Estimates day debate (Commons) on Health and Social Care - Feb 27

Dr Sarah Wollaston (Totnes) (Con) 

Today’s debate on the supplementary estimates and the financial position of health and social care matters, first and foremost, because of the impact of that financial position on patient care. I start by paying tribute to our health and care staff across the country and, at this particular time, by noting and thanking those who have come from across the European Union to work in this country.

The current financial position is of great concern. As a result of the wider economic downturn, we are now in the seventh year of the longest financial squeeze in the history of the NHS. Although the Department of Health’s budget has been protected in relation to many others, we cannot escape the fact that over the previous Parliament the average annual increase in its budget was 1.1%, which is far lower than the increase in demand and, of course, far lower than the historical increase of 3.8% since the late 1970s. All that is in the context of an extremely challenging position for social care. Between 2009-10 and 2014-15, there was a 10% real-terms reduction in social care spending by local authorities.

All that has taken place in the face of an extraordinary increase in demand, because of not only a rising population but our changing demographics. To put that into context, over the decade to 2015 there was a 31% increase in the number of people living to 85 and beyond, and we estimate that over the next 20 years we will see a 60% increase in the number of individuals who rely on social care. Over the years there has been an abject failure of Governments to plan for that, although it was entirely predictable. We absolutely cannot just keep ducking the question. We need not only to address the immediate financial problems that face health and social care, but to come together as a House to address the problems for the future.

Bill Wiggin (North Herefordshire) (Con) 

It occurs to me that this is not a uniquely British problem; it is in fact a global one. I have been trying to find out where in the world social care is best delivered and whether we can learn anything from those countries.

Dr Wollaston 

My hon. Friend makes an important point. We are all looking forward to the publication of the House of Lords report on future sustainability, because of course we have much to learn from other systems. I pay tribute to the Public Accounts Committee, which today published its report on the financial sustainability of the NHS. We have also seen the final position of trusts at the end of the previous quarter, so we now know that 135 providers ended that quarter in deficit. We are on course for a financial deficit across trusts of between £750 million and £850 million at the end of the financial year.

Caroline Lucas (Brighton, Pavilion) (Green) 

The seriousness of what we are talking about is demonstrated by how, as the hon. Lady will know, over the past five decades there was a downward trend, with falling death rates, yet new research shows that that trend has reversed since 2011, and that approximately 30,000 more people died in 2015 than in 2014. With such deaths occurring in the context of a massive disinvestment in health and social care, does she agree that the financial cuts are likely to have been implicated in that unprecedented rise in death rates?

Dr Wollaston 

I have seen the study to which the hon. Lady refers, and I think the Department of Health needs to look at it very carefully.

Mr Jim Cunningham (Coventry South) (Lab) 

We should look at it in general terms. For example, a local authority cannot deal with bed-blocking because it does not have the resources to provide social workers. The NHS as a whole in Coventry and Warwickshire has to find cuts of £250 billion, which is a tremendous amount of money. If we are not careful, we will create an insoluble problem.

Dr Wollaston 

I thank the hon. Gentleman for making that point, although I think we should use the term “delayed discharges” rather than “bed-blocking”, because the latter can make older people who are in that position feel as if somehow they might be to blame. Nevertheless, I take his point.

The estimates memorandum seeks a transfer from the capital departmental expenditure limit of £1.2 billion to prop up revenue. It also seeks a £23 million transfer from Her Majesty’s Treasury reserve, a £58.5 million transfer from other Government Departments, and a £6 million transfer to capital from other Departments. Again, we see an unsustainable position, as pointed out by the Comptroller and Auditor General.

Dr Andrew Murrison (South West Wiltshire) (Con) 

I am following closely my hon. Friend’s remarks, which are, as ever, wise. Does she share my concern that if we are to transfer money from capital to revenue, the sustainability and transformation plans, most of which imply a certain level of capital investment in order to save revenue in the long term, will not be possible?

Dr Wollaston 

I absolutely agree with my hon. Friend and will discuss that later.

The point about the raids on capital budgets over the years—this is the third year in which we have seen transfers from capital to revenue budgets—is that we are talking about the money required to keep facilities up-to-date, and for essential repairs and the roll-out of new technologies. Putting off such repairs and investments means they cost more down the line, so it is a false economy. It is simply an unsustainable ongoing mechanism. The Department of Health has indicated that it would like to see an end to the practice by 2020, but both the Public Accounts Committee and the Health Committee have called for it to be stopped immediately because we feel it is, as I say, a false economy. As my hon. Friend the Member for South West Wiltshire (Dr Murrison) pointed out, it is about raids not only on capital budgets, but on the sustainability and transformation fund. It is increasingly becoming all about propping up the sustainability part rather than putting in place the essential transformation.

Mary Creagh (Wakefield) (Lab) 

The hon. Lady is making some excellent points. The sustainability and transformation plan for West Yorkshire will take around £1.1 billion out of our health system over the next four years—£700 million from the NHS and £400 million from social care services—as a result of which centres such as the King Street out-of-hours health centre are set to close, putting even more pressure on over-pressed A&E departments like the one at Pinderfields, my local hospital. Does the hon. Lady agree that, by forcing even more pressure on A&E departments, such plans give the words “sustainability and transformation” a bad name?

Dr Wollaston 

I absolutely agree with the hon. Lady. It is undermining public confidence in sustainability and transformation plans. I shall discuss that in more detail later.

The financial position is starting to create a perfect storm of delayed discharges, rising waiting times in A&E, and rising so-called trolley waits for patients waiting to be transferred to the wards, which has quite serious implications for their safety. There are unsustainable levels of bed occupancy, and increasingly we are hearing stories of not only routine but urgent surgery being cancelled. Worryingly, there have been two cases in which urgent neurological procedures did not take place, resulting in the deaths of two patients. That is extremely serious.

John Redwood (Wokingham) (Con) 

Does my hon. Friend agree that when we look at the formulae for the distribution of money via councils, we cannot look only at deprivation, which tends to be highly weighted? It is an important issue, but in more affluent areas such as mine we have an even bigger problem with people living a very long time; although that is good news, there is far more demand for services because they live for so much longer.

Dr Wollaston 

My right hon. Friend makes an extremely important point: it is about not only the overall budget but the distribution. I think we would all agree, on both sides of the House, that deprivation must be properly weighted, but he is absolutely right that age and the resulting need for services is one of the key drivers of need. That is probably not adequately reflected in the way resources are currently distributed.

There is undoubted evidence of the impact of the financial position on patient care. fortunately, this whirl of hospitals having to cancel routine procedures has a further impact on their ability to meet their financial targets, because of the reduction in their income. I hope Ministers will not simply consider this as a short-term issue; more importantly, they must look at how we can fund these things sustainably in future. They must not look at health and social care in their separate siloes but see them as a single system and genuinely look at how we are going to take things forward.

If we do not address this problem, we need to be honest with our constituents about the consequences. People talk about a collapse in the NHS. I do not believe that that will happen, but what we will see is a continuing deterioration in performance, with a real impact on the quality of care, which will put lives at risk. The safety, which is essential to our patients and which the Department of Health has prioritised, is increasingly in danger of slipping.

A number of Members have commented on sustainability and transformation plans. In principle, they are extremely important as a way not only of acting as a road map for the Five Year Forward View, but of enabling us to return to a much more logical way of planning for integrated health and care. Hopefully, they will enable us to get away from endless contracting rounds in the NHS and move towards genuine planning. I am afraid that what has undermined them has been inadequate local consultation, inadequate working with local authorities, and, crucially, inadequate funding. If we do not have the funding to put in place the transformation of services, we will see these plans fail. Increasingly, those plans are being seen as a vehicle for cuts—

Helen Goodman (Bishop Auckland) (Lab) 

They are.

Dr Wollaston 

I say to the hon. Lady that, genuinely, these plans offer us an opportunity to produce a transformative process, but they are being undermined by a number of critical points, and we should address them.

Anne Marie Morris (Newton Abbot) (Con) 

Does my hon. Friend agree that one of the key pieces missing from the STP plans is the bit that enables that double running, so that we can move from the existing system to the new system? There is no money anywhere for any transition and double running.

Dr Wollaston 

I absolutely agree with my hon. Friend and neighbour. As she will know, in our area, we are seeing not only the closure of four much-loved community hospitals, but, on top of those 44 beds lost from community hospitals, the local trust wanting to cut 32 acute beds, at a time when its bed occupancy is already running between 92% to 94%. Unless we have that double running and the communities can genuinely see the change, those plans will be seriously undermined. Too often, the NHS plans for hoped-for demand, rather than actual demand.

Victoria Prentis (Banbury) (Con) 

I thank my hon. Friend for listening to me on a number of occasions when I have been worried about the situation in Horton general hospital. She has been kind enough to talk me through some options. One of the difficulties with the consultation process is that lay people—of whom I am one—are not given sufficient evidence to enable them fully to engage with the system and to have trust in the trusts that are seeking to engage them.

Dr Wollaston 

My hon. Friend is absolutely right. It is important that the evidence pis available not just to us, but to the local communities. There should also be a sense that consultations are a genuine process. As I have said, it is about the co-design of new services. Time and again, we have reports from the NHS that demonstrate that co-producing new services results in a much better service in the long run, so I thank her for her point.

We are talking about the cuts not only to the trusts, but to the clinical commissioning groups. What we are seeing now is that CCGs are being asked to hold back £800 million of their budgets to offset deficits in trusts. Again, this is about patient care that is being cut back. Alongside that, we have seen cuts to Public Health England and to Health Education England. The idea that we have an NHS that is on a sustainable footing is, I am afraid, simply not the case. I ask Ministers to be realistic about the current position, and I ask our Chancellor, in his forthcoming Budget, to address this matter by urgently giving a lifeline to social care, because that will benefit not just social care, but the NHS. In addition to announcing that lifeline, which I hope he can do by bringing forward the better care fund with new money rather than a transfer from the NHS, I hope that he will promise a genuine review of sustainable future funding covering both health and social care. I call on Members from across the House to agree that, rather than our having the usual confrontational debates, we should see this as a generational challenge that will face whichever party is in power over the coming years. We should all work together, for the benefit of our constituents, to produce a sustainable future for the NHS and social care.

Madam Deputy Speaker (Mrs Eleanor Laing) 

I call the Chair of the Public Accounts Committee, Meg Hillier.

Meg Hillier (Hackney South and Shoreditch) (Lab/Co-op) 

May I pay tribute to the Chair of the Health Committee for her sterling work in this area and to the Chair of the Communities and Local Government Committee? Our three Committees are united in the view that we need to bring the agenda of how we fund health and social care to the front and centre of this House and this Government. It is important that we work together on that. It is quite unusual for three Select Committees to co-ordinate in such an effective way—at least we hope it is effective. Ultimately, the proof will be whether this view will bite with Government.

We are clear that integration of health and social care is vital. In fact, we rushed to the Chamber from Committee Room 6 where we were debating the first phase of the better care fund, which had been used as a way of taking health money to prop up the social care budget. Amazingly, the head of NHS England and the Department of Health, who were appearing in front of us, denied that there was any failure in the better care fund. They said that there were not really any targets; it was all about taking money from one pot to pay for another. If that does not underline the challenges that exist in the many initiatives that are coming forward and the lack of sustainability for long-term funding, I do not know what does. I echo the comments of the Chair of the Health Committee that we need a long-term generational shift in how we are going to deal with this matter. We cannot just keep lurching from crisis to crisis and funding situation to funding situation.

My Committee looks very closely at accounts for many Members of this House. It may not be the most enjoyable bedtime reading, but we lap up the accounts of different Government Departments. We were disappointed that the Secretary of State laid the NHS accounts on the last day of the parliamentary term in July. When we opened them, we realised why: those NHS accounts were within target only by a smoke and mirrors approach and a series of short-term, one-off measures to ensure that they balanced.

I remind the Under-Secretary of State for Health, the hon. Member for Warrington South (David Mowat) that last year the Public Accounts Committee, of which he is a former member and so doubly thoughtful on this subject, gave the Department a yellow card warning that, if in 2016-17, these similar one-off measures and a similar approach to the Budget were carried forward, we would be giving it a red card. The Comptroller and Auditor General, Sir Amyas Morse, issued an unprecedented warning in those accounts, which had been audited by the National Audit Office, and laid out his serious concerns. As he told us, he walked down Whitehall to talk to the permanent secretary at the Department of Health to make it clear that he was concerned about those one-off measures.

To help the House, I will lay out how it was that, by some miracle, the Department managed to balance its books last year. First, £2.14 billion was set aside for sustainability and transformation funding, £1.8 billion of which was used to cover hospital trust deficits. The Department of Health did not notify the Treasury of the additional £417 million of national insurance receipts that it had received. It said that it was just a one-off reporting error. I am heartened to see that, in the current estimates, such a practice does not recur.

There was also a one-off super dividend of £100 million for the Department from the Medicines and Healthcare Products Regulatory Agency. That large cash balance was put into its capital departmental expenditure limit budget, which helped it to reach a final balance. Critically, it seems that this is becoming a long-term strategy for NHS budgeting—I hope the Minister will take this seriously and respond. As the Chair of the Health Committee has highlighted, we are seeing a trend of capital funding being pushed into revenue to keep the system going. That is not sustainable. Last year, in 2015-16, the Department of Health transferred £950 million of capital to revenue. The supplementary estimate that we are debating tonight shows that the Department will transfer some £1.2 billion of capital to revenue funding this year—so £250 million more than last year.

Bill Wiggin 

I am particularly interested in the private finance initiative element of the capital funding, because certainly, for all the years that I have been a Member of Parliament, the PFI burden on Hereford hospital has always held it back. Has the hon. Lady’s Committee had a chance to look at that?

Meg Hillier 

We have not looked at that directly, but we know that the biggest revenue cost for hospitals is staffing, which is followed, for some hospitals, by servicing a PFI deal. Early analysis suggests—I would not want the House to lay too much on this, because it comes from conversations I have had from auditors—that the challenge is that the cost of refinancing those PFI deals can swamp the potential savings. Perhaps Ministers could look into that further. A lot of technical work has been done to attempt it. The British Medical Association tells me that spreading the payback period over a longer time would reduce the day-to-day resource costs for hospitals, so that might be a way forward. However, I speak from work I have done outside the Committee Room, rather than strictly through the work of the Public Accounts Committee and the National Audit Office.

The supplementary estimate this year is worrying. The trend is going in the wrong direction for taking money out of the capital spend. As the hon. Member for North Herefordshire (Bill Wiggin) highlighted, a lot of the transformation in the NHS will require the reconfiguration of buildings and estate. Those sorts of capital expenditures are important to save money in the long term, so the estimate really is very short-sighted.

If we look at how NHS trusts are managing with their deficits, again we see a worrying trend. At the beginning of this financial year—2016-17—NHS Improvement committed to ensuring that the provider sector deficit did not exceed £580 million at the end of the year, which is now in a month’s time. However, NHS Improvement forecast a deficit of £644 million in quarter one. Its forecast declined further to a deficit of £873 million in quarter three. That pledge did not amount to very much, and it is moving very much in the wrong direction. NHS trusts have been overspending by approximately £300 million a quarter throughout this financial year. If that trend continues into the final quarter of the year, the overspend will be close to £1.2 billion. I have laid out the reality very starkly by picking out uncertain elements in the Department of Health’s consolidated accounts.

We hear a lot of discussion about how much money the Government are putting into the NHS. The Committee had an unedifying experience at a hearing on 11 January, in which the head of NHS England came before us on the very day that anonymous briefings in the national press from sources at No. 10 criticised him and NHS England. He defended his position in the Committee but, frankly, patients do not want anonymous briefings from people to save face when the Committee is actually looking at saving lives and treating patients. They do not want to see a ding-doing about the money. They need to know that the people running our health service, and the Government overseeing and channelling taxpayers’ money into it, are committed to long-term patient care and tackling future long-term challenges.

Let us be clear that protecting the NHS England budget is not the same as protecting the health budget. As the hon. Member for Totnes mentioned, Public Health England and Health Education England are being squeezed, and social care budgets—although not a direct national health cost—went down by 10% in the last Parliament. There are some clever measures by Ministers, saying, “Put up your council tax precept and it’ll all be fine.” That is still taxpayers’ money being found from somewhere to go some way towards solving the problem, but it will not solve it in the long term. Unless we tackle social care and health together, we will have an unsustainable future. There is too much robbing Paul to pay Paul—shifting money from one bit of the budget to another in a clever way that is not transparent to most people out there because it is buried in big numbers.

Seema Malhotra (Feltham and Heston) (Lab/Co-op) 

My hon. Friend is making a thoughtful and evidence-rich speech, as always. One issue that is not often talked about, but that appeared in the media again today, is the rise in physical attacks on NHS staff. The budget of NHS Protect, which deals with a lot of security issues, is also being cut. That is part of creating the perfect storm, with evidence that a lot of perpetrators of such attacks are those with mental health issues. Unless we have the resources for an environment in which we keep NHS staff safe, the issue could get worse.

Meg Hillier 

My hon. Friend makes her point well. It is important to protect staff. I echo the comments of the Chair of the Health Committee that staff cost more than anything else in the NHS and provide the direct patient care that is so important to its long-term sustainability. I will touch on workforce planning in a moment.

Mr Cunningham 

There is another dimension, which is that some people with mental health problems turn up at A&E units because there is no other place for them to go and they cannot get any other accommodation. The views and voices of the carers who look after these people are very often not listened to. I get many complaints about that.

Meg Hillier 

That is one reason that we need to be really clear that we are looking at a long-term integrated health and social care system. Social services support should be there for people—whether they are a frail older person, someone with a particular disability and need, or someone with a mental health challenge—when they need it to prevent them from going to A&E in the first place.

Rachael Maskell (York Central) (Lab/Co-op) 

Will my hon. Friend give way?

Meg Hillier 

I will, but I will then make some progress.

Rachael Maskell 

I thank my hon. Friend for her excellent speech. I am disturbed when I hear that the Government are putting more money into mental health, yet I have just received the figures on Vale of York CCG mental health funding, which will be cut in the next financial year. The budget is dropping from £46 million to £45 million next year in a city that has real challenges around mental health, which shows that services are not catching up with what the Government insist is trickling down into the system.

Meg Hillier 

My hon. Friend puts a face on the real challenge faced by many trusts and commissioners: they are having to make choices about where to spend the money. Despite the pledges about parity of esteem, there is a squeeze on mental health funding nationally.

The reality of the overall picture is that growing demand is outstripping the ability of the NHS to supply needs, which is having a direct impact on patients. There are now longer waiting times for GP appointments. I alert colleagues to the Public Accounts Committee’s hearing on GP services next week; any thoughts from hon. Members’ areas are welcome. People are waiting longer to see specialists, with the 16-week target being breached, and A&E targets are being breached too often. There is a real challenge.

NHS Improvement is a welcome body for trying to encourage best practice, because there is regional variation. It is quite right that any body as large and expensive to taxpayers as the NHS looks to perform as efficiently as possible but, once again, we are seeing NHS Improvement mask what look like cuts. A 4% efficiency savings target is once again being imposed. It was imposed in the previous Parliament by the then Chancellor, the right hon. Member for Tatton (Mr Osborne), and was acknowledged by the head of NHS Improvement, Jim Mackey, as particularly challenging. Worryingly, the reality was that everyone in the system knew that the target was too challenging, but there is a real lack of a culture of whistleblowing and calling it out in the NHS. It is difficult for people to speak truth to power, as we see over and over again. The head of NHS Improvement again acknowledged to our Committee recently, as mentioned in our report, which was published today, that the 4% efficiency savings required as part of the transformation programme are “challenging.”

Our report also describes a worrying correlation between the financial performance of trusts and their Care Quality Commission ratings, stating:

“Trusts that achieved lower quality ratings had poorer average financial performance, and the 14 trusts rated ‘inadequate’ together had a net deficit equal to 10.4% of their total income in 2015-16.”

That is a real issue.

I will touch on workforce planning before beginning to draw my comments to a close. We hear a lot about the cost of locums. Very often in the national debate, I worry that we fixate on smaller issues when we really need to look at the bigger picture. We often hear about the very high rates per hour or per day paid to individual locums. That certainly is a problem—paying someone several thousand pounds a day or a shift seems ludicrous—but the key issue is the sheer volume of locums needed.

Each year, the trust structures are set to meet the budget sent down to them from the Department of Health—our tax money, but not enough of it. From the beginning, they are just not set up well enough to meet demand. Trusts have to buy in locums to meet the needs of their populations, but that is not sustainable in the long term. There were challenges, with a reduction in the number of nursing places in the last Parliament, which is coming through now. We have recently seen the loss of the nursing bursary, which we hope does not mean a reduction in the number of nurses in the future. However, many women, particularly lone parents, in my constituency welcome the opportunity to better themselves and contribute to our NHS by taking that on. I hope the Minister will give us an update on the numbers of people going into nursing training now and, crucially, on whether the people taking those training places will stay and work in our NHS, especially given Brexit and immigration issues.

Mrs Anne-Marie Trevelyan (Berwick-upon-Tweed) (Con) 

My local foundation trust, Northumbria NHS Trust, has taken to training its own cohort of nurses so that local people who want to join the nursing profession will be able to do so knowing that they will be able to work in that local trust, which has a great reputation and which is leading the way on the financial and medical changes we need to see.

Meg Hillier 

I agree with the hon. Lady. My own hospital does the same, taking on healthcare assistants and bringing them up through the system. The challenge is: how many people will be put off without that bursary payment? We need a clear answer from the Minister about what analysis was done of the impact on the workforce of that change. The amount of money involved is relatively small compared with the challenges and problems of not being able to provide a health service if we do not have enough nurses.

Helen Goodman 

False economy.

Meg Hillier 

It may well be, as my hon. Friend says, a false economy.

Dr Philippa Whitford (Central Ayrshire) (SNP) 

The early figures that have come out from NHS England suggest a 23% drop in applications. Obviously, that is a significant change.

Meg Hillier 

The key thing, of course, is how that figure comes through the pipeline and how we fill the gap. While the Minister is on his feet at the end of the debate, it would be helpful if he could say what analysis the Department of Health has done of the impact of Brexit and any changes it may herald for our NHS workforce, because a high percentage of them are from Europe. We are hearing the right sounds from the Government, but we have not yet had any action on securing the future of those European citizens currently resident in the UK. If the Minister is able to give us any comfort on that, it would be very welcome.

I am heartened that so many Members are in the Chamber to discuss this important issue. I should mention that the Public Accounts Committee has also been working with the Procedure Committee to try to ensure that the House can discuss the financial details of estimates rather than just the general principles, although I have obviously strayed into those, too. Hopefully, we can base these debates on the figures we have spent so much time looking at in the Public Accounts Committee. It is unedifying for the public to hear anonymous briefings and public argument; that does not wash with them. We need to be on top of this issue so that we hold the Government’s feet to the fire and make sure that, every step of the way, they know we are watching the budget. We will not let you get away, Minister, with raiding the capital budget to fund the accounts this year.

Oliver Colvile (Plymouth, Sutton and Devonport) (Con) 

The hon. Lady is making a very interesting speech. One thing we should make much greater use of are pharmacies, especially to try to take some of the pressure off GPs. We should also ask GPs to go into pharmacies and to be located in them.

Meg Hillier 

The hon. Gentleman makes a good point, and I visited one of my local pharmacies only a few weeks ago and saw at first hand the work it does to help ease the pressure on GPs, where people are waiting a long time for appointments, and on A&E. The Minister has taken a keen interest in pharmacies, but there is nevertheless a cut to their base budget. While we are on that point, it is interesting to note that that base amount allowed them to have the certainty to employ a member of staff to conduct appointments directly with patients. If they rely just on the revenue income they get from selling products, they cannot be sure that they can maintain that salary every year. That solid base of funding was important in a constituency such as mine, where, for all sorts of reasons—culture, language and convenience—people often find their local pharmacy more readily than their GP practice, and they find it very useful. The Minister therefore has questions to answer on that point as well.

A cross-party group of us recently met the Prime Minister, and I was heartened that she at least acknowledged the need to look at the long-term issues around health and social care. She has made a pledge that her adviser at No. 10 Downing Street will meet a cross-party group of MPs to discuss this issue further. I hope that heralds a change of attitude in the Government that will see no more anonymous briefing and silly bickering, but a strong, concerted effort to make sure that we future-proof our NHS for us and our children and that it is the beacon to the world that we all believe it is.

Madam Deputy Speaker (Mrs Eleanor Laing) 

Order. It will be obvious to the House that a great many people wish to speak this evening. Of course, we have plenty of time, but it is limited. If hon. Members take a self-denying ordinance and speak for no more than nine minutes, everyone who has indicated that they would like to speak will have an opportunity to do so. I hope not to have to apply a formal time limit, because nine minutes is actually a very long time: if you cannot say it in nine minutes, you have to go away and practise. I know that no practice is needed by Anne Marie Morris.

Anne Marie Morris (Newton Abbot) (Con) 

Let us be clear: estimates are a serious business; they must be realistic. Every year, Parliament votes on how much can be spent. If excess is needed, Departments have to go back to the House, so getting estimates right is mission-critical.

The challenge I have with these estimates is that I have little comfort that the assumptions they are based on are realistic. As my hon. Friend the Member for Totnes (Dr Wollaston) said, there is an assumption that demand will go down. As the population increases, and as immigration increases, that seems a very unrealistic view to take. The Government need to look long and hard at the assumptions they have made, because I for one am not convinced that they have got them right.

We also need to look at what these estimates assume in terms of the negatives. They assume we can keep on course if we reduce public health spending. If we start reducing that spending, which prevents the need for NHS intervention—the most expensive form of intervention—will we really save money? It seems to me that we will not. The other assumption made in these estimates is that central administration will be cut. We should bear in mind the complexity of what is going on at the moment, with 44 STPs coming on board, as we all hope they will, and I agree with my hon. Friend that they are a good concept, although I have some real concerns about delivery. Overall, I am concerned that these estimates are not based on realistic assumptions, and Ministers will need to seriously address that.

As the hon. Member for Hackney South and Shoreditch (Meg Hillier), who leads the Public Accounts Committee, and my hon. Friend have said, the estimates must take into account what we need for health and social care. If we cut spending on social care, or do not adequately fund it, we will increase spending in the NHS.

However, underpinning all of that is the need to have measurements in place across the whole system, as my hon. Friend indicated, so that we know what the full scope of the demand is. We must measure the results achieved by the resource we put in and the outcomes for the population as a whole. We all talk about measures around A&E and the NHS. We all talk about waiting times, and the targets that are set are all around waiting times. However, nobody is looking at what impact that has on primary care—on our GPs—or on social care. If an estimate is to be right, therefore, we need to look at the whole system of measurement.

Jo Churchill (Bury St Edmunds) (Con) 

My hon. Friend is making powerful points. At my local district general hospital, West Suffolk, winter preparedness plans included a 5% uplift in demand—this is exactly the point she is making—but there was a 20% increase. I have exactly the same thing in social care, where my social care providers tell me people are older and more poorly. We have increased demand across the piece for that reason.

Anne Marie Morris 

I thank my hon. Friend for that helpful example. She is absolutely right.

If we look at the whole measurement system—this was acknowledged in one of our Public Accounts Committee sessions by the Department of Health—we see that there is limited measurement, and that there probably should be more. When I challenged the individual concerned on whether the Government would be looking at that, he stood from one foot to the other and could not give us much of an answer. These estimates have to be based on proper measurement of need, on what is operationally put into practice, and on the outcome for patients, but that simply is not the case.

We need to look at the differences between the NHS and social care as regards how the money is allocated. In the NHS, we have some ring-fencing, while in social care we do not, but because the two are inextricably linked, unless we look at the way in which each of those pots is managed, never mind how much is in them, we give rise to problems for the future. Social care is not ring-fenced. I am sure we are all grateful for the additional moneys that have been provided, but frankly they do not go far enough. The first chunk of money might cover the living wage, and the ability of local authorities to increase the precept by 3% is welcome, but as the Chair of the Public Accounts Committee said, that is taxpayers’ money.

Dr Murrison 

My hon. Friend is making a very good speech. Does she share my concern about the 3% precept, as shifting the cost of health and social care away from general taxation on to a property-based tax has obvious problems—not least, that it will disadvantage communities that are less well off?

Anne Marie Morris 

My hon. Friend makes a fair point. I have one of those constituencies where communities are not very well off. Many of the facilities that are there to provide social care are failing because we do not have the more affluent individuals who can ensure that some of our care homes, particularly nursing care homes, are alive and well. I am now down to just three for a very large constituency, and that is completely inadequate.

Tim Loughton (East Worthing and Shoreham) (Con) 

My hon. Friend and I both have constituencies with a large proportion of elderly people. Indeed, Worthing has the highest proportion of over-85s in the whole country. This is a double whammy, because people who are over 85 tend to require a great deal more healthcare, stay in hospital for longer, and have multiple problems in hospital that cost more—we are looking after them well and need to look after them better—and the social care side when they do come out of hospital, too often delayed, is costly as well. Those are the growing pressures that the estimates appear not to take proper account of.

Anne Marie Morris 

My hon. Friend makes an extremely good point. He is right that the cost of ageing is not adequately taken into account. The way the Government measure health outcomes is predicated on the number of births and looking at the lifespan of the population. Because people live longer in areas like my constituency in Devon, it is assumed that we therefore have better health outcomes, but that does not allow for the fact that we have a low number of live births. Many people move into our lovely area when they are much older, and so the level of improvement is small. There are some basic, fundamental flaws in the way the Government—not just this Government; it has gone on for years—estimate the need in an area. As my hon. Friend rightly says, one of the biggest challenges is age.

Integration is expected somehow to be the solution to all our problems, but there is no transition funding to allow for double running, and there are, as far as I am aware, not many pooled budgets. As we have heard, these plans make certain assumptions about the recruitment of individuals, but we cannot recruit at the level we need now, never mind what we will need for the future. There is also a lack of training in the specialisms that we are going to need. Specifically in some of our more rural areas—we have talked about the ageing population—we need more specialist generalists. That is agreed by most of the royal colleges, but it is not being put into practice. So many issues will impact on the effectiveness of integration that I doubt that it is really going to be a way forward in reducing costs. I am concerned that the integration model, while very welcome, has not been fully thought through. The barrier to its being successful is that there will be unbudgeted costs. There is no evidence for the assumption that demand will decrease, and so no evidence that integration will deliver savings. It therefore seems to me that these estimates cannot really be sound. Real cost estimates are needed.

We have failed to address the element of social care that is paid for privately. I refer here to the Dilnot report and the Care Act 2014. We are talking about how the Government’s money—the taxpayer’s money—is to be shared out between the two systems, but we should never forget that social care is means-tested as opposed to the NHS, which is free at the point of delivery. If we do not try to ensure that the necessary savings are made by individuals taking responsibility, with or without the Government stepping in, we will find that the demand on the NHS is simply too great for the system to succeed and for these estimates to be valid.

Mr Clive Betts (Sheffield South East) (Lab) 

The Communities and Local Government Committee is currently undertaking an inquiry into the funding of social care. We have not produced our reports yet, so anything I say should be taken not as the Committee’s considered view but as some of my own reflections on the evidence we have heard so far. I hope it will not be too long before we can provide a report for Members to look at on the immediate issues of social care, and then, in due course, we will go on to look at the longer-term issues as well. We have taken evidence from a variety of different organisations, including councils, care providers, directors of social care, the Nuffield Trust, and the King’s Fund. Carers and care providers, as individuals, have related their personal experiences to the Committee.

As a constituency MP, it is not terribly surprising to me to have heard what I have heard today. Unfortunately, as an MP, like everyone else here, I am sure, I see only the tip of the iceberg of problems. Cases about the nature, and number, of social care failings have undoubtedly been increasing in my surgery, my postbag and my emails in the past two or three years. Some of the cases are quite horrific. A council that has to cut its budget on social care does so by going out to the private sector, or agencies, and substituting their services for the service that the council used to provide through directly employed staff. The way in which those services are delivered—often the simple failure of people to turn up and provide the care when it is promised—causes real and increasing problems that I am certainly seeing as a constituency MP.

This is not surprising. The Chair of the Health Committee referred to the fact that we have had a 7% cut in real terms in spending on social care since 2010. Local authorities’ grants from central Government have been reduced by 37%. Councils have tried to prioritise social care—the evidence for that is absolutely clear—but they have not been able to protect it completely from the cuts. That is the reality. On top of that, not only has the money been going down but the number of elderly people requiring care is going up. We heard evidence that although the Care Act was great legislation in principle, all was not delivered in practice. The extra measures are welcome in trying to reward staff properly for the excellent work that many of them do in social care, but the increase in the minimum wage places additional costs on the system.

Amyas Morse, who wrote a very good article and made a good speech the other day about the relationship between health and social care, said that for a long time local authorities had been very successful in doing more for less, but have now got to the point of doing less for less, which is impacting on the people who received the services.

We should not blame local councils for failing to provide a certain standard of service. Simon Stevens told the Communities and Local Government Committee that even if every council did as well as the best, there would still be problems in the system. I challenged the Under-Secretary of State for Health, the hon. Member for Warrington South (David Mowat), to say whether there was a crisis in social care. He did not want to use the word “crisis”, but he did say that the system was “under stress”. Although we cannot agree about the word “crisis”, I think we can at least agree that the stress is obvious for all to see. An estimated 1.2 million people do not receive the care they need. That figure is 40% higher than it was in 2010.

We took evidence from people who were not getting the same amount of care as they had received in the past and others whose needs were increasing but whose care was not. We talked to care providers who were handing contracts back or pulling out of the service altogether, and to local authorities that are sacking care providers because the contracts were not being delivered properly. We also heard that people who pay for their care in care homes are subsidising local authorities because they cannot afford to keep increasing their fees. There is a cross-subsidy in the system, which does not seem fair to many people. At the same time, the turnover rate for care staff is 27%, so they do not have long-term experience and are not being trained regularly over time to deliver care. Those are all problems that we learned about from the compelling evidence that our inquiry received. The Committee will reflect on its conclusion, and I am sure that eventually we will, as always, come to an unanimous view in our report.

In the short term, of course the Government have done things, including the introduction of the council tax precept. I welcome the fact that, by and large, local authorities have taken that up, because the situation is so serious. There are problems, of course, with the fact that the council tax precept raises much more money for some local authorities than for others, and the better care fund, which is meant to stabilise the situation and help authorities that raise less, is back-end loaded. The new homes bonus cut and the additional grant are welcome for social care, but that causes real problems for some small district councils that are not social care providers and suddenly find that their budget position is fundamentally altered.

In his article, Amyas Morse described how the Government simply were not thinking through what would happen in the long term. They moved money—it is often a lack of money—around between social care and health without giving any real thought to the end result. Government officials, and sometimes Ministers, took decisions without any real understanding of what happened to the money at the end of the line, when local authorities faced with very difficult choices had to make decisions about the cuts that were being passed on to them. Those are just some of the issues on which we will reflect in our report.

Clearly, the link between health and social care is very important. We ought to join them up better and it will be interesting to see what comes out of the Manchester example, given that both services have been devolved. There is a clear link between the two, and not just with regard to delayed discharging; there is now virtually no money in the system for preventive social care. The only social care funding available is that for people with the highest need. If people do not get it in the early stages, that means that they are more likely to end up in hospital and cost the whole system much more. That is another thing that we learned.

I was pleased to sign, along with the Chairs of the Health Committee and of the Public Accounts Committee, the letter to the Prime Minister saying that we need longer-term arrangements. It is right, however, that the Government should respond to the here and now, because that is important. To put it bluntly, if we do not deal with the here and now, some people will not be around to see the long-term arrangements being put in place.

When the Communities and Local Government Committee went to Germany, we learned that it solved this problem 20 years ago. Those involved sat down on a cross-party basis and agreed a long-term solution. It might not be the right solution for this country—it is based on social insurance, because that is what the German health system, as well as its pensions system, is based on—but that is what they decided to do. It is interesting that it has stood the test of time for 20 years. They have recently decided, with cross-party agreement, to increase social insurance and there has been virtually no public opposition, because the system is seen to be reasonable and fair. The German system is not purely funded by the taxpayer—there are private contributions as well—but it is an example. For heaven’s sake, let us sit down on a cross-party basis, as the Chair of the Health Committee has said, and work out a solution that stands the test of time, whichever Government comes to power in the future.

Dr Murrison 

There is much in the hon. Gentleman’s speech with which I agree. Does he agree that the fundamental issue is that countries such as Germany, France and Holland, to which people here would reasonably compare this country, spend a great deal more money through either the Bismarckian system that he describes or others—this country’s system is based on Beveridge—and that somehow or another we are going to have to close that gap, as it is highly likely that the difference in mortality, morbidity and outcomes generally in this country compared with those aforementioned countries is causally related to the amount of money that we put into healthcare?

Mr Betts 

We heard quite a lot of evidence that, as a percentage of our national income, we do not spend as much as several others on health and social care combined. The Communities and Local Government Committee will reflect on that. Of course, it is not simply a question of asking for more public funding; I would not come to that conclusion, although I might personally believe it. There is, however, an issue with where we get the private funding from, because nobody has argued to us so far that the whole of social care can be publicly funded. There will be private contributions, so how do we raise that private money? Should it come from individuals who simply need care at that point in time, or should we ask people to pay more into an insurance system? How do we put in more money from the public sector? Indeed, can we rely on local authority funding alone, particularly if it comes largely from business rates, which will not grow at the same rate as the number of people who want social care?

Kevin Hollinrake (Thirsk and Malton) (Con) 

rose—

Dr Murrison 

rose—

Mr Betts 

I give way to my Select Committee colleague, the hon. Member for Thirsk and Malton (Kevin Hollinrake).

Kevin Hollinrake 

It was a pleasure to join the hon. Gentleman and other members of the Select Committee on that visit. Does he agree that the German example is all the more pertinent given that its system was also funded by local authorities prior to the change to social insurance in 1995? It discovered 20 years ago that that system was not fit for purpose and moved to a new system that, as he says, has cross-party support and is a long-term, sustainable solution.

Mr Betts 

I just want us to have a process that gets us to a similar position. Even if local authorities remain part of the funding solution, we cannot assume that the increase in business rates and council tax will keep pace with the level of demand.

I know that you have encouraged us to keep to a time limit, Madam Deputy Speaker.

Madam Deputy Speaker (Mrs Eleanor Laing) 

Order. I ought to say that, as the hon. Gentleman is the Chairman of a Select Committee, I do not apply the time limit as strictly to him.

Mr Betts 

I have gone two minutes over time, so I had better not stray too far. Of course, health and social care need to work closely together. It is going to be very interesting to see how Manchester develops. It is not, however, a panacea; it is not going to solve all the problems.

I agree with the Chair of the Health Committee: the sustainability and transformation plans are an interesting way forward, but unfortunately they are seen as a way of making cuts. They will need some pump-priming to make them effective. They have not been done properly, with full co-operation, in every local authority area. If they are done properly and consider how we can better plan and pull together health and social care for the future, I think they will make an important contribution. Ultimately, however, we have to acknowledge that the process is going to take time and that it will need up-front funding to make it work.

We also have to acknowledge that there are big differences between health and social care. There are not many differences in culture, but the funding arrangements are different. Health is provided free at the point of use, whereas social care is not and probably will not after any changes are made. There is also a fundamental difference between the two on accountability: social care is accountable to directly elected local councillors, whereas health is ultimately accountable to the Secretary of State. If Members want to see the problems that creates, they should read the evidence that the former Health Minister, the right hon. Member for North East Bedfordshire (Alistair Burt), gave to the Communities and Local Government Committee about his understanding of accountability in the Manchester system. It shows that the Government have not worked it out in such a way that they could flick a switch tomorrow and get it all operating smoothly. We have a lot of work to do. The Select Committee will consider all the evidence we have received and will produce reports on a range of issues.

Andrew Selous (South West Bedfordshire) (Con) 

It is a pleasure to follow the Chair of the Communities and Local Government Committee, the hon. Member for Sheffield South East (Mr Betts).

Notwithstanding the issues that have already been brought to the House’s attention, it is worth putting on the record the increase in the money—the extra £10 billion by 2020—that the Government are committing, with the 11,400 more doctors and 11,200 more nurses in the system, as well as the near eradication of mixed-sex wards and the huge reduction in hospital infections. I also note that health spending in England is nearly 1% higher than the OECD average.

Dr Murrison 

I am sorry to intervene on my hon. Friend so early in his speech. Does he agree with me that the OECD average is probably a specious comparator? It covers countries—such as Mexico and Turkey, and former eastern bloc countries—whose health economies, laudable though they may be, are not ones with which most people in this country would wish ours to be compared.

Andrew Selous 

My hon. Friend makes a fair point. I will outline some areas in which I think more spending is necessary.

I want to start by focusing on an individual case—it is not from my constituency—which highlights many of the issues that have been raised so far. It concerns a 98-year-old lady who was admitted to a hospital in one of our major cities on 22 January. Unfortunately, she died in that hospital on 31 January. It was made clear to the hospital on 25 January that the nursing home she had come from—she had been in its residential part—had nursing facilities, and it would have been able to take her back and deal with the deterioration in her health. Despite that, no action was taken to remove her back to the nursing home, which resulted in an extra six days’ stay in hospital.

The relatives who drew this true case to my attention asked me to raise two points. First, they thought it was not really good enough that the hospital concerned did not have a good knowledge of the fact that in addition to the residential facilities, the nursing home had facilities that would have been able to care for the elderly lady and thus free up a hospital bed. Secondly, they were disappointed that because her period in hospital spanned a weekend, they were told by several of the nursing staff that no doctor was available to make a decision about moving her back to the nursing floor of the home she had come from and where she had always wanted to end her days. That story illustrates some of the issues—I know Health Ministers are aware of them—of making sure that there is knowledge of what residential and nursing facilities are available in the community for elderly or frail people who go into hospital, and of making sure that there is weekend cover so that appropriate decisions can be taken and beds are not unnecessarily taken up in hospitals.

A couple of weeks ago, I sat down with a number of social care providers covering both residential and domiciliary care in Bedfordshire, and I asked them what they thought they needed to attract enough people into care provision. As the Chair of the Select Committee has just told us, there is a 27% turnover rate, and I learned that the providers cannot always attract people of the calibre they would like. For domiciliary care, I was told very clearly that the ability to offer a salary—perhaps of £16,000 to £18,000 a year—rather than paying people on an hourly basis when they provide care, would go a very long way to attracting the right sort of people into this profession.

That domiciliary care provider, which is one of the better ones in my area, pays 30p a mile for travel costs. All of us, as Members of Parliament, get paid 45p a mile when we travel in our constituencies. Frankly, I find it an affront that there is a division between rates for travel within the public sector. Social care staff do an incredibly important job and, frankly, it is not right that they are lucky to be offered 30p a mile, when Members of Parliament get 45p a mile. I am not just asking local authorities to put up what they pay to such a level straightaway. We must be realistic, and I fully recognise that that would come with a price tag that would have to be provided through taxation. However, having a salary of £16,000 to £18,000 a year, rather than hourly rates of pay that do not include travel time, and having travel properly paid for—it is currently paid for at a very miserly rate compared with what other people in the public sector get—would go a long way.

One of the issues that has not been highlighted so far in the estimates is the revaluation of the NHS litigation costs. There has been an increase of some £8 billion, which is a fairly large figure. It is worth focusing on that because litigation costs mean a couple of things. First, they mean that patients have not got the right quality of care first time around, and secondly, they mean that money is going out the door of the NHS, often to lawyers, that could be better used doing the job correctly the first time.

In that regard, I make no apologies for again drawing the House’s attention to the Getting it Right First Time initiative, which seeks to embed quality in clinical care across the NHS. I often find that we do not focus sufficiently on that in this House. Variability in the rates of infection and of the revision surgery that is required are significant across the NHS. If we could raise the quality of clinical care to the level of the best across the NHS, we could get the amount for litigation down substantially.

I was pleased to join a meeting that the Chair of the Public Accounts Committee, the hon. Member for Hackney South and Shoreditch (Meg Hillier), held a couple of weeks ago on the “Manifesto for a healthy and health-creating society”. It was led by Lord Crisp, the former permanent secretary of the Department of Health, with colleagues in the House of Lords and others. Although that may seem a long-term approach to the acute problems we face today—the Chair of the Communities and Local Government Committee is right to say that we need action now to get the preventive issues right, because not everyone will be around in the longer term—it is incredibly important, none the less, that we take a lot of the ideas in the report seriously to try to reduce the strains on the NHS and to create a healthier population in the years to come.

There are already some very good examples of such ideas. The St Paul’s Way transformation project in Poplar in the east end is doing sterling work. The Well North initiative, which is supported by Public Health England, is focusing on 10 cities in the north of England that have poor health outcomes and bad levels of health inequality. It is all about creating what it calls vibrant and well-connected communities to deal with issues such as debt, jobs, training, missed educational opportunities, poor housing and loneliness. Our late lamented colleague Jo Cox focused on the issue of loneliness, and many of us in the House are determined to carry on her work in that important area. Such long-term preventive work to increase the resilience and health of society is absolutely fundamental to all the issues we are talking about tonight.

On the sustainability and transformation plans, I have spent time with both GPs and hospital staff during the past couple of weeks, and I observed that clinicians in hospitals often point to the work that they thought should have been done but had not been done by GPs, while GPs pointed out that they do quite a lot of work that in the past they would have expected hospitals to undertake. As we move forward with the sustainability and transformation plans, there would be some merit in making sure that those in time turn into accountable care organisations, so that we get a proper join-up between the different parts of the system and such finger pointing between different parts of the health system becomes a thing of the past.

Finally and briefly on the issue of beds, I totally understand the Government’s correct focus on shifting more care to the community, but we have 8,000 fewer beds than we had five years ago, while the occupancy rate has increased from 84% to 87%. At times, operating theatres stand idle because of delayed discharges for care. I should like Ministers to reflect on that.

Rosie Cooper (West Lancashire) (Lab) 

The Department of Health explanatory memorandum on the supplementary estimates sadly has the feel of rearranging the deckchairs on the Titanic. The estimates and the reports highlight the extensive range of issues facing the NHS. My involvement in health issues in West Lancashire, from individual constituents’ cases to the commissioning of multimillion pound contracts, tells me that my constituency is a microcosm of the questions to which the multitude of bodies within the NHS need to find answers. My constituents can wait up to a week for a telephone conversation with a GP to assess whether they need an appointment—they then have a further wait for the appointment—so is it any wonder that people turn to A&E and minor injuries units?

Clinical experience at the top is laudable and to be welcomed, but there is a shortage of GPs and lost capacity because of the time GPs spend on clinical commissioning group governing bodies. In West Lancashire, CCGs have handed community health and urgent care services contracts to private providers, potentially threatening the future of Southport and Ormskirk Hospital NHS Trust by removing services and essential financial turnover. The chair of the CCG is a local GP who spends three days a week on CCG business. Five further GPs have executive lead responsibilities. Apart from the loss of capacity, there are the financial considerations of GP remuneration for their work on the governing body. One GP earns more than £100,000 a year for that three-day week, while the chief accounting officer is also on approximately £100,000.

There is a fundamental lack of direct accountability of CCGs, which I understand are the responsibility of NHS England. GPs hand out contracts to private providers in the face of significant and substantial local opposition in West Lancashire, and there is no mechanism for meaningful accountability for how those GPs spend taxpayers’ money. My constituents did not get to vote on who represents them on a CCG, and they have no means by which to replace them if they do not believe the GPs act in their best interests.

The question arises whether NHS England and NHS Improvement have enough resources to deal with the increasingly complex contracts and structures they are supposed to supervise within the NHS. Threats to the smaller acute trusts come both from local GPs and from the sustainability and transformation process, the name of which is increasingly a misnomer. The plans were quietly generated by small groups of people without the involvement of most of those who need those services or their public representatives both locally and nationally. Some of us miss strategic health authorities. I would be interested to hear from Ministers whether the STP process will provide capital resources to enable hospital trusts to develop transformational change projects.

Increasingly, NHS Improvement and NHS England cannot agree on the current state of NHS finances. NHS Improvement’s forecast for this financial year has worsened in each financial quarter. Currently in quarter three, it forecasts a deficit of £873 million, while NHS England appears confident that the final deficit figure will be no more than £580 million. I took a deeper look at the figures for quarter three. A huge question appears when we look at the sustainability and transformation fund moneys the Government have given to trusts. Admittedly, trusts retain the allocated funding only if they achieve certain financial targets at the end of the financial year. If they do not achieve those targets, the extra funding disappears like snow in July. The system deficit could therefore be much greater.

The Department of Health’s funding of the NHS has a consequential impact on services, but we are also witnessing savage cuts to local authority budgets. As the provider of social care, Lancashire County Council is perilously close to being bankrupt in the next five years based on current funding projections. We talk about health and social care as if they are absolutely intertwined, yet the Government allow the competitive existence between the two services to continue. As both systems seek to survive financially, each body makes decisions to seek to minimise their expenditure. The social care system is unable to get people out of hospital, while hospitals seek urgently to discharge medically fit patients. I have a great fear that, as each day passes, the struggle for survival owing to the ever-tightening financial strictures imposed by the Government, and their lack of solutions, means that patients are getting lost. Organisational form and financial considerations mean that patients are a distant third on the priority list.

I do not know whether creating chaos and turmoil within the system is part of a longer-term strategy to lead us to a new healthcare system of private providers and health insurance—the Secretary of State will have to answer that one. What I see from the estimates provided for the transfer of moneys between budgets is that we are just tinkering at the edges of a system that needs to be properly financed. We cannot just shove a few pennies into the left hand while taking pounds from the right. Our NHS and our constituents deserve so much better.

Kevin Hollinrake (Thirsk and Malton) (Con) 

It is a pleasure to follow the hon. Member for West Lancashire (Rosie Cooper), who made some interesting points, particularly about fundamental reform of services, which I will address later in my remarks.

Members on both sides of the House have alluded to the fact that this debate is set against the background of hugely increasing demand and, in many ways, decreasing supply, particularly in adult social care, to which I will restrict my comments. I was interested to take part in the Communities and Local Government Committee inquiry, to which the Chair, the hon. Member for Sheffield South East (Mr Betts), referred. On increasing demand, there was a 33% increase in the past 10 years in the population who are aged 80 and over. There is a projected 100% increase in that population over the next 20 years, and a 50% increase in 65s and over in the same period. Interestingly enough, there will be only a 4% increase in the population who are below the age of 65 over the next 20 years. That is an interesting dynamic when we think about who will provide the care that will be needed for all the people who are getting older.

An area of adult social care we can sometimes forget—it has not been mentioned—is care for those with learning disabilities. That population is increasing rapidly and will increase again over the next 20 years, which means more profound challenges for our health and adult social care services.

On the backdrop of the decreasing supply of provision, everybody has to take part in ensuring that the books balance. We are reducing the deficit from £156 billion a year in 2010 to around £68 billion this year, which is no mean feat. We must understand that there is no bottomless pit, and that we have to make difficult decisions on allocating our spending.

Local authorities have borne the brunt of the 37% reduction in overall spending—it is a 25% reduction after council tax increases. Adult social care accounts for around 33% of local authority discretionary spend. It is therefore inevitable that that will be a focus when local authority managers try to balance the books. There are other competing pressures, such as the national living wage, which soaks up a lot of the extra money allocated to adult social care. It is not just about local authorities: providers are also under huge pressure. Some 59% of care homes are below the profitability threshold. Homes are closing and some providers are returning their contracts to local authorities.

There are other elements relating to the provision of what we would call a well-functioning health and social care service. Other reductions include a 28% reduction in the number of community nurses, who provide the key services that stop people going into the health and social care system. In my constituency, simple things like sitting services, local dementia clubs or something called Kurt’s Club in my hometown of Easingwold have either closed or had services reduced in recent weeks and months. Again, that puts more pressure on the system.

Delayed discharges also have an impact on the NHS. Hon. Members who spoke earlier know far more about this than I do, but when Simon Stevens gave evidence to our Committee he estimated that the NHS spends up to an extra £1 billion due to delayed discharges. There is an impact on the whole system.

The Government have responded with £2 billion more since 2010, with the adult social care precept, the better care fund and the adult social care grant adding between £3.5 billion and £4 billion by 2020. There is no doubt, however, that all the evidence we have heard from a number of different sources—the King’s Fund and the like—points to an investment shortfall of between £1 billion and £2 billion.

Alex Chalk (Cheltenham) (Con) 

On the shortfall, does my hon. Friend agree that the time has come to bite the bullet and increase social care funding? Does he agree that doing so in the short term would provide the financial headroom to enable trusts like mine in Gloucestershire to achieve the meaningful reconfiguration of services through the STPs that will reflect the changing health priorities and demographics? It is a sprat to catch a mackerel.

Kevin Hollinrake 

My hon. Friend makes a very strong point. I do feel that we need more money now. I am sure the question of whether more money might be available is taking up some of the Chancellor’s time as he works on his Budget calculations for 8 March. In the short term, we need more money to plug the gap. In the longer term, we need a cross-party conversation on how we solve this problem.

The Select Committee has been an excellent forum through which to explore this issue and many others. As the hon. Member for Sheffield South East (Mr Betts), the Committee Chair, mentioned in his remarks, we went to Germany to examine its system. It was very enlightening. In 1995, Germany moved from one system to another: from a local government-funded system that just did not work—they clearly saw this coming before we did—to a social insurance system. They are more used to that system in Germany, which has similar systems in place for health, pensions, unemployment and accident insurance. It works very well. It is cross-party, seems to be apolitical and takes a salary contribution of about 1.175%. It is a bit like auto-enrolment, but it is compulsory—it is a mandatory scheme. It means that when people need care they have a pot to call on. Needs are independently assessed, so they receive the level of provision that suits them. It can also be used to provide domiciliary care. Money coming back out of the system at the right time can go to help family members look after the person who is ill, so it has a social benefit as well as being a sustainable system that works in the longer term. We should look at that model. It is not the only one, but I reiterate—I know Members on both sides of the House feel the same way—that we should look at this issue in a cross-party way to ensure long-term sustainability.

Kevin Foster (Torbay) (Con) 

I am very much enjoying my hon. Friend’s speech. Does he agree that the current method of local government funding does not help? There is a ward in my constituency where 9% of the population are aged over 85. Demographics are not properly reflected and the challenges faced by coastal communities in particular, as opposed to some of the more traditional challenges here in London, are not reflected in funding schemes.

Kevin Hollinrake 

My hon. Friend makes a very good point. The evidence clearly shows that the current methods of funding adult social care do not correlate with the needs in those areas. We need to take a strategic look at that. The Government are moving toward a different way of funding local authorities by 2020. A key part of business rates retention is the consideration of the allocation of funding. It is critical to put need first and foremost, so that need and the cost of delivering services are the cost drivers. Having a fair and transparent system is fundamental.

On adult social care and learning disabilities, one of the most heartening examples of how to deliver them in a different way, rather than looking at them from a single viewpoint, is the Botton Village “shared lives” concept, where people look after each other—co-workers and people in need of care alike. It is a fantastic and inspirational scheme.

Finally, I will touch on a couple of very small points. We should look at how people are charged for domiciliary care. Financial assessment for domiciliary care is different from that for residential care. I think money could potentially be taken out of the system—it does not make much sense to me that the Government fund one thing one way and another thing another way—or people could contribute, if their houses are taken into account in their domiciliary care assessment.

My final point relates to co-terminosity. There are so many different services provided by so many different agencies working in different geographical boundaries. Co-terminosity works well in Sheffield, where all the agencies work together very effectively. In my area, it is completely different. There is a real mish-mash of different providers and geographical areas, which makes it difficult to provide a joined-up service.

Steve McCabe (Birmingham, Selly Oak) (Lab) 

Often, the NHS estimates day debate is a rather perfunctory affair, but this year, five years into the reign of the present Secretary of State, we are entitled to ask what on earth is happening to our NHS and social care system. Can we any longer afford the extraordinary complacency of this Government? As an Opposition MP, I sometimes worry that, either by design or simple neglect, they will finally fulfil our worst fears that the Tory party is destined to destroy the NHS.

Kevin Foster 

So much for cross-party dialogue.

Steve McCabe 

I don’t think I need any lectures on cross-party dialogue from the party of the death tax and the £8 billion financial fib.

In Birmingham, we have seen £28 million cuts to the social care budget, bringing the service to its knees. Elderly people are being treated like cattle, lying around on trolleys, waiting in corridors and dispatched from hospital in the middle of the night. Everywhere we look, we see our hospitals, GPs and social care services collapsing under the strain.

This Secretary of State is quite happy to flex his muscles when it comes to bullying junior doctors, but it is always someone else’s fault when it comes to resources, management and administration of the NHS. There was a time when the deal was simple: in return for the red box and a ministerial salary, Ministers took responsibility —the buck stopped with them. But no more. I have lost track of how many parliamentary answers begin with the words, “The Department does not collect that data centrally,” or “It would not be cost-effective to provide information in that format”. Basically, Ministers do not know, do not want to know and do not want us to know what is really happening. They no longer preside over a genuinely national health service. Whether it is the postcode lottery that characterises the provision of IVF, with clinical commissioning groups ignoring NICE guidelines and making up their own criteria as they go along, or children’s dentistry, where there is a growing crisis and a heavy reliance on hospital emergency surgery because of the lack of provision and monitoring of proper dental services for children, all this Government want to do is hide behind and blame others for their shambolic decisions.

The latest disaster is the business rates revaluation, which in Birmingham is estimated to see a rise for University Hospitals Birmingham’s Queen Elizabeth hospital from £2.8 million to £6.9 million per year—talk about robbing Peter to pay Paul! And yet Ministers from the Department for Communities and Local Government and the Department of Health have not even met to discuss the problem—although I note that private hospitals get an 80% reduction because they are registered as charities.

In my constituency, we have been fighting a battle to save our Katie Road walk-in centre for several years: we have had stop-go consultations, money wasted, explanations and excuses that vary from month to month, consultations announced and then scrapped, and now we have a sustainability and transformation plan that sadly, as acknowledged, has turned into a secret strategy drawn up by non-elected bureaucrats from which the public and their elected representatives have been largely excluded. It seems that Katie Road is now caught up in this fiasco. With its contract scheduled to finish on the 31st of next month, we still do not know what is happening, although if rumours are true, even more money that ought to be spent on healthcare in Birmingham is about to be siphoned off to rescue bankrupt neighbours.

Only the other week, I discovered that the contract for South Maypole GP services was to be cancelled. It is apparently no longer cost-effective—not cost effective to provide GP services to the sick and elderly! Only under this Secretary of State could the NHS have come to this.

Kevin Hollinrake 

In my remarks, I talked about a cross-party conversation. I could easily have pointed out that between 2011 and 2014 there was an 8.6% real-terms drop in health spending in Wales, under a Labour Administration, while there was a 4% increase in England, but would it not be better to have a constructive conversation about how we take the NHS and social care off the front pages of the tabloids and to sit down and work out a solution together?

Steve McCabe 

It is always desirable to have that conversation when the Tories are in power. When Labour are in power, we talk about death tax campaigns and we hear about £8 billion funding fibs. It is funny how the argument always changes when they are responsible.

As I was saying, the contract for South Maypole GP services is about to be withdrawn. I found that out not when the CCG, which it turns out has been ruminating on this since November, told me, but when I was contacted by anxious constituents who had just found out they had eight weeks to find a new GP. Many of them are elderly people, and some have long-term conditions and rely on regular medication, but they are dismissed as if they do not matter. The loss of their GP service is treated like the closure of a local hairdresser or petrol station. They are told to shop around. Apparently the CCG thinks there are enough GPs in the area—enough at any rate to satisfy their little diagrams and tables on their secret little plans. Reducing demand for acute care is one of the Government’s plans to ease pressures in the NHS. Exactly how do we achieve that by closing walk-in centres and GP surgeries? Is that not the fastest route to our already overstretched A&E departments?

It is not just the estimates at issue here, but a proper long-term plan for the NHS and social care. This Secretary of State has failed us. His stewardship is a disaster. Rather than accepting more of it, the House should be calling for a motion of censure. The Government and the Secretary of State are presiding over the steady dismantling of the country’s greatest peacetime achievement. It is a total disgrace.

Maggie Throup (Erewash) (Con) 

I would like to start by paying tribute to the many thousands of health and social care workers who every day support some of the most vulnerable people in our society.

We are talking today about how to balance the books. The NHS five year forward view identified that, if the trajectory of healthcare spending continued at the same rate as just a couple of years ago, an extra £30 billion would be needed by 2020. It also stated that over £20 billion could be identified in savings and efficiency measures over that period, which is why the Government have allocated an additional £10 billion to 2020-21. We can quibble about whether it is £8 billion or £10 billion, but it must be recognised that NHS England asked for £8 billion and that the Government are delivering it.

To some extent, what has not happened yet is the other side of the bargain: finding the savings of £22 billion. Perhaps it was never possible. Perhaps the timescale for delivery was too short. Next year we celebrate 70 years of the NHS. So to change how it worked in less than five years was probably too big an ask. That said, in many areas of the NHS, change is happening and savings are being made. But it takes time. I want to give a couple of examples to illustrate where savings can be made. They might involve upfront costs but for long-term savings.

Prior to being elected to this place, I spent a lot of time and energy promoting diagnostic tests that could be carried out at a patient’s bedside, in a GP surgery or even in a patient’s home—possibly also in community pharmacies. Such testing is used extensively in Scandinavia and other European countries, but we are lagging behind. If we adopted such tests more widely, many savings could be made, but, more importantly, it would better for the patient, which surely should be the key determinant.

One example is the point-of-care test measuring a protein called C-reactive protein. The protein is raised when someone is suffering from a bacterial infection but not if the infection is caused by a virus. Without the test, patients might be prescribed unnecessary antibiotics, which is not good for the patient or the NHS budget, and in some instances, patients might be admitted to hospital unnecessarily. Yet all that is needed is a small device and a drop of blood. I know all this from personal experience: had such a test been readily available for GPs to carry out in surgeries or patients’ homes, it would have saved my mother a five-day hospital stay. Not only would that have saved the health service money, but my mother would have been far better off staying in her home at the time of her illness. We cannot continue doing as we have been and expect different outcomes.

Jason McCartney (Colne Valley) (Con) 

My hon. Friend talks a lot of sense. Does she agree that the NHS should not make the mistakes of the past by going down the route of more disastrous private finance initiative deals? As she might know, my local CCG is developing a business case to bulldoze Huddersfield royal infirmary, replace it with a small planned care unit and move everything else to Halifax, including A&E, and is coming forward for £285 million. If it does not get that from the main funds, it will go down the PFI route, but the trust is already crippled by the disastrous PFI at Halifax, which cost £64 million to build but will eventually cost £774 million.

Maggie Throup 

I thank my hon. Friend for his pertinent comments. I did my training as a biomedical scientist at Halifax general hospital and the royal infirmary in Halifax, so I know the area very well. Yes, we must not go down the route of more disastrous PFI agreements.

Fiona Mactaggart (Slough) (Lab) 

On the hon. Lady’s point about tests that are not being deployed, but which could save money, I have long been concerned that many areas do not issue women at risk of ovarian cancer with the CA 125 test. It is not a definitive test, but it can help identify the cancer early, which can save money. Does she agree that we need leadership from the top of the NHS on such clinical issues to ensure that short-term savings decided by an individual CCG are not putting patients’ health at risk?

Maggie Throup 

The right hon. Lady makes a very good point, and we could have an entire debate on the topic of prevention and screening.

The spending of the NHS budget affects social care, and the spending of the social care budget affects the NHS. As we have heard from other hon. Members, the two are linked, but are funded in different ways. All too often, these budgets are costed only in silos.

Taking the treatment of stroke patients as another example, there is a new technique available called mechanical thrombectomy. I recently met a young man who was fortunate enough when he had a massive stroke to be near one of the few centres in the UK that carries out that procedure—if a young man in such a situation can be viewed as fortunate at all. As a result of the procedure, the young man can lead a full life rather than being disabled for the rest of his life and possibly dependent on social care, too. However, the procedure cannot yet be rolled out across the country due to the limited funding available to train specialists to carry it out and to fund the procedure itself. What are the lifetime costs, mainly imposed on social care, for those patients who do not get that procedure or other such procedures, irrespective of the personal costs to the individuals?

There are great examples of integrated working between the NHS and social care, but it is far too slow to spread new and best practice. Locally in my constituency, Erewash CCG is a Vanguard site. One of its actions is to carry out what are classed as “ward rounds” in residential and nursing homes. There is already strong evidence to show that that is reducing hospital admissions for elderly people. However, it is not being rolled out quickly enough to other areas.

I do not believe that continually throwing more money at the NHS and social care is the answer. If we want different results, we need to do things differently. That is what the sustainability and transformation plans aim to do. I have read the Derbyshire STP in depth, and while I applaud the aims of the plan, there appears to be very little indication of how it will be implemented. My concerns are around workforce balance, transitional costs to implement the STP, capacity in the community and stakeholder buy-in.

I hope I am wrong with my analysis, because better integration and bold action are what are really needed. It is important for us not to shy away from the hard and difficult decisions that lie ahead.

Heidi Alexander (Lewisham East) (Lab) 

It is a real pleasure to follow the hon. Member for Erewash (Maggie Throup), who has made a characteristically well informed and thoughtful speech.

You do not need to be a brain surgeon, Mr Speaker, to have worked out that the NHS and care system are currently under enormous pressure. Anyone who has recently visited a hospital, sought a GP appointment or tried to arrange support for an elderly relative will tell you that the whole system is struggling. Inadequate funding, a workforce crisis and a failure to reshape services quickly enough to meet the needs of our ageing population mean that the men and women who care for our loved ones are simply running to stand still. This winter, we have seen the front pages of national newspapers covered by images of frail, older people stuck on trolleys in hospital corridors and a poorly toddler led on plastic chairs pushed together to create a make-shift bed.

If you happened to watch BBC2 on a Wednesday night in January or February, Mr Speaker, you would have seen the documentary “Hospital”, which showed the reality of people working on the frontline and taking really difficult decisions about patients, beds and operations in a big and busy hospital. It was captivating viewing, which left me, as a politician, feeling sad and frustrated that we are failing to create the conditions in which the NHS can thrive.

Many of the current problems plaguing our health and care system relate to a lack of money. It is not the only problem, but it is the major one. While the NHS budget has inched up in recent years, it has been outstripped by rocketing demand. Next year, NHS funding per head of the population will fall in real terms. Social care budgets have been slashed, meaning that the support available to the elderly and disabled in the community has been reduced. Even with the changes that the Government have made to the better care fund and the social care precept, the Local Government Association still predicts a shortfall of £2.6 billion by the end of this Parliament.

We cannot escape the fact that our population is growing and we are ageing. There are now more retired people in the United Kingdom than there are children in our schools. As the decades pass, medicine advances. We keep more babies alive when they are born with complicated medical conditions; we successfully treat more and more people who have cancer; we perform ever more complex operations which can give people many happy years of life, but which contribute to the fact that as we age, many more of us have underlying frailties and multiple health needs.

This situation has not come about overnight, and it is one that all recent Governments have had to manage, but the present Government are not managing it, and that is the difference. This Government’s head has been in the sand. Between 1997 and 2010, the Labour Government increased real-terms spending on the NHS by an annual average of 5.7%. The equivalent figure for the coalition Government was 0.8%, the lowest increase under any Government since the world war two. Under the present Government, the figure is 1.75%. The Government may talk a good game on NHS spending, but the truth is that we are in the middle of a decade of austerity, and when we add to that a slash-and-burn approach to local government and the social care services for which it is responsible, it is little wonder we find ourselves in our current predicament.

So what now? As we heard from the Chair of the Select Committee on Health, the hon. Member for Totnes (Dr Wollaston), we must be honest about the scale of the challenge. When it comes to NHS spending, this year is meant to be the year of plenty, the one year in the current Parliament when there is a relatively significant increase in available funds, but those funds have already been used to pay off last year’s debts. Money that was meant to be used to repair buildings and buy new equipment is, in effect, being used to pay salaries, and funds that were meant to transform services are being used to deal with the flow of people turning up at A&E. Hospitals are likely to end the year in deficit again, more clinical commissioning groups are overshooting their budgets, and NHS England is struggling to stay within its spending limits for specialised services. So-called efficiency savings really equate to the freezing of staff pay.

People who work in the NHS and social care system need to be honest about their ability to cope. The junior doctors were honest about it last year, and now it is time for others to do the same. NHS managers need to be honest about the time that it will take to transform services, and about the funding that that transformation requires. Hospital beds cannot be closed if services in the community are not already up and running, and have been proved to reduce the demand for in-patient care.

We need to be honest, but we also need action. The Government must provide direct support for local authorities, with funds for social care, in the Budget. How they pay for that is obviously for them to decide, but they cannot continue to shove partial solutions on to local government and wash their hands of the problem. If they do not address the long-term problems in social care, they will be leaving the NHS to pick up the pieces.

However, even if the Government are persuaded of the case for additional funds, we must think carefully about where the money would best be spent. It is tempting to say that it should simply be reinvested in what has been taken away—that there should be more comprehensive care packages and social care for a wider group of people, and the cuts affecting community health nurses and mental health trusts should be reversed—but I think the position is more complicated than that.

The current short-term fix of taking money from the capital budget to prop up revenue is wrong. New scanners are less likely to need repair than old ones, which means cutting waiting times and improving outcomes. Well designed, well maintained buildings can improve productivity and efficiency. Those who compare the new Guy’s cancer centre with the buildings at the Princess Alexandra hospital in Harlow will not believe that the two are in the same country. We should invest in new step-down care facilities for people who are well enough to leave hospital, but for whom care in the home has yet to be arranged.

There is also a massive need to invest in staff and build careers that people aspire to. This will take time as well as money. Perhaps we need to consider new roles in community health services that provide holistic care to older people in the home. Perhaps we need more GPs who are paid to dedicate time to residential homes, spotting problems among the elderly which would otherwise end up in a hospital admission. Perhaps the social care workforce needs a wholesale rethink. I will never forget the conversation I had with a senior A&E nurse who told me that the half-term holidays always result in more older people coming into hospital because the mums who do the part-time, zero-hours jobs in home care were looking after their children instead.

I fundamentally feel that the whole system needs to focus on how we provide care, in the broadest sense, to older people—the one in four people in a hospital bed with dementia, and the three in four people in care homes with dementia. We should focus on the real weekend effect—the one where if we happen to be in hospital on a Friday night, we are unlikely to make it out until Monday lunchtime at the earliest. Why do doctors talk of how it takes three minutes to admit a patient, but three days to discharge them?

I end by saying this: the Government might be absorbed by the complex task of trying to take us out of the European Union, but if they do not do something to address the scale of underfunding in the NHS and care system, the public will not forgive them. We need real answers to the real problems, and we need them quickly.

Maria Caulfield (Lewes) (Con) 

It is a pleasure to follow the hon. Member for Lewisham East (Heidi Alexander), although she will not be surprised to learn that while I agree with some of the points she made, I do not agree with all of them.

In the time that I have, I want to cover a few points; I do not want to repeat much of the excellent statements many Members across this House have made, but I do want to go over a few issues.

While I welcome the Government’s extra funding, and the £6 billion this year in particular, with the changes in national insurance contributions and pension contributions, the costs of running the NHS are going up all the time, so the extra money is being swallowed up without it necessarily going to frontline staff. I particularly agreed with my hon. Friend the Member for Newton Abbot (Anne Marie Morris) when she said that in an estimates debate we should not just be talking about the money we need to spend, but also need to look at the demand and the type of services that we need to fund. There is no doubt that the demand for NHS services and social care is increasing, so even by providing extra funding we are really just standing still in terms of the services we are providing.

We know there is an increase in numbers across the country. We know, as has been said, that there are new treatments that need to be provided. We know that patients are changing, too; they often have multiple co-morbidity, so whereas in years past they would have been admitted with one illness, treated and gone home, now when they are admitted they have many illnesses that are not so easy to treat, and that is often why discharges are delayed.

From NHS England’s own data, we know that there is around a 7% increase in demand for services across the board. There is also a 7% increase in the number of ambulance calls made. There is a 3% increase in the number of A&E visits. We know that the Tuesday after Christmas was the busiest day ever in the history of the NHS, and it takes extra money to be able to deliver that service. We know that there is a 6% increase in diagnostic tests, and consultant-led treatments are up 6%, too. So demand is rising, and although the extra money is welcome, it is not dealing with the level of service that is required.

I want to make a plea, as someone who still works in the health service and sees, and works with, colleagues across the NHS on a regular basis. While the services are under a lot of pressure and there is a lot that we can be concerned about, some amazing work is going on in our NHS, and I welcome NHS England’s announcement only last week that it is again going to start to fund second stem cell transplants. We have had debates in this place about how important that is to those patients whose first transplant fails. We also know that there are going to be new drug treatments for kidney disease and for pulmonary hypertension. All those announcements are really welcome, and we must recognise that there is great work being done on the frontline.

I am particularly pleased that the Department of Health has given £1 million to the British Heart Foundation to provide defibrillators up and down the country. That will make a tremendous difference, given that 12 young people a week die from cardiac arrest in this country. Innovative, ground-breaking work is also being done in cancer care. My old hospital, the Royal Marsden in London, is making strides in cancer research that are not only innovative in Europe but making breakthroughs worldwide. We should never forget that we often lead the field in research at a global level. We should be extremely proud of that.

In response to the Health Committee’s report, the Government made a number of recommendations on tackling the problems facing the NHS and social care, and I want to touch on two of them. The first dealt with the need to arrive at a degree of financial discipline in the health service. For years, there have been problems of financial mismanagement. As someone who has worked in the health service, I know how heartbreaking it is to see money being squandered. We have talked about the PFI deals, which have affected many parts of the country, but we must also remember the IT system that cost billions of pounds but never saw the light of day. It was supposed to move us away from paper records to a paperless system. Today, the NHS spends huge amounts of money on the storage of paper notes in offsite facilities. Hospitals have to pay to store those patient records. The agenda for change, which was introduced many years ago, was supposed to reconfigure the staff pay structure and improve patient productivity, but it never really worked. It just rearranged the deckchairs on the ship. It was a huge wasted opportunity that cost the NHS millions of pounds that could have been used to give staff a well-deserved pay rise.

Financial discipline is important. There are two big general hospitals near my constituency. They have the same financial settlement and a similar group of patients to look after. One of them is in special measures and struggling to cope with its discharging, while the other, less than five miles down the coast, is rated as outstanding and is able to provide excellent care. This has to be about more than the amount of money that is given out; it is also about what is done with that money. We need to look at that, and hospitals need to share best practice. It cannot be right that one hospital is able to manage its budget while another one is not. My experience of 20 years working in the NHS is that there are lots of opportunities in this regard. Financial discipline should not be about top-slicing; it should be about using the available money as wisely as possible. If Ministers want suggestions about how to make financial savings, I would recommend that they speak to the healthcare professionals. They often have the answers, and if they were only asked on a more regular basis, they would be able to provide some fantastic solutions.

The other recommendation that the Government want to take forward relates to reducing demand, which is easier said than done. I started by saying that demand was increasing by about 6% a year. For too long, we have focused on hospitals and—I say this with no disrespect to doctors, as my hon. Friend the Member for Totnes (Dr Wollaston) is sitting next to me—we have been much too medically focused in the way we manage our NHS. We have missed the opportunity to look at what other healthcare professionals can offer.

Pharmacists, for example, are highly educated, experienced and qualified individuals, and there is ground-breaking work happening out there in community pharmacies. This can involve simple things such as the scheme in Scotland in which patients have to register with a pharmacist as well as a GP. That would make a tremendous difference to patients’ lives if we were to introduce it here. Why are pharmacists not contacted on discharge, as GPs are? I was recently talking to a pharmacist who said that around 30% of readmissions are caused by patients not taking their medicine properly. If pharmacists had a list of chronically ill patients whose medicine they were in charge of, we could easily avoid so many readmissions. We heard earlier about nurse practitioners who are doing blood tests to predict bacterial infections and work out who does and does not need antibiotics. We need to upskill those healthcare professionals so that they can take on more roles. Some paramedics in the community are going to people’s homes instead of those people going to A&E, for example.

This is an estimates debate about how we use the money, but we need to forecast demand properly, use existing resources better and look at best practice to share the good work that is happening in our NHS.

Mr Speaker 

Order. Four Back-Bench would-be contributors remain, and I am keen to accommodate all of them. It might be helpful if I explain that I would like to call the Front-Bench winding-up speakers, of whom there are three, no later than 9.28 pm and slightly earlier if possible.

Karin Smyth (Bristol South) (Lab) 

It is a pleasure to be part of this debate among so many informed Members. Members may not realise that the debate is timely because the Public Accounts Committee, of which I am a member, published today our “Financial sustainability of the NHS” report, upon which I will base many of my comments. At the beginning of the report, we ask for an end to the years of arguing in public about the level of NHS funding and for the Department, NHS England and Downing Street to start working together in the interests of patients instead of bickering about funding levels.

I want to highlight two issues. One is about the work that has been done behind the scenes on the NHS accounts. You are a keen supporter of the work of Select Committees, Mr Speaker, but today’s debate was secured with the help of not only the Health Committee, the Public Accounts Committee and the Communities and Local Government Committee, but other contributors alongside Parliament. I thank the National Audit Office for the support that it has given to me and many other hon. Members to help us understand and interrogate this year’s accounts, including a meeting in a very quiet Portcullis House in the middle of August—perhaps when other hon. Members were on a beach somewhere. Helping Members to understand the accounts and what they mean for our constituents is an important and oft-neglected part of what the public hear about Parliament.

The NAO’s report on the accounts was unprecedented, and it is worth looking at what the Comptroller and Auditor General said about them. Several one-off actions were taken this year to bring the Department within its expenditure limit, some of which were worrying and some of which were just incredibly fortunate. Given the rigour involved in the accounts, the Department’s inability to find the extra £417 million that had been incorrectly given from the national insurance fund was quite extraordinary. There were the £100 million super-dividend from the Medicines and Healthcare Products Regulatory Agency and many central readjustments, and the capital-to-revenue transfers have been discussed. I also draw attention to the guidance that NHS providers were given by Monitor and the NHS Trust Development Authority—I use the word “guidance” carefully. That and the transaction reviews commissioned by the Department, whereby two accountancy firms undertook a review of accountancy policies and how they were adopted, happened so that provider results came out much more favourably than they perhaps would otherwise have done. Again, that demonstrates the incredible lengths that the Department and all its bodies went to this year to bring the accounts barely within the expenditure limit voted for by the House.

From whistleblowing accounts, reports from health and care conferences, the board papers that some of us read, discussions with chief executives, and reports in the specialist media, it is clear that the pressure on individuals within the service is immense, which is not good for anybody. I praise staff in all parts of the health service and the Department’s work, including clinical staff and managerial staff, of which I was proud be a part for many years, but the pressure, particularly on finance directors, to produce the right result and the right answer is deeply worrying due to the effect on safety. Only a few weeks ago we had the intervention of Sir Robert Francis who, based on his previous work, raised concerns about clinical safety in our health service.

The international comparisons on funding have been mentioned, and they are very clear. We are probably spending the money to be like Mexico, not France or Germany. My constituents expect to be treated in the same way as their European opposites. Whatever the right level of funding is, there must be agreement on that level and, crucially, on what it can provide. Over the past year, the Public Accounts Committee has held 11 or 12 sessions on what the service has promised to deliver for the money available, which takes me to my second point.

We are now in the realm of political choices, which is our responsibility as MPs. The taxpayer, the voter and the patient are not different people; they are one and the same, and they are wise. They understand that we get what we pay for, but they have to be informed. Currently, the scrappy, ill-informed public debate and the unedifying blame game are not informing them but letting them down.

It is clear to me and to many hon. Members that the Government are not inclined to fund the service to the standards that we have become used to, that we expect, that the NHS constitution gives us the right to expect and that our European neighbours have, so the Government need to be honest about the trade-offs and choices. The STP process allows that to happen. I have listened carefully to the debate, and particularly to Conservative Members. They cheer when the Prime Minister and the Secretary of State for Health say that they have increased the money given to the NHS or that the NHS was given what it asked for, but they then make passionate pleas for their own community hospital or for the various services in their area, as is their wont.

The STPs bring into sharp focus the trade-off between finance and quality, and I define quality in terms of patient experience, clinical effectiveness and efficiency. The STPs have given us a clear trade-off between the money and the mandate, and I hope the refresh of NHS funding that we expect from the five-year forward view in March, as discussed in the Public Accounts Committee, will be clear and that the public will be able to have that information at their fingertips.

Currently, patients do not have the information, and they should. They should know where the best-run and the worst-run hospitals are. I agree with the hon. Member for Lewes (Maria Caulfield) that it is unacceptable that hospitals a few miles apart with virtually the same population are operating completely differently. Patients need to know where the outcomes are best. It is not good enough to hold that information nationally and hide it from patients, or to leave it to well-informed people to interrogate board papers, and so on, to find out the answers.

The way forward is clear: waiting times will continue to increase; we will go back to the long waiting lists of the 1990s; access to GPs and other professionals will continue to decrease; the service will become largely an emergency one; the family, where there is one, will increasingly bear the cost and responsibility of social care; and access will continue to be restricted. The Government now have to be honest not just about the costs but about access. They have to be honest that there is no more money, if there is not going to be any, and they have to be honest about what that means for expectations, particularly with regard to the NHS constitution.

I look forward to the Minister’s response.

Judith Cummins (Bradford South) (Lab) 

It is a pleasure to follow my hon. Friend the Member for Bristol South (Karin Smyth). We are here to debate the financial sustainability of the health and adult social care sectors. Although health and adult social care are almost inseparable, I will focus on adult social care for brevity’s sake.

Although the acute care and adult social care sectors face similar unprecedented pressures, adult social care is different in one important way. Unlike the NHS, which has the ear of the Chancellor and the Treasury, adult social care certainly does not. All the evidence in recent months has served only to confirm that. The Chancellor’s decision not to make one extra penny of new money available in his autumn statement was met with almost universal criticism from across the health and local government sectors, and his recent decision to introduce the adult social care precept is damning evidence that a desperately outdated view of funding remains strong in the Treasury.

Because adult social care is delivered locally by local authorities, the Chancellor views its funding as a locally devolved issue. The Government’s decision to pass the blame to local councils and to underfund adult social care is nothing short of moral cowardice. They are deliberately underfunding adult social care in my home city of Bradford.

What is most desperate is the Government’s abandonment of the hundreds of thousands of older and vulnerable people who are reliant on vital adult social care services, day in, day out. We are talking not about hypotheticals but about the care happening today, right now. Real people are struggling to get by in my constituency of Bradford South. Bradford is a relatively young city; nevertheless, the number of people in Bradford over the age of 65 has grown substantially. Between 2012 and 2015, an extra 4,500 people were living in the district, and the number of people in Bradford with complex physical disabilities has grown by 400.

My local council, Bradford Council, agreed its budget last Thursday. Like many others, it had the task of agreeing swingeing cuts to scores of community services. In recent years, it has reduced its budget by more than £218 million, and a further £82 million in cuts will have to be made by 2020. Adult social care, as the biggest service overseen by Bradford Council, faces the lion’s share of the looming budget cuts. A further £19 million of cuts will fall on the city’s adult social care sector. The Government are washing their hands of any responsibility. By 2020, the revenue support grant, which is the primary source of central Government funding to Bradford Council, will drop to zero—zilch; absolutely nothing.

The Government’s half-baked answer is the adult social care precept. In the next two years, the precept is expected to raise an extra £6.6 million in Bradford, but that extra money is dwarfed by the huge cuts to Bradford Council’s revenue support grant. More to the point, the extra £6.6 million is not even enough to meet the increased cost of adult social care that will flow from the Government’s so-called national living wage. Because of the unprecedented increase in demand, such bruising budget cuts are only the tip of the funding shortfall. It is expected that the cost of supporting increasing numbers of older people, coupled with larger numbers of working-age people living with disabilities, will mean Bradford Council will have to shoulder an extra £1.5 million, each and every year.

Maggie Throup 

Will the hon. Lady give way?

Judith Cummins 

I am nearly at the end of my remarks, and the hon. Lady has had her turn to speak.

What is beyond doubt is that the Chancellor must act in the upcoming Budget. He faces his greatest test in this Parliament. I hope that he and his Government do not disappoint. Time will tell.

Helen Goodman (Bishop Auckland) (Lab) 

I am pleased to follow my hon. Friend the Member for Bradford South (Judith Cummins), who spoke with great feeling about her constituents’ needs, as she always does.

If my constituents were here and saw the estimates, they might be a bit disappointed. A few weeks ago, we had an interesting public meeting. They said to me, “Helen, it’s marvellous: because of Brexit, we’re going to get £350 million extra for the NHS every week, and our A&E department can be reopened.” There seems to be no mention of that in the estimates.

Under our local sustainability and transformation plan, there is a proposal to close the A&E department at Darlington hospital, which would be an unutterable disaster for my constituents. We are continually told that the purpose of the STP is to improve services, but I really wish the local NHS managers would stop pretending. They have also told us that by 2020 there is going to be a funding shortfall of £281 million, so nobody believes it is about improving services; everybody believes it is about managing on limited resources.

I appreciate that pressures on the health service are increasing because of the ageing population, but this level of austerity in the health service is unnecessary. The British economy is bigger now than it has ever been; it is 14% bigger than it was in 2010. Other hon. Members have pointed to the disparity between spend in the UK, which is $3,235 per capita per year, and in Germany, which is $4,800 per capita per year. In the UK, there are 2.8 hospital beds per 1,000 people, whereas in Germany, the figure is 8.3. It does not need to be like that.

I wish to focus on the needs of rural communities, which we have not spoken about this evening. Were the A&E department in Darlington to close, it would be an extremely serious problem for the people to the west of Darlington, and at the top of Teesdale. People are already travelling 30 miles to get to hospital. The response times of the North East ambulance service are not what they should be. People often wait 20 or 30 minutes for an ambulance to arrive, which means that it could be an hour before they get into the hospital.

One of my local councillors has done an absolutely brilliant piece of analysis, looking at the journey times that would be needed were people to have to go to the James Cook university hospital in Middlesbrough. At the moment, someone living in Bishop Auckland would take 25 minutes to get to hospital. It would go up to 39 minutes. If they live right up in the top of the dale, the journey time is 39 minutes. That would go up to 64 minutes. The STP managers running the review say that they want to treat cardio-vascular and trauma patients in specialist centres where a critical mass of staff can maintain their skills. That sounds reasonable enough, but my constituent, Judy Sutherland, asked them, “What proportion of emergency journeys are not cardio-vascular or trauma cases?” The answer was 94%. So, for acute asthma, adrenal crisis, anaphylactic shock, appendicitis, diabetic coma, meningitis and renal failure—the list goes on—there would be no benefit to being in a specialist centre.

The extra mortality from the longer travel time goes up quite dramatically. In Bishop Auckland, it goes up by 2.4%, Barnard Castle by 3%, and in Middleton in Teesdale by 3.2%. That is why the pretence that this is about improving the quality of healthcare is not believed by my constituents. They are tired of being told that services should be nearer to home when, in fact, they are being pushed further and further away. There is a question mark over the Richardson community hospital in Barnard Castle. The A&E and the maternity services have been taken out of the hospital at Bishop Auckland. When that was done, we were told that it would be absolutely fine, because people would be able to go to the Darlington A&E, but now that A&E is under threat. People in rural communities are facing this constant process of attrition.

Peter Heaton-Jones (North Devon) (Con) 

I have similar challenges in my rural constituency of North Devon. The STP is looking at the same issues that the hon. Lady is raising, and they, too, will lead to long travel distances. As Ministers know, that is something that I have raised with them and brought up in this House on a number of occasions. Does the hon. Lady agree that the challenges that the STP is trying to address have not happened in the past 18 months or the past six years; they have built up over many years and over many different Governments?

Helen Goodman 

The proposal to close Darlington A&E has come up only under this Government. It was not proposed under the coalition Government or the previous Labour Government. This Government must take responsibility for what is happening now.

On Saturday, I went to Alston in Cumbria. The people there are also running a campaign to stop their local hospital closing, because they will then have to go to Carlisle, which is 34 miles away. That is a long way, especially in Cumbria, where the weather is absolutely terrible and the road is often blocked. Ministers need to take more account of this big rural issue. People in Alston are also worried that there will be a cynical saving—the hospital in Copeland—and that they will face even bigger cuts. Perhaps the Minister will give us an assurance about that. The interaction between health and social care is well understood. We all know that cuts to social care mean a worse quality of care and less time for individuals.

Maggie Throup 

Will the hon. Lady give way?

Helen Goodman 

I would rather not because of the speaking limit.

Cuts also mean pressure on the NHS. Durham has faced really big cuts to social care. Between 2011 and 2017, it has had to make £186 million of savings. Child and adult care services comprise 63% of the total budget in the area, and adult social care cuts have been £55 million. The much vaunted precept only raises £4 million, and we have another £40 million of cuts to come. Even taking into account the better care funding, cuts by 2019-20 will come to £170 million. That means that there will be no social care in whole villages in my constituency. We are told that the Chancellor is minded to do something about it. Will he make up the full £4.6 billion that was cut in the last Parliament?

We have discussed the long term, which we do need to think about. The discussion about social insurance is important and significant, but we should also think about which institutions we would be asking people to put their money and their savings into. A lot of private sector organisations are, frankly, ripping people off with fees of £600 and £900 per week, even in my constituency in the north, where costs are not the highest. With fees like that, we do not even see highly trained people with expertise in dementia, but the same workers on minimum wages with low levels of training. We need to look at a stronger mutual approach and cut exploitative private sector contractors out of adult social care.

Mr Speaker 

I remind the remaining speaker that the Front Bench wind-ups need to start at 9.28 pm, so speeches need to conclude relatively promptly.

Patrick Grady (Glasgow North) (SNP) 

I do not intend to detain the House for desperately long. The debate has been filled with trepidation and anticipation as Members, and perhaps the wider public, wait to see whether the House will actually debate any of the estimates before us. To pay tribute to hon. Members, we have not done too badly. The estimates document, HC 946—all 748 pages of it, at three and a half inches thick—and the Order Paper give us an estimate of £8,716,216,000 for the NHS. That takes up pages 137 to 151 of the document, but the only line that actually includes expenditure for health and social care is for the

“Health and Social Care Information Centre (known as NHS Digital)”

on page 151, which has £151 million of resources. That might have made for a considerably shorter debate, if hon. Members had not used their ingenuity to quite the extent they have.

We have debated the 10 detailed reports from the Health Committee and the Public Accounts Committee. I congratulate the Chairs of those Committees on securing time from the Liaison Committee, but even that raises the question of why 10 reports are squeezed into a three-hour debate that is supposed to be about supplying the Government with the resources needed. I congratulate the Committees on securing that time, but perhaps those reports ought to have had more time to themselves.

The NHS is one of the biggest areas of Government spending, second only to pensions. Adequate funding of aspects of the NHS is a constant major feature of political discourse, as it has been today, but there are no means to seek to amend any of this in any meaningful way through the estimates process. All we can do is table amendments that might lower the amount, but the theme of the entire debate seems to have been that the NHS in England needs more money, not less. Of course, any change to the NHS budget in England has some sort of Barnett consequentials in Scotland. I wonder whether, at any point today or anywhere in the Supply estimates book, we can find out what those are. I suspect we cannot.

Nevertheless, a number of important points have been made. The Chairs of the Public Accounts Committee and the Health Committees spoke in detail about the different budget lines and departmental spending lines and about the important long-term consequences of the transfers from the capital budget to the revenue budget. The hon. Member for Newton Abbot (Anne Marie Morris) spoke about the need to ring-fence certain lines. The hon. Member for Colne Valley (Jason McCartney), who is no longer in his place, made important points about the disaster that PFI has been in the health service, and that is true north and south of the border.

The hon. Member for Bishop Auckland (Helen Goodman) rightly asked where the £350 million a week for the NHS was. It certainly is not in the Supply documents brought to the House by the Government today. There is, in fact, a systematic underfunding of the NHS in England under this Tory Government, and that has serious implications for the NHS across the UK as a whole. As we have heard from Members on both sides of the House, that environment will only become more challenging as the population ages and demographics continue to change.

The Scottish Government, as I am sure we will hear from my hon. Friend the Member for Central Ayrshire (Dr Whitford) on the Front Bench shortly, are focused on these challenges and on building a health service that meets the demands of the 21st century. They are not just investing in the NHS but reforming it—integrating health and social care, and engaging with communities and the medical workforce, to bring about sustainable and positive NHS reform, as opposed to pressing ahead with the hasty cost-cutting exercises that seem to be the priority of the Tory Government.

However, perhaps it suits the Tory Government to have an NHS that is in the crisis described by Labour Members, because that gives Ministers an excuse to bring in private capital and private management and to outsource services to private providers. That, in turn, would have major consequences for the NHS budget in England and consequentials for the devolved budget, which brings us back to the inadequacies of the estimates and Supply process in this House.

The former Leader of the House promised us that these Supply days and estimates days were our chance to scrutinise the Government on things that we were otherwise excluded from during the English votes for English laws processes.

Mr Speaker 

Order. May I just very gently say to the hon. Gentleman that he is a distinguished ornament of the Procedure Committee, which has deliberated upon this matter? The question of the character of debates on the estimates has been, at this point, decided by the House, and the hon. Gentleman should not use his opportunity to speak in this debate, which he should guard jealously, to dilate on his disapproval of the process. What he ought to do is to focus on the subject which has been chosen. [Interruption.] It is no good him grinning at me like a Cheshire cat—I trust that that means that he is acquiescing in the judgment that has been reached. We always look forward to the mellifluous tones of the hon. Gentleman, but they should focus on the subject that we have chosen and not on that which he would prefer to have been chosen.

Patrick Grady 

Indeed, Mr Speaker. I do not intend to detain the House very much further. What I have been trying to demonstrate is how the health and social care budget in England and Wales affects the health and social care budget north of the border and the overall Scottish Parliament budget. We have precisely proved the point that we do not have the appropriate opportunities to scrutinise those things in this debate, so the Government have to live up to their promises, and then we will see whether they are prepared to allow Members of this House a proper say over spending on the NHS and social care or on any of the other budget lines or Departments included in the estimates.

Dr Philippa Whitford (Central Ayrshire) (SNP) 

I certainly welcome the fact that, in recent months, since the hearing of the Health Committee, the Secretary of State for Health has stopped using the £10 billion figure and has recognised the £4.5 billion figure, which is much closer to reality. Spending is normally allocated on the basis of health spending, not just NHS England spending. The increase in NHS England spending was at the cost of significant cuts to public health, even though we all recognise the need for prevention, and cuts to Health Education England, despite the attempt to have 1,500 extra doctors every year, extra nurses and 5,000 extra GPs, which is therefore rather a challenge.

As has been said, last year was the good year before we come to the lean years. I am not going to go into details of the pockling that was required to get anywhere close to the required outturn, which was missed by £207 million, as that has been so clearly explained by those on the Public Accounts Committee. That results in what the Auditor General has described as short-termism—people simply working to meet the bottom line instead of lifting their chins up and looking at what the real challenges are.

There are three big challenges. We have talked about the ageing population, we recognise that we have significant workforce challenges, and we all know that money is tight and does not grow on trees. Those three things create a conflict. People are sometimes putting in a short-term patch that will actually cost more money in the end. Providers across England can be recognised for getting their agency costs down, although they are still more than twice what they are in Scotland, but what is lying ahead? How will we meet the challenge of providing the workforce after Brexit—not just the challenge of people leaving, but of how we recruit in future? The turnover at the level of nurse and social care worker is about 25%, and we need a constant stream. A Government Member mentioned the tiny proportion of population below the age of 65—of working age. That is exactly why we needed immigration in the first place. Are we going to end up with more agency workers, or will the Government take action to make sure that we can attract nurses, doctors and social care workers from Europe?

A lot of these problems are blamed on an ageing population. In fact, Scotland’s demographics are worse than England’s, and going through the hard winter that we have all faced, we did not meet our A&E target either. However, in Scotland the A&E department four-hour achievement level was 92.6%, while in England it was 79.3%—the worst level since records began. That shows that there is a real crisis. This is not meant to be a measure for us to attack each other with. In general, this has been a great debate compared with what some of our debates are like. Rather, it is meant to be a thermometer to take the temperature of the whole system—not just the whole hospital system from A&E to discharge, but from home to GP, to A&E, to hospital, to getting back home again. The problem lies in the significant cuts made outside the Department of Health but within social care. Obviously patients require the support to be able to get back into the community, and preferably even back to their own homes.

Why are we are managing, despite our demographics, to keep our nostrils above water when NHS England is not? It is partly because in Scotland we have focused absolutely on integration rather than financial competition. The convoluted system that now exists between CCGs and outsourcing contracts, bidding and tendering is estimated to take £5 billion to £10 billion out of NHS England’s budget. That would be enough to cover the deficits—to plug the social care hole—and yet the Department of Health does not even keep data on it, so it is not keeping track of how these administration costs are growing. There is no possibility of a cost-benefit analysis of bringing in outside providers and causing this fragmentation instead of people being able to work together.

In Scotland, as I have said before, we have gone down the route of integrated joint boards between health and social care, taking money from both sides so that we do not have the argument over whose purse is funding a patient. We have used other innovative approaches such as community pharmacies, which we have debated here previously, and minor ailments units within community pharmacies. As a result, in the past five years attendance at A&E in Scotland has increased by 3.4%, while in England the figure is 11.8%—three times our attendance rate.

The situation with admissions is similar. Our emergency admissions have increased by 4.6%, while those in England have increased by 14%. That is all because the effort is not being made in the community.

There is a lot of talk, all the time, about the five year forward view. Frankly, we are halfway through the five years, so we are left with a two-and-a-half year forward view. That does not look far enough ahead. Scotland did “2020 Vision” back in 2011, and we are now working on 2030, by which time the number of people aged 85 and over will have doubled. That is what we need to think about: how do we design not only our social care services, but out health services around the ageing population?

Our Cabinet Secretary is focused on what keeps people independent. Members may think that that is because I represent the Scottish National party, but I am talking about people being independent and living high-quality lives. What is it about? It is about hip replacements, knee replacements and eye surgery. If someone cannot see or walk and they are stuck in their house and lonely, we are going to have to look after them. Therefore, we have invested in—this is often laughed at here—free prescriptions so that people take medication to control chronic illnesses. We have also invested in giving free personal care to people in their own homes so that they do not land in hospital and get stuck there. That is why last year our delayed discharges went down by 9%, while here they went up by between 25% and 30%.

People also laugh at free bus passes. The hon. Member for South West Bedfordshire (Andrew Selous) mentioned loneliness, an issue that was championed by Jo Cox. It is as big a killer as diabetes. Older people in our community are out and about. They are taking day trips and going shopping, and they love it. They are not stuck in their houses. This is about starting with looking at that population.

STPs are the best change going forward, but at the moment they are being handed a bottom line and told to work back from it. It cannot be budget-centred care; it must be patient-centred care. All of us across the House can recognise that place-based planning for a community will provide the best service to those patients and our constituents. That is what we should be doing. We need to get real about public health and preventing chronic ill health in later life, and that means addressing health in all policies. It is really bad that, day by day, this House considers individual decisions that completely contradict each other. We should always ask of every decision, “Will this make the health and wellbeing of our citizens better or worse?” If it makes it better, in the end it will save money. That includes poverty—the biggest cause of ill health.

I call on Members to consider the systems and how we do things, but we need to provide the care in the community before we take it from the hospital. Let us also think a little more broadly in some of the other decisions that we make.

Barbara Keeley (Worsley and Eccles South) (Lab) 

I thank the Chairs, members and staff of both the Health Committee and the Public Accounts Committee for their work on the reports under discussion. I also thank the two Chairs for their excellent opening speeches.

The Health Committee noted a tight financial situation for health and the fact that deficits were growing and widespread. The King’s Fund and the Nuffield Trust reported in November 2016 that there was a net deficit of £2.5 billion for NHS trusts in 2015-16. Furthermore, they said that the 1.3% funding increase for the NHS in 2017-18 would largely be absorbed by deficits. We have heard many useful contributions on the issues with trust deficits. NHS funding increases will be 0% in 2018-19 and 0.3% in 2019-20. Those are seen as “inadequate” and not enough

“to maintain standards of care, meet rising demand from patients and deliver the transformation in services outlined in the NHS five year forward view.”

I take the point made by the hon. Member for Central Ayrshire (Dr Whitford) that we are now halfway through the five year forward view, so in fact we have only a two and a half year forward view. If the opinion is now that the view is inadequate, we have got some issues.

On social care, the Health Committee has said that increasing numbers of people with genuine social care needs are no longer receiving the care they need because of a lack of resource, and we have had very many contributions about that. The Chair of the Health Committee, the hon. Member for Totnes (Dr Wollaston), talked about increases in demand for social care. The King’s Fund and the Nuffield Trust have said that six years of “unprecedented” budget reductions have led to a 26% fall in the number of people aged over 65 accessing publicly funded social care, which is

“imposing significant human and financial costs on older people, their families and carers and”—

as we know—

“exacerbating pressures on the NHS.”

They also estimate that the publicly funded social care system faces the prospect of a £1.9 billion funding gap next year, and one of at least £2.3 billion by 2020.

As we have heard in this debate—it has rightly focused on this—the cuts mean that 400,000 fewer older people now receive publicly funded care packages than in 2010. An Age UK report shows that nearly 1.2 million people do not now receive the care and support they need with essential daily living activities. It is worth breaking that down further: nearly 700,000 older people do not receive enough help for their daily care needs; and 500,000 people receive no help, not even from family and friends. Taking into account tasks such as shopping and taking medication—the hon. Member for Lewes (Maria Caulfield) mentioned the important factor that older people need to be reminded to take their medication—Age UK says that 1.5 million people are not getting the help they need day to day.

It is shocking that nearly one in eight of the entire older population now lives with some level of unmet need. Of course the impact on the NHS of the crisis in social care funding is important—I will come on to delayed discharges—but the real impact, which we must never forget, is on all those older and vulnerable people living without care. Cuts to social care budgets also hit the 6.5 million unpaid family carers and the 1.4 million people in the care workforce who provide care. The impacts on those groups are often overlooked. The hon. Member for South West Bedfordshire (Andrew Selous) talked about the terms and conditions for the care workforce, and he was right to raise that point, but cuts hit those 1.4 million people as well. There have been dreadful cuts in terms and conditions; providing care is an important job and that should not happen.

The Government responses to the social care funding issues in the Select Committee reports are inadequate. The responses talk about the social care precept and the additional funding in the better care fund, but most of that funding is proving to be a problem because it is back-loaded to 2019-20. The King’s Fund has described using the social care precept as an

“inadequate response that just passes the problem to local government”.

That is a key factor. There is also the question of whether the precept is adequate or otherwise. The precept raised £382 million in 2016-17, and it will raise £543 million in 2017-18. In both cases, that is less than the cost of the national living wage to be paid by care providers.

Sadly, this Government’s inadequate funding of social care was made worse by measures in the local government finance settlement. Having passed the problem of extra funding for social care on to the council tax payer, Ministers went on to make the problem worse by announcing the creation of the £240 million adult social care grant, with funding recycled from the new homes bonus. One third of councils providing social care will be worse off next year as a result of this inept settlement. My own local authority, Salford, will have £2.3 million less in its budgets for social care, and Tower Hamlets Council is set to lose £3.3 million. Where does the Minister think we, with such notice, can find £2.3 million in one local authority budget? Sadly, the answer will be rationing, which is not where we should be.

The Public Accounts Committee has published a report on discharging older people from acute hospitals, but the situation has got worse since the Committee’s report was published. In 2016, a record number of hospital bed days was lost as a result of problems with social care. The number of days lost has increased by over 400,000 in the past year. Over a third of those days were lost as a result of social care problems, and we must take into account the fact that the proportion attributable to social care problems has been increasing. Given the funding cuts, we should not of course by surprised by that. My hon. Friend the Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, said:

“Delayed discharge is damaging the health of patients and that of the public purse.”

Unnecessarily long stays in hospital can affect patient morale and mobility, as well as increase their risk of catching hospital-acquired infections. In 2014, Professor John Young said of the mobility effects of long hospital stays:

“A wait of…seven days is associated with a 10 per cent decline in muscle strength”,

which is clearly not desirable.

The funding crisis in social care is a theme in many of the reports we are debating. The Public Accounts Committee report on personal care budgets expresses concerns that

“funding cuts and wage pressures will make it hard”

for local authorities

“to fulfil their Care Act obligations”.

That is serious. The legislation was passed only in 2014, but councils now find it hard to fulfil their obligations. On underfunding, the Local Government Association said in its recent Budget submission:

“Without bolder action the Government will need to re-evaluate its offer to residents and consider whether the set of legal rights and responsibilities contained within the Care Act are appropriate and achievable.”

The Chair of the Communities and Local Government Committee mentioned that.

The Public Accounts Committee report on improving access to mental health services described the ambition to improve services as “laudable”, but, given the current pressures on the NHS budget, it said that it is

“sceptical about whether this is affordable, or achievable”.

The Committee rightly said that achieving parity of esteem between mental and physical health is a task

“for the whole of government”.

I trust that that includes the hon. Member for Mid Norfolk (George Freeman), who heads the No. 10 policy unit, and who said that disability benefits should go to “really disabled people” rather than those

“taking pills at home, who suffer from anxiety”.

I should say that that has been mentioned already today, and that I have informed the hon. Gentleman of my intention to mention it this evening. Comments such as those reinforce stigma about mental health rather than reduce it. They are profoundly disappointing coming from someone who was until recently a Health Minister. They show just how far hon. Members and the Government have to go on parity of esteem.

Underfunding of mental health services by commissioners has dominated many debates in the House. The Government have failed to deal with the problem that funds intended for mental health services have been used by the NHS for other priorities. In their response to the Committee’s report, the Government say they accept all the recommendations and have implemented them, but I question that. The Government response says that the mental health five year forward view dashboard published in October 2016 monitors key performance and outcomes data. In December, the Royal College of Psychiatrists released compiled figures on spending by CCGs on child and adolescent mental health services, which are vital and which we often discuss in debates in the House.

A number of hon. Members have mentioned the scale of variation that came out of the Royal College of Psychiatrists figures, because the range was from £2 per child per annum to £135 per child per annum, which is a disturbing variation. They have been told only that the CCGs were reporting the data on their spending differently. I say to the Minister that it hardly helps transparency for CCGs to report on their mental health spending differently.

I wrote to the Under-Secretary of State for Health, the hon. Member for Oxford West and Abingdon (Nicola Blackwood). From her response, I understand that further guidance has been issued to CCGs. I would be grateful if, in the Minister’s response, he could tell the House whether we can expect the actual spend and planned spend on mental health services reported will be accurate and comparable. Hon. Members have mentioned in the debate their local CCGs decreasing spending on mental health. We hear that that is not the Government’s intention, but we cannot track what is happening if CCGs do not report accurately. We know that one in four young people who need mental health services are being turned away. The Government should therefore do all they can to ensure that young people can get that access. Extra funding prioritising mental health should be spent as intended and not spent on other NHS priorities.

In its report on NHS specialised services, the Public Accounts Committee said:

“Accountability, to both patients and taxpayers, is undermined by the lack of transparency over NHS England’s decision-making”.

The Committee recommended that NHS England should

“improve the transparency of its decision-making”.

I note that 30 charities from the Specialised Healthcare Alliance wrote to the Prime Minister recently to raise the issue of NHS England restricting and rationing treatment because of underfunding, especially for patients with rare and complex conditions. The charities say that this has taken place without sufficient public scrutiny. Lack of transparency in decision making is a serious issue and I ask the Minister to address it in his response.

There are many issues raised in the Committee reports relating to funding for the NHS and social care. Media reports say that the Chancellor is considering a short-term, ring-fenced cash injection for social care worth hundreds of millions of pounds for councils, but I hope the Minister will convey to the Chancellor that adult social services directors say they need an immediate injection of £1 billion for social care to prevent the weakening and collapse of some parts of the sector. As I have said, the funding gap in social care will be between £1.9 billion to £2.3 billion by 2020. I hope the Government are not going to try a quick fix in the Budget that is too little. The hundreds of thousands of vulnerable people who need social care certainly deserve better.

The Parliamentary Under-Secretary of State for Health (David Mowat) 

The hon. Member for Central Ayrshire (Dr Whitford), who speaks for the Scottish National party, described this as a great debate. I agree that it has been a very good debate. Members on both sides of the House have spoken with a great deal of passion and, in general, with a great deal of knowledge. A number of clinicians, as well as three Select Committee Chairs, have spoken. I join the shadow Minister in thanking the Select Committees for the reports we are discussing today. An awful lot of comments have been made by Members and I will do my best to respond to the majority of them.

The Government accept that these are challenging times for both the NHS and social care. My hon. Friend the Member for Totnes (Dr Wollaston), the Health Committee Chair, talked about this at length. The demographics—both the number of people and their age—are uncompromising. I was at a Health Check conference recently and one of the speakers described the process we have been through. We have been very successful at elongating quantity of life. Until now, however, quality of life has not kept up. Increasingly, older people are living with multiple long-term conditions. Having one long-term condition is becoming unusual, whether it is diabetes, chronic obstructive pulmonary disease or heart disease. This is a fact we all have to face. One reason why we are so keen for the STPs to address this issue is that 70% of total expenditure on the NHS is spent on long-term conditions. Frankly, if we were starting with a blank piece of paper, we would not start with the NHS we have now. Instead, it would be organised around those long-term conditions, meaning more work in the community and all that goes with that. I will come on to talk about the STP process and how we are trying to achieve that.

We know, therefore, that there is an issue with demography. I think it was a Public Accounts Committee report that said that, in 1948, 50% of people lived to be over the age of 65. In 2017, only 14% die before they are 65. That is a massive demographic change and we all need to step up to the mark to meet it. We will try to do that. Drugs and treatment are becoming more expensive. They can do a lot more, but we have all heard the discussions around the cancer drugs fund. The third driver is that patients’ expectations are, rightly, higher than they were decades ago.

The Government response in the spending review was a front-loaded £10 billion injection into the NHS budget, representing an 8% or 9% increase, depending on how it is counted. I agree with the hon. Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, that we should not bicker about these amounts. We can argue about whether it is enough, but the facts are that this is a real increase over the course of this Parliament. There is a discussion to be had on whether that real increase is enough—I accept that. What I do not accept is what we have heard about cuts from some of those on the Opposition Benches. There is a valid discussion to be had about whether an 8% or 9% real-terms increase is enough—I gently remind the Opposition that at the last election they said they would not be in a position to fund more than that—but it is not right to talk about it in the context of cuts, as some Opposition Members have done.

Barbara Keeley 

We get into this repeatedly. The Opposition have no plans to cut £5 billion from social care or to cut the budgets of local councils. That is the difference between us and the Government. Given that we have talked mainly about social care and cuts to social care, the Minister ought to take that into account.

David Mowat 

I will come on to social care. We have covered the NHS, which this Parliament will get a real-terms increase of 8% or 9%. Let us accept that and move on. On social care, a 5% or 6% real-terms increase has already been made available—that is not the Budget; I do not know what is in the Budget. Again, we can argue about whether that is enough, given the demographics, but we cannot argue whether it is true.

I want to spend a little time on the international comparisons, about which we heard some discussion earlier. According to the OECD, in 2014 this country spent 9.9% of its GDP on health. The OECD average is 9%, so that is 1% more, but it is true that the OECD average includes countries such as Mexico with which we would not necessarily wish to compare ourselves. The average for the EU15, which by and large does not include the newer states in the east, is 9.8%. So in 2014 we spent more than the EU average. It is true that we spend less than some of our comparator countries—we spend less than France and Germany—but it is completely wrong to say that there is a massive gap between us and the EU.

Dr Philippa Whitford 

I thank the Minister for giving way, but 2014 was three years ago, and are we not heading towards a figure of less than 7%, which will put us 13th out of 15 among the EU15?

David Mowat 

No. The 2014 figures are the most recent available—and they do not include the comparatively large settlement on healthcare and the front-loaded money in the spending review.

The Government spend 1.2% of GDP on health and social care—we spend another 0.6% privately. That is more than countries such as Germany—the Chair of the Communities and Local Government Committee talked about Germany—which spends 1.1%, and more than Canada and Italy. Again, it is less than some countries—Holland, an exemplar country in this respect, spends considerably more; I accept that there are choices to be made—but it is wrong to pretend that we are massively out of kilter with the sorts of countries we would regard ourselves as equivalent to.

Heidi Alexander 

Does the Minister accept that if we continue on current spending rates as a proportion of GDP, by the end of this Parliament we will be spending less than countries such as Costa Rica and Iceland? Is that the sort of health service his constituents aspire to?

David Mowat 

There are assumptions in that—to do with our GDP growth, their GDP growth and everything else—so it is a difficult question to answer. I would just refer again to the latest OECD figures, for 2014. Those figures are accurate. There is a valid debate to be had about whether they are enough, given the demographics and all the rest of it—that is fair—but it is not fair to imply that there is a massive disparity between us and our EU neighbours.

Barbara Keeley 

rose—

David Mowat 

I have given way to the hon. Lady once already, and I need to make some progress.

Patrick Grady 

Some Conservative Back Benchers have suggested—not in today’s debate but at other times—that some of the 0.7% gross national income aid budget could be used to fund health and social care. Can the Minister confirm that the Government remain committed to that target? By reading out the proportions of GNI spent on health and social care, he has shown how small that budget is in comparison.

David Mowat 

The 0.7% budget for overseas aid is not being discussed here today and it is not my ministerial or my Department’s responsibility. I am proud that we are one of the few countries in the world that meets that commitment, and many of the other countries among our EU partners that have been mentioned do not make that commitment. However, I shall not be diverted any further down that road today.

We have of course had a difficult winter in the NHS. We know that A&E targets are on about 86% rather than the 95% we expect; and ambulance targets are at 60% rather than the 75% we expect. As we have heard, delayed transfers of care—not “bed blocking”—have probably doubled over the past three years. In response, I make one point that I am always keen to raise in these discussions: we do not talk enough about cancer. There are cancer metrics, and we should be proud of the fact that in NHS England, we are meeting seven of our eight cancer metrics. The trend is towards meeting them more easily than in the past. We have heard quite a lot this evening about how well they are doing in Scotland. In fairness, to redress the balance that we have heard about in respect of A&E, I make the point that Scotland is doing somewhat worse than we are on those cancer metrics.

Karin Smyth 

I regret to say that it has been a disappointing response thus far. We have had a very informed debate, so we do not need to have the figures regurgitated to us as if we have not. Will the Minister address my comment that the money is what it is, but is it sufficient to deal with the programme of care and support in the NHS that has been promised? That has been the subject of the Public Accounts Committee’s report for every single month since last January. Is the money enough to do what has been promised?

David Mowat 

The money is what we were asked to provide by NHS England’s senior management, and we provided it. At that time, the chief executive said that the Government had listened and acted. That is what we did, and that money is now available. That is not the same as saying that we do not accept that the system is under pressure in certain ways. Again, though, we talk about the money that is being spent in France and Germany. In Munich, 15 of the city’s 19 hospitals stopped taking people in over this winter. Right across the world—this is the point—there are challenges in national health systems, and we need to work to ensure that money is spent as effectively as possible. We know that £120 billion will be in our health system in 2020. What this Government have to do and what this ministerial team is doing is ensure that every penny is spent as effectively as possible.

We have talked about the five year forward view, and I accept that we are two years into it, but we know that the health system must tilt back towards community health, and the STPs are part of making that happen. We know that we need to get better than we are so far in terms of mental health and parity of esteem.

Mr Betts 

I think the STP approach is capable of being a good one. The problem is that when I go to the chief executive of the Sheffield Teaching Hospitals NHS Trust, Sir Andrew Cash, who is respected in government as well, he tells me that the process of transferring resources to the community will not work unless there is some transitional upfront funding for the whole process. We cannot stop doing what is being done in the hospitals and simply transfer it to the community.

David Mowat 

He is right about that. NHS England is evaluating the STPs at the moment and during March and April, and it will decide which STPs are high priority, which will be invested in and which will be taken forward at speed. We heard the phrase “accountable care organisations” used earlier, and it is the Government’s intention to ensure that those high-performing STPs that we proceed with—it will not be all of them; frankly, the standards are variable and locally driven—will in time become accountable care organisations.

The shadow Minister asked me to talk about social care, and I will do so. During the present Parliament, accessible funding for social care has risen by 6% in real terms; it fell during the last Parliament. Last year 42% of councils increased their social care budgets in real terms, and in December £900 million was provided in new homes bonus payments.

Barbara Keeley 

Will the Minister give way?

David Mowat 

No, I will not.

Barbara Keeley 

rose—

Mr Speaker 

Order. The Minister is not giving way at the moment.

David Mowat 

The Care Act 2014 was introduced by this Government, and it has transformed social care, although we accept that the system is under pressure. The number of delayed transfers of care in Newcastle, St Helens, Bedford and Nottingham is nil. The Chairman of the Public Accounts Committee, the hon. Member for Hackney South and Shoreditch (Meg Hillier), said that she had been told by Simon Stevens that if the top-performing councils—in terms of delayed transfers—were emulated by all the rest, the consequence would be very small. The truth is that there is a 30 times difference between the top 10% of councils and the bottom 10%.

Mr Betts 

Will the Minister give way?

David Mowat 

No. I have given way to the hon. Gentleman twice already, and I need to finish my speech in two minutes.

We accept that there are challenges and pressures in social care, but we also know that we need to make progress in mental health care, and we are doing so by working towards parity of esteem. By 2020, there will be 5,000 more doctors in general practice and 2,000 more pharmacists. We have talked about the need for more pharmacists. I visited a pharmacist’s practice in Perivale on Friday, and I know that we can transform the way in which general practices work. There will be 3,500 mental health therapists as well.

Nearly 3 million people work in healthcare, in the NHS and care sectors. Many of them are remarkable people doing remarkable things, and they deserve our support. It is important for us not to weaponise this entire discussion. It is important for us not to produce election leaflets about dead babies, and all that that means. Our healthcare system and the NHS deserve our support, and the Government are committed to ensuring that they receive it. I commend the estimate to the House.