The noble Baroness, Lady McIntosh, talked about the importance of the arts. Pupils in this country, on average, take more than 11 GCSEs or equivalents, so there is plenty of scope up to 16 for a very balanced curriculum, with plenty of room for arts subjects. All children should have a broad, balanced and fully rounded education, and I shall certainly look at the website that she referred to. We need to encourage more pupils, particularly girls, to consider taking more STEM subjects.

This Government are committed to tackling deprivation and promoting social mobility. We have introduced a number of key measures to tackle health inequalities, to support parenting and to provide high-quality early education to children from low-income families. We have a strong record of success: relative child poverty is at the lowest level for 30 years, there are 300,000 fewer children in relative poverty since the election and nearly 400,000 fewer grow up in workless families. At the same time, we have had a massive programme of improvements to the education system, particularly for less advantaged children. The quality of education is improving, with more children doing better at school. This is a record of which we can be proud. I again thank all noble Lords, particularly the noble Baroness, Lady Massey, for their contribution to this debate.

1.56 pm

Baroness Massey of Darwen: My Lords, this has indeed been a splendid debate, as I thought it would be. I thank all noble Lords for their contributions, which have been well informed and based on research and experience. I also thank the Minister for his very thoughtful response. I may challenge some of his precepts but I thank him for his concerns. Surely all of us, whichever political party we belong to, want to see better and more confident parents, happy and active children, better citizens, and greater prosperity. I just want to comment on four or five points, as I cannot possibly comment on the whole debate,.

First, we should beware the tips of icebergs. I will not sing the song from “Frozen” at this point—I think it is called “Let it Go”, which is what I am about to do. However, we should really get down to the grass roots and, as many noble Lords have said, co-ordinate agencies and initiatives to target children and families so that they do not get a mass of things coming at them without any co-ordination or without key workers. Neither we nor children come in pieces; therefore nor should services. That co-ordination needs leadership and vision. It also needs, as has been said, continuous intervention; this is not just about early intervention but about intervening along the whole children’s pathway. Children do not come either in age-related bits, so we need cohort studies to show how we are doing in a more protracted way.

A lot has been said about the costs of not using early intervention as a tool. We should be dismayed by the costs, certainly of health and education issues. I hope that whichever Government—or Governments—come into power in May, they will take this by the scruff of the neck and say, “We will co-ordinate services,

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we will provide leadership and vision, and we will get to grips with this issue of children’s achievements and performance”.

Motion agreed.


Question for Short Debate

1.59 pm

Asked by Lord Fowler

To ask Her Majesty’s Government what lessons they have learnt from the recent Ebola outbreak in West Africa.

Lord Fowler (Con): My Lords, I welcome the opportunity of this short debate. First, I would like to pay tribute to the brave people who have gone from other countries, very much including the United Kingdom, to help tackle the outbreak of Ebola in west Africa. Obviously, I am thinking of Pauline Cafferkey, being treated at the Royal Free Hospital in London, and we all very much pray for her recovery. But I also pay tribute to all the others from different occupations and disciplines who have gone to help, including the 70 volunteers from the National Health Service. They have put their own health at risk and we should remember that, among the 680 healthcare workers who have contracted Ebola since the first outbreak of the disease, no fewer than 400 have died. These men and women have come from other countries in Africa and from around the world and have paid a terrible price for their altruism and selflessness.

Of course, the major casualties of the outbreak have been the 8,000 men, women and children who have died so far in countries such as Sierra Leone, Liberia and Guinea. There is perhaps a failure of imagination by us in the West about what a bare statistic such as that means for families on the ground—the individual tragedies that make up the total, with families torn apart and children left without one or both parents. The epidemic may have now reached a peak, I hope, but whether it has or not, one point is certain: we need to examine what measures should be taken to prevent further epidemics on this scale.

It is also worth remembering that any policy changes that may result from Ebola may also have the effect of helping in the fight against other diseases such as AIDS, TB and malaria, where the death toll is actually even greater. Around the world today there are 1.5 million deaths from AIDS each year, a further 1.5 million from TB and 600,000 from malaria—predominantly of children. The challenge must be to reduce radically this entirely unacceptable total of death.

What are the lessons that we can draw so far from the latest Ebola outbreak? I suggest that there are at least three. The first is that one of the reasons why the Ebola epidemic has spread so widely, so quickly and with such devastating effect is that in many parts of sub-Saharan Africa health systems are inadequate; the staff are under enormous pressure and their working conditions are often far below what any of us would consider acceptable in this country. Again, there is perhaps a failure to recognise the conditions in which

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medical staff have to struggle to make an impact. A few months ago I went not to west Africa but to Uganda and visited a hospital on the banks of Lake Victoria which had not received a budget increase for 10 years. Inadequate and underfinanced health systems remain the truth in so many African countries.

Sierra Leone is a prime example. The country lies 11th from bottom of the United Nations Human Development Index. The figures for infant, child and maternal mortality are bad even compared with neighbouring Liberia. Up until the crisis, Sierra Leone, with a population of around 6 million, had something like 136 doctors and 1,000 nurses to care for the population. The Health Secretary said in the other place on Monday that the Government,

“have committed more than £230 million to fight the disease in Sierra Leone”.—[

Official Report

, Commons, 5/1/15; col. 40.]

That is enormously welcome and makes Britain one of the biggest contributors in the world. However, my concern is not just what we are doing now but what we did before to strengthen the health system and what we will do in the future, because the whole need is for consistent policy applied year after year. My concern is that, once emergencies are over, there is a tendency for countries to fall off the agenda. We treat the casualties but we do not do enough to prevent those casualties taking place.

An excellent all-party report by the House of Commons International Development Committee, under the chairmanship of Sir Malcolm Bruce, found a strange lack of interest among the NGOs in even giving evidence on the position prior to the Ebola outbreak. The committee would have expected something like 100 pieces of evidence; it received 10. In passing, I pay tribute to Marie Stopes, Plan and Save the Children for being the exceptions to this trend. Unfortunately, the same view seems to have been taken by DfID. In paragraph 33 of its report, the committee found that bilateral programmes directly managed by DfID for Sierra Leone and Liberia were planned to reduce by £14.5 million in 2014-15 compared to the previous year, a reduction of around 19%. The committee commented that it was “appalled” that the budget was being cut in this way. Since then, policy has changed. Emergency money has been put in. A vast effort is being made to help. I welcome that, but my view remains that the priority of policy should be, above all, to provide consistent support for a country such as Sierra Leone, which is one of the poorest in the whole world.

My second point also concerns consistency. I declare an interest as a non-executive director of the International AIDS Vaccine Initiative, which is a non-profit organisation working to develop a vaccine for AIDS. My point today is a more general one about vaccines. If we can develop them successfully, this can have a dramatic effect, as we have seen in a number of countries in relation to the polio vaccine. But there is one point about vaccine development that is also absolutely certain. They take a long time to develop—sometimes a very long time. For example, the polio vaccine took 47 years to develop and the whooping cough vaccine took 42; with some of the diseases—malaria, for example—the search has been continuing for well over a century. The development time has a number of

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impacts. It means that the pharmaceutical industry is not always able or willing to invest what could be very substantial sums in development. The result is that, in my view, there is a particular responsibility on Governments to finance development here. The United States does a vast amount in this respect. I fear no one would claim that the United Kingdom proportionately does the same.

The third and final lesson that I believe we should examine is the medical staffing position of some of the poorest countries in Africa to see whether the developed world is taking too many of the doctors and nurses who have been trained in Africa but then come to work and settle in countries of the West and the Middle East, including the United Kingdom, of course. Let me be absolutely clear: the doctors and nurses who have come here have made an invaluable contribution to the health service. There is no doubt about that. But that is not the end of the story. Seen from Africa, the problem is that many of the doctors and nurses who have been trained at some expense have left Africa, which is in vast need of their care, to go abroad. Taking Sierra Leone as an example, around 600 members of National Health Service staff received their primary medical qualification in Sierra Leone. That is small in our terms but absolutely massive in terms of Sierra Leone. Relatively few return.

I do not claim that it is going to be easy to reverse that trend. It is a question not just of salary but of the medical conditions to which doctors and nurses will return. What we should be aiming at is a situation where there is investment in inward migration but also in outward migration—a two-part thing. It is neither desirable nor possible to have a blanket ban on the immigration and emigration of medical staff. Ideally, it should be a two-way process, as an excellent report by VSO makes clear. But what is clear at the moment is that Africa appears to be a very heavy loser from this process and that we in the West would do well to mount an inquiry to see what can be done to correct that position.

These are just three questions that the Ebola crisis raises: whether we are doing enough to develop and produce vaccines; whether our policies in the West are taking away a disproportionate number of doctors and nurses from African countries which badly need them; and, above all, how we can further strengthen the health systems of countries such as Sierra Leone so that further human tragedies can be prevented. My hope is that the tragedy of the Ebola outbreak today may point the way to producing more permanent answers for the future.

2.10 pm

Baroness Kinnock of Holyhead (Lab): My Lords, I thank the noble Lord, Lord Fowler, for initiating this debate and for his extremely thoughtful introduction to the subject, which made many of us think of the complexity of the issue.

After more than a year, the current outbreak of Ebola continues to destroy lives, livelihoods and communities. It impairs national economies and has damaged already fragile basic services. Ebola is a frequently recurring and fatal disease. Since its discovery

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in 1976, there have been several separate outbreaks with casualty rates as high as 90%. As Kofi Annan has said, it was only when the disease got to Europe and America that the international community really woke up to the crisis. This judgment was echoed by Dr Margaret Chan, the director-general of the World Health Organization. Speaking on the reason for the failure to produce a vaccine or a cure after 40 years, she said:

“Because Ebola has been, historically, geographically confined to poor African nations. The R&D incentive is virtually non-existent. A profit-driven industry does not invest in products for markets that cannot pay”.

She made that sombre statement in a world in which 38% of the population do not have access to essential medicines and 50,000 people die each day from largely avoidable causes. Governments and industries should by now have recognised the need for co-ordinated efforts to make registered medicines available at low cost or no cost. Surely Ebola has reminded everyone that, wherever a health crisis occurs, it affects us all. Professor Peter Piot, who first identified Ebola, has said that it would not have been difficult to contain the outbreak if those on the ground had acted quickly but he said that tragically,

“something that is easy to control got completely out of hand”.

Investments in healthcare as well as in drugs are essential everywhere. The unimaginable suffering endured in poor countries by poor people urgently needs and deserves a response. Liberia has 51 doctors to serve a country of 4.2 million people. Sierra Leone has 136 doctors for a population of more than 6 million, an average of 0.2 doctors per 10,000 people. There are too many similarly pitiful shortages. Clearly, the reason we do not have a vaccine against Ebola is that the likely victims of the disease are not wealthy enough to pay for the full cost of treatments and medicines.

The BBC reported this morning that the current epidemic has taken more than 8,000 lives in the three west African countries most affected. The mortality rate is estimated to be 70%. Around 75% of the sufferers in Liberia, for instance, are women who, obviously, are the primary carers and the ones with the responsibility for caring for sick and dying relatives. All three countries lack functioning health systems and access to clean water. They have poor hygiene practices and, generally, an absence of sanitation. According to the NGO WaterAid, such is the enormity of the current challenge that the costs of the emergency response to this crisis will amount to more than the total health and water and sanitation aid committed to Liberia and Sierra Leone over the past five years. That gives us an idea of the nature of the crisis. Lessons must be learnt from the fact that the effects of the response in Nigeria and Senegal have clearly shown that the virus can be contained with a functioning healthcare system and a rapid administrative response.

There are now signs of some progress, but the epidemic is far from over and experts are urging caution. Infection rates, they advise, could oscillate and reinfection could occur. The WHO assistant director-general has warned against claiming that this very dangerous disease is under control. He said that a few mishandled burials could,

“start a whole new set of transmission chains”,

and the incidence of the disease could increase again.

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A report published in last week’s Lancet Global Health by three specialist professors from leading British universities made it clear that IMF conditionalities have required Governments receiving aid to adopt policies that prioritise,

“short-term economic objectives over investment in health and education”.

Using IMF archive detail, they came to a view on the effects on the health systems in Sierra Leone, Guinea and Liberia. IMF economic reform programmes,

“required reductions in government spending, prioritisation of debt service, and bolstering of foreign exchange reserves. Such policies have often been extremely strict, absorbing funds that could be directed to meeting pressing health challenges”,

with the result that all the countries “failed to meet” the very modest IMF “targets for social spending”, and,

“to keep government spending low, the IMF often requires caps on the public-sector wage bill—and … funds to … adequately remunerate doctors, nurses and other health professionals … ‘often … without consideration of the impact on priority areas’”.

Such caps,

“have been linked to emigration of health personnel”,

and massive reductions in community health workers.

The article states that,

“the IMF has long advocated decentralisation of health-care systems”,


“in practice … can make it difficult to mobilise coordinated, central responses to disease outbreaks”,

and led to a deterioration in the quality of health service delivery. The professors concluded that:

“All these effects are cumulative, contributing to the lack of preparedness of health systems to cope with infectious disease outbreaks and other emergencies … Although Lagarde’s comment on prioritising public health instead of fiscal discipline is welcome, similar comments have been made by her predecessors. Will the result be different this time?”.

That is a fundamental question, a matter of life and death. The UK Chancellor and Secretary of State for International Development have governor status in the IMF.

Lord Bourne of Aberystwyth (Con): I remind Members that this is a time-limited debate.

Baroness Kinnock of Holyhead: I must ask the Minister, therefore: what is Her Majesty’s Government’s answer to this problem?

2.17 pm

Lord Chidgey (LD): My Lords, I, too, add my congratulations to the noble Lord, Lord Fowler, on bringing this debate to us today and on the eloquent way in which he set it out, for which I am very grateful.

There are clearly some fundamental lessons to be learnt from the Ebola catastrophe in west Africa, which can be summarised in terms of healthcare practice and provision, public health resources and general infrastructure. The year-long epidemic has now claimed more than 8,000 lives and infected more than 20,000 people. While the number of new cases in Liberia is falling, it continues to rise in Sierra Leone. The data from Guinea continue to be inconclusive,

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underlining the remoteness and inaccessibility of the mountainous forest region through Guéckédou, Macenta and Seredou.

Apparently the Ebola virus was discovered as long ago as 1976. I can vouch for the fact that in the mid-1980s, while I was working in the Guinea interior along the borders with Sierra Leone and Liberia, villagers would speak to me of their terror of a killer disease that they believed was caught by eating bush meat from monkeys, which may well have been Ebola. At the time, we were doubling the water supply of the capital city, Conakry, but nothing was being done for the remote villages scattered throughout the interior of the country.

A primary lesson is that by not developing a vaccine to tackle Ebola in the intervening 40-odd years, the pharmaceutical establishment bears witness to the eventual deaths of probably tens of thousands and the infection of many more. The reasoning is unclear, but seems to be associated with concerns over cost recovery from desperately poor communities. However, the cost to the regional economies of decimated and crippled communities does not seem to have been taken into account.

The decision by the board of Gavi, the Vaccine Alliance to support large-scale vaccination efforts with $300 million procurement funding as soon as a safe and effective vaccine is recommended by the World Health Organisation is very welcome. However, the WHO has been strongly criticised for its slow response to the Ebola outbreak, which to date has affected more than 20,000 people and caused more than 8,000 deaths. There are clearly lessons to be learnt on the effectiveness of the mobilisation, distribution and administration of global health relief.

The Ebola outbreak has underlined the need for a fresh approach to strengthening health systems in Africa. Strengthening must be community led. Donors need to prioritise and support community ownership of health systems. The top-down approach does not fully appreciate the spiritual, cultural and political undertones to health that exist among many communities and groups.

The NEPAD organisation of African countries has agreed that each should allocate 15% of GNI to the provision of state-funded universal healthcare, but, so far, there has been little progress. In this context, it seems bizarre that some donors are promoting USA-style healthcare models, based on the principle of private healthcare being purchased by the user, in communities where abject poverty is the norm.

There is now a thing called “Ebolanomics”, or the role of the pharmaceutical sector, which raises many questions about the interaction between market economies and the pharmaceutical sector. That needs to be analysed, understood and reworked into a modern model that responds to the needs of the global population. Barriers that have prevented earlier development of treatment need to be overcome, with more support being focused on the growth of the African pharmaceutical industry. The current business model needs to be redesigned. What would that model look like? Should there be a legally binding framework

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to guarantee funds to research and to produce and stockpile vaccines for diseases that would otherwise be neglected?

An unforeseen effect of the Ebola epidemic is its impact on programmes to tackle other pandemics, in particular malaria. The Ebola virus is distracting attention from other diseases that still ravage west Africa. Malaria patients in Sierra Leone, Liberia and Guinea—the countries worst effected by Ebola—are now so terrified of the impact of the virus that they will not attend their local hospitals where their malaria could be easily treated with a package of available drugs. Fatoumata Nafo-Traoré, head of the UN’s Roll Back Malaria Partnership, says that without the necessary treatment, malaria patients are going to die.

The economic impact of Ebola on the sub-Saharan region as a whole will be significant, according to Roger Nord, deputy director for Africa at the IMF, who spoke at an Africa All-Party Group meeting recently. He reported that if it takes another nine months to get the outbreak under control, it is expected to reduce growth in Guinea by 1.5% and by around 3.5% in Liberia and Sierra Leone. Neighbouring countries such as Senegal and the Gambia are also starting to see tourism activities decline.

Margaret Chan of the WHO, while recognising the delayed international response and the need for increased international funds, has said that more important than anything else is the need for community funding and support. In this regard, community-level media and radio have an essential role to play, and I pay tribute to the work of the BBC World Service and BBC Media Action, which work with local FM stations that are trusted by their communities. In particular, I pay tribute to BBC reporters in the field who have overcome formidable physical obstacles to reach the most isolated communities in the grip of the Ebola virus.

Much of the work to defeat Ebola is being done by local people. Nigeria and Uganda have sent hundreds of health workers and South Africa has contributed significant funds. The media have a responsibility also to report what African people and Governments are doing to fight Ebola.

2.23 pm

Lord Patel (CB): My Lords, I, too, thank the noble Lord, Lord Fowler, for initiating this debate. I thank him also for his brilliant speech and for his great concern for those who volunteer to do this work. I associate myself with the comments that he made about Pauline Cafferkey and I wish her a speedy and complete recovery.

I want to speak on four issues as far as the lessons learnt are concerned. Could the crisis have been spotted earlier? Was the UK’s response timely and appropriate both in scale and support? What needs to happen to cope with future pandemics? Did the UK have appropriate safeguards for NHS and other volunteers who went to Sierra Leone, including on their return?

Peter Piot, in his book No Time to Lose, described the dramatic effects of Ebola infection since its outbreak in 1976 and warned us to be prepared. Previous outbreaks were controlled by prompt notification, deployment

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of specialist teams, quarantining of exposed individuals and isolation of patients, but the lessons were not learnt. The current outbreak started in Guinea at the end of 2013. Despite hundreds of deaths, neighbouring countries did not take any notice. Surveillance systems were not effective and warnings from organisations such as Médecins Sans Frontières were ignored. Official agencies were either complacent or did not have the resources or personnel in place to monitor the outbreak. Hundreds died. Worse, in countries where health workers were in poor supply, several hundred health workers died.

Did the WHO botch its response to the developing crisis in Sierra Leone and Liberia? The answer is most likely yes, but the question is why. Africa office representatives were not filing Ebola reports to the head office. There are lessons here as to how the WHO, the only global health agency, should operate in the future and how its performance could be improved. There is no doubt that its effectiveness was weakened by decades of policy failures and budget cuts by wealthy nations trying to fund their deficits. Wealthy nations need to restore their funding of the WHO. The Ebola crisis has confirmed a new reality: that we live in a shrinking world. To cope with future pandemics—which are sure to come and might be worse than the current pandemic—strong international organisations working with national organisations is absolutely necessary.

My second point relates to the UK response. Here I can do nothing but congratulate the UK Government on the speed with which they responded, with both personnel and finances—the second-highest donor nation after to the United States—and commend the continuing effort that DfID and WHO are making to bring this crisis to an end. We need to learn lessons as to whether we could have done better—it is always possible to have done better—but, hitherto, I have nothing but praise for our Government.

This leads to my third, and important, point—already mentioned by the noble Lord, Lord Fowler, and other noble Lords: what should we do about future pandemics? Why were countries such as Guinea, Sierra Leone and Liberia not able to cope with the crisis, when countries such as Nigeria curtailed it very quickly? The answer is very poor health systems, as has been mentioned: lack of facilities or equipment, deficit of a health workforce, lack of appropriate public health measures, and lack of surveillance and controls. Both Larry Summers, the previous Treasury Secretary of the US, and Bill Gates, when he spoke in the Robing Room, asked for help in developing health systems in those countries.

Larry Summers’s report, Global Health 2035, published in the Lancet, identifies that we will need some $30 billion a year for the next decade. Building health systems requires time and money, and the richer nations of the world need to come up to the plate to develop that. Otherwise, we will continue to have such crises, which will begin to affect us even more than they do now. The UK can take a lead in building health systems. We are the right country to do so because we have demonstrated that we can have effective influence.

My fourth point relates to whether the UK’s support for our NHS volunteers has been appropriate. It is important that we make sure that people who volunteer

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to go to affected countries are in a safe environment, are able to work safely and can return home safely afterwards. Comments that we have seen in some of the media, particularly social media, demonising those who return from such work, are unacceptable. Sarah Wollaston, MP for Totnes and chair of the Health Select Committee wrote a very good article about this in the


. I was disappointed to learn—if accurate—that some BBC staff feel that they can no longer interview in person people who come back from west Africa, and therefore that a telephone interview would be more appropriate. Brave BBC workers have reported from there, but such comments from the media—if correct—are also inappropriate.

2.30 pm

Lord Giddens (Lab): My Lords, I also thank the noble Lord, Lord Fowler, for securing this debate and introducing it in such compelling fashion. I join noble Lords in paying tribute to Pauline Cafferkey as she struggles for life in a hospital not far from where we are today. The latest report on healthcare workers who have died from Ebola puts the number at 500 rather than 400, which shows the awful toll it is taking in so many different areas.

I will concentrate on the economic consequences of the epidemic, to which the noble Lord, Lord Fowler, alluded. There is another tragedy unfolding alongside those of a medical and humanitarian kind. Prior to the Ebola episode, all three main states involved experienced strong economic growth following years of war and inept or tyrannical rule. Growth rates have already halved in Sierra Leone and Liberia and could even turn negative in Guinea. Tourism has come to a halt, as the noble Lord mentioned. Restrictions on mobility severely hamper trade. Agricultural production—a key area in all three countries—is way down. Rising food prices have helped create steep inflation—a very unpleasant economic scenario—which was running at more than 13% in Liberia in 2014. That situation could quite easily get completely out of hand. Meanwhile, investors are running scared and there is a serious risk of capital flight from these countries. Economically, this has the makings of a truly tragic situation.

The emancipation of women is a key aspect of economic development in emerging economies. Many women in the labour market have turned instead to the care of sick family members or others in the community. In Sierra Leone, for example, women were heavily represented in cash crop production, local trade and microenterprises. Many had to quit and most are highly unlikely to re-enter the labour force at any time soon.

As a result of this, I have three basic questions for the Minister to comment on. Like the noble Lord, Lord Fowler, and other noble Lords, my great fear is that if and when Ebola is effectively contained in west Africa, the international community will lose interest in the countries affected. Can we avoid them sinking back into despair and perhaps fragmentation? The possibility is very real that these countries could be worse than back to the point zero of some years ago when they were racked by war. These are, as every noble Lord knows, among the poorest societies on the

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face of the Earth. We must ensure that the international community does not lose interest if it appears that the epidemic can be contained—although some medical specialists now say that it could become endemic, which is an additional worry.

Secondly, how will the Government assess the success or otherwise of the World Bank in the budget support it pledged to facilitate trade, investment and employment in the three countries involved? The World Bank promised substantial sums of money. Does the Minister have any information about whether any of that money has been forthcoming? As we know, promises are easy to make. The sums involved were very large and it would be good to be updated on that if the Minister has that information.

Thirdly, it is clear that regional aid and investment will be crucial, coming from surrounding African states. How much progress has been made with the fund for renewal set up by the Economic Community of West African States? Any western intervention concentrated on the three principal countries must also seek to involve other African countries, and perhaps fund them in addition so that they can help the three countries most affected.

2.35 pm

Baroness Hayman (CB): My Lords, like other speakers I congratulate the noble Lord, Lord Fowler, on introducing this debate and his consistent commitment to health in the developing world. I am delighted to be able to take part in the debate but fear my contribution would probably be more useful in five weeks’ time, when I will have returned—I hope—from a visit to Sierra Leone to see for myself the work of some of the agencies with which I am associated. I declare my interests in those, recorded in the register.

Many lessons of the Ebola outbreak are already emerging. The speed of response is one that others referred to. The need for the international community to have a plan that is both flexible—because not every emergency is the same—and already funded is tremendously important. We all have a responsibility to look at how the international community could prepare for further outbreaks. As others said, not only will they occur but we cannot consider them to be someone else’s problem. Ebola is not an airborne disease, for which we all throughout the world must be extremely grateful, but other diseases are airborne. The interconnectedness of health in our global world is a lesson we must learn.

Another lesson that no one will quarrel with is that, however much international aid and however many volunteers—I, too, pay tribute to them—we parachute into a situation such as the one we have seen in west Africa, there can never be enough to replicate a basic health system that reaches into every village and community and is the absolute foundation not only of public health in normal times but of dealing with disease outbreaks. What we as a world do post-2015 in terms of the objectives for health and providing support for health systems will be tremendously important.

That will be shown in Sierra Leone because, as others pointed out, once Ebola is, we hope, no longer rampant—the noble Lord, Lord Giddens, rightly pointed

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out there is a possibility of it becoming endemic in the country—there will still be a tremendous specific health need left behind by the effects of the crisis. There will be the patients with malaria. We have seen a terrible spike in malaria deaths. There will be the women who died in childbirth because they were not able to get to attended facilities. There will be the health of the orphans left behind. There will be the vaccination programmes that have been interrupted. There will be a tremendous health need. As the noble Lord, Lord Giddens, said, it will be a test of us all that we do not walk away from that at the end of this process.

The other lesson that we can learn is that we can rightly be proud of the response of professionals in this country who have volunteered, of the British public, who have given more than £30 million to the Disasters Emergency Committee, of which I am a trustee, and the work of the agencies funded by that money, which goes far beyond medical treatment to provision of food and latrines for people who are in isolation, the care of Ebola orphans and safe burials. That is a tremendously important contribution.

We should also pay tribute to those in the affected countries in Africa. I will also be considering the work of Restless Development, the charity that my husband chairs, which has about 2,000 community volunteers in the field working on social mobilisation. The trust and behaviour change of communities that is needed is on a tremendous scale and does not come from lecturing by people from outside; it comes from the mobilisation of community leaders, religious leaders and individuals who are connected to their communities, who are trusted and who give the right messages and support people to change behaviours to protect themselves.

An understanding of the need to marry the command and control and international response with the grass-roots, culturally sensitive response of those on the ground, is something that we hope we can learn from this outbreak. I cannot finish without endorsing what the noble Lord, Lord Fowler, said about vaccines, to which the noble Baroness, Lady Kinnock, also referred. We have a market failure in vaccines and medicines for the poor. We cannot simply shrug our shoulders and say that the pharmaceutical industry as currently constructed cannot and will never produce the goods. We need to ensure, through government, philanthropy and voluntary organisations, that those goods are produced for the poor.

2.42 pm

Lord Collins of Highbury (Lab): My Lords, I, too, thank the noble Lord, Lord Fowler, for ensuring that this vital issue remains high on the political agenda. Last November, my noble friend Lady Kinnock initiated a similar debate, and many of the concerns raised then remain relevant today. The Government’s response on the ground has been positive, so far providing more than £200 million for treatment, facilities, expediting NHS staff who heroically volunteer and helping to finance trials and develop new treatments and vaccines for Ebola.

The UK medical workers who have volunteered in their hundreds to join the fight against Ebola in Sierra Leone are playing a critical role in the front-line

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response. The tragic case of nurse Pauline Cafferkey highlights their exceptional bravery and compassion. My thoughts—and, I know, those of everyone here and all noble Lords—are very much with Pauline and her family during this very difficult time.

As we heard from the Statement in the other place on Monday, Save the Children is conducting an urgent review, which I understand will involve representatives from Public Health England. Clearly, the sooner we know the results, the better. Can the Minister update the House on the review? When are the results likely to be published? As the next group of NHS volunteers leave for west Africa in the coming weeks, they will want to know whether procedures and guidance will be changed in the light of that case. Will the noble Baroness also liaise with the Department of Health to ensure that the employment and careers of volunteers who show their compassion are not adversely affected by any further quarantine restrictions that may be introduced following the review?

The role of British volunteers has been significant in the campaign against Ebola. What plans do the UK Government have to establish a standing roster of medical workers for possible deployment in future health emergencies? As we have heard in this debate, this crisis underscores the importance of investing in a strong system of research and development for global health. In Justine Greening’s own words, new technologies are,

“vital if we are to improve the health of the poorest people through better treatment and prevention”.

The UK Government have shown leadership in supporting solutions, including product development partnerships. PDPs have been instrumental in bringing through 37 new therapeutic products for poverty-related diseases registered over the past decade. Will the Minister commit to prioritising within DfID, and promoting among other key donors, the need properly to fund and support R&D for global health?

The three countries facing the largest burden of Ebola are among the poorest countries in the world and, as we have heard, have some of the most fragile health systems. They have had insufficient investment in infrastructure, the healthcare workforce, health information systems and medical supplies and equipment over decades. What is the Minister’s assessment of the state of preparedness for Ebola in neighbouring countries? What plans do the Government have to provide specific support to the high-risk countries on the WHO watch list to reduce the risk of further outbreaks? What is the Minister’s assessment of the factors contributing to the decline of cases in Liberia? What lessons from Liberia are being applied to the UK response to Ebola in Sierra Leone?

As we have heard in this debate, the main issue has been health systems not being resourced or strong enough to deal with the issue. That is a key factor. Universal health coverage, whereby there is access for all without people having to suffer financial hardship when accessing it, is a key way that we can make countries more resilient to health concerns such as Ebola before they become widespread emergencies. Universal health coverage is a clear and quantifiable goal, and 2015 is the year when international development

8 Jan 2015 : Column 503

will be high on the international agenda. On 19 January, negotiations start in New York on the replacement of the millennium development goals. I know that I have asked this before, but I ask the noble Baroness to support universal health coverage in the language of the health goal in the successor to the MDGs, the SDGs. I ask her to back that strongly because, as we have heard in this debate, universal health coverage is the key to avoiding such catastrophes in the future.

2.48 pm

Baroness Northover (LD): My Lords, I start by thanking my noble friend Lord Fowler for securing this important debate and all noble Lords who have contributed for their considered responses. As my noble friend Lord Fowler and others have made clear, this epidemic has terrible individual consequences, as well as wider social and economic consequences.

I join noble Lords in my extremely deep concern for Pauline Cafferkey. The Royal Free has just issued a statement, and I understand that her condition remains critical and is unchanged. The bravery and compassion shown by Pauline and her colleagues have helped to save thousands of lives in Africa. Like my noble friend Lord Fowler, I pay tribute to all those who have volunteered to help in that dreadful crisis. I here commend the son of the noble Lord, Lord Patel, Dr Neil Patel, as he undertakes his own challenging tasks in Sierra Leone, leaving shortly. It is vital that we never compromise the safety of such extremely brave volunteers and I can give the Government’s unequivocal commitment on that. Clearly, Save the Children and Public Health England keep this under constant review. They are reviewing the situation at the moment and we will update noble Lords as soon as possible.

I note what the noble Lord, Lord Collins, said on that and what he said about standing rosters. We have taken forward quite considerable amounts of development to ensure that those who wish to volunteer are properly trained before such a crisis and are able to be deployed in humanitarian disasters. There is new training offered by the Royal College of Surgeons to ensure that those who volunteer are safe and effective in dealing with the need in question, so I hope that the noble Lord will be encouraged to hear that. Guidelines on this particular crisis are kept under review all the time.

Noble Lords will appreciate that DfID is still focused on containing and eliminating the Ebola virus in Sierra Leone, where the UK has the leading international response. I thank the noble Lord, Lord Patel, for his tribute and I will pass it on to my outstanding colleagues in DfID. So far, we have committed more than £230 million to combat Ebola in Sierra Leone, and have already delivered more than 1,200 treatment and isolation beds and three new Ebola testing laboratories. We are also working closely with the Government of Sierra Leone to train and equip burial teams to ensure safe burial practices.

The noble Lord, Lord Collins, mentioned differences in Liberia. I am sure he will know that there are all sorts of cultural differences between the two countries—different social norms and so on—which underpin what has happened in them in this epidemic. I am quite happy to go into further detail outside as to why there have been differences here.

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As the noble Baronesses, Lady Kinnock and Lady Hayman, indicated, there are tentative signs that we may have reached the peak of the disease in Sierra Leone. But as both were saying, we should not be complacent; the response is far from over. Like my noble friend Lord Chidgey, I pay tribute to the response that has come from African countries.

The economic impact of this should not be underestimated. Various noble Lords, including the noble Lord, Lord Giddens, made reference to that but I think we are all aware of it. The noble Lord also flagged the financial commitments of the World Bank. We are acutely aware that promises do not necessarily get delivered and we are working very hard to ensure that, where promises have been made, they are duly delivered.

We agree that a long-term interest in affected countries is essential to ensure recovery. The EU is convening a meeting in early March to look at resources for this and the WHO has a special session in late January to agree reforms, so a number of things are under way.

While our principal focus must continue to be on the ongoing response, it is essential, as my noble friend Lord Fowler pointed out, that we learn lessons from these actions both here in the United Kingdom and internationally. This Ebola outbreak has been unprecedented. More than 8,000 people have died and it is crucial that we make changes to ensure that this never happens again—and that lessons are carried over for other potential epidemics, as was pointed out by noble Lords, in particular my noble friends Lord Fowler and Lord Chidgey.

It is evident that international reform is required. The World Health Organization and the wider international system did not respond quickly enough to this threat before it got out of control. While progress has been made in efforts to strengthen global health security following SARS and avian flu outbreaks, the Ebola outbreak demonstrates that there is still much to do in responding efficiently to public health emergencies. As I have mentioned, the WHO executive board is convening a special session later this month to examine some of these issues, and I am sure that the points made by noble Lords, including the noble Lord, Lord Patel, must be considered. In particular, we need to look at surveillance, stronger early warning and response mechanisms, and how the global community identifies and responds to potential crises in the future. Like the noble Baroness, Lady Kinnock, I noted that Nigeria managed to check cases in the initial stages and it should be commended for that. Lessons needs to be learnt from how that was achieved, even though, again, we cannot be complacent.

The international community needs to be ready to respond rapidly and deploy public health experts immediately. The noble Baroness, Lady Hayman, had a number of important perceptions here as to changes that might be needed and the way in which the international system needs to link to what happens within a particular country and be sensitive to the arrangements and the views, beliefs and practices within those countries. This was a point which my noble friend Lord Chidgey also made.

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In linking to national systems, a number of noble Lords emphasised the importance of strengthening health systems. We have been investing heavily in strengthening health systems in Sierra Leone through our bilateral aid programme but, barely 10 years after the end of a devastating civil war, health systems are still fragile and unable to cope with a crisis of this scale. My noble friend Lord Fowler made it crystal clear that the weakness of health systems is fundamental in this case. International support from DfID, but also from the World Bank, IMF and UN, will be critical in supporting Sierra Leone and the wider region to recover from this devastating crisis. Supporting the health sector ravaged by Ebola will be a priority, as well as supporting vulnerable groups such as orphans, children, women and girls.

I heard what my noble friend Lord Fowler said about consistency in support. That seemed to me to be an argument for the 0.7% Bill, which will come before this House on 23 January. I hope that noble Lords will support it. The aid budget has often been subject to easy battering in the past. Consistency and predictability are vital, which is why it is important to legislate for that level of aid. I welcome the support of the party opposite on this. Investment in human development is vital to the elimination of poverty and the growth of developing countries. I can assure noble Lords that we fully recognise that. In DfID, 20% of our budget in Sierra Leone has been spent on health programmes, and that will continue to be the case when this crisis is over as well. We agree that weak health systems in the affected countries have contributed to the rapid spread of Ebola.

We also agree that there has been a significant drop in the utilisation of health services, a point made by my noble friend Lord Chidgey and others, including the noble Baroness, Lady Hayman. We are therefore working with experts to determine strategies to decrease malaria deaths, including using new drugs and making sure that there are adequate stocks in Sierra Leone to try to address this. We recognise that it is vital to prepare the health sector for future shocks and have started to consider this challenge. National institutions are crucial but we also recognise that it will take time to build up health systems capable of dealing with major epidemics. That is why we focus on poorer developing countries; that is where the need is greatest.

To improve response to infectious disease outbreaks we need to ensure that, as far as possible, we have proactively identified potential diseases and developed technologies such as vaccines and treatments to address them. A number of noble Lords made this point. We need to be able to deliver rapidly clinical trials of promising candidates, resolve intellectual property disputes over them, scale up production, put in place adequate delivery capacity and manage the increased liability risks, while securing financing for all this.

I would dispute what my noble friend Lord Fowler said about reducing our aid spend in Sierra Leone. In 2010-11, we spent £51 million; in 2013-14, it was £69 million.

Our support for vaccines has been a major move by DfID under this Government. My right honourable friend Stephen O’Brien was quite remarkable in the

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way that he brought forward the proposals on support for what were called neglected tropical diseases, and I think that people will pay tribute to him and DfID for the work that was done. I think that we have a strong record in this regard, and that is something that we will continue to focus on and to regard as very important.

Our focus remains on ridding Sierra Leone and the surrounding region of Ebola. It is critical that we learn the lessons from this crisis to ensure that it never happens again. We realise how a crisis like this affects us all and how it has devastating consequences, both individually and more widely on societies and economies. We understand that, and we all need to see what lessons need to be learnt and then—most importantly, as the noble Lord, Lord Giddens, indicated—acted upon.

National Health Service

Motion to Take Note

3 pm

Moved by Lord Turnberg

That this House takes note of the future of the National Health Service.

Lord Turnberg (Lab): My Lords, it is a privilege to be able to open this debate on the future of the NHS. It comes at a time when we are gearing up for the election and when it seems entirely possible that the NHS will be of some interest to the electorate. I will try to set the scene with a broad brush and leave it to other noble Lords to focus on various specific aspects.

We are going through a time when the media are full of one NHS disaster after another; with reports of cancelled operations, GPs and A&E departments being overwhelmed and waiting lists rising. We have not been short of media analysis in the past few days. That this is not simply the usual media hype is pretty obvious. We have had a number of careful reports from the Nuffield Trust and the King’s Fund, for example, that make sobering reading, with titles such as Into the Red? The State of the NHS Finances and Is General Practice in Crisis? suggesting that all is not well and that we cannot continue as we are.

The Government have woken up rather belatedly, with a sudden rash of activities. We have had NHS England’s Five Year Forward View, full of interesting aspirations; the Dalton review, with some ideas about how to go about achieving some of them; a number of crisis funding rescue efforts; and the Prime Minister reportedly sending in his pre-election “hit squad” to try to sort things out. However, it is pretty clear that quick fixes are not the answer and that the nature of the difficulties we face requires much longer-term solutions. It is good to hear that my own party is making some realistic proposals that might make a difference.

The causes of the problems are pretty widely understood. A service designed largely around acute hospital care has ignored for too long the needs of people with multiple long-term illnesses, especially those of the growing band of elderly patients whose needs are much better met in the community than in hospitals. This demand is certainly rising. The number

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of over 80 year-olds is set to double over the next few years and, for example, the number of people on more than three different pills for their multiple illnesses is growing by the day. I dare say that there will hardly be a Member of your Lordships’ House who is not on at least two pills keeping them in the fine trim that we see today, and I fear that I am no exception.

However, it is not only the growing proportion of the elderly and the worrying rise in the number of people with dementia that is causing difficulties; it is also the pressing demand placed on acute services. We can do so much more for patients than we ever could, and the population increasingly expect that they will be given the most effective treatments available. Many of those treatments are now very expensive. Complex scanners and investigations, coupled with the development of designer drugs produced specifically in response to an understanding of the genetic make-up of smaller and smaller subsets of patients, pose severe problems for a service working within rigid financial constraints.

It is in that financial squeeze where the nub of the problem lies. The fact is that the rate of inflation in health service costs is running way ahead of general inflation rates and certainly ahead of the growth in GDP. So every year the gap between demand and the funds available is widening, and this is what is responsible for the idea so often trotted out that the NHS is a “black hole” into which money just disappears. I do not believe that for a moment, and I will explain why shortly.

You might think that a Government would try to keep pace, if not with inflation then at least with the rise in GDP, small though that might be. In fact, the slice of the national cake devoted to health has gone down from about 8.5% when Labour left office in 2010 to 7% now—that is a fall of 17% in our share of the nation’s wealth. Even worse, predictions by the King’s Fund point to a further fall to 6% of GDP by 2021, on the current Government’s projections. That, I suppose, is all part of their plan to reduce overall public expenditure to pre-1940s levels, despite their protestations about a desire to protect the NHS.

It might be asked why these problems seem to have become much more acute in the past few years. After all, we have not all suddenly become older and sicker. The fact is that when Labour left office five years ago we had managed to get rid of waiting lists, patients were seen on the same day by their GP and patient satisfaction levels were high. It is no coincidence that we had appointed some 130,000 more front-line staff to cope with demand. So what has happened that left us with our current difficulties? Certainly, the distractions of the Lansley reforms did not help, with all the redundancies and re-employment of senior managers and the loss of continuity in leadership that followed. As Maynard Keynes said:

“It is not sufficient that the state of affairs which we seek to promote should be better than the state of affairs which preceded it; it must be sufficiently better to make up for the evils of the transition”.

I fear that we are still suffering from the evils of transition.

Then we have had the Nicholson challenge and the so-called efficiency savings of no less than £20 billion over the past five years. Of course anyone working in

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the service knows that it is always possible to improve efficiency, but now it is clear that the pips are being made to squeak too loudly as we run out of such short-term measures as wage freezes and the like. The inevitable result is that we are failing to keep up. GPs are overwhelmed, waiting times in A&E departments are rising, waiting lists are growing, social service departments are failing to cope and many such departments are now able to deal only with those in most serious need.

So what is to be done? I shall focus on four specific areas: disease prevention by public health measures; bringing hospital and community services much closer together; focusing on some specific aspects of care where we are clearly failing, namely A&E services, general practice and mental illness; and stimulating much more research and innovation where the potential dividends in health and well-being, as well as economically, are considerable. Of course none of these sounds entirely novel, but the fact is that we have failed miserably to achieve them so far. I want to examine why that is the case and what we should do now to ensure that we do not fail again.

First, with regard to prevention with the aim of reducing demand, no one can argue with the need to try to prevent the many illnesses caused by smoking, drinking too much alcohol and eating too much food. That is why I believe that the Government must get on with the plain packaging legislation, for example. We also know that the most effective measure to reduce alcohol consumption is to increase the duty on alcohol. It is pretty clear that whenever the price of alcohol goes above the rise in the general cost of living, the incidence of death from liver disease goes down—and, let’s face it, the increased revenue generated could make a useful contribution to the Exchequer and the NHS. I will leave it to other noble Lords to go into why the Government are reluctant to use this most effective measure, but the problem here is not that these are not vitally important things to be doing—they clearly are—it is the expectation that we will see financial savings from doing them in any reasonable timespan. Any impact on costs will inevitably take time.

Secondly, I turn to the need to see much greater co-operation and collaboration—what we used to call “integration”—between community-based and hospital services. The report from Sir David Dalton provides some very helpful ideas about how this might be achieved. He, of course, has managed to show how it is possible to integrate services extremely successfully in Salford and his report describes a number of other potential models for collaboration that fit in with different local circumstances. Clearly, the removal of the barriers between hospital and community is highly desirable and the idea of pooling health and social care budgets could be a very supportive measure. However, we have to be sure that current competition laws do not get in the way, and even more importantly, we have to be clear that the funds are available to facilitate this transition. It would be naive to believe that it could be done within existing budgets, even though in the longer term that sort of joined-up service will be more efficient, and of course it will suit patients’ needs much better. But in the short to medium term, it will need transitional funding.

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The idea behind the Government’s better care fund was to try to bolster community services at the expense of the NHS, which itself is pretty cash-strapped. Robbing Peter to pay Paul is never going to be popular with Peter, and we now have the lowest number of beds per head of population than anywhere in the western world. If we are to see this vitally important change in the way services are delivered, we have to accept that fresh money will have to be found from somewhere.

Thirdly, I turn to three of the biggest challenges facing the NHS at the moment: problems in general practice, gaps in mental health services, and the troubles in A&E departments. The problems in general practice have been well rehearsed. I had a letter from a young general practitioner the other day in which she encapsulated the difficulties she faced. She said she was increasingly exhausted as her workload just seemed to grow and grow. She pointed to the shortages of practice nurses and care workers, the difficulty in recruiting to those posts, the fact that many of her colleagues were retiring early and that general practice was becoming a very unpopular option for young medical graduates. It seems likely that that is the reason why it has proved difficult for the Government to encourage medical schools to get 50% of their graduates into general practice. It is striking, too, that she said that she had to spend up to 50% of her time in administration. What a waste of her valuable time, which could be much better spent in dealing with her patients.

So there is much to do there. We need to recruit and train more support staff, especially practice and district nurses, who are in such short supply; we should bring together bigger groupings of general practices into multipractices or the like so that there are economies of scale; we need to recruit and train more GPs by making the job much more attractive; and we definitely need to reduce the horrendous bureaucratic burden under which they labour. I am afraid that once again your Lordships will have noticed that none of that can be done without some additional funding.

On accident and emergency departments, which have been in the news so much of late, there is this somewhat optimistic view that once we have stopped people smoking, drinking and eating too much and once primary and community care is up to scratch, the pressures on A&E departments will disappear. But that, of course, is some considerable way off and it denies the evidence from everywhere else in the civilised world that there is a universal rise in A&E visits. So, once again, moving the deckchairs here will not solve the problem and it seems inevitable that more funds will be needed to recruit and fill posts, both medical and paramedical, in these desperate departments. We are clearly wasting far too much money on expensive locums when that money should be directed to permanent posts.

Mental illness, despite much rhetoric about parity of esteem between physical and mental illness, remains a Cinderella service. I suspect that other noble Lords will expand on this, but there can be little doubt that more resources are needed there, too.

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Finally, I will say a few words about research and innovation in the NHS. The UK has been pretty successful in supporting medical research through both public funds and the research charities—and here I should express my interest as scientific adviser to the Association of Medical Research Charities. Some good things are happening here: for example, with the National Institute for Health Research, under the direction of Dame Sally Davies with the strong support of the noble Earl; the Health Research Authority is streamlining ethical approval; and the MHRA is providing quicker routes for licensing new medicines. However, there are many problems, too, because while we may be good at research, we are too often sluggish in taking up innovations. There are concerns that future funding for NIHR and its invaluable academic health science networks and centres remains uncertain, and there are also worries about the willingness of CCGs to support the Charity Research Support Fund. We are also failing to encourage and support those entering a clinical research career while their conditions of service are being neglected.

A tortuous funding approval process also gets in the way. It may come as some surprise to learn that to get the approval of NHS England for a new medicine to treat a rare disease there are no fewer than eight committees through which it has to go. It has been said that if you want to avoid making a decision, set up a committee. If you want never to make a decision, set up eight committees. That is a case where NHS England needs to look at its own efficiency, and if it is just an example of its committee structures, it has some way to go.

In the pressure for ever more efficiencies, we must avoid being so short-sighted as to leave research and innovation to wither away. The dividends we will lose are just too great. I believe we know what should be done—there is a growing consensus on that. However, it is increasingly clear that without an input of more resources we will not be able to rescue the NHS from this downward spiral. Even Simon Stevens, the chief executive of NHS England, has said as much. The next Government will have to face up to this issue and square with the public about how they intend to protect an NHS and a social service system that is so precious to them and to focus on the sources of the increased funds that are needed. I look forward to the speeches of other noble Lords and to the Minister’s response.

Baroness Jolly (LD): I remind the House that time is very tight, so I ask noble Lords to keep their remarks to six minutes. When the clock shows six, your time is up.

3.16 pm

Lord Horam (Con): My Lords, I think we are all very grateful to the noble Lord, Lord Turnberg, for initiating this debate. Obviously, it could not be more timely. He may recall that he and I first met when he was president of the Royal College of Physicians and I was a Minister at the Department of Health. Even then, we had the same post-Christmas problems—we may also be taking the same pills, for all I know, but I will not speculate on that.

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I will put forward two particularly positive points as we review the situation, which is obviously worrying, and the longer term situation, which the noble Lord wants us to address. The first is that the NHS remains a good and a tried and trusted model for the delivery of healthcare. If you look around the world, it is very difficult to find one that is better as regards value for money and quality—although we know that there are gaps. It is also, as my noble friend Lord Howe pointed out in his Statement yesterday on the winter problems, remarkably flexible when it needs to be. We see that a number of hospital trusts are coping with these sudden increases in demand in a very innovative and sensible way.

The second positive point I will make is that there is wide consensus—although one would not think so in the political debate that is going on—over the way the NHS should evolve. I will concentrate in my short remarks on the Five Year Forward View, which was produced by Simon Stevens, the chief executive of the National Health Service England, in October last year. That has received general support from all sides of politics, and it was both realistic and sensible. However, the conclusions it reached have been underplayed. The central conclusions Simon Stevens points out in his report’s final two paragraphs are that even if funds remain broadly flat in real-terms increases—and in fact, despite what the noble Lord, Lord Turnberg, said, spending on the National Health Service and on health in this country as a whole has more than doubled in real terms since I was a Minister back in 1997—and if the service continues its annual increases in efficiency of 0.8% a year, which is not a huge annual increase, the £30 billion gap which he envisages by 2020 would reduce to £21 billion. If the increase in efficiency was doubled to 1.5% every year—again, not a huge increase—it would reduce that £30 billion gap to £16 billion. If efficiency could be increased to 2% to 3%, which is quite normal in other industries and services, the funding gap would be almost wholly eliminated and we would be able to reach the nirvana of a continuingly progressive and successful health service.

In that context, I make one suggestion to my noble friend Lord Howe. We know that many hospital beds are occupied by people who do not need to be there, who do not need acute care any longer, and who could be in a recovery situation or intermediate care elsewhere. It is the fact that many housing associations and mental health trusts have been lobbying hospital trusts up and down the country, asking to provide intermediate and recovery units for them, so they can transfer patients from acute services into those intermediate or recovery services. I noticed on the BBC last night that a trawl had been done of where the problems were; a spokesman for Addenbrooke’s Hospital in Cambridge said that 20% of its beds were occupied at this moment by people who could be cared for in a recovery unit or in another form of intermediate care. But the housing associations and mental health trusts are finding that, although very often the chairman and CEOs of hospital trusts are glad to have this support, it is simply impossible to get decisions. The noble Lord, Lord Turnberg, pointed out that among other things it is very difficult and

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slow to get decisions through the bureaucracy of even the trusts themselves, let alone the overall NHS, and this is causing a real problem.

I hope that my noble friend Lord Howe will look at this issue, where there could be an immediate improvement, within a matter of months, in the number of facilities being taken up by people who do not need to be in hospitals. It would save the capital costs, because housing associations would pay for them out of their own capital funds. It would also save current costs, because an NHS bed costs £2,000 a week to maintain. The housing associations tell me that they could do it for less than £1,000 a week, halving the current costs as well as providing capital money for the NHS. So there is an example of where efficiency savings could be made in a very short space of time. We are talking about months or even a year or two.

Simon Stevens’s conclusion, following the final two paragraphs of his report, was that,

“nothing in the analysis above suggests continuing with a comprehensive tax-funded NHS is intrinsically undoable”.

I believe that to be correct and right, but we will achieve that only if the trusts up and down the country stop being just administered and manage the resources, using the funds available to them properly.

3.23 pm

Baroness Jay of Paddington (Lab): My Lords, I congratulate my noble friend on his timely debate, which has become even more relevant in the face of the tsunami of so-called special incidents which are apparently swamping the NHS at the moment. On the face of it, the A&E tsunami is rather unlike the other winter crises that we have experienced. After all, the weather is not particularly severe and we are not experiencing a threat from a new infectious illness, such as SARS, or even a normal seasonal flu epidemic. Indeed, as was rightly asserted in this House yesterday, much of the primary cause of the present situation is government policy—and, specifically, the reduction in social care and the fragmentation of health services to which the noble Lord, Lord Horam, referred.

The only possible political silver lining that I can see is that the Secretary of State Mr Hunt seems to recognise that he is accountable and responsible for what is happening. I was surprised and somewhat relieved to hear him say yesterday in Commons Hansard:

“I take responsibility for everything that happens in the NHS”.—[Official Report, Commons, 7/1/15; col. 277.]

That is in sharp contrast to his attitude last autumn when the Secretary of State received the Five Year Forward View as though it was a rather interesting contribution from an independent think tank. In exasperation in response to that, the shadow Secretary of State, my right honourable friend Andy Burnham, commented:

“I do not know who runs the NHS these days, but I do know that it is certainly not him”.—[Official Report, Commons, 23/10/14; col. 1045.]

He also said that this was a clear illustration,

“of the serious loss of public accountability”,

following the 2012 reorganisation Act.

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Those of your Lordships who took part in the long drawn-out proceedings on that Act in this House will remember the battles that we had to retain the central responsibilities of the Secretary of State in the legislation, responsibilities that had after all been there since 1948. We eventually succeeded so that the Act now reads:

“The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England”.

The noble Lord, Lord Mawhinney, a previous Conservative Health Minister, said in our debate that everyone now knew that the,

“Secretary of State is the boss and is held accountable”.—[

Official Report

, 8/2/12; col. 303.]

I certainly hoped that this meant that in spite of the determination to transform the NHS into a regulated but independent competitive industry, the personal statutory accountability would prevent the most harmful results that we feared from the Act. I was wrong. Now I can only hope that the present damaging crisis may suggest to Ministers that they should exercise greater responsibility and accountability, not just for expenditure but for at least some of the policies proposed in the forward view.

I want to focus in my remarks on paragraph 3 of that report, which says:

“The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health”.

I certainly accept that clarion call; my concern is that the 2012 Act has made it difficult to fulfil. Noble Lords will be aware that public health programmes are often rooted in community-based, sometimes voluntary organisations. These can be very useful, particularly when informal outreach schemes dealing, for example, with problems such as drug or alcohol abuse, can be much more successful than statutory services. but today the competitive reorganisation has led to a hugely expanded pool of non-NHS community providers—a staggering 69% of the new contracts agreed. In my estimation, that must lead to enormous fragmentation and great difficulty in achieving national goals.

In particular, I draw noble Lords’ attention to very real problems in delivering good sexual health and HIV prevention and treatment services under this new system. In recent months, as the noble Lord, Lord Fowler, has just done, we have rightly focused on the Ebola virus, but the latest figures for HIV in this country are a cause for a new concern. In the past 12 months, the numbers of gay men newly diagnosed are the highest since the figures were first collected 20 years ago. During the intervening years, of course, we have developed world-leading clinical care in this complex field and created much-admired prevention programmes, but those are now threatened. Part of the problem is that the public health commissioners in local authorities simply do not have the relevant specialist knowledge and experience. I have learnt, for example, of a particularly stark case in Chester, where the hospital-based specialty services created and led by a very senior consultant are to be replaced by a consortium of GPs. There the Countess Of Chester Hospital put forward a comprehensive tender for an integrated

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sexual health service led by five consultant doctors costing £2.4 million. This has been rejected in favour of an exclusively GP service with no hospital specialist input, costing £2.8 million. It is very hard to see any financial or clinical logic behind this. I wish it was just one example, but it is not.

I want also to explain my concern about the particularly bad situation in relation to HIV prevention. The Government have now said that the programme for national HIV health education will be cut by a staggering 50% in the next financial year. We cannot afford complacently to allow the prevention and treatment of infectious, dangerous diseases to slip from the effective grasp of a national health service. I fear that that is likely to happen.

Overall, I would like to be optimistic about the future. I agree with many of the ambitions in the Five Year Forward View and respect Simon Stevens, who was a special adviser when I was a Minister in the Department of Health. However, he is far too complacent about the encroachment of independent advisers and the resulting fragmentation of important services. Overall, we must retain the national leadership of the NHS not only through the executive managers but essentially through the Secretary of State. His accountability to Parliament and responsibility for the provision of health services should always be the keystone of the health service.

3.29 pm

Baroness Barker (LD): My Lords, I, too, thank the noble Lord, Lord Turnberg, for giving us the opportunity to discuss these matters today. He, like a number of other noble Lords, is a veteran of such discussions. While I pray in aid documents such as that produced by the Royal Commission on Long-Term Care, the Wanless report, Wanless II, the Darzi report and now the Five Year ForwardView by Simon Stevens, he will perhaps agree with me that, over the time that he and I have been Members of this House, the issues facing the National Health Service have not changed but have remained the same. We have had report after report telling us in varying degrees of detail what the shortcomings of the National Health Service are, how it does not integrate with a sufficiently unbroken social care system and what it needs to do to put that right.

My right honourable friends in another place, Norman Lamb and Paul Burstow, have similarly followed those discussions. I am pleased to say that, in their time in government, they have enacted quite a number of the recommendations put forward, not least the return of public health to local government. Back in the time of Derek Wanless, the observation was made that if our tax-funded National Health Service was to endure, it would have to do so in the context of a population that was informed and engaged about its own health, and that the NHS could not tackle that on its own. I hope that any future Government, tempted as they no doubt will be to rearrange the service—let us call it not a top-down reorganisation but a rearrangement—will resist the temptation to take public health back from local government and will leave it where it is, with the health and well-being boards, to give them the chance to build on the work they have done on prevention in

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the past two years. Some 70% of the health service is now about enabling people to manage long-term conditions.

It occurred to me—particularly in the past week, when we have been inundated with stories about how the NHS is failing to deal with emergencies—that much of the literature on the NHS is directed at how we deal with an ageing population. At the same time, we have rather lost sight of how young people engage with the NHS. The most interesting findings over the past month or so concerning the problems in A&E were not about lots of older people who are no longer being supported by social care turning up inappropriately in accident and emergency units but rather the number of young people who turn to accident and emergency units as opposed to their GPs. That is a very worrying issue to which we should give great thought, because GPs continue to be the linchpin in terms of most people’s ability to manage their own healthcare and their health and well-being in the longer term. If young people are engaging only with A&E on an episodic basis, that will store up problems for the NHS in the longer term.

Finally, one of the most laudable things that has happened in the past two years is the increased attention that this Government have given to mental health, which is supported by the Opposition. We are finally beginning to understand the importance of mental health and the problems that we cause the country in the longer term if we ignore it. Some interesting work has been done by new organisations which have not previously taken any part in our health debate, such as Mumsnet, which has talked for the first time about the incidence of mental health problems in very young people aged under 11. It also talks about the high incidence of perinatal mental health problems beginning to challenge orthodox providers in the National Health Service and the voluntary sector. I sincerely hope that the next Government will continue to work with organisations, perhaps new and emerging voluntary providers, to take a completely fresh look at some of the long-standing problems that we know have challenged the NHS.

We as a party have said that we will aim to increase NHS funding by £8 billion. We will do so on the basis of continuing challenge and reform. It is possible for there to be a 25% reduction in preventable mortality by 2025, but only if we continue to change the way in which the NHS interacts with the population, the voluntary sector and the people who are capable of addressing the problems upstream that present as emergencies to the NHS.

3.35 pm

Baroness Masham of Ilton (CB): My Lords, I thank the noble Lord, Lord Turnberg, for securing this very timely debate. The National Health Service is so important that it should not become a political football. Patients need accurate, safe healthcare to enable them to get better quickly. If that is not possible, they should have compassionate care. All services need to co-operate and communicate with patients. Integration should be the aim, not working in silos.

I give myself as an example. I had been coughing for months and had an X-ray on 21 November but

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have never had the result. Having had three antibiotics, I decided to come off the statin that I was taking as I became frustrated with the cough. It seems to have worked. So much of patient care seems to be trial and error.

I take this opportunity to stress some of the difficulties surrounding rural health. Our surgery at Masham is open only every other Saturday for half an hour, for a half day on Thursday and is closed every day between 12.30 pm and 2 pm. The surgery needs to be improved but no one will pay, so my doctor went to Canada.

Next door to the surgery is the Marsden pharmacy, which has a four-inch step with no handrail or ramp, making it inaccessible for people using wheelchairs unless they are super-fit, and for those using walking frames. It is frustrating that this building has just been renovated and disabled peopled, who perhaps need the pharmacy more than most, have not been considered.

On Sunday, I spoke with a member of the Army from Catterick, which has the largest military camp in Europe. I was told that the Catterick Medical Centre has been given a bad report and has to close every day at 3.30 pm, leaving the A&E department at the Friarage Hospital as the only alternative. More military personnel are coming back from Afghanistan and Germany. Therefore, urgent improvements are needed if the future of the NHS is to improve.

I was very pleased to be invited to give the awards to the Yorkshire Ambulance Service last autumn. I found the staff to be dedicated and enthusiastic. In rural areas, where the countryside can be challenging and public transport in some areas is non-existent, the ambulance service can be vital. Without doubt, the Air Ambulance is the most popular charity in north Yorkshire. The impact on the ambulance services in England is very great. There continues to be a year-on-year increase in demand. The major increase has been seen in top-level emergency calls.

There is a worrying situation in that there is a shortage of district nurses, with many having retired or gone off sick. They are so important in helping with ill and disabled people in the community. What plans are there to increase the numbers in the future? I have a cousin married to a registrar surgeon. The surgeon tells me that there is concern about the modern shape of training for surgeons. She tells me that hospitals with poor records should not be training and that sometimes deaneries come round and find poor standards but do nothing about it. She also tells me that the European working time directive has not helped with the training of surgeons. Surgical training should be a priority. I ask the Minister: should we not be aiming for the highest standards of surgery and safety, and stop the worrying increase in negligence claims that is draining the NHS?

I am so pleased to see my colleague, the noble Baroness, Lady Wilkins, back in her place. As president of the Spinal Injuries Association, I ask the Minister to look into the worrying situation where so many excellent doctors and surgeons working in spinal injuries have retired and new young doctors are not coming forward to take their place. Also, the cutting of physiotherapists and occupational therapists is detrimental to rehabilitation. High-lesion tetraplegics on respirators

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are often kept in intensive care beds in general hospitals because of the lack of beds in spinal units. Therefore, there is a blockage in intensive beds in general hospitals, causing huge problems.

Because of paralysis, the “three Bs”—bowels, bladders and bedsores—become very important to these patients. One of the distressing problems for spinal patients being in general hospitals is the difficulty of having their bowels evacuated, as nurses seem to shun this essential part of care. I hope that in future the NHS will recognise the importance of specialised spinal units with trained specialist staff.

I end by saying that there are many complicated conditions that need to be researched, but of concern is the increase in people with liver disease and hepatitis C. I hope that in future they will get the new, crucial drugs that are available but not yet approved by NICE.

3.42 pm

Lord Rea (Lab): My Lords, I am sorry that we are missing a contribution from the noble Lord, Lord Ribeiro. He is always worth listening to. I hope that being scratched from the debate does not mean that he is unwell.

I thank my noble friend for bringing up this wide but highly topical subject, given the daily headlines about one NHS crisis or another, including today. The issue is also high on the agenda of all parties in the run-up to the election. What is becoming increasingly clear—my noble friend Lord Turnberg referred to this—is that the NHS and social care are underfunded and that this is the main reason for longer waiting times and deteriorating services. To call for greater efficiency in a health service that is recognised internationally as highly cost-effective can only mean staff reductions or lower salaries, and worse care. Some say that this is deliberate to encourage more people to move to private medicine.

I want to focus on prevention, which is highly relevant to today’s pressures, as described in the Five Year Forward View, to which several noble Lords have referred. It is better written than the average document from the Department of Health and freer of jargon and acronyms, although I noticed one or two lapses—for example,

“the need to transition to a more sustainable model of care”.

The report puts prevention of disease high on the agenda in the section headed, “Getting serious about prevention”. This phrase is taken from the health review written by Derek Wanless 14 years ago. At this point, I should declare an interest as trustee of the UK Health Forum, formerly the National Heart Forum, which advised Wanless when he was writing his report. He suggested, as the noble Baroness, Lady Barker, said, “a fully engaged scenario”, in which all sections of society should become aware of the health implications of their activities and products. He warned that unless the country took prevention seriously, we would be faced with a sharply rising burden of avoidable illness. As the Forward View put it,

“that warning has not been heeded—and the NHS is on the hook for the consequences”.

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Instead, one in five adults still smokes, a third of people drink too much alcohol or do not take enough exercise and almost two-thirds are overweight or obese. This has had consequences in increasing the flow of costly treatments.

Our expectation of life, however, continues to go up. Part of this is due to the success achieved in reducing cigarette consumption, partly due to the measures introduced by the last Government, including banning tobacco advertising. This Government have also brought in some tobacco control measures but, rather worryingly, they seem to be dragging their feet on the important issue of plain packaging. It is important to get this legislation on to the statute book before the election and to do that it must be laid before Parliament before the end of this month or sooner. I think that the noble Earl is aware of the widespread desire from across the health professions and elsewhere for this to be done. I hope that he will be able to assure the House, perhaps today, that this legislation will reach the statute book before the election. If not, the Government and the Conservative Party will lose even more credibility when they claim to safeguard the nation’s health.

The NHS should also take some credit for the continuing increase in life expectancy, but the increasing incidence and prevalence of avoidable non-communicable disease is a major cause of the heavy pressure that the NHS is now under. One example of this is the avoidable burden that heavy drinking places on A&E departments at weekends. The Government have not taken the first step in reducing alcohol consumption that minimum pricing would provide. There is little doubt that the drinks industry is putting pressure on the Government to avoid this simple measure. It would have most impact on cut-price off-sales, which many young people indulge in, “preloading” to avoid higher bar prices when having a night out. In the past few days, the alcohol health association has said that there should be more information on alcohol products, giving not only the strength but the calories and other health implications.

The Five Year Forward View puts it rather admirably:

“We do not have to accept this rising burden of ill health driven by our lifestyles, patterned by deprivation and other social and economic influences. Public Health England’s new strategy sets out priorities for tackling obesity, smoking and harmful drinking; ensuring that children get the best start in life; and that we reduce the risk of dementia through tackling lifestyle risks, amongst other national health goals ... While the health service certainly can’t do everything that’s needed by itself, it can and should … become a more activist agent of health-related social change”.

3.48 pm

Baroness Thomas of Winchester (LD): My Lords, belatedly all political parties are waking up to the fact that the future of the NHS is top of most people’s agendas in this country, which is why it is going to be prominent in all manifestos for the coming election. The country is also recognising that not only is the population getting older, needier and more disabled but disabled people like me are living longer than we probably would have done some time ago. Boys and young men with Duchenne muscular dystrophy only

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15 years ago were dying in their teens, yet today, thanks largely to night-time ventilation, they are living into their 30s and 40s.

The lessons in the field of rare neuromuscular conditions—the field that I know best—are clear. Money spent wisely now by commissioners on access to specialist support and better care in the community for people with these conditions will save a significant sum later in unplanned emergency hospital admissions. That was the finding of a 2011 audit by Professor Michael Hanna of the National Hospital for Neurology and Neurosurgery in Queen Square, yet it appears that commissioners are not prepared to invest in this way to save in the future. I count myself lucky that I live in the capital, near a centre of excellence in this field, but there are significant gaps around the country in specialist care. The ideal is the development of managed clinical neuromuscular networks that bring together consultants, physiotherapists and family care advisers. An example is the one in the south-west, which co-ordinates service provision and the sharing of skills and expertise.

I now turn to research, which was a hugely important but largely unrecognised part of the Health and Social Care Act: the Act places a duty on the NHS, for the first time in statute, to promote research. A future NHS must do more to promote research and ensure that the UK has the clinical trials infrastructure to attract investment from pharmaceutical companies wishing to conduct trials. That was mentioned also by the noble Lord, Lord Turnberg. With the right support, the UK could become a world leader in this field—for example, through support for patient registries and databases for rare diseases. At present, the Muscular Dystrophy Campaign funds the NorthStar database and the national neuromuscular database, but this arrangement does not guarantee long-term security. Does my noble friend agree that if the NHS is to promote research, it should provide support to databases and registries for rare diseases?

I now turn briefly to funding for new treatments. The NHS will face an increasing challenge to deliver innovative but high-cost treatments with advances in genetic medicine. Will increased competition for funds mean that treatments for rare diseases lose out? To avoid that situation, will the Government introduce a ring-fenced fund for rare disease drugs, as has been done in Scotland?

That brings me to my last point, which is that the NHS must have a clear and transparent means of approving new treatments. I am sorry to say that the experience of the Duchenne treatment Translarna does not bode well, with one of the final stages of the process being held up. I know that my noble friend’s colleague, the Minister for Life Sciences, has been closely involved in helping to find a solution. Will my noble friend encourage his colleague to redouble his efforts to help steer through an interim solution that would allow patients access to this drug, which is available in Europe, by April of this year? It is effective only in boys who can still walk. There are many parents who watch in despair while the days pass, knowing that without a drug such as Translarna eventually their young sons will take their last steps.

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3.53 pm

Baroness Cumberlege (Con): My Lords, my interests are in the House of Lords register but I should declare that I am executive director of Cumberlege Connections and of Cumberlege Eden & Partners.

I, too, congratulate the noble Lord, Lord Turnberg, on initiating this debate. He is a truly remarkable man and is probably one of the most qualified and experienced of your Lordships when it comes to analysing the health service, as was evidenced today in his remarkable speech. I did not agree with it all, but it was remarkable. If one looks further, it is really interesting and fascinating to read his book, Forks in the Road. Does not that title really sum up the views of the nation? The NHS is hugely valued. We are at one in wanting to ensure its future. We are journeying on the same road, but there are many choices to be made on the way.

The ethic is inalienable. Whether we are rich, poor, young, old, black or white, we want a service that is largely funded by the taxpayer. I say largely because successive Governments, including the Labour Party when it was in government, have largely eroded the ethic by stealth—introducing prescription charges and other charges. The general public do not want to produce a credit card for services rendered but they are ambivalent as to who provides the service. If the service is compassionate, kind, professional, efficient and provides value for money, albeit that it is provided independently, the public are largely satisfied.

I endorse the views of my noble friend Lord Horam. Worldwide the NHS is recognised as a winner. We have been ranked as the top health system in the world by the Commonwealth Fund. We also know that when it comes to asking the British what makes them proud to be British, the NHS is top of the list, before the Armed Forces and even the Royal Family. We also know that there is always room for improvement. Lest we get complacent, we only have to think of North Staffordshire, Winterbourne View and so on.

The noble Lord rightly highlighted the challenges that we face and they are beyond dispute, but we should not ignore the progress that we have made. At a time of austerity, we have increased the NHS budget by £12.7 billion. “Not enough”, is the cry but it will never be enough. In the past five years, the number of clinical staff has increased by 12,500, and 850,000 more operations are being delivered each year compared with 2010. The number of patients looked after in mixed-sex wards is down by 98%, which is a subject I know is very close to the heart of the noble Baroness, Lady Jay, from when she was in opposition and when she was in government. Listening to her speech today, I was deeply worried when she quoted the shadow Health Minister as saying that he did not understand how the current system works. I respectfully suggest that he looks at pages 88 and 89 of the book by the noble Lord, Lord Turnberg, which clearly sets that out in a diagram.

Looking at the next five years, as has been said, NHS England’s priority is to engineer a radical upgrade in prevention and public health. It goes on to say that the NHS will,

“back hard-hitting national action on obesity, smoking, alcohol and other … health risks”,

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which I welcome. I share the view of my noble friend Lady Barker that we should stay with the health and well-being boards, and not be tempted for another reorganisation.

In Britain, we attempt to run a fair society, a society which protects citizens from abuse by those unwilling to respect others. We have cracked down on drunken or reckless drivers and on faulty cars. People who abuse our roads are prosecuted and our roads are safer for it. The problems of the NHS are in some measure due to people abusing the system. Resources are spent on dealing with drunks, time-wasters and drug misusers, leaving the system in danger of being overwhelmed so that those in real need are deprived of life-saving treatment. The NHS constitution is very strong on rules for staff but is ineffective and weak when dealing with users. The contrast with drivers who have to learn and adhere to the law is very stark.

Looking to the future, we have to introduce rules to protect and enhance the treatment of people who are ill. Without known rules, any organisation, including this House, can descend into chaos. With a strong economy, we can afford to pay for its use but we should not fund its abuse. Does my noble friend agree?

3.59 pm

Lord Liddle (Lab): My Lords, I, too, congratulate the noble Lord, Lord Turnberg, on the way in which he introduced this debate. It has been a civilised and, in many respects, expert debate. I am worried that I may lower the tone because I want to make a couple of more political comments. However, I shall try to do so in a civilised way.

The basic reason I wanted to speak in this debate is that I fear for the future of the National Health Service given the implications of the emerging Conservative approach to public finance in the next Parliament. I do not in any way doubt the sincerity of Members opposite—my friend the noble Lord, Lord Horam, the noble Baroness, Lady Cumberlege, who has just spoken, and the Minister—the Secretary of State for Health or the Prime Minister, or their commitment to the principle of the National Health Service. However, I doubt the sustainability of that commitment given the approach to public finance set out in the pre-Budget report at the beginning of December, particularly the prioritisation of tax cuts when resources become available and the intention to reduce by the end of the next Parliament the share of public expenditure in GDP to 35%.

The Government have done their best in this Parliament, in their way—I congratulate them on that—to maintain NHS spending in real terms, which, given the financial pressures on the country, was a good thing to do. That has worked for a while. The previous Government increased spending on the NHS a great deal. There were productivity gains to be made from that increase in spending and we have continued to see outcomes improving in the present Parliament.

However, the strains are now beginning to show. We know that, because of the increase in population, NHS spending per head is falling. Simon Stevens’s five-year analysis—I confess to being an admirer and

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friend, having worked with him—is brilliant. It demonstrates that there is a large potential funding gap unless, as the noble Lord, Lord Horam, pointed out, it can be closed by a more rapid rate of efficiency gain. With respect to the noble Lord, that will be difficult to achieve in a highly labour-intensive service. It is not like private sector manufacturing. This is a highly labour-intensive activity and 3% efficiency gains will be very difficult to achieve. So we will need additional investment.

As to what will happen to the rest of the public sector under this public spending outlook in the next few years, we will see severe austerity in welfare and public services, as set out in the pre-Budget report; more strain on poor families; a continuation of inadequate supply of social housing; weaker children’s services unable to protect children at risk; a narrower school curriculum because schools cannot afford to teach more broadly; and local authorities unable to meet the needs of all but very needy people in adult social care.

What will be the consequence of all this? Every academic and expert in public health tells us that if there is an increase in poverty, ignorance, bad housing and social neglect, what we will get is more pressure and problems for the National Health Service. On a holistic view of public spending, the Government’s plans are flawed and we need a more sustainable position. So I congratulate my party on at least indicating what it will do in the first year of the next Parliament in terms of extra spending and how it will be paid for.

Finally, we need cross-party debate and consensus on a long-term funding model for the NHS. I firmly support Frank Field’s ideas for a broadly based hypothecated tax that would take the funding issue out of politics and enable managers in the NHS to plan ahead for a more efficient service.

4.06 pm

Lord Kakkar (CB): My Lords, I join in thanking the noble Lord, Lord Turnberg, for securing this important debate, and in so doing I declare my own interests as professor of surgery at University College London, consultant surgeon at University College London Hospitals NHS Foundation Trust, and chairman of University College London Partners, our academic health science centre and network.

It is striking that in 1948, some 48% of the population failed to reach the age of 65. Recently it was calculated that only 18% of the population would fail to do so. That is a remarkable manifestation of how important universal access to free healthcare has been in securing the health prospects of our fellow citizens. It is also striking that by 2025, it is estimated that 18 million of our fellow citizens will be living with a long-term chronic condition. With an ageing population and all that chronic disease, it is inevitable that there will be increasing demands on the facilities and resources available for the provision of healthcare. Indeed, we have seen in recent weeks increasing demands being made on accident and emergency services. The Nuffield Trust recently published a report which estimates that by 2022, if the current changes in demographics with an ageing population and the present growth in demand is maintained on a similar trajectory, we will need to

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provide 6.2 million extra bed days a year, which equates to some 17,000 extra hospital beds, the equivalent of 22 new 800-bed hospitals. It is therefore important that the noble Lord has tabled this debate about the future of the NHS because we must ask how we will address this increase in demand.

We have also heard that it is not only about an increase in demand. Quite rightly, it is about an increase in expectation. That is because in the United Kingdom we pride ourselves on having invested substantially in a strong science and research base and in biomedical research. Much of that investment is taxpayer-funded, and it is therefore absolutely right that our fellow citizens expect to see the benefits of that research applied to improvements in healthcare and the provision of better long-term prospects for a healthy life long into old age.

The noble Baroness, Lady Cumberlege, mentioned the recent US Commonwealth Fund report grading 11 different healthcare systems. Ten healthcare systems from around the world are compared to the United States system, and once again, for 2013, the NHS ranks number one for the quality of care—that is, the efficiency of care, the safety of care, patient-centred care and the co-ordination of care. Interestingly, however, we rank 10th out of the 11 nations in providing healthy lives for our citizens. So there is more to do to deliver effective healthcare and, in this regard, as has been noted in the debate, it is important to pay attention to the NHS England Five Year Forward View. Quite clearly, the funding models described in that Five Year Forward View expect some degree of efficiency gain further to the substantial gains that have been achieved during the lifetime of this Parliament. What assessment have Her Majesty’s Government made of how much of that additional gain in efficiency will be derived through the application of innovative therapies and interventions as well as innovative models for the delivery of care?

In this regard, it is particularly important to take note of the announcement made yesterday by NHS England of the national Innovation Accelerator programme and of the appointment of the new national director of new models of care. In this regard, I emphasise my declaration of interest as chairman of UCL Partners, as UCL Partners is the host for the national Innovation Accelerator programme, which is being supported by NHS England and the Health Foundation.

There is no doubt that innovation plays, and has played in recent years, an important role in the delivery of healthcare. What assessment has been made of the emphasis on the adoption of innovation, for instance the approach towards telemedicine? What progress has been made in providing telemedicine solutions to the management of chronic long-term conditions for the 3 million people living with long-term conditions that it is anticipated would be covered through these new strategies by 2017?

In addition, of course, there has been great emphasis on the whole area of personalised medicine, and the announcement of the 100,000 genome mapping programme. Again, I wonder whether the noble Earl could comment on how much progress has been made

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in that regard. How much progress also has been made in respect of the UK Biobank and the development of a national health and informatics strategy combining data from all of those to provide a very strong basis for improving health outcomes and driving improved healthcare for our fellow citizens?

The challenge for improved workforce planning will also need to be addressed. As part of changes introduced in the Health and Social Care Act 2012, Health Education England was to take an important role in ensuring that local needs for the provision of healthcare—understanding the local needs of local populations—would better drive workforce planning. Is the noble Earl content that that journey has begun and that Health Education England is able to perform in that way?

Finally, great emphasis was put on the need to develop clinical leadership. In this regard, I wonder what assessment has been made of the NHS Leadership Academy and when we might see the report of the noble Lord, Lord Rose of Monewden, and his assessment of how leadership in the NHS might be improved to ensure a greater chance of our achieving the goals that we all share.

4.13 pm

Baroness Wilkins (Lab): My Lords, I thank my noble friend Lord Turnberg for securing this debate. I want to concentrate on the future of the spinal cord injuries unit. I declare an interest, having been spinal cord injured at university in the 1960s. Last year, I returned to the national spinal injuries centre at Stoke Mandeville Hospital to do four months of unsolicited in-patient research, having broken both my legs. The scene is depressing. I found that the speciality in which we led the world is pinched and demoralised. The result is a pointless waste of NHS money as well as of precious lives. Even in this sorry state, the relief to have been found a bed there after 10 days in a general hospital was overwhelming. I cannot thank the noble Earl and my noble friends enough for all their appeals to secure me that bed. Such help should not be necessary, but I will be undyingly grateful.

It is tragic that the demand for the spinal injury service far outstrips the supply, yet bed numbers have been and continue to be cut, leaving newly injured people in district general hospitals. Twelve spinal beds at Stoke have been changed to general use since September 2013 and, despite continual assurances, have still not been returned. Nationally, as of 6 January, 151 newly injured people that we know of are being treated in general hospitals by non-specialist staff, at the risk of developing complications such as urinary tract infections, pressure sores and psychological difficulties. The most vulnerable patients are those high-level tetraplegics who need ventilation to assist with their breathing. Currently, 19 ventilated patients are waiting to be admitted to specialist care, with an average waiting time of six weeks. Their intensive care beds cost around £1,500 per night, 50% more than a ventilated bed in a spinal unit.

Delayed discharges badly frustrate the optimal use of spinal units. The situation at the Salisbury Odstock spinal unit is not unusual. One patient has been awaiting

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discharge for more than two years, and another for more than a year. They are occupying spinal beds that cost £500 to £600 a night. We know that the drastic cuts to social care and the appalling lack of accessible housing have caused bed-blocking but, as I found, so has the intransigence of the CCGs. To protect their own budgets, CCGs refuse to accept the spinal centres’ advice and insist on their own assessments when the patient is almost ready for discharge. A completely unnecessary delay then ensues in organising care packages and essential equipment. In some parts of the country the local CCG will not even take the unit’s advice on providing the appropriate wheelchair. Instead, a patient has to be transported, with an escort, to their local wheelchair centre, with all the costs that that involves. As a result, there are considerable delays and in some cases rehabilitated patients have even been discharged home on stretchers to wait for a wheelchair at home—what a waste.

The situation with delayed discharges has now reached such a critical level that the All-Party Group on Spinal Cord Injury is about to conduct an inquiry into the causes and to make recommendations. I ask the Minister, first, to support that inquiry and, secondly, who now is in a position to be able to do something about this? The spinal centres have no power to compel the CCGs to address these issues; neither, it appears, does NHS England.

NHS England directly finances spinal injury as a specialism but the money is not ring-fenced. The centres will tell you that up to half their budget is absorbed by their host trust before it reaches them. Would it not be better if the NHS funding went direct to the spinal centre, which could then pay the host hospital for the services it uses?

Underlying all these issues is a general downgrading of spinal cord injury as a specialism in its own right, which must have Ludwig Guttmann turning in his grave. Currently there are consultant vacancies right across the service due to the lack of suitable candidates. Sadly, once we aligned our specialist medical training with Europe, spinal cord injury became part of the medical specialism of rehabilitation rather than a specialism in its own right. There appears to be no clear mechanism to ensure sufficient numbers of spinal consultants or adequate nursing staff and therapists to meet the need. Is anything being done to change this?

At Stoke Mandeville the trust has merged the spinal unit into a specialised services directorate along with haematology, pathology, sexual health and miscellaneous others. As a result, the spinal unit is managed by senior managers who have no knowledge or experience of working with spinal cord injury. I found that the staff feel neither valued nor supported. As a result, key staff have left, with the loss of their invaluable specialist knowledge, skills and expertise. When we have such a shortage of staff, surely it is vital to retain the ones we have.

Finally, whichever party wins the general election, will the new Government recognise that our world leadership role in this area of specialist medicine is now being sacrificed because the management of the

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service is driven by concern with local issues? Will they develop a strategic vision once again to keep the UK in the forefront of the care, treatment and rehabilitation of people with spinal cord injuries?

4.19 pm

Lord Cormack (Con): My Lords, it is a pleasure to follow the noble Baroness. How good it is to have her back among us. She is a testimony to the care that she has received. It is good for her to remind us of some of the problems that are faced by those who have to undergo spinal surgery.

I begin my remarks by referring to the noble Lord, Lord Liddle, because he ended with a plea for consensus and for taking the NHS out of party politics, and I endorse that entirely. He also made clear how important and central funding is. That is the issue.

Let us remind ourselves that the health service is, in effect, via Beveridge, the product of a grand coalition. Whether we will ever have a grand coalition like that again, I do not know; I certainly hope that we will never have the war that created it. However, it may be that the strange results in June could make that an infinitely preferable solution to the SNP holding the balance of power—but I must not digress because I wish to say that we are not serving the interests of the country or the health service by bandying about words such as “privatisation” and “weaponisation”. We have to focus on the service, what it needs and the funding it needs, and there has to be—I have said this many times in this House and in another place—a plurality of funding.

When I entered the other place in 1970, I did not have a single constituent with an artificial hip or an artificial knee, let alone a transplanted heart. By the time I left, 40 years later, the situation was very different. When I first entered the other place, I used to write a letter to every 18 year-old coming of age, and I used to write a letter to every 80 year-old, because it was quite an achievement in those days to reach the age of 80. I could not have done that in 2010. That is really the underlying problem. We are living longer, we have far better medical techniques, drugs and cures, and we are still relying on a single funding base.

I would like to see a commission set up after the election—Frank Field would be an ideal chairman—to look at funding and to rule nothing out. We have charges at the moment for prescriptions for certain people. Many GPs of my acquaintance say that it would cut down the absent rate—people who do not turn up for their appointments—if we charged for them. We could have a charge for those who are in hospital if they are in full-time employment. I quite like the Field idea of a hypothecated tax. We could have £1 on every bottle of alcohol and 50p on every packet of cigarettes devoted specifically, absolutely and totally to the NHS. We could have a system, as other countries do, of obligatory insurance. I am not particularly commending any individual one of these remedies, but I am saying that there are many alternatives.

The noble Lord, Lord Turnberg, who introduced this debate very splendidly, made the point that there has to be—he did not use the words—a plurality of funding, and there does. We should have a commission

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under a respected figure—and I believe that it would be entirely right that that respected figure should come from the left of the political spectrum. I do not believe that the Labour Party can for a moment claim entire credit for the National Health Service—of course it cannot—and I am proud of what Conservative Governments have done, but it was brought into being under a Labour Government and I see no reason why a respected figure whom we could all trust could not chair such a body, which would be broadly representative, to look at these alternatives, ruling absolutely nothing out.

Another thing that we should look at is what treatments are properly available under the National Health Service. If somebody is smashed up in a car crash, of course plastic surgery should be available on the NHS without any charge—but should a man or woman be allowed to change their shape through plastic surgery on the NHS? No. We have to look at a whole range of things, and we have to say what is appropriate for a world-class National Health Service to deliver to all people and how we contribute best to it.

After all, we all do contribute to it through our taxes—those of us who pay taxes, and the vast majority of us do. If there are additional charges here or there, and if there is a hypothecated tax such as Mr Field has recommended and the noble Lord, Lord Liddle, has endorsed, that is fine, but let us get this out of the petty party-political arena. Health is of supreme importance to all of us. There is no politician in any party who is not sincerely dedicated to the health of the people—of course there is not. Let us accept, as the noble Lord, Lord Liddle, said, the absolute integrity and sincerity of those on all sides of the political spectrum. Let us say that funding is the fundamental issue and let us try to get a consensual answer to the problems to which I have alluded.

4.25 pm

Lord Desai (Lab): My Lords, it is a great pleasure to follow the noble Lord, because he has taken the discussion in the direction that I wanted to take it. I start by saying that the NHS is a miracle; it has a great staff. It works by consensus, but, as Lord Bauer, who was here some years ago, used to say, the more we are similar, the more we exaggerate our differences. The differences that we have over the NHS are actually very small, but it pays us politically to exaggerate how large they are. For as long as I have lived here and taken part in debates on the NHS, it has always been in crisis. I do not remember a single debate in which everybody said, “Isn’t it great? Things are fine. Everybody is happy. Nurses’ and GPs’ morale is no longer shattered”. It never works like that. We can live with this miracle only by being dissatisfied with it constantly.

There will always be the cliff-hanger idea that there is not enough money. There is absolutely no way of having enough money in a zero-price service which will not generate excess demand. That is not even elementary economics. If you do not know it, you should not be allowed even to enter a course of economics.

But we have still managed. We have managed to finance the NHS by and large from a single source of funds—although there are peripheral aspects. One problem will be—and this is not a matter of who wins

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the next election—that there will no longer be the kind of money there was. As I have said in other contexts, we are about to enter a low-growth period for the next 10 or 15 years, and the good times are over. They are not going to come back—this is nothing to do with me, nothing to do with the Labour Party and nothing to do with the Conservative Party—so we will have to think of smart ways of meeting the needs that we will have. Not only is the NHS a zero-price service but the types of demand that it faces are proliferating. People are not only living longer but they want a better quality of life, a better shape and things like that—and then we have to address new problems, for example in mental health.

Let me concentrate on one big lacuna that I see in the system. The system does not ask consumers to do enough. We provide them with a zero-price service, but, in return, the consumer does nothing. The consumer is not asked to look after his or her health, to cultivate good habits of not drinking too much or not smoking too much, or whatever it is. The consumer expects, upon presenting himself or herself, to be treated. In any zero-price industry and with any zero-price commodity, if you are not going to allocate resources by price, there has to be something else to ration, and the rationing that we use is time. Waiting time is one rationing device that we use. As we have seen from recent coverage of the A&E crisis, people feel that if they are asked to wait for hours, it is the end of the world. They should have gone to their GP, as the noble Baroness, Lady Barker, said, but going to their GP is too much of a hassle, so they suddenly present themselves at the cheap option, A&E. But if you have to wait, you should accept the price because you did not invest the time in going to your GP. You think this is cheaper? It is not. You have to pay in extra time.

One thing I have advocated off and on is that patients ought to be made aware of how much things cost. They should not be charged but they should be made aware of the shadow price of the things they get, especially the things they waste. If they do not turn up for an appointment, they should be told what it costs. For a long time, I have advocated that we should give each person a shadow budget per head of NHS spend—perhaps £1,500 or 1,500 points. Every time you go to a GP or anywhere, you have a little Oyster card and it deducts so many points from that amount. You do not have to pay but you will be made aware at the end of the year by getting an account of how you spent your 1,500 points.

People ought to be made aware that these things have different prices. If we can make them at all aware of this, it might change their behaviour. We will need not only more productivity but better behaviour from consumers. We will all have to economise. We cannot let the consumer out of the need to economise to get a better health service. I do not have time to say much more than that, but I hope that if we can change behaviour with shadow pricing in the National Health Service, we will have taken a great step forward.

4.31 pm

Lord Morris of Handsworth (Lab): My Lords, I, too, commend the noble Lord, Lord Turnberg, for securing this important and timely debate. Like other

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noble Lords, I also come to the debate as a long-term user of the NHS, but one who fears for its future as I see the most tried and trusted institution disappearing almost daily in terms of its ethics, values and what it stood for.

In 2006, the current Prime Minister told us that the NHS would be safe in his hands. He promised that there would be no more pointless, top-down, disruptive reorganisation and that changes would be driven by the wishes and needs of NHS professionals and patients. As a matter of fact, this Prime Minister has presided over the biggest, most costly and I would say pointless reorganisation in the entire history of the NHS. Patients and professionals alike have personally experienced the results of this destructive reorganisation which the majority neither wanted nor needed. No Conservative or Liberal Democrat manifesto contained any mention of this approach, nor was it mentioned in the coalition agreement.

Last October, the CQC report described some A&E departments and maternity units as so short of doctors and nurses that they posed a danger to patients. NHS staff are leaving the profession feeling undervalued, underpaid, overworked and not consulted. The result of this mass exodus means that last year the NHS spent £1.3 billion on agency and contract staff.

Let’s face it. This has been one of the worst weeks in the history of the NHS. Day after day we have heard that one health authority after another is unable to cope with patient numbers, with waiting times increasing, operations postponed, staff demoralised, ambulance services under pressure and many operating below mandatory levels. People are urged to use A&E departments for genuine emergencies only, yet many have been unable to get a GP appointment. As a nation, we are of course living longer. The official statistics show that over the course of the past few years more than 700,000 elderly people have blocked hospital beds because a care home or a support home could not be found to accommodate them.

Throughout the world, the NHS has been admired and even envied for its record in providing healthcare to people when they need it most—publicly owned, publicly funded, publicly respected and publicly accountable. However, the NHS is becoming unrecognisable. I am not alone in fearing for its future. The British people want an NHS dedicated to making a difference rather than a profit; a service which belongs to the people and which is not for sale. I want the workers to be properly represented in the decision-making process, properly remunerated and consulted about how the service is run and delivered.

I, for one, look forward to the British people having the opportunity to rescue the National Health Service and hand it back to those who need it, those who use it and those who care for it.

4.36 pm

Lord Balfe (Con): My Lords, I congratulate the noble Lord, Lord Turnberg, on securing this debate. My first point is that we may have differences, but the National Health Service is basically safe in the hands

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of all the parties represented in this Chamber. We disagree about how we do it, but we do not disagree about the fundamental aim: to provide a health service free at the point of demand. I was very interested in what the noble Lord, Lord Desai, said. I have known him since I was at the LSE many years ago. The points that he made about a zero-price service are absolutely spot on.

I am interested, even pleased, to hear that we are top of the world rankings. I am also surprised, having had experience for 35 years of the Belgian and French health service, that we have outranked them, because that has not been my personal experience with those two health services. None the less, I will believe it: the survey is obviously right.

Why do I speak today? When I was at the LSE 45 years ago, I wrote my dissertation on out-of-hours GP services. Although my career moved me to a distinctly different area, that is a subject that has continued to interest me. Today, I want to speak particularly about the problems—note that I say “problems”, because I think that the word “crisis” should be used sparingly—facing the out-of-hours medical service. First, many people do not find the out-of-hours medical service easy to access. That is in part caused by the lack of GP cover. The previous Government negotiated a GP contract which, I am told, gives the average GP the highest pay and the lowest hours in the European Union.

Evidence suggests that about 30% of patients who self-present at A&E would be better advised if they had called NHS 111 first. However, using A&E may be preferable, particularly for young working people, to trying to get an appointment with a GP. Some young and generally healthy migrant workers do not understand our medical system and do not register, so recourse to A&E is a natural consequence of unexpected illness. The out-of-hours service which exists to provide medical cover when doctors are not on duty is not widely understood.

In Cambridge, where I live, we remember Dr Ubani, the doctor with imperfect English who, after a full week’s work, flew in from Germany to do a session of weekend cover and killed a patient through overprescription. Few people are, however, aware of the considerable steps taken to prevent such a tragedy recurring.

Doctors’ surgeries are, for much of the time, dark and closed. A&E services have the lights on and, whatever the figures say, you will be seen swiftly if there is a life-threatening condition. If not, frankly, there is an option of settling down with a book and waiting one’s turn. This is not necessarily an unwelcome scenario, especially if the alternative is taking time off work, sometimes from a zero-hours contract, to see a GP.

We also know that the present system of dealing with calls through the 111 service can lead to additional referrals to A&E. The 111 service is staffed by trained advisers but their training is in operating the system, not in medicine. The system has a fail-safe and evidence would seem to suggest that this can lead to more referrals. However, imagine the outcry if the system

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allowed discretion without knowledge. We would soon have an outcry, and rightly so, if there were unnecessary deaths.

Finally, there is considerable evidence that in nursing homes and for other carers of the elderly the first manifestation of a medical issue will lead to the calling of an ambulance. This has rightly followed a lot of inquiries about failings in homes but, as a consequence, it adds to the pressure.

It will be evident from what I have said that a stronger and earlier medical input is a crucial part of dealing with this problem. I would like the Minister to look into the following suggestions and, in due course, come back with a response. First, in Cambridgeshire the clinical commissioning group is in the process of establishing a joint emergency team that will provide integrated care covering community and hospital care, for a fixed price per person per year. This project, which begins on 1 April, will provide a round-the-clock emergency service that will work alongside ambulances and out-of-hours GPs. Will the Minister take a close look at this initiative with a view to promoting its use elsewhere? I notice that it is mentioned in the report.

Secondly, I ask that consideration be given to integrating the 111 and out-of-hours service. Thirdly, I suggest that the introduction of a GP input into the A&E front of house or reception areas could deal quickly and effectively with some of the less serious cases. Finally, I ask the Minister to continue to look at ways to extend the hours that GP services are available. We are no longer in an economy nor do we follow lifestyles where a visit to the doctor is easy to fit in. We need to build an element of consumer choice into the provision of medicine.

I have lived partially in Belgium for the last 35 years. It has a fully socialised medical system, not a private system, but the patient can shop around. There is patient power there at GP level, much more than in the United Kingdom. Maybe this is another European practice that is worth studying with a reference to importing more patient power into the National Health Service.

4.42 pm

Lord Warner (Lab): My Lords, I, too, congratulate my noble friend on securing this debate at such an appropriate time. I share his analysis, particularly around what I see as the decline in the effectiveness of general practice. However, I want to focus on just two strategic issues: the FiveYear Forward View and the funding issues; and the problem of social care and the role of local government.

First, on the forward view, everybody should be extremely grateful to Simon Stevens for the leadership that he has shown in bringing forward this document and securing such a large measure of agreement for many of the ideas in it. I very much support his approach of pointing people in a direction of travel but without what I would regard as an overcentralised, detailed game plan or a further reorganisation. The emphasis on local solutions is a big step forward but I want to draw attention to the key funding assumptions underpinning the forward view vision.

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The document acknowledges what many of us have been saying for some time: that the NHS faces a £30 billion funding gap by the end of the decade. It says clearly that this can be closed only by a combination of reducing demand, increasing NHS efficiency and more generous “staged funding increases”, in its words. That is absolutely right, but whether you close that gap depends a great deal on what combination of those assumptions actually takes place. You need everything to work in order to close the funding gap entirely.

Underpinning all that is a set of assumptions about the efficiency gains that we have talked a bit about today. Under this vision, the NHS is required to achieve an annual efficiency gain of at least 2%, possibly even 3%, for five years on the trot. Its long-run performance is 0.8%, rising recently to about 1.5%, with a big chunk of that 1.5% being achieved by pay restraint—not a card that you can keep on playing year after year. Some would say, “The assumptions on efficiency in this document are heroic, Minister”. As someone who has been in this field a long time, I have to say that I cannot see the NHS sustaining that level of efficiency gain over a five-year period.

My second point concerns one of the provisos that the Five Year Forward View assumes will actually take place—that is, and this is the document’s term, “sustaining social care”. The reality is that the huge reduction in adult social care funding over the past five years has been a disaster for the NHS. The hospital “bed-blocking” that we so glibly talk about today is in large part a direct result of the draconian cuts in social care funding over that period, which, as the Dilnot commission’s report pointed out in 2011, was in any case underfunded in relation to demography even before the 2010 election. Here I should declare my interest as a member of that committee.

The continuing tightening of the eligibility criteria for social care has produced an extremely efficient pipeline of frail, elderly people for A&E departments, many of whom then seamlessly become acute hospital bed-blockers. The Better Care Fund is a belated attempt to stop the situation getting worse, but it does little to repair the damage already done and has itself been criticised for its highly bureaucratic approach by one of the Government’s own Ministers, Mr Francis Maude. I have real concerns that unless something is done to tackle the continuing shrinking of the resources for adult social care, the NHS can only get into a worse set of troubles, and many of its patients will receive a poorer service. Acute hospital medical wards are about the last place you want to leave frail elderly people who are confused.

I close by drawing attention to the issue of local government. Successive Governments have neglected local government; too often they have seen it as the problem rather than part of the solution. I hope that my party will pay attention to this problem. Attention needs to be given to the excellent report for the Labour Party by Sir John Oldham’s independent committee on treating the whole person and integrating care, and not seeing medicine as a collection of professionals attending to various body parts of the individual. Unless we can actually get real about funding and

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about repairing the damage done to adult social care funding and services, we are not going to make much progress in sustaining our NHS.

4.49 pm

Baroness Wall of New Barnet (Lab): My Lords, I, too, thank my noble friend Lord Turnberg for securing this debate; almost every other speaker has referred to the appropriateness of its timing. I declare an interest as the chairman of Milton Keynes Hospital NHS Foundation Trust, as I will refer to it considerably.

This debate is about the future of the NHS. I was fortunate as the chairman of Milton Keynes Hospital NHS Foundation Trust to meet a group of young students who have just started their medical training at Milton Keynes Hospital through a partnership that we have just sealed with the University of Buckingham. They were bright, enthusiastic and committed people who are looking forward to their future and, I suggest, to the future of the NHS.

It perhaps seems appropriate to look back, as other noble Lords have done, at where we are now and what we are learning from where we are, alongside debating and sharing what future this magnificent service can have—a service of which we are proud and which offers care from cradle to grave. My noble friend Lord Turnberg referred to medical and technological interventions and developments, as did other noble Lords in their speeches. As other speakers have said, although these have clearly made a huge difference to people’s lives—and we welcome that—I do not think that any of us realises the strain that has fallen on the hospitals as a result, in particular on acute hospitals that provide these services.

I will share things that I know happen in my hospital and elsewhere. It is now almost taken for granted that, if a baby is delivered at 22 weeks, it will survive and flourish, which is an admirable thing to achieve. However, to do that, the service required from the NHS is huge as regards the care that that baby needs—in some instances it involves one-to-one specific nursing requirements. The same applies, as other noble Lords have said, at the opposite end of the service. Milton Keynes is a community that includes people of all ages, from the very young to the very old, so it has the same problems as many other hospitals. The interventions and developments that we have had in treating cancer and other medications for improving health, to which noble Lords have referred, have made immense improvements and breakthroughs in people’s lives. However, I am not sure that, as the noble Lord, Lord Desai, rightly said, although in very different terms, we—patients, communities or any of us—understand just what the effect of that is. We all welcome the improvements made in our lives—any of us would want our relations to have all that—but the implications for an acute trust of funding and service provision are extensive.

Over the last few weeks and even days, my trust, like many others, has been seeing very poorly patients, mostly old men and women, brought in with chest pains, breathing difficulties and even with pneumonia, and others are heading that way. We, like other hospitals, have dedicated staff, from consultants and nurses to

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healthcare assistants and, importantly, porters, who are often not mentioned but who make the wheels of the organisation move—porters moving trolleys in and out of A&E can make a big difference to the facility that we have to look after patients, and that support is absolutely crucial, particularly at this time. The staff have a huddle every morning or at every shift change and look at what is going on. If you come in, morning after morning, and find that not a single bed is available for anyone who comes through your doors that day, that is a big challenge to start the day with. However, every member of staff works in high spirits and with complete dedication. They care—as I think we all do—about the type of service that they are going to give. They worry, as we all do, when the stress goes on for as long as it has, that they are not able to give the care that they want each and every patient to have who goes through their hands.

The reasons for that are multiple and we have discussed many of them today in this debate. I will pick up on one thing that my noble friend Lord Warner just talked about, which is our relationship with local authorities. As my noble friend Lord Warner and other noble Lords said, many of the bed-blockers—it is a most unfortunate phrase; these are wonderful people who have had interesting and dedicated lives—are there because there is nowhere else for them to go. The ability of local authorities to purchase places in nursing homes and care homes, not just in Milton Keynes but elsewhere, has been reduced because of the cuts, so there is nowhere for people to go.

In addition—and I shall say this quickly, because I am running out of time—what has accelerated the process and caused the overwhelming concern over the past few days is that we have just experienced what in hospital terms is called a “double weekend”. Christmas Day was on Thursday, Boxing Day was on Friday and there followed Saturday and Sunday. The consequences are that we already have challenged services but we also have consultants and nurses who are not working over those days, which means that we cannot provide the usual service.

The Front Bench is getting anxious that I am not finishing in time, so I will finish there. All that I would seriously ask on behalf of my staff in the hospital is that we should not have massive change. Please let us not have a whole new look at what we are doing, with someone coming out with something entirely different. Everybody is weary with that, so let us just look at what we have and make sure that we can make it work better.

4.55 pm

Lord Mawson (CB): My Lords, I thank the House for allowing me to speak briefly in the gap. In the debate led by the noble Lord, Lord Kakkar, in November, on health and innovation, I described a piece of health innovation that I am leading in Tower Hamlets, bringing a health centre, a school, housing and a whole range of enterprise projects together in an integrated health and education project. Professor Brian Cox and I are embedding a science summer school in this project, focused on how Britain becomes the best place in the world to do science. It has taken us seven years to create the health centre; we have lived through three

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different Governments. I have to thank the noble Earl, Lord Howe, for helping us to resolve this issue; it is very good news indeed.

What lessons have we learnt from a real project on the ground over the past seven years? My first point is that we need consistency. The message and the people constantly change. Secondly, there needs to be accountability. No one seems able to take a decision; there are layers and layers of approval processes, requiring business case after business case, then point one comes in—I refer to my point about consistency—and you are back to square one.

Thirdly, we need clarity. To the outside world, the NHS is the NHS is the NHS. Unfortunately, within the NHS there are so many silos that only the NHS can understand and which all have to have their say, and they all have different approval mechanisms. Then, because of the accountability processes, nobody can take a decision, so it becomes a game of “We will agree if they will agree”, with no one willing to make a final call.

Fourthly, there must be local empowerment. The centre has to make all the decisions but it is the people on the ground at a local level who should be leading. Locally, things are either done to you from the centre or not done at all.

Fifthly, there needs to be partnership and trust. We are not all the evil private sector, all out to screw the NHS. Partnership can achieve so much and has done so to date. The NHS has got to learn to trust and work with others, and it may just find that it can benefit enormously. The best local authorities have made real progress here, but the NHS by and large has not. Our project is bringing large amounts of money, which are coming from outside the NHS budget, into health initiatives on a housing estate. That is what partnership does.

Sixthly, on primary care premises development, the Secretary of State is continually talking about moving to a more preventive and proactive approach, and he is right to do so. To do this, you need to do all that I have mentioned above. However, NHS estates have been given a very narrow, financially driven brief. They need fresh instruction and leadership with a specific brief to foster partnership and opportunities for GP practice developments that will then deliver a preventive and cost-effective, proactive approach. They need to be the solution, not the problem—because not despite.

Most importantly, it must be about patients, patients, patients. Some parts of the NHS seem to have forgotten all about that.

4.58 pm

Lord Hunt of Kings Heath (Lab): My Lords, as this is a general debate on the NHS, I remind the House of my interests as a consultant trainer with Cumberlege Connections and president of GS1. As I am going to raise the Cancer Drugs Fund, I also declare that a relative of mine, Joe Wildy, is an employee in the government affairs department of Sanofi.

I, too, congratulate my noble friend Lord Turnberg on securing the debate and on the quality and breadth

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of his opening speech. It is clearly timely; never has the health and social care system been under so much pressure.

As many noble Lords have suggested, this pressure can only grow with technological and medical advances, and the sheer fact that the number of those aged over 80 will double by 2037. Implicit in the Motion of the noble Lord, Lord Turnberg, is the question of whether a comprehensive service is still feasible and affordable. I have no doubt that it is but nor do I doubt the scale of the change that the NHS must effect to ensure that sustainability. I have identified seven key areas of change. First, we have to undo the damage caused by the Government’s 2012 Act without undergoing a huge restructuring, as my noble friend Lady Wall said. Secondly, we have to ensure a sustainable funding regime for the NHS and social care. Thirdly, we have to integrate health, mental health and social care. Fourthly, we have to invest in and re-energise primary care. Fifthly, we need a much more assertive public health programme. Sixthly, we need more personalised care and innovation and, seventhly, we have to invest in and support a workforce to help us transform services.

It is a truth universally acknowledged that the 2012 Act has been pretty much a disaster. Despite all the protestations of Ministers, a huge amount of money has been spent and services have been fragmented, and too much energy is spent by all the players simply trying to keep the new system’s head above water. At a time of real crisis in emergency services, it is palpably clear that no one is in charge locally or nationally. My noble friends Lady Jay and Lady Wilkins, and the noble Lord, Lord Mawson, identified the buck-passing of responsibility between a mishmash of clinical commissioning groups, commissioning support units, local area teams and health and well-being boards, which are all quite unable to show the required leadership.

It is the same at national level. Ministers, the Department of Health, NHS England, the NHS Trust Development Authority, Monitor and the CQC vie with each other, often conflict and certainly provide no clear leadership. No wonder the National Audit Office commented in November that it is not at all clear where responsibility for strategic change lies. Quite! It is not surprising that performance is problematic. The Government inherited an NHS that was meeting the then 98% four-hour A&E target. They reduced that to 95% but hospital A&Es have missed that target for 76 weeks, with many hospitals in the last two weeks declaring major incidents. It is clear that the service is under extreme pressure.

On resources, never has the NHS had to cope with a flat-line budget—which is essentially what it is—for such a long time in its history. The recent NAO report on the financial sustainability of the NHS makes for sober reading, as does NHS England’s Five Year ForwardView. My noble friend Lord Liddle pointed out that the Chancellor’s intention to reduce public expenditure to 35% of GDP by the end of the Parliament means that the actual resources going to the NHS will be bleak indeed.

I want to ask the noble Earl about an aspect of the immediate funding problem, which concerns the Cancer Drugs Fund. In August last year, the Government

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announced additional funds for the CDF to ensure that as many people as possible could access these pioneering, life-enhancing drugs. However, I understand that six months later NHS England is poised to remove that access for unknown thousands of patients. What is the Government’s policy on the CDF?

I ask the noble Earl yet again about the money now being paid back by the pharmaceutical industry to underpin the cost of certain drugs, subject to a modest inflation figure every year. Where is this money being spent? Why is it not being spent on new medicines and new treatments, where surely it ought to go? Is it a fact that NHS England does not accept the agreement that the department reached, and that is why it is not playing ball in ensuring that the money is invested where surely it ought to be invested?

On funding, my party has committed itself to a £2.5 billion Time to Care fund. We also want to remove some of the wasteful costs of the current restructuring. However, we should listen to my noble friend Lord Warner on the gap identified by NHS England. The fact is that the 3% efficiency target is formidable, or heroic, as he said. We will have to tackle this one way or another.

We also have to tackle the integration of physical health, mental health and social services. We need personal care plans and a single point of contact. We can see the current problems, which my noble friend Lady Wall identified. We see the fruits of a lack of integration. First, adult care has been impossibly squeezed. This has forced frail older people to rely on the NHS as the provider of last resort. It also means much less support for people when they are ready for discharge from hospital. Delays then happen, with longer lengths of stay. That is the problem we face. Without a properly resourced social care system, and without integration, we are not going to be able to move away from it.

Then there is primary care. Is it any wonder that A&Es throughout the country—recently the Great Western trust in the south-west, the Walsall trust in the Midlands and the Royal Surrey County Hospital in Guildford—are having to warn patients to stay away? It is no wonder when people find it so difficult to see their GP. In the east Midlands, the CCG in Erewash reported that one in five patients had to wait a week for a doctor’s appointment. Barnsley Hospital in South Yorkshire recently surveyed patients, many of whom complained about difficulties in getting a local GP appointment. This has to be tackled. I remind the Minister that whatever one says about the contract, the fact is that this was not a problem in 2010, even though the period between 1997 and 2010 had seen a steady increase in the number of patients coming through the door.

Investment in primary care has definitely fallen behind, and a workforce crisis is emerging. One good start would be for the Secretary of State to desist from his thoughtless attacks on GPs. We have pledged to use part of our £2.5 billion Time to Care fund to recruit more GPs, but we need to do much more to bring GPs into the core of the system. I remind the noble Earl, Lord Howe, that when Andrew Lansley proposed the 2012 reforms, he said that the reason was that, “GPs

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spend all the money and we want to give them the levers because that will effect change”. However, the huge gap in the system is that clinical commissioning groups seem to have no impact whatever on the performance and behaviour of GPs. I thought that that was the whole purpose of delegating budgets to CCGs. The reason, of course, is that the contract is held with NHS England, which has been quite unable to impact on the performance of GPs.

My noble friend Lord Rea talked about public health. I certainly agree with him and NHS England on its five-year plan. It says that we need a radical upgrade in prevention and public health. It says that it will back hard-hitting national action on obesity, smoking, alcohol and other major health risks. That is very welcome. The question I would ask the noble Earl, Lord Howe, is whether the Government will let NHS England do that—because I have to say that the Government’s record on public health has been very disappointing indeed.

There is one other area that I have time to mention: the adoption of innovation in the National Health Service. The noble Earl knows that he and I share the concern about the slowness of the NHS to adopt new treatments and new medicines. Surely, given our fantastic life sciences, and the strength of our pharma and medical devices industries, we have to find a way to encourage the NHS to move to adoption much more quickly than heretofore. I certainly hope that in his winding-up speech he can say a little more about how we are going to do that.

5.08 pm

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con): My Lords, I start by congratulating the noble Lord, Lord Turnberg, on securing this debate and thanking those noble Lords who have contributed to it.

As noble Lords will know, having covered the health portfolio continuously since 1997, I still find myself continuously in awe of the NHS and the principles that underpin it, as well as of the people within our health service who live out these principles, not least at the moment.