 2023-24. We are now enshrining that in law, and I know that we will have a significant debate about what that means for the NHS. As my right honourable friend the Secretary of State for Health and Social Care announced, this is a significant cash settlement for the NHS, and it means that we are already delivering on our manifesto commitments. We are also committed to delivering 40 new hospitals over the next decade, 50,000 more nurses, 6,000 more doctors in primary care and 50 million more GP appointments. As requested, I will update the House on the specific questions on that.

The noble Baroness, Lady Crawley, asked about the EU workforce. We have been clear that our priority is to ensure that the 181,000 EU staff currently working in the NHS and in social care are not only able to stay but feel welcomed and encouraged to do so. Since the referendum, we are pleased that 7,300 more EU staff are working in the NHS, including 900 more doctors. We are not only working to make sure that they are able to navigate their way through the EU settlement scheme easily and effectively; we will also introduce a new EU visa to make it easier for suitably qualified doctors, nurses and other staff to come and work in the NHS from overseas. We are working across government to make sure that this goes through smoothly.

In addition, a number of Peers, including the noble and gallant Lord, Lord Stirrup, and the noble Baroness, Lady Watkins, asked how we will go forward with the people plan, which will provide a constructive and holistic approach to our management of the framework for collective action on workforce priorities. This will be published in early 2020. It needs to take fiscal priorities into account, so there are questions around the Budget and the spending review. It will focus on growing and sustaining a well-skilled workforce across the NHS, particularly on creating healthy, inclusive and compassionate cultures. I know that this was raised by a number of Peers, including the noble Lord, Lord Turnberg.

To date, in addition, capital funding amounting to £2.4 billion has been provisionally awarded to over 150 STPs. I know that the noble Lord, Lord Hunt, has raised this on a number of occasions. This investment will modernise and transform NHS buildings and services, which the noble and gallant Lord, Lord Stirrup, asked about. The money will go towards a range of programmes across the country, including new urgent care centres, integrated care hubs that bring together primary and community services, and new mental health facilities. This money will be spent on upgrading facilities, increasing capacity so that more people can be treated and shifting emphasis towards prevention, making sure that we can deliver on the prevention Green Paper.

My right honourable friend the Prime Minister also announced a further £1.8 billion increase in NHS capital spending, which will deliver on 20 hospital upgrades so that they can come forward as soon as possible. This frees up the NHS to take forward and expand its existing plans for investment in infrastructure, and to unlock the delivery of commitments already made.

We have taken into account the questions about backlog maintenance and equivocal infrastructure asked by the noble and gallant Lord, Lord Stirrup. There has been a commitment that this will be taken into account as part of the spending review. It is recognised that, for too long, this has not been undertaken suitably strategically. I hope that that reassures him.

To respond to the noble Baroness, Lady Thornton, we have committed to growing the workforce by more than 600 doctors in general practice. NHS England and HEE are working with the profession to increase the workforce in England. This includes measures to increase recruitment, address reasons why doctors are leaving the profession and encourage them to return to practice. We have discussed this on a number of occasions. I am pleased to report that, last year, HEE recruited the highest numbers of doctors into GP training ever, at 3,540 trainees. We are moving in the right direction.

The noble Baroness, Lady Masham, rightly raised earlier diagnosis. We are committed to making sure that we drive forward on this. It is a crucial part of the long-term plan: as part of prevention, we also want to make sure that we are diagnosing earlier, reducing demand and pressures for patients and clinical trials. This is why we announced funding to replace outdated cancer diagnostics and treatment machines. Some £200 million, consisting of £100 million this year and £100 million next year, will be used to replace MRI and CT scanners or breast cancer screening machines that are more than 10 years old. I know that the Labour Front Bench wanted to be reassured about this so that we can ensure that we get earlier diagnostics and patients on the right care pathways as soon as possible.

The noble Baroness, Lady Gale, asked some specific questions about Parkinson’s. I hope to give her some helpful answers. In 2018-19, the NIHR clinical research network supported 323 dementia and neurodegeneration studies, 99 of which were new studies in this area. In addition, to address access to mental health support for people with long-term medical conditions such as Parkinson’s, we aim to increase access to psychological therapies for an additional 600,000 people each year by 2020-21. We have committed to ensuring that this will address care for patients, such as those with Parkinson’s. I hope that this answers some of the noble Baroness’s key questions.

In the short term, NHS England has prioritised funding to support performance for this winter. I know that this was raised by the noble Lord, Lord Hunt. Additional capital and revenue funding was made available to systems and trusts to support staff and bed capacity throughout the winter. This has allowed trusts to increase bed numbers and facilities to support better flow through the system. I am pleased that the NHS has reported that over 1,000 more hospital beds are open this winter than at the same time last year.

In addition, a further £240 million has been provided again this year for adult social care to help reduce delays in patients being discharged from hospital by providing social care support. The noble Baroness, Lady Brinton, was quite right to highlight the value that the better care fund has provided in integrating the links between adult social care and the NHS. She is quite right that this is a relatively short-term solution; we look forward to more sustainable long-term solutions from ICS and others. However, I am very pleased that we committed a total of £6.4 billion to the better care fund in 2019-20 and that further funding is committed for this year.

This is all in addition to winter funding that provided £145 million for hospitals last year and has gone up this year. It has also provided ambulance services with 256 new state-of-the-art vehicles and make-ready hubs, which shorten vehicle turnaround times. I know that the noble Baroness, Lady Masham, was concerned about this.

To support performance, the NHS has continued to focus on longer-term solutions. This means that, as we go on in years, we will not see the same performance challenges, transforming and improving urgent and emergency care services. The priorities are as follows.

The first is to increase the provision of same-day emergency care so that patients are seen quickly and not admitted to hospital overnight if that is unnecessary. We have seen some good progress here, with over 89% of hospitals now providing SDEC for 12 hours a day. Other priorities are: to reduce the number of patients who have unnecessary long lengths of stay of more than 21 days in hospital; to increase the number of urgent treatment centres delivering a standardised level of service to provide patients with an alternative to A&E; to continue to make improvements to the use of GPs at major A&Es, allowing less acutely ill patients to be streamed away from the emergency departments, and to consider the issues raised by the noble Baroness, Lady Watkins, about the higher training of GPs and other practitioners so that patients do not feel the need to go to A&E; and to enhance NHS 111 services so that people calling can receive a clinical assessment and be offered immediate advice.

To respond to the important point made by the noble Lord, Lord Young, about the spreading of best practice across the system, we have brought in very important measures recently—not only NHSX but Getting It Right First Time to support NHS Improvement’s work, as well as the Accelerated Access Collaborative to drive innovation and best practice across the system.

I turn to the questions about clinical waiting time standards. This review is being clinically led by Professor Stephen Powis, the national medical director of NHS England, to consider whether improvements can be made to access standards for urgent care, planned care, cancer and mental health treatment. It is not a question of abolishing or removing these waiting time standards.

I will briefly address the point made by the noble Lord, Lord Hunt, about the introduction of the four-hour waiting time and the Patient’s Charter. Let us remember that that was 15 years ago. Under this Government, last year, 1.7 million more patients were treated within four hours than in 2010, and hospitals delivered 2.4 million more operations. Let us not forget that, when the Labour Administration left office, over 18,000 people were waiting for more than 52 weeks to start elective treatment. It is now 1,400. I would like for us not to look with rose-tinted glasses and forget some of the challenges being faced then as now.

Regarding the questions on current A&E waiting times, the standard sets out a maximum four-hour wait from arrival to admission, transfer or discharge. The initial clinical review of standards report set out some key reasons why we should consider clinically whether there are better ways to deliver this care. First, the standard does not measure total waiting times or differentiate between severity of conditions. It measures a single point in what is often a complex care pathway, and there is evidence that hospital processes rather than clinical judgment are resulting in admissions or a discharge in the immediate period before a patient breaches the standard—in other words, perverse incentives.

In addition, since the introduction of the waiting time standards 15 years ago, practices in medicine and urgent care have naturally advanced, for example with the introduction of specialist centres for stroke care, urgent treatment centres, NHS 111, trauma centres, heart attack centres and acute stroke units, increased access to and use of tests in A&E and new ambulance standards, as well as the increased use of same-day emergency care to avoid unnecessary overnight admissions. This is all being led by clinicians on the best advice to improve the standard of patient care. Any changes will be reviewed only after full evaluation and clinical advice. I hope that that is reassuring for the House; I am sure that we will be robustly tested on it. I hope that it clears up some of the questions asked and responds to some of the points made by the noble Baroness, Lady Watkins.

I will close so that the noble Lord, Lord Hunt, has time to respond. I close by expressing the hope that I have reassured the House that this Government not only understand the importance of world-class health and social care provision but have made it our number one domestic priority. We are listening to the concerns raised regarding not only the quality of, and access to, NHS care but social care.

The measures I have outlined are helping to ease pressure on the health and social care system and to improve performance. The funding we have committed through legislation is intended to provide the certainty that the NHS needs to deliver the long-term plan and, with it, the world-class service that each and every one of us wants, so that clinicians, patients and the public can have confidence that they will always be able to find the right care at the right time, no matter where they live in the United Kingdom.

The Minister has given a comprehensive response to a range of questions. Could she answer in writing the question on NHS apprenticeships? I would be grateful.

My Lords, I first thank the Minister for her comprehensive response, and I thank all noble Lords who have taken part in what has been a wide-ranging and excellent debate. I congratulate my noble friend Lady Wilcox on what was, on any count, a brilliant maiden speech. I hope that she will speak many times in your Lordships’ House over the coming months.

In such a wide-ranging debate, one cannot do justice to what has been said, but I would identify three core themes. First, on social care, we are united in wanting to see a solution. The Minister is reassuring about the proposals that will come from the Government at some point in the year. I say to her that it is very important that these proposals deal with the now as much as they do with the future; it is now that so much pressure is being felt. I say to the noble Baroness, Lady Brinton, that if she is really looking for a quick solution, she just has to go back: you legislated for Dilnot. Raise the means test cap; implement Dilnot; and put more money into adult social care—that at least would give you a fundamental way to go forward. Your Government legislated for it; this is the remarkable thing about capping the cost of social care for individuals. It is quite remarkable that we are here, still desperately hoping that we will get a solution for the future, when we had it.

Secondly, I echo all noble Lords who have spoken so highly about the work of staff and so many great things happening in the health service. There is no doubt about that. The noble Lord, Lord Bates, referred to the US Commonwealth Fund designation of the NHS as the number one healthcare service in the world. He was right to do so. As he will know, the reason for this is that we came out very highly on cost-effectiveness and access to services. He will also know that we came bottom, with the US, on health outcomes. My concern about the issue of targets is that our continuing failure to meet them will lead to worsening health outcomes in the future.

This brings me to my final point. The Minister referred to the pressures that we are under. These are not going to go away, whether demographic pressures, growing health inequality or the fantastic opportunities of new medicine and treatments, which cost additional money. This is the way that health will go over the next period; it is not until the 2060s that the population demographic will start to change again. At the moment, the health service is reeling under huge pressure. It is simply not sustainable to think that we can go on like this over the next 10, 20 or 30 years. We have to level with the public that, if they want the NHS—and I think they do—they will one way or another have to pay for it.

We cannot run away from the kind of debate that the noble and gallant Lord, Lord Stirrup, said that we ought to have. I go back to what the House of Lords Select Committee on Long-term Sustainability of the NHS said three years ago: that we must face up to the long term to have any hope at all of getting through this and landing the NHS in the excellent shape in which we want it to be. I thank noble Lords for the opportunity to debate this.

Motion agreed.