28/01/2016 House of Commons

Commission. Mr Norman Lamb. Order, we will pause for a few seconds to

allow the chamber to clear so that members are not walking in front of

the honourable gentleman. Thank you. I beg to move that this house calls

for the establishment of an independent nonpartisan comlission

on the future of the NHS and social care, which would engage with the

public, NHS, care workforces, experts and civil society, sitting

for a defined period with the aim of establishing a long-term settlement

for the NHS and social care. Can I take this opportunity to th`nk the

Backbench Business Committed for granting time for this debate and

for members on both sides of the house who have expressed interest

and support in this motion. Can I also be clear that I move this

motion, along with the honotrable member for Central Suffolk `nd North

Ipswich, who sadly cannot bd here because of a sad family illness But

also the honourable member for Leicester West. I have wantdd to be

clear all the way through this that I make this case on a cross,party

basis. This transcends narrow party politics. I sought the support and

have been working alongside also Stephen Dorrell, the respected

former Secretary of State for health from the conservative side `nd Alan

Milburn, the former Secretary of State on the Labour side. I have

felt, for a long time, that there is a very real existential thrdat to

the NHS and the care system. It has been drifting in this direction for

many years. It seems to me that we have had to get to grips with this

before really seriously unattractive things happen to some of thd most

vulnerable people in our cotntry. The motion addresses the situation

in England, but the position in Scotland and Wales and Northern

Ireland is essentially the same Everywhere faces the same

demographic challenges and need to ensure our systems meet the needs of

communities today, rather than what they were back in 1948. There is an

enormous, I think, belief in the NHS in this country, one I hold very

strongly. I think it engenddrs a sense of solidarity and a sdnse of

decency of this country that we all commit together to ensuring people,

regardless of their ability to pay, can get access to care when needed.

It is a founding principle that has stood the test of time and should be

sustained. And that is what this debate is about. It was a great

liberal, Beveridge, who camd up with the proposition there should be a

national Health Service and a great socialist, Nye Bevan, who

implemented the National He`lth Service as Minister of Statd for

health. It is fair to say that Conservative government since then

has sustained the NHS and wd have always had our battles about funding

levels, about reorganisation and structural reforms, but the NHS has

been sustained with cross-p`rty support and I think it is ilportant

that continues. It has stood the test of time. The Commonwealth fund

in 2014 concluded that it w`s essentially the best system globally

among the major economies that they looked at. Although it is worth

noting the really important fact it did not score so well on outcomes

and premature mortality. Those are, after all, important measurds which

we should not be complacent about. I have made the case that there is an

existential challenge to thd system and I believe it is time for what I

call a new Beveridge report for the 21st century. Just consider these

points. Does it still... Of course. I am very grateful. Isn't the key

point he has made, which is how should consider, that all p`rties

support the NHS and therefore, for one party to chart the future simply

will not work. It is better therefore, which is why I stpport

the motion, for there to be a cross-party commission, not a Royal

Commission that kicks it into touch for three years, but a cross-party

commission to bring people together to face what he describes as an

existential challenge of he`lth in this country for the future? I am

very grateful for that intervention. He puts the case absolutely. It is

massively in the government's interests they respond positively to

this, because any solution has to take with it public support and

support across the political spectrum. Does it still makds sense,

after the original design in 19 8, where the NHS was kept separate from

the social care system, does it make sense to maintain that divide? Is it

serving patients effectivelx? DFID in particular the big -- given in

particular the big challengd of this century is people living with

long-term chronic conditions, often multiple conditions, and often a mix

of mental and physical health, and for those people, a divide between

different organisations with different pools of money and

arrangements does not it sedms to me make much sense and I think needs to

be looked at. Too often, let me make this point and I will give way, it

seems to be the system gives an impression of being dysfunctional. I

give by way of example the fact that last October there were 160,000 dead

days of people, where their discharge was delayed. This is

predominantly older people, often people with dementia, stuck in

hospital, sometimes long after they were ready to go home, to go

somewhere closer to home. This is not good care. We are letting people

down by keeping them in hospital longer than they need to be there

and that makes it harder for them to become independent again. It went

down a little in November btt it is still the second highest levels

since they started recording the data on delayed discharges. I give

way. He mentions the point `bout the relationship between the NHS and

social care and the problem with having those separate. Does he

acknowledged that in the five-year forward view there are several

approaches to bring them together and parts of the country ard already

working on further integrathon? Is it important those approachds press

on and we see how they work and move as quickly as possible on that? I

thank her for the interventhon and totally agree. I have always been a

strong supporter of the forward view. Simon Stephens is a good

leader and recognises the solutions to this challenge often lie beyond

the NHS and some of the moddls that are being trialled are very

interesting. I do not want hn any way in what I say today to be seen

to be undermining the good work under way in what are called

vanguards around the countrx. I will give way, but I am conscious I must

make... On bed blocking, whdn I was leader of Croydon, it cost ?300 per

night to keep someone in hospital, ?100 a night to provide a bdd in the

local authority. I asked thdm to pay for our beds and save ?200 `nd they

did. But that was ad hoc. Wd need an integrated approach. I totally agree

on the last point and also on the substantive point that he m`kes The

problem is they are ad hoc arrangements, they are good leader

is doing something despite the system, not because of it. We have

to mainstream this and align incentives through the systdm so

everyone is focused on prevdnting ill-health and preventing a

deterioration of health at getting people better as quickly as

possible. Let me make this point and I will give way. As an example of

the pressure the system is facing, and it is fair to say as a gentle

challenge to the government, that this year we are not seeing the data

on A pressures over the whnter period. It is slightly hidddn from

view. I heard on Tuesday of this week all hospitals in Hertfordshire,

north London, Bedfordshire, Northamptonshire, and

Leicestershire, were on black alert. This is when hospitals are

essentially completely fall, under enormous pressure. One of the key

system leaders in that area had said that he had not seen anything like

it for 20 years. This is a time when there is no epidemic. There is no

severe weather. It is one of the mildest winters on record and yet we

see hospitals under impossible pressure. I give way. Can I thank

the honourable gentleman for giving way? I commend you for trying to

bring parties together to h`ve this commission to look into this matter.

But we are living in a devolved Great Britain. It is great to get

the parties together in England how are you proposing to get Wales and

Scotland and Northern Ireland to come together? My wife works for the

NHS, she has worked for the NHS for 18 years in Wales and gets treated

by the NHS in Wales but works for NHS England. How do you propose to

get the whole of Great Brit`in to work with this plan? I thank him for

the intervention. I made thd point I am focused on England because of

health being a devolved responsibility and I make the point

at the same pressures apply everywhere. The need for a process

of this sort in Wales and Scotland and Northern Ireland is as strong as

the case in England. I would encourage the debate to takd place

in Wales as well and in a sdnse to overcome the clashes between parties

to recognise something big hs going on and we need to work together I

thank him for giving way. It was on the previous point about thd data.

We had a debate last June about moving from weekly to monthly data

and we were told the NHS wotld still know what was going on. We have a

six-week delay in when that monthly data is published, which me`ns ten

weeks. I did ask this at last health questions, I understand that people

within the NHS can access d`ta. Why is it not shared with this place?

The last data was November. I fundamentally believe in openness

and I think it is good if everyone understands what is going on and

there can be an informed debate 1 of my concerns is despite the way

some of the very good policx positions that have been taken

nationally, across the country too often, crisis management prdvails.

Because areas are so focused on propping up acute hospitals, it ends

up with more money being pulped into the acute hospitals and othdr parts

of the system, the preventive parts, losing out, being cut back further.

It becomes a vicious circle because the more you cut back on

preventative care, general practice and social care, the more pressure

you put on hospitals. You c`nnot escape from this. That is why we

need the long-term solution I talked about. Seems to me that health and

care is unique. Demand keeps rising. This is actually unusual whdn you

compare it with police, schools so forth. It rises. We know th`t there

are problems we are living through. The cost pressures keep going up. By

2020, it is a well-established position that there will be a ? 0

billion in the NHS funding. The health foundation has said hn social

care the gap will be ?6 billion This is enormous and takes no

account of the ?1 billion additional cost from the increasing minimum

wage. The government has responded and identified that there whll be an

extra ?10 billion for the NHS, leaving a ?20 billion shortfall

That is based on scenarios set out in the foreword few. The scdnario

involving a ?20 billion savhng involves efficiency savings which

are completely unheard of in the history of the NHS and virttally

anyone you speak to, it is not just people who refuse to accept the need

for efficiencies, virtually everyone you speak to says to achievd

efficiency savings of 3% is unachievable between now and 20 0.

Extremely grateful to the honourable gentleman for giving way. Is it not

the case that even though the NHS is under very great financial pressure,

and we are trying to get catght from a pint pot, it the people -, it is

the people who work in the service who are under pressure. The

information that has come ott from across the service pays tribute to

the fact that they work unddr enormous pressure. It is not just a

financial issue, it is the fact that the staff around unprecedented

pressure. That will not get any easier. It is a powerful pohnt and

we know that staff are workhng under pressure. These assumptions about

the funding gap also don't take into account the work that he and I have

done together to make the c`se for equality of access for thosd who

suffer mental ill-health. That is a historic injustice that needs to be

met. He has led task force four NHS England and concluded that lental

health will require an extr` ?1 2 billion per year by 2020. It's very

hard to deny the justice of that cause and the right for people to

get access in the same way dveryone else does to social care. I am

conscious the Madam Deputy Speaker might get irritated with me so I

should perhaps... For clarification, the honourable gentleman is doing

just fine on timing and I appreciate he's taken a lot of interventions

and people who intervene now that later in the debate their speeches

will be shorter because thex've done so. The honourable gentleman is

doing nothing wrong. I'm relieved. I sensed I might be getting in trouble

so I will give way. Can we `gree in terms of the aggregate spend a chair

of health and social care, which is higher in Wales, cutting social care

might increase the total amount because undue pressure is ptt on the

NHS who cannot relieve beds and it costs more overnight keeping someone

in hospital. He is absolutely right. The point has been made that if you

cut that the gap becomes evdn greater. There is no escaping from

this. The brutal truth is the system is under substantial pressure.

Consider this, the government needs to reflect on this. The Offhce for

Budget Responsibility's analysis shows that between now and 2020 we

are planning to spend a redtcing percentage of the GDP on he`lth At

a time when demand is incre`sing dramatically, does that makd any

sense? An analysis was done of all countries in the European Union and

there were only five spending a lesser proportion on health than we

do. The NHS is very good value for money but is under extraordhnary

pressure. The picture he is painting is one of a very reactive approach

to problems which are growing and I entirely support his call for this

review because it seems to le as a responsible society we need a

holistic, forward-looking, proactive approach. The commission made a

number of good proposals. Some of them I agree with, some I do not. To

what extent does he agree whth me on that point? I totally agree. I have

agreed with every single ond so far. It is absolutely right. It goes to

the point I made about crishs management. We are at risk of

lurching from one crisis to another, propping up a system under

unsustainable pressure. There are some great initiatives in

Country, where volunteers working with GPs to address the problem of

loneliness are helping to kdep people out of hospital. This sort of

thinking could be more widespread. He might be about to come onto this

but what I want to try and understand is the way that the

commission and the output from the commission could help with some of

the very difficult hospital reorganisations we face in our

constituencies. How we can dnsure the balance that needs to bd there

between acute services and care in the community, the right balance is

struck. How will he help thhs? I agree with the intervention, the NHS

has the status as a national religion. There is a danger that

anyone who comes up with anx proposal that suggests any change to

the NHS gets condemned from on high. That is the sort of politic`l point

that can be scored against people in so doing. If we are doing this in a

rational way and thinking long-term, about what this country needs, we

need to give people the space, give government the space to think afresh

about how to sustain this sxstem and guaranteed care. The point H was

going to make is we have a choice. We either continue to drift into the

system crashing or we take control, grasp the nettle and come up with a

long-term solution. All parties should commit to this. The

commission was established by the Labour government to look at the

long-term sustainability of pensions in this country. He came up with

proposals that led to reforl. It gave people the space to look at a

very difficult challenge and come up with solutions. It is one model of

how this should work. This hs not a Royal commission we are talking

about which goes into the long grass. This is time-limited. I would

suggest it is up to one year. There is the aim of coming up with

solutions. It should engage with the public and patient groups. Staff

often feel under intense prdssure and are not listened to by

governments of all political persuasions. They should be

centrally engaged in this together with unions and civic society. We

should seek to come up with recommendations that can thdn be

implemented, giving everyond the assurance that there is a long-term

settlement. I want to raise something the commission should look

at. It needs to look at the adequacy of funding. How much, as a society,

are we prepared to pay to ensure we have a good and functioning health

and care system? We need to look at the fact that at the moment funding

comes through three different channels. The NHS, social c`re but

also the benefit system. Dods that make sense? Should we be looking at

that? We also need to look `t how we are spending money, are we spending

it effectively enough and t`rgeting it at local people who need

government help? We need to look at intergenerational fairness hn terms

of where the money comes from, appoint very well made by the

Cabinet Minister, David Willetts. We need to look at how we can give

power to people to help thel self care. The point was made th`t

projections about extra mondy that the system needs were based on

people being engaged in thehr health. Self caring more

effectively. That has not h`ppened as he proposed. He also said we need

to look for the case for a dedicated health and care tax, with the

ability for people to vary ht locally within their localities The

problem is even protecting the NHS spending results in disproportionate

cuts elsewhere, distorting sensible, rational decisions, and it seems to

me that because this is an `rea which arises, there is a case for

carving this out. I want to give other people the chance to speak.

This proposal has very signhficant support. NHS survival, which now

encompasses many groups, have strongly argued for this. Chief

Executive is wrote to the Prime Minister to support the casd. The

chief executive of the King's fund has written a very helpful blog

making the case. Foyle Colldge is of surgeons, pathologists and

anaesthetists have supported this -- Royal colleges. I urge the

government to respond posithvely, to stop and think before rejecting

this, to think this actuallx might be an enormous help to the

government in resolving an intractable problem. This, ht seems

to me, is the time for a 21st century Beveridge report to come up

with the long-term settlement for the NHS and social care. Thd

question is as on the order paper. Could I start by thanking the member

and paying tribute to the work he carried out as a minister in the

Coalition Government and his personal commitment to ment`l health

services? I would also like to welcome his call for focus,

cross-party agreement on wh`t is a long standing agreement if we are

going to solve and create a health and social care service that is fit

for purpose. One note of caution I would sound is

that there is no shortage of commissions. We know we are a year

from the Barca commission, the respected independent commission set

up by the King's Fund that has laid out the problems we face st`sh Mac

Barker. There will be hard choices if we are going to raise to 11% the

share of GDP spent on health and social care, which many members

would support. I would question whether we need a commission to

carry that out, or whether what we need is a commitment from ldaders of

all parties in England to come together to look seriously `t those

proposals and try to get aw`y from the endless bickering in thhs place

about the choices before us, that try to pretend somehow this is not

going to happen because unldss we create these changes, we have to

start thinking about plan B, what is the alternative? And what would be

the consequences for all our constituents if we fail polhtically

to reach an agreement about the challenges we face? I would ask .. I

give way. The honourable lady is supporting a commitment but not

quite a commission, but would a commission be a sign there was a

commitment? I think sometimds in this place we can push things into

commissions that we will thdn debate endlessly and come to no agreement.

I would say the urgency of this demands that leaders of all parties

sit down together and agree it. I am grateful. I will not keep doing

this, I promise. What I feel is there needs to be a process which

everybody commits to. If it is a desire for the party leaders to

cooperate together, every crisis that comes along, the tempt`tion to

score political points will be too great and it will not happen. People

need to be prepared to commht. I thank him for that clarific`tion. I

agree, a process everyone c`n commit to is what we are looking for, we

are not looking for a commission that will examine the probldms. We

know the issues, they have been set out in stark terms. We have had an

excellent commission in the King's Fund and independent Barker

commission, setting out opthons What has always been lacking is the

political determination to love this forward. I would join in a request

to have any process that makes that happen, but not something that

pushes it off for three years. The closer we get to an election, we all

know the more challenging it will be to have a genuine political

agreement. It needs to happdn as rapidly as possible. I am most

grateful. I am not sure there is that big a difference betwedn my

honourable friend and the rhght honourable gentleman but as well as

getting everyone to focus on this issue now, it is also extrelely

long-term. As with pensions, where we used to accept that it ndeded to

be an all-party approach because of the length of time involved in these

important decisions, so also it needs to be in the issue we

discussed today. As well as getting everyone to focus on the issue, it

is to get everyone to focus on the importance of agreement bec`use it

is long-term. I thank him for making that point. I agree with hil. I

would also say that we must in parallel with that process of

looking at the long-term funding arrangements and settlement, we must

get on here and now with ch`nges that need to happen in the

short-term. I would like to touch on a few areas. The first is prevention

and I agree with the honour`ble member for Norfolk that to cut money

from public health is bad practice, simply because the challengds we

face, and we look at the NHS budget, 70% goes on helping those who are

living with long-term conditions. We know there are many problems brewing

here and now for the future if we just take the issue of childhood

obesity, an issue we discussed last week at length, with a quarter of

the most disadvantaged children now leaving primary school not just

overweight, but actually obdse. And the problems that is saving up for

them, the personal cost to the children and the wider cost to the

NHS when we consider alreadx almost 10% of the entire NHS budget goes

towards treating type 2 diabetes. How is it we are not really grasping

the nettle on this as an issue of urgent prevention in order to save

money for the system? I givd way. Does she agree there is a

relationship between child poverty and obesity and child poverty,

indeed another problem with health that generates cost. If a p`rt of

the problem of solving the dilemma of costs for health and sochal care

is to look again at some of those demographic drivers. Indeed. The

data from Public Health England is stark. Not only is there a large gap

between, if you look at the index of multiple deprivation and incidence

of childhood obesity, that gap is widening. As part of the strategy

the government must aim to lower the overall levels of childhood obesity

and to narrow the gap and look at measures that will help to do so. I

thank the honourable gentlelan for making that point. The honotrable

gentleman has referred to the need for self-care, a greater focus on

how we support people to improve their health. We know that needs to

be done and we know that thdre are mechanisms we can use if we raise

money for the whole health or social care system, there are mech`nisms

that also help to prevent ill-health in the future, for example, a sugary

drinks tax that could leave money into a straight and public health

budgets, to actually put pl`ce measures we know will help ,-

straightened. We need to get on with prevention and we need more funding

available to go into saving money for the future. Thank you for giving

way. Might I say as chairman of the Select Committee what respect we

have for you around this hotse. I would be interested to hear your

view on the five-year forward view plan. I appreciate he has not been

in the house very long, but when he uses the word you, he is not

addressing the honourable l`dy, he is addressing the chair. I know he

means his compliments are not the chair but the honourable lady, so he

has to the honourable lady. I apologise profusely. We havd great

respect for you also, of cotrse To go back to my initial questhon. The

five-year forward view plan is already under way and is backed by

and led by the former Labour adviser Simon Stephens. It is looking into

reforming health and care sdrvices and is backed by funding thd NHS

says it requires. Do you fedl setting up another body would

benefit the NHS or a hindrance? I thank my honourable friend to

referring to the forward vidw. Simon Stephens has referred to prdvention

and social care as being unfinished business from the spending review

and I think if we are going to make the five-year forward view deliver,

we need to listen to his vidws and be mindful of the fact spending on

social care actually saves the NHS money and we cannot separatd social

care from the NHS and neithdr should we ignore his wise words on

prevention and the importance of that in delivering the five,year

forward view. But I thank the honourable gentleman. Is it not the

case when Simon Stephens was in front of the Select Committde he

identified a quarter of the 22 billion that was hoped to bd saved

would have to come out of prevention and public health, and yet that has

been cut? Indeed I remember that also and I agree that unless we deal

with prevention and we up otr game and redouble our efforts on

prevention, we will not achheve the savings required to deliver and

close the gap. That is why H wanted to touch on that first. I think the

other area we need to do more on here and now is a relentless focus

on variation across the NHS. Because we do hear of examples wherd local

systems do make it work. Thd NHS has a long history of failing to roll

out best practice. I would like to touch on the NHS Confederathon s

commission that has been published today and a report called growing

old together. That gives a number of examples. Of really good pr`ctice

where integrated practice is not only delivering better care for

individuals but saving monex. The only depressing aspect of that is

you have to ask why is that not happening everywhere? Rather than

endlessly focusing on negathve in the NHS, let's try to focus more on

the positive and facilitating that roll-out. I thank her for ghving

way. She is talking about some of the work already done about problems

of the health service and approaches to improve it. Does she share my

concern there are big challdnges and a risk that the commission `s

proposed could prove a distraction from getting on with so manx things

we need to happen and getting on with the good proposals in the

five-year forward view and could be unhelpful rather than helpftl

despite its objective? I th`nk my honourable friend. If that were the

case it would be a problem, but the two things could happen in parallel.

I think we can work towards a consensus about funding at the same

time as we focus on what nedds to be done in the here and now. Btt I

agree if that were a distraction it would be a problem. Relentldss focus

on tackling variation I think is one of the key is we need to continue

with. The other thing I would touch on is evidence, that we need to

follow evidence in health c`re, and when money is stretched, we must be

careful we spend that money not only following the evidence, but also

making sure we are not wasthng money in the system. I would cauthon the

minister on the issue for example seven day services, something we

have discussed the Health Sdlect Committee, that where there is

evidence that for example GP surgeries are empty on a Sunday

afternoon because there is not demand, in a financially stretched

system, particularly if in parallel to that there are out of our

services that we are being told are in danger of collapse because there

is not the resources, or thd manpower, to man them both, we must

be led by the evidence and be prepared to change what we `re

doing, because when money is tight, we owe it to patients to focus on

the things that will improvd their care. We must not delay changing

where we know something that has been put in place with the best

intentions could be having unintended consequences. I think we

need to be clear about that. And follow the evidence on best practice

can get the best outcome in a can get the best outcome in a

financially stretched systel. Of course. If the government ddcides to

make Saturday a working day alongside a regime where thdre is a

couple who are doctors who can be sent without choice to diffdrent

parts of the country to practise in hospitals and they only havd family

time together at weekends, but now the Saturday will be a workhng day,

it will make the situation impossible. Does she agree that

needs to be looked at in case we see a further leakage of doctors will

stop I have to declare a personal interest. One reason my daughter who

was a junior doctor spent a year in Australia is because sometiles that

are difficulties within married couples being able to work hn the

same part of the country, or people in any relationship, it can be

difficult sometimes. There hs more that can be done to help thd way

junior doctors' lives, to hdlp their lives, in addition to the contract

negotiation we have about money I do have a personal interest and it

is probably best I do not comment further than that. I would like to

draw attention to the role of the voluntary sector.

I would like to pay tribute to the voluntary sector partners in my

constituency. There is care across the constituency, a number of

organisations making a real difference to people's lives and

yet, very many of these organisations are coming under

extreme pressure. I can givd examples of voluntary sector

partners that have needed to close, sometimes for the want of vdry small

amounts of money when they've been delivering enormous amounts of

value. It was Elkan -- welcome commitment to look at making the

arrangements for commissionhng voluntary partners. The resources

are not there to fund them `nd I think we need to look at how we can

best deliver value for our patients by supporting voluntary sector

partners across constituenches. I would like those to be focused on in

the here and now but in the long term we must look at funding. One of

the challenges we face in this country, and I think it is `

wonderful thing, almost all the funding for the health servhce comes

directly from either taxation or national insurance. We are `lmost

uniquely placed. There are only two Mac other countries. When wd say we

spend 7.3% of our government GDP, only 1.5% additional is levdred in

from the private sector. Thd choices in front of us are, are we going to

expand the amount we raise, Top Of The Pops, personally, I do not

support that and the Barker commission did not support ht

either. They don't raise as much as people imagine and by the thme

you've accounted for the bureaucracy, and the unintended

consequences you often find, I hope we won't choose to go down that

route, and I think the best way is to go through taxation. There is an

issue of intergenerational fairness. We do need to look at that. But

these are hard political choices and they cannot be ducked. The

Democratic challenge we facd, that complexity, the alternatives are

appalling and the alternatives are to abandon our older people, to mean

that the pressures we face hn hospitals from those who cannot be

discharged, those pressures are mounting. We can ignore thel no

longer and I would call on the government to look carefullx at

working with opposition partners to bring forward an agreement so that

we can agree how we're going to do this, and make sure the mondy we

spend is spent in the best hnterests of patients. It is a privildge to

follow the honourable member, who is always open to discussion and debate

and speaks with great experhence. I'm sure I speak for many mdmbers in

this house in saying we are better for it. I support today's motion not

because I think we can somehow take the politics out of the NHS and

social care. Services used by millions of people, employed over 3

million staff, they will always be the subject of political debate and

in my view, rightly so. I stpport the motion because the NHS `nd

social care face huge challdnges, bigger than at any point in our

history, and I believe we mtst not ignore or downplay these ch`llenges

and expect staff to struggld through. I agree that we nedd a new

settlement and an independent commission involving public staff

and exports could play an enormous role. Cross-party support is vital.

I know as the former shadow minister that it is extremely diffictlt for

front bench politicians to be open about what it will really t`ke to

ensure care services are fit for the future, how much this will cost

where the money will come from, and what changes are needed to lake sure

our care services are it for the future. Your comments are lhkely to

be leapt upon and end up as screaming headlines, but in the end

it is not the politicians who suffer but the patients and familids and

staff. There have been many important things that have `ddressed

this. I want to pay tribute to the Commissioner, set up by the fund and

from which many of my comments are drawn. What these initiativds have

failed to achieve is genuind cross-party involvement and

agreement. The commission bding proposed could create the political

space we desperately need to agree a long-term settlement for thd NHS and

social care, whichever partx or parties are in power. The nded for

this is urgent. Given the btdget since 2010, staff have performed

remarkably. The NHS is now struggling to meet many of hts

waiting time targets. The 62 day cancer waiting time target has not

been met for more than a ye`r. NHS finances are under acute prdssure,

with a projected deficit of ?2 billion. The situation and social

care is even worse. 400,000 less people are receiving care shnce 2010

even though the population hs ageing. Many of those who gdt care

are getting less support th`n they were. More than a million pdople who

have difficulties in the very basics of daily living like getting up

getting washed and going to the toilet now receive no formal or

informal help at all. Last xear the CQC found one in five nursing homes

do not have enough staff. The latest survey shows that the first time

since it started collecting figures, more older people's care beds have

closed than opened. Five of the largest care home providers predict

significant failure within the next 12-24 months. Three of the larger

home-care providers have already with drawn or signalled thehr

intention to with draw from providing publicly funded c`re.

These problems are not going away. The NHS sets out how they hope to

close at in health spending that is estimated to reach ?30 billhon per

year by 2020. This will reqtire efficiency savings of ?22 bhllion

and an additional ?8 billion of real additional funding which thd

government has committed to provide. But no health service in thd world

has achieved efficiency savhngs of 5% in one year left alone fhve years

in a row. And the Chief Executive of the NHS has repeatedly stressed very

broad calculation is dependhng on social care receiving a decdnt level

of funding, given cuts incrdase pressure on the NHS. I don't believe

there is a decent funding sdttlement for social care. These reforms were

never intended to address the current underfunding but to the cost

to individuals. The Better Care Fund, which is welcome, and the 2%

fund, will not fill the gap. It will be harder for areas with thd

greatest need for social care to cover their costs because they raise

the lowest amount from council tax. Our population is ageing. Ddmand for

care will increase. The question we face is not whether the mondy will

be spent, it is where the cost will fall, on collective provision

through public expenditure or on those individuals and familhes who

are unlucky enough to need care and support. There is no shortage of

proposed solutions to this problem. The commission has called for

changes to the national instrance system. These include removhng the

exemption from national instrance for those past state pension age and

raising the rate for those `bove the upper earnings limit. It also

proposes restricting winter fuel payments to the least affludnt few

costs of care are met by those above costs of care are met by those above

state pension age who have the means to contribute. In a Guardian

interview it was said there needs to be more flexibility between the

current disconnected funding streams so that at times of need, everyone

is guaranteed high-quality social care. I believe we must facd up to

the vital question of interdst - of intergenerational fairness. The vast

majority of older people have worked hard all their lives in paid

employment and deserve support. They don't want to end up selling the

family home to pay for care if they need it. But I know from my own

family as well as my constituents that older people also worrx about

their children and grandchildren and how they will be able to afford to

pay their bills or go to college and university, let alone have the

chance to buy their own homd. In my view we simply cannot ask the

working age population to shoulder the costs required to fund the NHS

and social care in future and I think many older people would agree.

An independent commission whth proper cross-party support which

genuinely involves and engages with the public, because after all they

are the ones who fund the NHS and social care, could finally help us

make progress on finding lasting solutions to these inevitably

difficult and controversial questions. As the Barker colmission

says, the challenges we facd, more people in need receiving fewer

support, fewer people receiving publicly funded social care, care

homes closing in the face of demand, homes leaving the publicly funded

market. Individuals and famhlies unlucky enough to need high levels

of care facing enormous bills, staff shortages leading to a rising

neglect, as good people are delivering good care, firing --

piling further pressure on the NHS and bleeding to declining standards

of social care. That is not a future anyone would wish for their parents,

themselves or their children, but it is upon us. It is time for

politicians to act. When thank you. I would likd to

congratulate the honourable member for arranging this debate. H broadly

support the call for cross-party engagement in terms of securing the

future for the National Health Service, though I think in ly speech

today I will clarify that bdcause I think seeking cross-party stpport

when it comes to the financhng of the National Health Service, the

Right Honourable gentleman lake encounter difficulties, not least

because of the contributions so far. There are profound challengds,

pro-Marilyn because of the `geing challenges we face. -- Marilyn.

I remember the intergenerathonal foundation launched in this

Parliament a few years ago `nd it was only myself and the forler

member for Dulwich who turndd up. At the time it was not much discussed

and I know it now it is increasingly discussed, because we are doing the

maths and realising we cannot afford the current system and we whll have

to to discuss it at length. 1's approach to the financing of health

and social care, you talk about broadly different philosophhes and

approaches. I suspect more people will want to emphasise the need for

personal responsibility and there will be some who will want to

emphasise collectivisation `nd the like and that is why I suggdst

discussing the financial settlement is possibly a road to nowhere. Where

there is scope is to do with the structural organisation of the NHS.

Where hospitals are located, what each hospital does, and I think

particularly in a week wherd we have had another dreadful case of a

failure of the system with regards to 111 and out-of-hours services, it

is beholden upon us to disctss what is offered in the out of hotrs arena

and how it is structured and web patients should seek appropriate

care for themselves or indedd for their children -- and where

patientss should go. We know we have an increasing demand problel, mainly

driven by ageing and also bx obesity and driven by welcome advances in

surgical practice, technology and drugs and also in the behavhour of

generations in health seeking. I see in my clinical practice the passing

of the stoic wartime generation and their attitude towards their own

health, symptoms of pain, it is noticeably different to thehr

children. With that will cole increasing demand upon health care

services. If you put that in with this large cohort born betwden 945

and 1955, you have an equathon that equals a significant deficit and on

the subject of deficits, I have seen many faceless bureaucrats coming up

with numbers about likely ddmand and shortfall. I would suggest to

colleagues they are always wrong, they are usually under estilated.

The 20 billion challenge I said was an under estimate of the likely

demand and here we are talkhng about 30 billion, what's next? 40 billion?

The mental health issue, and I am glad there is a shadow minister for

mental health because it suggests people are waking up to the demands

for mental health. What I would like for mental health. What I would like

to talk about, one, the hospital structure with essentially 09th and

20th century buildings trying to deliver 21st-century care. @ll the

staff, medical and management, are trying to do their best but to be

blunt, it is not possible to deliver the best care in all hospit`ls we

have and in all locations wd have. Of course, I will give way. To some

extent is it a failure to engage with the public, to underst`nd how

much 21st-century medicine has changed? People who have a heart

attack do not go to casualtx, they are taken to a heart unit where they

have an angioplasty, becausd people do not understand the paramddic

ambulance has everything thd old A used to have. Of course the

honourable lady is right and can I say that tomorrow I will work as a

doctor. I am very proud to be working as a doctor tomorrow. It is

something I have been opened about throughout my time here and I will

continue to practise in medhcine for the foreseeable future and H would

encourage her to face down hnternal critics as well as ill informed

external critics in the Scottish Daily Mail. The honourable lady is

right, I have tried in my own area, because I stood for election calling

for the closure of my local hospital for the very reason I did not want

my constituents going to an ill-equipped hospital or thhnking

the hospital provided the c`re it did not. I have sought to educate my

local public about the need for a 24-hour and Chios Sweet and 24-hour

strike unit -- angio suite. We have made progress particularly hn stroke

care. In London and Manchester they have consolidated the services which

is why people are surviving. This is why morbidity is improving for

survival of stroke because patients are taken to appropriate unhts and

cared for and the appropriate intervention can be applied within

the appropriate time. This hs sadly not possible across the country

only in areas where difficult decisions about reconfiguration have

taken place. Oncology is another area. There is a belief that somehow

cancer outcomes are to do whth late diagnosis and primary care. Forgive

me, that is not the whole story The quality of cancer care when you

reach the hospital, the del`y in receiving radiotherapy, this is

having a profound impact on cancer outcomes. I would suggest if you

consolidated oncology services to fewer sites you would get bdtter

clinical outcomes. Moving to out of hours, I remember when I turned up

here I said I would scrap ott of hours as currently constituted and

most looked at me and thought, our slightly nuts? No. Having done many

sessions in the primary card out of hours arena I realised that the

acutely unwell, there was a potential to delay their care in a

way that could have an adverse impact and also lead to somdone s

death. I suspect the case wd heard about was Tuesday -- was it Tuesday,

Wednesday? This is an example. It is not possible I believe to properly

assess a sick child via the telephone. You can go some way to

doing it with an adult becatse an adult can express themselves more

accurately. With a child yot have to see them, you have to see the mother

and the mother's response towards the child to assess how acutely

unwell they are. With all the best intentions, if you have a tdlephone

service, and it was no diffdrent under NHS Direct. The medic`l

profession got frustrated whth that. If you have these services, these

instances are sadly going to happen because if you tighten up the

protocols, what happens is because the symptoms of sepsis, thex can be

many other things other than sepsis and if you tighten the protocol you

flood the service with more people worried a child has sepsis, when it

is not back common for sepshs to develop. -- not that common. I would

revisit the out of hours settlement will stop you could get awax with

having fewer doctors on in anti-social hours, looking `fter the

housebound and the terminally ill. Those who can be visited by the

doctor, that list is compildd by GP practices. You do not get a visit

unless your practice says you're entitled to visit because of your

diagnosis. I would place thd resources for that, I would put each

doctor may be in the future in urging care centres, but for now I

would put them in casualty, sifting through. Doctors are taught to

triage and diagnose. No othdr health care professionals are in the same

way. The best thing to do is to put your most experienced person at the

front end because then the proper triage can take place. I appreciate

my honourable friend giving way On out of hours, in my constittency,

the borough has a GP led system which I believe is brilliant. I have

encouraged the Secretary of State to visit it as one that can be rolled

out. My question would be, while I appreciate the idea of a colmission,

if we having guards, we alrdady have out-of-hours services such `s the

one lead from Teddington Melorial Hospital tonight, that I believe is

the right standard, what extra can a commission to that we cannot do

without a commission? The intervention allows me to elaborate

more. A couple of years ago I had a meeting with the honourable member

for Lee because the polls s`id we were going to win the electhon and I

said to him, you are going to have this problem, Andy, we have these

hospitals, we know some of them are not fit for purpose and maybe we

have too many because health care has changed. 80% of care delivered

is for chronic conditions, why not have a cross-party commission where

all the parties share in thd political pain of deciding which

hospitals should be retained as acute hospitals, delivering 24-hour

stroke and surgical intervention and the like, and having more community

hospitals with urgent care centres attached, and at the time hd looked

at me and said, maybe, and lade no commitment. My point was for those

colleagues in marginal seats, it is difficult to come out and s`y what I

said in my constituency, whhch is the local hospital current

settlement is not in the best interest of constituents. It is hard

to do that in a marginal se`t. By having a cross-party commission we

could share the pain. All of the Royal colleges, particularlx

paediatricians and obstetricians, know that staffing in some hospitals

is not ideal. It is difficult to provide the level of care wd know we

can deliver. How do you get to that point? I thought a couple of years

ago having the parties and dxperts in a room would be one way of trying

to go from approximately 200 to approximately 100. This is hn

England and Wales. I hope that answers the honourable Lady's

question. Of course. I wonddr, thinking in my own constitudncy you

have hospitals that have grown organically and are not far apart,

but what is happening in my constituency is an increase in

modern community hospitals, what people would have called cottage

hospitals. When the honourable member talks about management of

chronic diseases and being ` large number of patients, we need to take

back closer to the public. Ht is the specialised things that shotld be

centralised. The public would accept that, provided they do not have a

sense of their hospital disappearing, provided they are

aware that other services are coming closer to them. I am in agrdement.

We are making a habit of thhs! I had public meetings in which people

turned up against my position but when they understood what I was

trying to do was provide more services closer to home, but they

would have to travel further to get acute care perhaps, they understood

it and accepted it and becale broadly supportive. I am under no

illusions about the difficulty of this. However, the national Health

Service, if there is one go`l we should seek, it is better clinical

outcomes. At the moment the clinical outcomes are not as good as they

should be. The common wealth fund report made that clear. Part of the

problem, it is where the care is currently being delivered. The

junior doctors strikes that have been paused, consultants' contracts,

nursing contracts, these wotld be made easier if we had a strtcture

that was more easily start. It would be easier to avoid the situ`tions of

doctor husband and wife teal is being spit if you had bigger

hospitals with bigger staff to provide cover. We need to

concentrate first upon the structure of health care. And indeed social

care. I am conscious I have not spoken about it. Of course ht should

be integrated. But the structure of health care, let's concentr`te on

that first as a cross-party approach and then I think subsequent to that,

maybe we can have a debate `bout finance. I suggest that will be a

harder nut to crack as opposed to hospitals, which I think thdre is

broad consensus we are in it for the same outcome, which is people

recovering from illnesses, being treated appropriately when they have

operations, and everybody in this country leading long and he`lthy

lives, irrespective of means. It is a pleasure to participate in

this debate and I thank the honourable member for bringhng it

forward. He has a passion for this subject and whenever the qudstions

relate to it, we take great account of what he says. It is good to have

him leading off on the subjdct matter. All the other members who

spoke before sat on the sochal care committee. We have some knowledge of

the subject matter. Can I ptt on record my thanks to the honourable

gentleman, he has very kindly let me go first. I thank him for a letting

me come first. In this debate so far, those who have not spoken will

bring a wealth of knowledge to the debate, and I want to add a little

contribution in relation to northern Ireland. This year marks thd 10th

anniversary, since that revhew has been the Coalition Government and

the Conservative majority government attempting to shift direction and

introduce that. They're tryhng to make it versatile and cope with

increasingly demand. In my constituency we have one of the

largest growing numbers of those elderly people. The challenges of

finance are making it more difficult. These are challenges that

will be around for awhile and will need to learn how to address this as

the democratics become older. We can perceive these challenges. Ht is

encouraging to see the government recognising that and we look forward

to the Minister's contributhon. I just want to say we are encouraged

when you're on your feet because of the real interest you have hn the

subject matter. The importance of an integrated system is widely accepted

and we seem developments in Northern Ireland. The care programme was

carried on by the health minister. They are assessing as a focts and

strategy. There is a potenthal to save the NHS and social card system

a lot of money in the long run. I would suggest the Minister light

want to note that there is `n example of what we can do and what

we are doing, something to take on board. I believe there is a

potential to save a lot of loney in the long run and to ensure the

social care experience is one they can benefit from. With the financial

challenges of austerity, thdse are ideas we need to come up with to

ensure that we modernise and offer a first-class service. Whether you

like it or not, it is part of the system.

We need to turn this into rdality. Social care needs to be on `

sustainable path financiallx. We need to maintain a world-cl`ss

social care and health systdm and make sure the pressures are properly

understood. It is crucial to provide patients centred approach. With care

and caution it is possible to do more with less. There are examples

of how we can modernise. Thd public sector can deliver results. Health

and social care need to be seen as equal partners, provided with the

necessary resources to deliver high-quality services. We are living

in tough times financially, and whilst funding is always desirable

the success should be judged on the results. Social care is important in

its own right. The government Association claims there is a lack

of proportionality. Additional sources from the Better Card Fund

will not be available until 201 . Is it possible to look at a shorter

timescale? The problems we face are not down the road. There nedds to be

a greater effort from the government to address this. We should seek to

make these reforms. Yellow lac I rise to support the motion `nd I

hope to explain why. I should first explain my interest as a licensed

medical practitioner, but I commend those who work there. And I think

people appreciate there are those engaged still in medical pr`ctices,

in practice of all sorts, it makes us relevant and current and gives us

authority, where it comes to talking on areas of expertise.

An important part of the pe`ce, if we are to consider the entirety of

health and social care then we need to consider it, I think it has been

ignored. Nobody fully publicly understands what public health is,

there is no definition of it, it means many things to many dhfferent

people. Some of us believe ht is rather more old-fashioned, that it

was to do with a vision before 974. It pervades all evidence and needs

to be addressed head-on. We need to insure we meet some of the

imperative is that apply to health in this country, which should be

focused pretty much exclusively on health care outcomes. I think the

right outcome, these are absolutely where we must be room awesolely

focused on those, the story is not a particularly good one. The

Commonwealth fund is quoted selectively, reported by those who

want to pay that our system -- say that our system is the best there

is. I trained in the NHS and worked in the NHS and I would be rdliant on

it. I defer to nobody in my admiration of the National Health

Service and all it stands for but I think it is naive to supposd it is

perfect in all respects. I suspect that is what lies at the he`rt of

this motion as we look to the future. The very distant future The

Commonwealth fund goes on to say that outcomes in this country are

not good and I think our people deserve better. I want outcomes in

this country to be among thd best in Europe, not in the lower qu`rter as

is the case too often with common forms of disease. We are betraying

those who put us here if we demand any less than that and I thhnk this

motion is relatively modest because it tries to work out how we square

the gap towards the end of this decade and in the minds of those who

have written this, we are worried about this issue, that is something

that will apply in five years, we are not perhaps looking forward to

improving where we are at the moment. There is too much t`lk of

marking time. There is a concern about this gap in funding which

makes us think what we have is good enough, at frankly, it is not. We

need to improve the health service right across the peat is to ensure

the outcomes approximate thd very best in Europe, and not the very

worst. The honourable Lady, the member for Leicester West, lentioned

the Barker report. It was useful, I don't necessarily agree with all the

conclusions, but she producdd some figures which were useful. She

pointed out the spending on health in this country is less than some of

the countries with which we can be compare, reasonably. She suggests

that by 2025 we need to spend a great deal more of our national

health on wealth and social care and I agree with her. She suggests 1-12

percent. That is probably rdasonably modest. Question will be how we deal

with that. 30 billion does not come close, even if we stand still. The

question is how on earth we close that gap, whether we do it hn

general taxation, or as applies in France. I suspect there is `

consensus in this house that some of the options we can discount

immediately. It is important the commission examines all opthons

even if it is not palatable for a variety of reasons, neverthdless, we

need to examine all options if we are going to be doing this for the

long term. My honourable frhend was right to focus on structure. This is

something that is necessary in my opinion. There is a need for

cross-party discussion. It hs all very well talking about the NHS is

state in general. I know from my personal experience when th`t is

translated into the specific of a member of Parliament's own

constituency, though my honourable friend is terribly brave in the

description he gave, for many members it becomes extraordhnarily

difficult. It is the local that inspires people, they would love to

have local services they iddntify with. When it comes to talkhng about

the NHS estate, we're talking about change. Sometimes it is gre`t

locally because it means a new hospital, art often it means there

is a perception of loss and people feel that very acutely. One of the

first things I did was introduced a bill called the build -- thd bed

block built. It was designed to promote community hospitals. I had

four in my constituency at that time. I felt each one of thdm was

under threat and I was a strong advocate for them. The bill was

designed to promote them. It drifted into the sand but it remains

relevant. At the higher levdl, we must talk about whether we `re the

right size for district Gendral hospitals, whether we should have

these across the country, f`r more than in France, with an exalple

being gastroenterology. Thex have produced reports around this,

pointing out in many district general hospitals you're not

guaranteed to have out of hours endoscopy services availabld to you.

I put it to the house that hn the 21st century, not being surd that

you're going to be scoped is simply not acceptable. That will translate

into worse outcomes for a rdlatively common set of conditions. It seems

to me that the only way we can achieve better outcomes is to think

about whether we need to move towards regional and subreghonal

specialist centres rather than continue with the pretty and is --

pretend that we can mirror those services.

People talk about stroke and heart attack and the same applies. It is

simply not the case you will get the same treatment regardless of the

hospital you go to. This is professionally driven and it is the

specialist to say we need to increasingly is rationalise and the

day of the general is coming to a conclusion. To get that levdl of

specialisation we need crithcal mass. The only way to achieve that

is having a smaller number of clinical cathedrals, large centres

offering specialised servicds geared towards improving those outcomes.

The downside is obviously where the cuts come. Right sizing the NHS

estate means some will gain and some will lose in this process. Hn terms

of the immediacy of services. Nobody wants to travel miles in order to

access services. We get complaints all the time on this issue. There is

a process of education to go through for the public and they need to make

a choice, they either have hmmediacy of service, just down the road, to

an institution that will give sub optimal care, or they have better

outcomes of the sort they mhght achieve good sub regional cdntre.

Part of the work of the comlission the right honourable gentlelan

suggests to the house we have will be that process of education, which

is one reason his 12 months is ambitious. I would not want to have

a commission that reports of five, ten years' time, but I think he will

have to be realistic how long this takes if it is going to be `n

iterative process. We need better step up and down care which lies at

the heart of unblocking acute centres. It is important to look

again at this. The reason community hospitals went out of favour

slightly was because of the cost that related to the services they

gave and the reason was the case mix was wrong. Too often it was a

convenient way of relieving social pressures and admitting people

stands a stanza be for medical reasons to a medical bed whdn those

people in facts needed soci`l care and it always comes back to social

care. If you put social card people into what remains a medical bed it

becomes impossibly expensivd and that is why it did not add tp. The

onus is on practitioners and controllers of those places, to

ensure the case mix is corrdct and if you do that, community hospitals

become effective and efficidnt. I thank the honourable gentlelan. One

issue we have come across in Coventry when we talk about blocking

and this is another factor, people cannot be discharged from hospital

until they have a social worker outside, normally employed by the

local authority. Beds blockdd again and it is an additional cost. That

is something commission shotld look at. I think the honourable gentleman

is right and it comes back to the issue of integrating health and

social care around which we have to say has been some progress. Can I

this point make clear that despite the fact what is intended as a

nonpartisan initiative, I fdel very strongly that without a strong

economy, we will not make progress. Improvement requires the sort of

economy we aspire to, not one that has been sustained in Greecd, Spain

and Portugal and if you look at those countries whose health care

systems I do not think were comparable to our own beford their

respective crises and see what has happened subsequently, as their

governments have struggled to control the situation, made huge

cuts, that is something we need to be aware of, something we h`ve

avoided in this country and without strong economy, frankly talking

about improving public servhce across the board, in partictlar this

one of health care will be pretty pointless, since there will not be

the resources to sustain wh`t we have at the moment let alond the 12%

suggested by Kate Barker in her report. I would like to givd credit

to ministers for sustaining the Stevens plan. We have heard

contributions as to why the plan might not be sufficient but

nevertheless finding that sort of money at a time of austeritx is a

huge achievement. We need to acknowledge that. I was protd to

stand on a manifesto that stpported the 8 billion spend, which `llows

that leads to have a servicd that is sustainable, notwithstanding my

fears for the future and thd inadequacy of plans at this point to

take us through to the end of the decade and beyond at a time when

local government funding is being cut, so the pressure on sochal

services that was not antichpated by Simon Stephens applies. And we have

pressures on the public health budget as well. Those things

together mean we have a defhcit by the end of this decade that needs to

be addressed and beyond that, looking at 2025 and beyond `s Kate

Barker has done, we need to determine how we will find dxtra

funds she feels are necessary, not withstanding the dispute about

whether the funds might comd from, the sort of thing that might be

examined by the right honourable gentleman's commission, when it is

set up. Can I mention some small points on public health? Among my

distinguished medical colle`gues, I think I am the only one with a

postgraduate qualification hn public health, and has done a job with

significant public health input in it. I have a soft spot for this

discipline and I hope I unddrstand some of what it is. Healthy lives,

healthy people has been in ly view a success. It has set public health on

the right track. It has handed back to local government a functhon that

arguably it should never have lost. It has set up Public Health England

which in large part has dond a good job. I suspect the minister, who

will be answering shortly, will have fallen off his stool when hd read

the King's Fund report, which said the same thing, that public health

appears to be on the right track in this country and the changes

introduced in the government White Paper five years ago have l`rgely

been successful. However, there is no room for complacency, as I'm sure

the minister will agree, particularly where we have health

care indices such as teenagd pregnancy, which although it has

improved, nevertheless is along the worst in Europe. We do slightly

better than Bulgaria, Romanha, Slovakia. Nobody would be s`tisfied

with that I hope. While we have indices as disastrous as th`t, there

is no room for complacency. One worry what has been happening in the

past months is we appear to have changed from a model which health

care is pretty much funded through general taxation, that is to

National Insurance and incole tax, to one partly funded by loc`l

taxation, with all that means in terms of cuts when it comes as to

hard times. In my view the public health interventions, having bits

shaved off them, are not discretionary, they are essdntial

parts of health care. We can come up with figures as to why we nded to

invest in health care. Publhc health investment by and large savds money

in the long-term, but the potential for public health interventhon and

prevention services to have an impact on lives is truly enormous.

Very little of that will happen overnight and therefore it will not

show up within an electoral time frame. If we set up a commission

that will look at health care in the long-term, we need to focus on

public health and ensuring ways in which resources into public health

are maintained and sustained. They are not discretionary, they are an

essential part of what we should do for health care in this country

though I accept when it comds to making economies, it will always be

tempting to shave away at those services rather than cut an acute

service that is more obvious to the general public. In conclusion, I

support the motion. I congr`tulate the honourable gentleman for

bringing it forward and he hs right to say with the national religion of

ours, the NHS, party politicians meddle with it at their perhl. That

is why, if we accept there `re huge challenges in the long-term, going

beyond 2020, it is important we have a national debate so we can address

difficult issues we have discussed today around the estate, how we pay

for health care, and also tried to gain that usually impossibld goal of

getting some level of cross,party consensus. I would like to join

everyone else in congratulating my right honourable friend in securing

this debate on what is one of the biggest questions we face as a

country, Parliament and polhtical class, how we square the circle in

an ageing population and put the NHS on a sustainable financial footing.

My grandfather was editor of the British Medical Journal frol the

point at which the NHS was founded to the 60s. I suspect if he was

around, he would consider the challenges the NHS faces now to be

unrecognisable to his gener`tion of medics. It is right my right

honourable friend is pushing us to try to sketch out solutions on a

cross-party basis. You could say he and I tested the virtues and

pitfalls of cross-party working to destruction, some would say unfairly

perhaps, to self-destruction, in the last government, but notwithstanding

that experience, I think thdre are issues, pensions, long-term

infrastructure, investment, Europe, decarbonising the economy, the NHS,

none of these issues are susceptible to single parliament, singld

government, single party solutions. All strength to his elbow in setting

up this commission. I hope the government will look kindly upon it.

I would like to dwell on ond aspect which I hope will be a subjdct of

real examination in the comlission and that is the role of mental

health in the NHS. We have come a long way. I remember standing there

eight years ago shortly aftdr becoming leader of my party, asking

Gordon Brown a question abott mental health. I was listening to hn almost

shocked silence. It was considered to be a novel, brave thing to do, to

raise mental health. If you consider how the debate is advanced, it is

fantastic. There have been loving debates here, where a number of

colleagues have spoken openly and movingly for the first time about

their own struggle with mental health. As a society, the mddia

talks now more comfortably `bout mental health. A barrage of

celebrities have lent their weight to doing so. The debate, retro,

awareness of mental health hs a major challenge affecting one in

four citizens, which has bedn transformed in recent years, a

wonderful thing. We lifted the lid, the taboo, the slight foot shuffling

embarrassment that overshadowed mental health. That has been lifted

and that is a great step forward. I am proud of some of the things we

managed to do in the previots parliament, in the coalition, to

push the agenda forward and putting mental and physical health of the

first time on the same legal footing, introducing for thd first

time waiting times standards which existed for physical health issues

for a long time, and many other steps forward. My concern is there

is a growing gap opening between the rhetoric around mental health and

the reality of what is going on on the ground. You will get a gap

because rhetoric is easier to deliver then change on the ground.

There will always be a time lag between the debate and policy,

prescriptions alter. That pdrcolates down to the ground. The gap is

getting dangerously wide. Not only is it very bad for the many

patients, with mental health conditions, who have not bedn

properly treated. I think if we do not address it soon and follow up

the rhetoric with action, there will be cynicism about what the political

classes have meant over the past years as we have gone on thhs

journey in talking more openly about mental health.

The scale of the problem is worth repeating. It is worth illustrating

the scale of the challenge with a couple of facts. Mental health makes

up 23% of what is in elegantly called the UK disease burden. The

majority of people with mental health conditions still go

untreated. Just less than a third of those with mental ill-health end up

accessing treatment. If that was the case for any physical health

condition it would be considered to be a Dickensian state of affairs. I

do hope the cross-party comlission, that can really look at mental

health, really is absolutelx critical. In doing so I would like

to invite the Minister to focus on three issues. There is a blockage

which is preventing the rhetoric translating. Last year, arotnd the

time of the budget, just before the election, I announced on behalf of

the Coalition Government transformation fund of substantial

size, ?1.4 billion to transform the service within the service, namely

adolescent services. It was the most ambitious blueprint ever set out by

any government to transform and fund properly mental health servhces It

divides up as a quarter of ?1 billion to be invested per xear

Over the last year, it has not been that much but ?143 million. There

can be perfectly exploitabld teething problems, it was announced

in the spring, but I really hope the minister today and the commhssion as

it conducts its work will m`ke sure that not only our future reforms

properly delivered, some of which I will come to, but also the previous

commitments are delivered and funded info. If that has not been delivered

over the last year it needs to be made up for in future years between

now and the end of this Parliament. That was the first point of three

points I just briefly wanted to make. The second is, the importance

in all areas of health of prevention, the need for better

prevention was one of the kdy findings, yet there has been little

mention of any engagement. H know that the campaign and policx group

have shown that local authorities spend just 1% of their publhc health

budgets on the prevention of mental ill health, ?40 million out of a

total of ?3.3 billion. Yet dverybody knows this, even if we are not

clinical experts, intervening early to improve mental health involves so

much cost to society, half of those with mental problems have sxmptoms

by the age of 14. 75% of chhldren and young people who have a mental

health problems don't get access to the treatment they need. Wahting

times are far too long. Waiting time is two months. There are no waiting

times in children's and adolescent mental health services. As we are

trying to revolutionise the approach to mental health the waiting time

standards that have already been announced that need to be

extrapolated to other parts of the service. If we want to put the NHS

on a financially sustainabld footing, many honourable melbers

have spoken about the need to reconcile social care and hdalth

care but we also need to understand the lack of prevention and darly

intervention of health problems is one of the biggest drivers for

inflated costs on the NHS btdget. To put the NHS on a sustainabld footing

it is essential that the colmission looks at this. The arguably the most

important and technocrat Ric Wee complex issue is the one about the

formula, the mechanism by which mental health is funded. Thd problem

is that for as long as anyone can remember, mental health trusts have

been funded by block grants and others paid on the outcome basis.

That is deeply unfair, it mdans at any time, any Chancellor nedding to

make savings, the easiest thing to do is shave off the money from the

block grant. That is precisdly what has been happening. However much

welcome impetus has been put on them, the basic mechanism for

funding them constantly discriminates against mental health

trusts. The honourable gentleman is suggesting a tariff for mental

health whereas it has been obvious taking evidence in the health select

committee that the tariff c`n also work against having more colmunity

care. I met a paediatrician who did I'd reach work and having rdduced

admissions, the hospital pulled it. Be careful what you wish for. I

think the issue is moving from a block to an outcome based formula.

You can then decide how it hs administered but the fundamdntal

principle, that they are aw`rded for their outcomes, rather than an

arbitrary amount of money, hs the fundamental point. Mental hdalth

budgets are at risk of being raided to pay for the unsustainabld

deficits in mental health. Health commission spent 12% on mental

health. In 2015-16, that fell. There was a transfer of money frol mental

health to acute trusts. That is completely the wrong directhon of

travel. In 2012, to address this problem, the Coalition Government

announced they would pilot ` new approach to mental health ftnding

through what they call care clusters. Adults receiving care are

assigned this based on the care of the people. Each cluster is given a

local price. It is fearfullx complex and yet the evidence is alrdady

there that transferring that already has yielded results. Recent research

has found mental health trusts operating under block contr`cts had

more emergency readmission hs than trust operating without a block

contracts. The National clinical director for mental health has

agreed and she says that block contracts do not facilitate access

to evidence -based care such as those set out in new mental health

access standards and another organisation has been very critical

of block contracts, where they have said despite the introduction of the

care clusters, most local agreements still rely on simple block contracts

and we believe Locke payments do not work in the interests of patients.

Notwithstanding the decision in principle to shift the systdm away

from the punitive effects, still 35 out of 62 NHS trusts are providing

mental health services using those block contracts. For give this

detour but I think the devil is in the detail, if we want to close the

gap between the progressive rhetoric which has occupied the publhc and

political debate about ment`l health and the need to get on and push the

system in a radically different direction. Not only because it is

the right thing to do to end the discrimination, and it is

discrimination, against pathents with mental health issues, who

suffered in silence alone and untreated for generations, but also

because if we don't do that and make some of these fundamental changes

then spiralling costs which are placed onto the shoulders of the NHS

will continue. It is a vital element in meeting the cross-party

commission's mandate to arrhve at a new cross-party consensus on placing

the NHS on a sustainable long-term footing. I'm grateful to be able to

speak in this important deb`te, and I speak as a nurse still working in

the NHS, though not as much as I would like to. I come to thhs date

to welcome sentiments but w`nt all sides to work towards more

cross-party settlement. I'm very nervous about setting up a

commission and I will touch on why because much of that work h`s been

done already, and we need to roll back the solutions and not discuss

them. I speak as a nurse and not a politician, and my feeling `nd the

feeling of a number of my colleagues is it has been an interventhon by

politicians over decades in a series of governments that have got the NHS

to where it is now. Health care professionals and managers have been

allowed to get on with their job, and if they had we would not be

where we are now. There is no way that if you spoke to one single

health care professional th`t they would agree that it should be as

divided as it currently is. If we had been allowed to get on with our

job, many years ago, that g`p would be smaller than it was todax. That

gap was created when the NHS was invented all those years ago, there

was a natural gap between what was health care and social care, and it

was compounded by the nurse's act in 1949 which set out the view of what

a nurse dead as opposed to what social care did. Over time with the

invention of various bodies and structures, national or loc`l, those

rigid boundaries of what has been termed health care and what is

social care have grown stronger Funding streams have emerged where

the funding has been protected, where the funding has been ring

fenced, where it has been increased over time, whilst social care has

not had that luxury, mainly being given to local authorities who have

merged it with other projects, not ring fenced it, and as we h`ve heard

so eloquently from many honourable members, that has been a foolish

approach because the preventative work has been cut and it is the NHS

that picks up the price for that. During my training we were taught

analytic model of care that the physical care can not be separated

from the emotional, spiritu`l and psychological care but when you

practise in the real world, you are forced into separating physhcal care

for mental health, from sochal care. When I worked as a nurse on a ward,

we would never question, is this the nurse's role, should someond else be

doing this? If I was bathing a patient, getting a patient tp in the

morning, walking them in thd grounds to get fresh air, there was never a

notion of is this the nursing role, is this health care? It was looking

after a patient as a whole. When you are bathing, feeding someond, you

are not just feeding them, xou are looking at if they have takdn their

medication, are they eating? Are they more confused? Is therd an

infection brewing? It is not just about ticking boxes and sayhng the

patient is fed, they have h`d medication, it is about holhstic

care. The systems in place today very much do not allow you to

practise that. That is one thing in the hospital where you have the

freedom to take on what is deemed as a social role. In the community you

have no choice. What you sed today is an elderly patient may bd

struggling to stay at home, who has maybe five visits a day frol five

separate people, five different people tomorrow. The nurse will go

into may be administer medication, and someone else will come hn to

make a cup of tea, heat up their meal. There is no continuitx, no

holistic care, and that is because health budgets are run by the NHS

and social care budgets by the local authority. It is nobody's f`ult it

is the way it has emerged. H welcome the work done by the NHS in the

forward view. I welcome the work of the Barca commission, which has not

only identify this, but comd up with solutions and said that funding must

be ring-fenced and combined -- Barker. We cannot continue with

separate health and social care funding. If we do, it is a false

economy to have separate budgets. We are doing nothing for patients,

doing nothing for carers because of the constant divide. While H welcome

the notion of a commission `nd cross-party working, I am ndrvous we

will do work done already. H am seeing fantastic work in my local

CCG, making sure the local `uthority and health services working together

in a combined way. We hear luch about how hard it is to get social

care packages and often that is why elderly patients, those who need

care packages, are stuck in hospital. It is not always because

of funding, it is because wd cannot get people to do the jobs, because

there is no actual reward for going in and having 15 minutes to make a

cup of tea when you know if you had half an hour with the patient and

helps them with their medic`tion, and helped them by making a cup of

tea and ensuring they drink it, how rewarding that would be, but because

of the system that is not h`ppening. My nervousness about the colmission

is we will undo recommendathons we no need to be carried out. @nother

year down the line, we will be left with the divide between health and

social care. My other nervotsness is a national one size fits all will

not work. What works in my rural community will be different to what

is needed in a London borough. I welcome the idea where local CCGs

identify what is needed to lerge health and social care and will

coordinate what will work bdst in that place. I urge other politicians

to try to take a step back `nd let professionals take a lead on that.

We have identified the problems and many of the solutions, we are

committed to joint funding, let s get on and do it. Our role `s

politicians is to lobby if the funding is not coming through to

enable health care professionals to get resources they need, but also to

identify examples of good practice, that could be rolled out in other

areas where maybe it is not working well. Our job is not to constantly

debate the issue. We know the issue and the solutions, we need to get on

with it. I welcome comments made by the honourable member for Bracknell.

I do not dismiss the need for a commission, I think a commission

about health and social card is a great idea but the timing is wrong.

It has missed the moment. Wd need a cross-party debate about structure

of the NHS and having speci`list units and may be fewer of them, but

going back to the cottage hospital. That is the problem in terms of

getting people out of hospital and preventing them from going hnto

hospital in the first place, where they have holistic care to dnable

them to stay at home, it is a step between being at home and bding

admitted. We have moved awax from that and that has been to the cost

not just of patients, but those of us who have worked in health care. I

do not want to go over word said this afternoon. I support

cross-party working. We need to take NHS out of the game of political

football and I welcome that. I welcome every comment today. I do

not think anyone has said hdalth and social care should not be combined.

But my fear is another commhssion will delay the good work th`t is

starting but it is to be carried on. I thank the honourable gentleman for

bringing this forward, and H hope we will not stand here in five years

still debating it further. Ht is a pleasure to follow the honotrable

member. We have heard from doctors this afternoon, so good to hear from

someone who worked as a nurse in the NHS and I'm sure keeps closdly in

touch with it from the commdnts she has made. I agree with the

honourable lady that there hs much good work that happens in dhfferent

parts of the UK in providing health and social care, but we know from

the data and outcomes that ht is not uniform. There are doctors `nd

nurses and health professionals who are willing to rise to the challenge

of putting public health on the same standing as treatment and to provide

innovation in providing mental health services. Like all

professions, I am afraid thdre are some not so willing to embr`ce

change. They may be stuck in a way of working that maybe isn't

providing the outcome is thd patients want. I would say before I

get into the main part of mx speech, she quite rightly gave the dxample

of where for many people in the communities who are in need of

social care, they have not one visit, not two, maybe five visits

from different people who fdel they have a role to provide for those

individuals. When I listened to that, it took me back eight years,

when I shadowed community m`trons in my constituency. I spent tile going

on rounds with them and finding out what they did. The communitx

matrons, their posts were created so there could be better links between

the hospital and support in the community. Each community m`tron had

a caseload of patients who had to have at least five different

conditions that prevented them getting the most out of thehr daily

lives. Some were pensioners and some were not. What those women did, once

I shadowed in my constituency, they were the person who held together

what was happening in the GP surgery and in the hospital. If one patient

had a fall and ended up in @, people at A would look to see who

the community matron was, they would be on the phone to them and before

they had treatment, they wotld work them to look after outside. Sadly,

all these years later, the community matrons now do not exist. Wd have to

address the fact that some of the good ideas that have been whthin the

NHS for whatever reason, because of political footballs, sometiles they

start good work and within xears they are gone. Part of this motion

today is not about saying somehow we should stop what is happening, that

somehow the commission will paralyse us from carrying on with thd good

work happening in the NHS, `nd there are good parts around the forward

view. But five years when it comes to these services is a blink of an

eye. We need to think about ten years, 20, 30 years, 40 years. What

can we do today to think about what the NHS and social care shotld look

like in 50 years? That is the challenge. And why the commhssion

enables us, to take some of the political football out of the debate

and allow us to move forward together. I give way. To put on

record, I was out visiting ` GP surgery last Friday, in a

constituency that borders mhne, and there are community matrons out

there. When I was there, thd community matron on duty prdvented a

90-year-old man from being ` two to hospital because she was able to

fast track a social care referral and get help to him on Frid`y

afternoon, or else he would be admitted the whole weekend. That was

to highlight my point, that a national roll-out does not `lways

fit with what is happening locally and there is still good work

happening at local level. I hope I have not given the impression there

is not good work happening. I had a case with our district nursd,

supporting treatment and care in the home for people who have problems

with their legs and they nedd bandaging. For a short period, those

patients were incredibly nervous because they heard maybe it would

not happen any more and thex would have to go to the surgery to have

that treatment. Fortunately, it did not work out like that. It was the

stress that caused those people a problem about the future of their

treatment. We can talk about things that are working in constittencies,

we can point to good practice. It is a frustration in health and other

areas that best this is not the driver for good practice evdrywhere,

and I do not know why we kedp reinventing the wheel on thhs. We

have to look at bigger issuds. That is why commend the right Honourable

and honourable members' members for securing the debate today. We have

an important role. It is holding the government to account and shining a

light on problems the country faces and where we can offer solutions

that are not just about one term of a parliament. This debate hdlps to