Examination of witnesses
Chris Hopson, Chief Executive, NHS Providers, Margaret Willcox, Vice President, ADASS and Rt Hon Stephen Dorrell, Chair, NHS Confederation.
Q87 The Chairman: Thank you all for coming. Just a few administrative matters: the whole session is on record and when the “Broadcasting” sign is on we are all being broadcast. Any private conversation may be picked up so please be careful. That goes for Committee Members as well. Committee Members will declare any particular interests when they ask questions, even though it might already be in the register of their interests. At the end of the session you will be provided with a transcript. You cannot change it but you can correct it, if you so wish. Before we start, please introduce yourself and if you want to make an opening statement please feel free to do so on any aspect of our inquiry. Can I start from my left?
Chris Hopson: My name is Chris Hopson. I am the chief executive of NHS Providers. We are the membership organisation for the 238 acute, community, mental health and ambulance foundation trusts. I will say five very quick things. First, it seems to us that if you look at the future projections for demand and disease patterns, there is a spike in demand that the NHS faces which, to be frank, our perception is, it is wholly unprepared for. The second point to make, linked to that, is that there clearly is a set of workforce demands that that extra demand will create, which again we feel the NHS is wholly unprepared for. The third is that we cannot see how the NHS can meet those challenges and the wider social care system within the existing model and we therefore need to move to new care models much more rapidly. We are concerned, although that process has started, about the ability of the NHS to get there quickly and consistently enough. The fourth point to make is we believe we will need to increase funding and that current funding levels will be insufficient to meet that demand. The final point is that if we are to keep a taxpayer-funded system we feel very strongly, if there is to be increased funding, it will require public consent and if we are to gain that public consent we need a much better quality of debate about the NHS, its funding and its outcomes.
The Chairman: Thank you very much. It is nice to have a previous Secretary of State here.
Rt Hon Stephen Dorrell: Not everyone in the room may agree with that, my Lord, but thank you for the invitation. Can I introduce myself as chair of the NHS Confederation, which has members from the provider side, from the commissioning side of the health service and has associations with the Local Government Association? We seek to develop a broad health and care view of the health and care economy. I should declare two interests, if I may, to the Committee. The first is that I am an adviser to KPMG, and the second is that I chair LaingBuisson. I refer to that because I want to refer briefly to the report published by the ONS on the total size of the health and care economy, which relied, to some extent, on work done by LaingBuisson.
There are two points I would like to make in an opening statement, agreeing with everything Chris has already said. The first is to refer to the total health and care economy, which the report I have already referred to assesses as 9.9% of the UK economy—this is a reassessment published by the ONS earlier this year—and, to some extent, draws the fire on those who draw attention to, allegedly, how small our health and care sector is by international comparison. We are still, incidentally, 1% behind France and Germany but at significantly higher levels of spend on health and care services than some of the earlier numbers suggested. It allows me to make the more important point than the “moment in time” comparisons on the size of the health and care economy, and that is to refer to trends.
I very much welcome the work of this Committee, which, if it is focused on the long-term sustainability of our health and care sector, is presumably focused on trends—where this is going over the next five, 10 or 15 years. There is a tendency when people talk about the health and care sector to regard it, because it is largely tax-funded, as a kind of national overhead and a burden, and we are worried because we devote a rising share of our national income to delivering health and care services. I would like to invite the Committee to look at it exactly the other way round. As society becomes richer, of course, it is true that the elements of our society that deliver health and care services to the sick and the elderly take a rising share of our economy. Why would they not? It is Maslow’s famous hierarchy of need that, as societies become richer, in this country, all over the world and throughout history, these services take a rising share of our rising national wealth.
The question for this Committee and for those concerned about the future of this sector, it seems to me, should be how to ensure that that expressed wish of consumers in this and every other country throughout history is not obstructed by the fact that we choose to fund the majority of our services through the tax system to secure equitable access. It is that policy challenge which is at the heart of good policy-making in health and care services: how to facilitate the growth rather than, as the Government’s current plans suggest, restrict that growth—I would argue artificially—during the whole of the current decade. That is the core question.
The second question I would like to touch on briefly during the evidence, if the Committee is interested, is not just the quantum of money but how we ensure the money is properly spent to deliver the objective of improved life experience for the consumers I have been talking about. We tend, again, because we think of them as services, to think about medicine and the service we deliver over a period of years, rather than the outcome we deliver and the experience of the people who rely on these services. That is a theme I would like to come back to.
The Chairman: Thank you. We will come back to some of the comments you made in the first question.
Margaret Willcox: I am Margaret Willcox. I am currently the vice-president of the Association of Directors of Adult Social Services, so we represent the directors and assistant directors, both past and current, in the country. My opening remarks would be that we are very well rehearsed on the ageing population that the country faces and, in particular, the fact that many of us are living longer, with more complexities. The number of those aged over 85 in the population has seen a very significant rise. We urge people to consider the fact that there are other groups also in that rising group. There are more people with learning disabilities now and we are predicted to have 21% more by 2030. There is a rising number of people with mental illness. We have made more Mental Health Act assessments and more deprivation-of-liberty assessments in the last few years, and they continue to rise year on year. We are seeing dementia in people with learning disabilities—situations we have not seen before. Regardless of whether they have a mental health problem, a learning disability problem or indeed a physical disorder, people are likely to have more complex needs because of the nature of the advances we have seen in medicine and, to a certain extent, in social care.
I urge the Committee to think about the fact that for people to have a fulfilled life for as long as they can, we need a range of services across health and social care and into broader areas such as employment, so that people can have a fulfilled life and contribute to the economy. The services and providers we have are a form of taxation, but it is important to remember they also contribute huge numbers to the economy. The social care workforce in this country is bigger than the NHS workforce; people often forget that and the contribution they give back. The situation we currently face, which I am sure will come out in the debate, is about where that future workforce is and what sort of model we can expect for people to live at home for as long as they possibly can, or at least in their own community with the right support—not too much support, but enough to be motivated and enough to keep them safe and as healthy as possible for as long as possible.
The Chairman: Thank you all for that opening statement. Much of what you have all said comes out in my first question, which was related to the funding issue for future sustainability and the use of the money. If I go back to that, you may all wish to comment: how do we make spending on all these health aspects part of the public service agenda? Maragret mentioned the housing issues and we have also heard about integration of social care. Do you have any comment on either of those questions?
Chris Hopson: Stephen should go first because he is very strong on this issue. I will follow behind you.
Rt Hon Stephen Dorrell: You might wish to manage expectations. If I may say so, my Lord, this is at the heart of it. I would like to dive straight into a short-term issue, which is the sustainability and transformation plans, but enlarge that to show where an important part of the longer-term answer lies. Last December, NHS England initiated the STP process. It is variable as it has been, in the famous cliché, built in flight and it is certainly imperfect but I am absolutely clear that it is the right direction of travel. It is insisting that you cannot deliver what I talked about, outcomes for citizens, if you see the NHS either as a single silo or, more accurately, as a group of silos. The NHS is not a city on the hill. That is the simple way of putting it. It is a public service and you can deliver effective outcomes and good value, high-quality services for citizens only if the NHS is part of the broad range of public services delivered in a place.
STP is the NHS route into the devolution agenda that was pioneered by Sir Howard Bernstein in Greater Manchester. One of my roles is as an independent chair in Birmingham and Solihull STP. We are seeking to insist that NHS acute hospitals, NHS primary care community health services, social care services, social housing services and education services are all part of a continuum of public services. If you cut, for example, mental health services in schools or you cut independent living through the DWP or you cut extra care housing through the housing budget, the public service economy as a whole shrinks, the outcome delivered to citizens shrinks and people become unnecessarily ill. People express this as an economic argument but the real challenge is the social policy point that if people are not able to live independently they become unnecessarily ill and then present in GP surgeries, A&E units and emergency admission wards.
Chris Hopson: The evidence is very clear. Michael Marmot’s work is absolutely crystal clear: effectively, the determinants of health and wellbeing go much more broadly than just focusing on health. They are determined by issues such as: are individuals in secure employment? What is the quality of their housing? Stephen tells a great anecdote: at the NHS Confederation conference, the chief executive of New York Medicare came over and said the single biggest intervention that had improved health outcomes in New York was the installation of air conditioning units in low-cost housing. In the summer spike in the heat, old people were becoming ill because they had inadequate housing and air conditioning. There is a real opportunity here, as Stephen was saying, to place health in its appropriate set of wider determinants. For example, Salford Royal acute hospital trust is developing a much closer relationship with its local authority and not just having a conversation about, “Yes, we are very happy to take on social care”, but looking at how it can relate much more closely to the housing department, the leisure department and the education department so that we can put health in this much broader set of determinants.
The reality, it seems to us, is that we have a national illness service. We do not have a national health and well-being service where we use the full range of public services to support people to have healthy, independent lives for as long as possible. All the money, emphasis, management bandwidth, capacity and capability seem largely focused on treating people who are ill, whereas, as Wanless showed 15 years ago, we will not be able to cope with that demand unless we focus much more effectively not just on prevention and health promotion but on putting health in that much broader range of public services.
Margaret Willcox: I would concur and add that because of the restrictions in funding and the drop in funding that everyone is familiar with, a lot of the funding we now have is focused on that acuity end. It is all about sorting out today’s crisis; it is not about sorting out tomorrow’s solutions. If anecdotes are acceptable, one of the things we see regularly on every acute ward is a point at which a patient has been admitted and reaches the stage of realising that their isolation, lack of independence, loneliness and miserable housing means they do not want to go home. Their family has reached a point where it does not know how to look after them any more and you have a desperation point where people make poor choices. Instead of us thinking, “How can we get this person home?”, we should be looking after their carers—personal carers not paid carers, although they have a role, too—to keep that family together in an extended way, if possible, and give them things which are quite small and relatively inexpensive but will stop them using the A&E front door, which, as Sir Keir would say, is its own success as it is always open. That is where people go when they do not know what else to do, but it is not the right place.
Rt Hon Stephen Dorrell: Can I support the narrative with some specific statistics on the balance of spending within the health and care system? Between 2005 and 2015, a ten-year period, NHS spending in total went up 25% in real teams, social care spending flatlined, primary care spending went up 3.5% in real terms and spending in the acute sector went up 31% in real terms. The evidence is clear that, despite ministerial rhetoric—I have been responsible for it myself and I see some faces round the Committee who have also been responsible for it—we have all said how important it is to channel your resources into the community and into primary care, but what has happened is they have gone to the acute sector and not to the place where Ministers say, quite rightly, they need to go.
Q88 Lord Warner: Stephen, you made a very helpful comment at the beginning about the proportion of GDP realistically being estimated and updated now, but within that sum I suggest there has been huge variation year on year over time between what goes into the NHS and, certainly at the beginning of the year, what it can expect to spend in the 12 months further forward. As you rightly pointed out, there has been huge variation. There has been no synchronisation between the uprating of NHS expenditure and social care expenditure. What do you think we should be saying as a Committee about what more should be done to synchronise that over time so that we do not have this random system of uprating year on year, and it is a guesstimate on the part of managers in both systems as to how much they will get next year, particularly if you want to go down the path of the STP model? What are your ideas for synchronising those spending patterns over time?
The Chairman: Before you answer, may I say that your comments have produced a lot of excitement? I have a whole series of people before we even get on to the second question, and there are another six questions. Can we have a quick-fire response and a quick-fire question session before moving on to the next one? Please go ahead.
Rt Hon Stephen Dorrell: The Committee will know that I proposed, together with Alan Milburn and Norman Lamb, at the beginning of this year that there should be a commission which looked at some of the issues your Committee is looking at precisely to provide a longer-term context to address the issues Lord Warner mentions. I emphasise that none of the three of us thought this was to take the health sector out of politics—the health sector is intrinsic to politics in a democratic society—but it was to try to provide a longer-term context to the different funding flows coming into the sector. Incidentally, it is worth drawing out to the Committee that the piece of work Lord Warner referred to made it clear this is 10% of all economic activity in the UK, but only 80%—only—of the funding for it comes from the taxpayer, so it is not exclusively a taxpayer issue.
The Chairman: Could we go quickly now to Baroness Redfern, Baroness Blackstone, Lord Mawhinney, Lord Bradley and Lord McColl?
Baroness Redfern: I have two very quick questions, one for Stephen. You mention devolution and STPs. What are your views if the STPs are not coterminous with a devolution deal? It is vitally important that people in that area know their subject. As the leader of a local authority, I have views on health and social care. The second one, to Margaret, is that only 44% of disabled people have health checks. We debated that last night in the House. How can we get more GPs to support increasing those health checks so they can have a personal plan and move on?
Rt Hon Stephen Dorrell: The short answer to Baroness Redfern’s first question is simple. I refer to the fact that STPs are in process and being built in flight. I have already said that in Birmingham and Solihull I do not think it is appropriate for an outsider to be chair of this board and I propose to sign off my report to the proper governance processes tomorrow. There needs to be governance that allows decisions to be made, which clearly is not the current state of the STP process. Having said that, I give significant credit to NHS England for having initiated the process of ensuring that the NHS is part of that broader devolution agenda. It clearly needs to be. The boundaries issue needs to be addressed, but if we argue about boundaries we shall never get any work done at all. It is a process not an event.
The Chairman: Does anybody else have any quick-fire response to add?
Margaret Willcox: I suggest there are parts where we have made good progress here, particularly for people with learning disabilities, whose health check levels have gone up, and the diagnosis of dementia, which is vastly improved; and it is learning from those. It is also trying to have a relationship with primary care that says the health check is more than about whether this person’s physical condition has deteriorated or not; it is about how are they employing themselves in their daily life, and what they are contributing to it. It is about trying to make it more rounded than just the diagnostics. Then it is of much greater value to the individual service user and their family.
Baroness Redfern: They can support them.
Baroness Blackstone: I want to follow on from what Norman was saying about the need for more synchronised spending from the figures you were giving, Stephen. If we are to have the integrated social policy that you are proposing, can we continue with a system where local authorities are quite separate from NHS institutions and organisations? Should we think very radically about this and consider whether, to achieve this, we should go back to a single form of governance via local authorities; rather as was proposed not that long ago by the then-Chancellor, when he was trying to develop ideas about the Northern powerhouse in Manchester—that there should be proper devolution of health to either regional or local authorities? Only then will we have some sensible decisions made about how funding should be allocated and more joined-up thinking on the relationship between education, social care, housing, et cetera.
Rt Hon Stephen Dorrell: If I was pushed for a one-word answer it would be yes, but may I enlarge on it a little? The debate between central and local is as old as the NHS itself—indeed, it goes back, before the NHS, into the Cabinet minutes before the NHS legislation came forward. My very strong view, first of all, is that there is a role for the “N” in the NHS—an important role in defining standards, ensuring it is a transparent service where you can see what is being delivered in one part of the country by comparison with another, and looking at sharing resources, in particular in specialised areas. There is definitely a role for the “N”, but the balance has gone far too far in favour of the “N” and away from the local. Not only has that created unnecessary and deeply damaging fissures within local public services, it has also reduced the accountability of the health service to local communities.
It was an argument I remember having with Ken Clarke in 1990 when we first introduced the purchaser/provider split—commissioners for providers, as it now is. I was in favour then, as he was, of removing councillors from trust boards on the grounds these were enterprises that needed to be managed as professionally as possible. He was also in favour, and the legislation reflected this, of removing councillors from what we now call the commissioning side of the health service. I argued with him then that that was wrong, and I still think I was right then, and that policy is being put into reverse in this respect, which is a good thing.
Lord Mawhinney: It is good to see that your clarity of thought and expression has not decreased over the passage of time.
Rt Hon Stephen Dorrell: That is kind of you.
Q89 Lord Mawhinney: That was an excellent summary of public service, where you took six or eight different things and rolled them all into one entity. The budget for public service would be astronomical. My question is: how do you think we should write a report that persuades the Government, which operates on the basis of 20 silos, roughly, to forget about silo-ing health and social care and put them all into one ginormous, economic entity called public service?
Chris Hopson: If you put health and social care together, it is not a massive increase in terms of the budget. Again, Stephen, you will know the figures better than I do, but we are talking about a £110 billion NHS budget. We were not necessarily saying that you would lump all of those budgets in a single place.
Rt Hon Stephen Dorrell: I am.
Lord Mawhinney: I am just quoting Mr Dorrell.
Rt Hon Stephen Dorrell: Let me answer Lord Mawhinney because I absolutely do not think it follows from what I was arguing that there should be one organisation delivering housing services, education services and hospital services. The reductio ad absurdum of that, which is the anecdote I tell in Birmingham, is this does not mean that University Hospitals Birmingham runs the primary schools in Smethwick. That is barmy. It illustrates that this is not about changing the boundaries of managing the acute hospitals or the primary care system, or the schools system; this is about creating a commissioning process that looks across the range of public services and insists there are proper digital exchanges of information, proper professional exchanges and proper resource exchanges.
Lord Mawhinney’s question is: what is the key argument to the Treasury short of money to justify this? The Treasury is interested in efficiency. We endlessly hear how the health service could be made more efficient, and nobody disagrees with that. We usually hear about agency staffing ratios and about procurement, and every Health Minister in the room will have made speeches about both subjects. Health care is just like any other sector in the economy; this is a sector of the economy we are talking about. How do you create transformative efficiencies in an economy? It is by rethinking what you are trying to do. We are no longer trying to deal with a world where communication is paper-based and people present with a condition for diagnosis, treatment and cure. We are dealing with a range of services where success relies on a joined-up service to the citizen. If that is the exam question, let us start with the right question and we will have a greater chance of delivering the right answer.
Chris Hopson: It is also important not to forget Lord Warner’s point. There is a degree of frustration in the present government about the inability of the members we represent to deliver the efficiencies being asked for. One of the problems is there is no credible, medium-term financial strategy for the NHS. This year is the year of plenty, where we have a 3.7% increase, which just about keeps up with demand and cost. When we all saw the settlement last year we said, “How on earth is the NHS meant to deal with a year in which funding increases by 1.4% next year, 0.3% the year after that and 0.7% the year after that?” It becomes incredibly difficult to run the system effectively when you do not have an evenness, a consistency and a smoothness of funding increase but also a funding increase that reflects the underlying cost and demand.
As one of your former colleagues, Lord Lansley, said to our annual lecture about three or four weeks ago, everybody knew we were due a five-year squeeze between 2010 and 2015; nobody expected we were going to have a second five-year squeeze between 2015 and 2020. My argument to you would be that the unevenness of having a front-loaded year but then years which, to be frank, are miles off in the increase needed to keep up with demand, makes it much more difficult for our managers to run their hospitals, community mental health and ambulance services effectively because of the unevenness with which those funding increases are flowing.
Q90 Lord Bradley: I should declare my interest: I am an executive director at Pennine Care. Perhaps I should also declare I lived in Manchester because that is relevant to the conversation we are having. “Devo Manc” is about setting joint commissioning arrangements across place and people. Crucial to that, in my view, as a first step, is the recognition that you are trying to integrate physical and mental health into one commissioning arrangement. I absolutely support everything you have said, Stephen, and the STPs are a mechanism for that change, but the problem, as Chris has identified, is in the short term. Because of the financial situation, it is more sustainability that those plans are looking at, rather than transformation. How do we shift to have that long-term sustainability and the funding transformation that is not being absorbed into ensuring current services are maintained across health and social care, physical and mental health?
Rt Hon Stephen Dorrell: That is a challenge for any manager at any time in any economic sector. It is a particular challenge in the health and care sector. At the moment, the figure Chris was quoting for the spending profile in health in the NHS budget, narrowly defined, is true in spades, incidentally, in social care, where there is significant resource planned for the last two years of the spending plan, 2019-2020 and 2020-21, but in the short term there is a significant further reduction planned in social care. This is the sector that the CQC last week described as “approaching a tipping point”. Lord Bradley’s point is very well made when looking at the health and care sector as a whole. There are two levels of answer. First, to Lord Mawhinney’s point on efficiency, it is not efficient to use an acute hospital as a care home, which is the practical result of the world we are creating. Bringing forward some of the funding planned for social care at the end of the spending profile is an immediate fix that could certainly create some headroom for the kind of change Lord Bradley is looking for.
While the health and care sector, as a whole, in the lifetime of every person in this room—and of our children and grandchildren, I hope—will be largely a public sector-provided service, a good commissioner of public services applies Lord Adebowale’s principle that a public service is a service to the public. As a commissioner of services to the public, the key question is how we bring parties to the table who are able to facilitate the type of change Lord Bradley, quite rightly, says is needed.
The Chairman: I am managing the time in this session extremely badly, because we have not moved past the first question. Lord McColl, a quick question from you and then we will move on.
Lord McColl of Dulwich: Margaret Willcox, you mentioned all the causes of the increasing expenditure in the NHS but you did not mention probably one of the greatest, which is the obesity epidemic.
Margaret Willcox: Absolutely.
Lord McColl of Dulwich: Do you have any figures on exactly how much this grotesque increase is costing?
Margaret Willcox: I do not but we can obtain them. They may have been in the original evidence submitted. This goes back to the previous argument. One of the concerns we have, as Stephen has mentioned, is if we concentrate only on the acute end of when the obesity crisis is here or when the person has had a fall and is in a crisis when they are elderly then we are looking at it from the wrong end. The answer to obesity, from all the public health arguments we have seen, is about people’s lifestyles and social parts; about education and good learning and about exercise. They are about our children and getting the young people of this country to take some responsibility for themselves, but to do it in a way that is also enjoyable and sustainable rather than a quick fix.
One of the things I would add about the integration of funding, whether at commissioning or at any other point, is that if we concentrate the funding on the acute end we will never treat the problems we are building up. We need to come much further forward into how we deal with the prevention end. We know from history that whenever finances are tight, it is prevention that goes first because we have to make the quick fixes for the acute situation. It is about trying to redefine it and about moving away from a medical model and a medical solution to everything when there are alternatives.
The Chairman: If you have those figures we would be pleased to have them.
Margaret Willcox: Certainly.
The Chairman: A lot of the issues have been covered so hopefully we can keep the questions and subsidiaries to the original one and be quick fire because we have a lot of material to cover. Baroness Redfern, can I start with you?
Q91 Baroness Redfern: My question has almost been answered. I agree with the panel: funding acute beds as residential beds is not the best place to spend scarce resources. I am interested, as I say, in the health and social care end. If there is additional funding after 2020, where would you see that funding being targeted?
Chris Hopson: If you take a short-term view, one of the interesting things at the moment is that the entire NHS seems to believe that if you were going to put more money in it should go into social care, which is a very interesting statement.
Baroness Redfern: In the past more has gone into the acute sector.
Chris Hopson: Correct. We identify that if you want to sort out the issues that, for example, acute hospitals are currently dealing with, probably the best place to spend the money is on social care to ensure we do not have 30% of people on older people’s wards occupying beds when they are better off with care being provided close to home because they are medically fit to discharge. Stephen has also pointed out primary care where, if you look at what is currently happening, the 6% increase in demand coming into A&E in the first quarter of this year, both in presentations and admissions, is a function, partly, of the fact that primary care is completely overwhelmed and is unable to cope.
There is an illustration of a wider point here. We spend a lot of time talking about the need to transform the system, and we tend to talk about the money. The bit we do not tend to talk about is that, if you want the system to transform, we have to incentivise our leadership teams to focus on transformation. If you ask our members what they are most incentivised to do, you effectively lose your job as a chief executive or a chair if you cannot make today’s money work—if you cannot pass today’s CQC inspection, if you cannot ensure that you are meeting your 95% four-hour target and if you cannot ensure you are providing the right quality of service, all of which are very important. No chief executive or leadership team has ever lost their job by failing to come up with a long-term transformation on their local health and social care economy.
One of the arguments I would be making to you is that if we want the system to transform we have to achieve a much better balance between the focus on today’s performance targets and today’s money and balance it appropriately in the way that we do in most other systems, but not in the NHS because of the operational pressure it is under, and say to management teams, “We want you to focus on long-term transformation”. All we are doing at the moment is running faster and faster and harder and harder inside a broken model, and one day we will wake up and realise that we have not spent the management time and capacity on moving towards a transformed system. That is where we are, partly, to be frank, because of the pressure the existing system is under.
All our members say they are spending their whole time trying to prop up this increasingly fragile system, and they simply do not have the management capacity or bandwidth to do the really complicated bit of bringing everybody together in their local health and social care economy and plotting a path to a sustainable future. One of the reasons for that is perfectly understandable; they have spent their whole time being measured against today’s targets, not against, “How well are you doing to deliver the transformation?”
Margaret Willcox: May I add to that? We would ask, in respect of the finances but also the way the STPs work, that we are trusted with the money. Local government has demonstrated it can make the cuts needed to bring local government into some form of balance. To always passport money through another route to us, as has been demonstrated by the Better Care Fund, is not the greatest confidence builder if you are working in local government. We know how to prioritise things, we understand how, as I said before, the impact of things such as housing and employment and equipment can transform people’s daily living and make such a difference to the level of demand they put on other services. We need to be trusted to do it.
Rt Hon Stephen Dorrell: May I add a point here? I absolutely agree with what Chris and Margaret have said and would link that to the STP process, because that is exactly the issue the STP process is supposed to be trying to address; to encourage people to think slightly longer term. I have already mentioned his name once but let me mention it again. If Sir Howard Bernstein was sitting in this chair now and was asked how he would achieve the kind of transformation we are looking for, when he makes his presentations on this he always starts not by talking about the deficits in the hospital service but about employment and liveable cities and green spaces, so that people have a fulfilling life. The great mistake in the health and care world is to imagine that demand is a given and then to reduce it to money. Demand is people’s healthy living, and if they have employment then, as Lord Bradley pointed out, there is a direct link between mental health and physical health. There are libraries of evidence demonstrating that roughly 20% of demand for physical health services can be traced to mental health causes—mental health problems caused by isolation and all the social conditions we are concerned about.
We should not imagine that the rest of local government is somehow divorced from, different from and unrelated to the hospital deficit. The failure to deliver those services and to deliver a joined-up version of local government is one of the key underlying causes of the hospital deficit.
Q92 Lord Mawhinney: I very much appreciated Mr Hopson’s analysis; I thought it was spot on, but you stopped at exactly the wrong time. You got to transformation and then left us hanging on a branch. If you want to have serious reform of health and personal social services, do you continue to leave it with local authorities but not ring-fenced so they can decide how to spend the money however they want; do you wrap it up with the NHS into a new body; or do you set up a special health and personal social services commission which works in parallel? All those would be transformational. Could you give us the second paragraph of what you said earlier?
Chris Hopson: What we are trying to do in the NHS is achieve this process through the sustainability and transformation plans that Stephen has already talked about. Yes, you could try to do a top-level structural reorganisation. My sense is that the NHS does not have a particularly strong history of effectively moving around organisational blocks. This has to be a bottom-up process where you have different workforces, different leadership teams which are currently separate. I can tell you five or six places where this is beginning to work, and there is a single thing that underlies all of them, which is that the local authority chief executive has sat down with a hospital chief executive, the leaders of the local GPs, the accountable officer of the clinical commissioning group and they have hammered out between them an agreement about how they will do things differently. They will completely ignore all the stuff raining down on top of them from NHS England, NHS Improvement and everywhere else and say, “We are going to do the right thing for our local population”.
The key, for me, is not necessarily a structural reorganisation but about local people—local leaders working together effectively to do the right thing for their local populations. That is happening in Manchester, Yeovil and Northumbria, and it has been achieved without primary legislation to create brand new structures. It is bubbling up from underneath, encouraged and supported from above, not mandated from above in a structural reorganisation.
Lord Mawhinney: GPs talk to me about being forced into new GP structures for 30,000 people and about how concerned they are for their patients. Will all that pass in the night and not be a factor that anybody needs to worry about?
Chris Hopson: If you said to us, “Where are the tensions likely to be?” one of them, clearly, is in a primary care structure that, in some places, still feels as though it is a 1948-created cottage industry. I would observe that in places such as Birmingham and Salford we are seeing the growth of GP federations, where GPs are willing to come together to create organisations of a critical mass that are then capable of interacting effectively with these much larger organisations, such as mental health and acute hospital trusts.
The Chairman: Are you saying the current model of primary care needs to be changed?
Chris Hopson: I am saying there is a widespread agreement that the 1948-bequeathed structure of a bunch of single-handed practices led by individual GPs is unable to provide the kind and scale of primary care that we now need, and there is a rapidly growing development where people are coming together in GP federations which make it easier and more effective to then link up all these different parts of health and social care.
Lord Warner: There seems to be a general agreement that we should have more direction of money towards social care, if there was more money to be directed. What are the processes for how you would redirect the money from the centre to achieve that objective? Bottom-up is fine, but at the end of the day money flows down from the centre.
Chris Hopson: The immediate answer is in the submission we have made to the Treasury about the Autumn Statement. Effectively, what we have said is that already laid out in the Government’s plans are two ways of increasing money to go into social care. The first is a back-loaded increase in money in the Better Care Fund, where this time the Government will put money into the Better Care Fund. The second is enabling local authorities to raise more through the precept; taking away the 2% cap and raising it to 4%. Our argument in the Autumn Statement is both of those should be brought forward.
The combination of the two is important because we know that the precept is potentially discriminatory on the grounds that there are local authorities with lower tax bases which will not be able to raise as much money through the precept. If you are a relatively less well-off northern council, such as Gateshead, for example, you will not be able to raise as much through a 4% precept as you would if you were leafy Surrey. Hence the need, in our view, to balance the increase in the precept with the opportunity to cross-subsidise using a Better Care Fund that is there to make up the gap.
Lord Warner: That is a short-term fix.
Chris Hopson: I accept that it is a short-term fix.
Lord Warner: We are dealing with after 2030. How do we change this system? What should we say in our report to change this system for the next 15 years? That is to all of you.
Rt Hon Stephen Dorrell: I heard Lord Warner’s question as directed at the short term and I agree with what Chris said, in particular, about the Better Care Fund. That is money that the Government have committed to social care. It is in the budget for 2019-20, 2020-21 and it is necessary, as the CQC was arguing last week. The broader question, as Lord Mawhinney referred to, of how this joined-up version of public services is to be financed fundamentally comes down to a question of financing local government and, in his second question, the relationship between local government and the NHS central budget. I do not think anybody is suggesting there will not continue to be a nationally voted, parliamentary vote to the NHS; the question is the relationship between the NHS central commissioning authority and the local commissioners of service within a place.
If we are looking beyond 2020, there is absolutely no escape, nor do I look for one, from the point with which I started in response to Lord Patel’s initial question about an opening statement, which is that health and care services are a growing part of the economy. If we seek to manage the structure of public policy or public finance to restrict the growth of the public sector—for all the reasons with which I, as a lifelong Conservative, am fully familiar—we have to reconcile the ambition for manageable tax burdens, small state and all that with an explicit commitment to allow the health and care sector to grow in a way that reflects the ambitions of the society it is there to serve.
Chris Hopson: If you are right, Stephen, it seems fundamental, if you are going to increase funding in a taxpayer-funded system, you must have a quality of debate with taxpayers where you set out the options for them and the consequences, for example, of carrying on with flat funding or reduced funding, and the consequences and potential benefits of increasing those funding levels through increased taxation.
I did an interview for ITN last night. They had done a poll where, effectively, they said that 70% of people interviewed would be prepared to see 1p extra on income tax and 50% would be prepared to see 2p extra on income tax. My argument would be that in a taxpayer-funded system, if we are to have the kind of debate that Stephen is talking about whereby we say we are going to increase public funding, you will only do that by building public consent. I have to say I do not see a quality of public debate at the moment that enables us to have that proper discussion and to gain that consent. It is urgent that we find a way of having that proper debate with an appropriate level of underpinning evidence to enable an informed debate, rather than the quality of debate we had in the general election, which tends to revolve around things such as the “War of Jennifer’s Ear” and such like, as opposed to the real fundamentals that underlie this.
Margaret Willcox: We appreciate the precept and, as you know, a large percentage of councils took it up. There is an irony about it in that if you have a high level of self-funders in your particular local authority and you are more likely to raise the precept, you are also less likely to have the need that other areas have where the precept is very difficult to collect because there are lots of people below that threshold and their level of need will be the same. Clearly, the north/south divide is an example, but it is there between particular councils as well. There are perceptions that this is a local tax and, therefore, local people are paying for what they can locally afford, as opposed to having a national scheme for everybody to meet a level of eligibility criteria and service. There is a balance to be had between having a local tax and saying, “This is the level of qualification we want for the country; this is what you should expect to pay in return for your major taxation”.
The Chairman: This discussion leads very well to your question, Lord McColl, about funding issues.
Q93 Lord McColl of Dulwich: If more money is not forthcoming, what exactly should be done? Should alternative types of funding, such as charging for some services, encouraging greater private spending and limiting what the NHS provides be considered? What alternative funding models do you consider viable alternatives to the present arrangement?
Rt Hon Stephen Dorrell: May I link that to Margaret’s last answer? There is an important point that is quite often lost in the discussion of funding health and care. The Government, quite rightly, say they are committed over the lifetime of this Parliament to additional spending of either £8 billion or £10 billion, depending on your point of view. What it does not then do is add the yield of the precept as additional funding. By opening the precept as funding available to the health and care sector, the Government unlocked a significant level of additional funding to which, in our view, access should be brought forward through the Better Care Fund. As I have said, in a sector where we are talking about £180 billion, of which the total taxpayer contribution is about £139 billion, roughly £40 billion already comes from other sources into this single sector. Going beyond the debate about the NHS to a debate about health and care, and preferably to public service more generally, puts you into a world where there is already more than one funding stream. The question is how you secure the objective of equitable access to high-quality services without changing the free offer of the health service but in the context of a broadly funded public sector with sufficient resource to deliver the outcomes we have been talking about.
Lord McColl of Dulwich: Do you want to increase the £40 billion from other sources?
Rt Hon Stephen Dorrell: Given that the whole basis of my argument is that, as societies become richer, all of us, as citizens, choose to spend more on the services delivered by the health and care sector, we should be looking for ways of accessing the widest possible revenue sources without changing the free offer. The question Lord McColl is hinting at is should we go for a revised funding basis of core NHS? My answer to that is no; it is a question for Parliament, not for NHS managers. My answer to that is no, because it misses the point. The point is that this sector already has diverse funding streams, and what we are doing at the moment is relying unnecessarily on the tax-funded core because we have not set up a structure that attracts sufficient funding into the sector more broadly defined.
Chris Hopson: I accept, quite rightly, that we are talking about the wider health and care sector but you would expect me to bring an NHS provider-specific focus to this. We went on record about four or five weeks go to say that we have now reached a tipping point where the NHS is being asked to deliver a set of services that it simply cannot carry on delivering for the funding available. We would make the observation that, yes, it is perfectly understandable that the Prime Minister and the new Chancellor should be saying to the NHS, “You have the best settlement of the public services; you have had extra funding, go and deliver”. The reality is what has happened to most other public services faced with similar pressures: we have had more money but the demand we are experiencing is much greater and staff numbers have been reduced. We have 450,000 people who are no longer eligible for social care because the social care eligibility criteria have been changed; bins are now being collected once a fortnight rather than once a week and libraries are closing.
The key point we are trying to make to the Government at the moment is that the NHS is unable to adopt any of the strategies adopted by other public services because we have an NHS constitution that specifies what the performance standard should be, specifies the targets for four-hour waits in A&E and has a bunch of recommended staff ratios that are enforced by a very rigorous inspection regime. Our members are saying very clearly, “You can’t have your cake and eat it. You cannot expect the NHS to deal with 4% or 5% increased demand every year but increase the funding by only 1% and then not allow us the service flexibility that other public services have had to change the offer, change the eligibility criteria or reduce staff numbers. The NHS has now reached the point where it cannot carry on meeting those formal criteria on the funding available.
Rt Hon Stephen Dorrell: Particularly, if I may emphasise the point, when the effect of many of those other changes in other public services is to divert demand into the NHS.
Margaret Willcox: Also, to distract the people we rely on, such as the informal carers. If we had a better offer for informal carers we would have a broader capacity of workforce available to us. We have spoken very little today about how the future workforce across health and social care is seriously under pressure because we are all fishing in the same pond for staff. The status of carers in the voluntary sector has dropped dramatically. The public do not have the respect for them they used to have. We have a retail market that is now far more attractive to what would have been the unqualified workforce than social care can achieve. In areas where you have low unemployment, it is absolutely impossible to recruit to those posts. We have a whole sea change which is much broader than just the delivery of the acute service; it is about how we change the way we run our community service and what sort of models of expectation you should have if you want to stay at home. Who do you think should be coming through that door to look after you? How should they do that? The days of having a routine four visits a day by four different people is not what the public expect and it has not been satisfactory. To some extent, some of that has led to the need for acute care when people lose confidence in being able to manage for themselves at home. They become frightened.
Q94 Bishop of Carlisle: From what you have all consistently said, your answer to what I am about to ask is fairly predictable. I would like to pick up on this issue of tipping points. It is an expression that has been used more than once in the conversation. May I focus the question around the recommendations of the Dilnot commission? As we all know, the implementation of the recommendations has been deferred until 2020. Do you think, if that happens and they are not implemented sooner, as seems likely, we will have reached a tipping point and the implications for long-term sustainability of health and social care will be severely damaged?
Rt Hon Stephen Dorrell: My view of the Dilnot recommendations is that they ask the right question, which is the one we touched on in the earlier answer: how you get more private funding into the delivery of a more broadly funded service. I am not entirely convinced that the Dilnot recommendations achieve the objective of more private funding. They certainly have the effect of targeting taxpayer funding at people who probably would not be at the highest end of the urgency list if we are dealing with urgent pressures in the system. The Dilnot process probably needs to be rethought but was addressing precisely the right question.
Margaret Willcox: We were hopeful that if, by deferring it, we would have had access to the £6 billion allocated for that, we could, at least in this particular time, have tested out what those opportunities would have been and may have been able to find some solutions. From an ADASS point of view, some of the figures still look a bit understated on the volume for the future. We would have had a longer lead-in time to be able to know what it is. The longer before we know whether the implementation of the legislation will come in 2020—not in respect of the money because we are still optimistic that some of that may come forward—then the longer it is before we can test out those issues.
Chris Hopson: What is particularly worrying as well is that, since the Dilnot proposals were put forward, the social care market and sector has become even more fragile. In other words, the funding gap has grown. I point to one other thing. One of the things the CQC pointed to and that we are very concerned about is the number of private providers who are saying they are struggling to see this as a viable proposition. If you look at the number of big organisations and medium-sized and small organisations withdrawing from the market because they are no longer able to provide and earn a sensible, commercial return, you can see, even if we were to have Dilnot Mark II quickly, some of those underlying market factors have fundamentally changed and worsened, making things even more difficult than they were when Dilnot was making his report.
Bishop of Carlisle: Is anybody revising or looking at a revision of the Dilnot proposals?
Margaret Willcox: I do not know at a national level. I certainly know, because I work in the south-west, that Bournemouth University has done some very interesting work looking at the predicted figures. ADASS will pick those up in the new year. If my memory was good enough I would be able to tell you who it was, but it has just shot out. They have certainly done some work on it and are coming up with slightly different calculations.
Bishop of Carlisle: Without more money in the near future we will have real problems.
Margaret Willcox: As the CQC pointed out in its report, we know that small organisations in private care provide better quality, as a generalisation. Some of the big ones do, too, but those small, local organisations provide very good services for their local community and they are the least likely to survive in the current climate because they are too near the margins of sustainability. That is a great loss because we do not want everybody to be treated the same; we want a local flavour for what is, at the end of the day, community care and not institutional.
Lord Lipsey: I want to make a clarification on Dilnot, which Norman Warner knows about very well. Dilnot made one set of recommendations. They were not adopted by the Government. The Government adopted ones with a much higher threshold and those are what have been postponed, obviously having much lower cost than the Dilnot proposals. We ought to be absolutely clear about that.
Q95 Baroness Blackstone: I turn to the very big variations that exist in social care services in particular. I wonder whether you have any suggestions as to how to deal with these variations.
Rt Hon Stephen Dorrell: My answer to that would be to emphasise the importance of national visibility in the experience of citizens in need of social care. It is often said that, as an overcentralised service, the National Health Service is supposed to deliver the same to everybody. Increasingly, as anyone who has ever worked in it knows perfectly well, that is not true. Increased transparency of patient experience within the NHS is making it more obvious that that is not true. That is a good thing because it focuses attention on where variation does occur. Exactly the same principle should apply across the range of public services, not just specifically in social care, so that—to use the jargon—the place-based services we have been describing this morning can see both the experience of quality of service delivered to a community and, ultimately, much more importantly, the outcome achieved for the residents of an area. The thing that really matters is the measure of life expectancy, morbidity and the way people lead their lives.
All this debate, so often, as we have inevitably seen this morning, is about funding mechanisms and structures, not about the difference of citizen experience as compared in east and west London, London and Berkshire, Berkshire and Northumberland, and so forth. If there was more visibility and discussion about that, we would have more genuinely accountable public services.
Margaret Willcox: There is also an issue about certainty. The market is so uncertain about where it is going: it is uncertain about its migrant workforce; it is uncertain about future pay structures; it is uncertain about the types of qualifications available to people and how we develop new models of care. It is uncertain about the future strength of the GP workforce because they are clearly not coming forward. It is not the career it used to be so there is a new model there. It is uncertain about future funding, either through local government or through social services, or indeed, from self-funders. Therefore, the growth in that market we saw 20 or 30 years ago has completely subsided. Then you have the geographical variation, which I have already alluded to, whereby richer communities will have more sustainable services—as it has greater demand for them, it is easier to create them—whereas an area with greater poverty has few self-funders, has local levels of government funding which are lower than its neighbours and, therefore, to a certain extent, there are lower expectations among that community because they are not familiar with them and, therefore, the aspiration needs to be built. Unless we have a period of certainty, it is very difficult to reassure people that this is a business they want to be in.
Chris Hopson: We should also be honest with you. You took an NHS perspective. There is no doubt—again, you know this because you have been very involved with an NHS provider—that there is excessive, unwarranted variation between individual trusts and foundation trusts. The Carter review has absolutely shown that in the number of different variables in clinical outcomes and procurement efficiency. When I say to our members, “This variation clearly exists. Do you accept the argument?” everybody accepts that variation exists. I hope you will not think this too feeble, but the conversation goes on in which managers and leadership teams say to us that to get that variation you need quality of data, a really difficult and challenging debate, often with senior clinicians, change management and project management, and sufficient management bandwidth, capacity and capability to drive a very far-reaching and difficult change process.
As a classic example, I was speaking to a very good chief executive of a district general hospital on the phone last week who said, “I know it’s there. I am having difficulty persuading my senior clinicians about what we should do about it but, to be honest, I simply do not have enough data analytical people, change managers, project managers and people to bring that senior clinical workforce with me. This entire leadership team has spent the last year trying to prop up the day-to-day operation. If I could find £2 million to employ a group of people to drive that change and take the senior clinical workforce with me, over a two or three-year period I could probably get to that variation, but you are asking me whether I can get there now with my existing resource and given the pressures I have, keeping this increasingly fragile system upright.
She said, “We have been counting detocs—delayed transfers of care—and there have been double the number of delayed transfer of care from last year”. They therefore had to use elective beds and they were now having financial problems because they could not have elective surgery going through. She said, “It is just a nightmare trying to keep this up and going. If I am going to get to this complex, difficult-to-winkle-out variation, I just do not have the bandwidth and I do not have the middle management capacity because, if I am honest, I stripped it out when I was doing the first set of cost improvement programmes between 2010 and 2015.”
I know it sounds feeble, in some senses, but the reality is that is what our chief executives are telling us. They can see the variation there, they know they should be getting to it but it is a very complex, difficult task, particularly the relationship with the senior clinicians, and they do not have the bandwidth or the people to be able to do it. If we want to get to the variation with the speed and consistency we would all like and which Lord Carter would like, we have to recognise that we need to support our trusts and not beat them up and spend the whole time saying, “Why have you missed today’s target?” That is the reality of what it is like trying to lead in the NHS today.
Lord Warner: A quick question: are we whistling in the dark about the social care sector? Are we not at a point where, if we get to 2020 and not much changes, there will not be a publicly funded social care sector to provide the services anyway? That seems to be the message coming out of the State of Care report by the CQC. Is it now at a tipping point where, even if later this decade we start pumping money into this sector, there will not be any providers who trust the public sector to go on funding them to run this sector?
Chris Hopson: There is a real risk of that.
Rt Hon Stephen Dorrell: I do not agree with that. Economic sectors are more flexible than that. Pressures build, spending is reduced in care homes and quality suffers. At the margin, capacity is falling—that is not a prediction; it is falling—and pressure, and the pace of pressure, continue to build. Chris and I were at my former committee in another place last week and the question was asked: where should money go in the system? Where is it most unstable? Chris and I were of the view, reflecting the view of NHS England—it cannot be too often that NHS England or its predecessor organisations have argued for extra resource for a different spending head from the NHS—that to protect the NHS it is necessary to stabilise social care. It is not right to say the sector would not be there by 2020 but it is being damaged and the pace of damage is quickening.
Lord Warner: Can we hear from the local authorities?
Margaret Willcox: It differs geographically in different parts of the country but it is about having the capacity to build up an alternative, much broader domiciliary care market. If we take the example of personal assistance, generally speaking we have had quite a lot of success in getting that model to support people with physical disabilities and learning disabilities, less success with mental illness and very little success, generally speaking, with some exceptions, for older people because it is not something they are familiar with. We have started the personal assistance model for younger people and that has worked well.
As I said, the attraction of being a domiciliary carer in the current market is not good and we need to build career structures. Many of us are talking to our universities already about linking it to the associate nurse programme and the apprentice nurses, and having an apprenticeship for the voluntary sector. Again, it is about building up that esteem and building a career for people who want to look after other people. We know those people are out there but we cannot attract them at the moment because of the instability of the market.
The Chairman: If there is no funding available now, the system, no matter what you try to do, will not be there by 2020?
Margaret Willcox: I would not say it will not be there but it will be under even more pressure.
Q96 Lord Kakkar: I should declare my interest as chairman of University College London Partners. To be absolutely clear, then, a sustainable health service will not be possible without a firm and established social care system beyond 2020. I want to focus on the importance of the two being properly integrated. Would you agree that for there to be longer-term sustainability, healthcare and social care have to be fully integrated in a way that they are not at the moment? Do we have any evidence that the Better Care Fund is providing that type of integration in a way that will be sustainable in the long term? Do we have some early examples now to show that it is achieving what needs to be achieved in the period between 2020 and 2030 for us to have confidence that that route forward is feasible? Can we be clear that local authorities are being funded, at this stage, beyond the funding that is going into the health service, to drive that kind of thinking in integration and allow them to be courageous enough to bring the two services together?
Chris Hopson: My argument would be, absolutely, that to get a sustainable NHS and a sustainable health and social care system the two systems need to be integrated, and they need to be integrated effectively and consistently right across the piece. If I am honest, the Better Care Fund is a complete red herring and was right from the beginning. The reality is, if we are being kind, that it was an attempt to cover up the fact that the Government were pulling money out of the health and care sectors. Finally, we are at a point where, at the end of this Parliament, the Government will be putting money into the Better Care Fund, but as a means of driving better health and care integration, for me, it is mostly a red herring.
What is happening, though, is that through social sustainability and transformation planning processes and other processes, as I was describing earlier, local health and social care systems are coming together. For us it is a very differential process. I can point to four or five places where it feels pretty well advanced. Often they are places which are NHS England vanguard sites deliberately designed to speed up this health and care integration, but in other places, to be frank, it is lagging a long way behind. What is clear, and the international evidence absolutely suggests this right the way, consistently, across the piece, is that when we do this integration, first, it takes a long time—it is not three to five years, it is more like five to 15 years—and, secondly, it does not produce significant amounts of extra savings. What it does relatively quickly, it seems, is produce a better quality of patient and service-user experience.
When we talk about health and social care integration we need to understand that it is something that needs to happen on multiple different levels. It needs to happen at a national structural level, at a local leadership level, at a local workforce level and in the way we treat funding streams. It is a very complex, multi-layered process in which a whole load of different things need to change. Culture is a very good example of where we need to get past this idea of separate silos. This is a complex process that will not take a short time; it will take a long period and it will not fundamentally solve what appears to us to be a growing gap.
One thing we have not talked about is forthcoming demand. Demand patterns in the NHS are not going to be stable. As the post-war baby boom comes up to its 70, 80, 90 year-old natural life, we are about to have a huge spike in NHS demand where we struggling to make the system work workforce-wise and money-wise. We are wholly unprepared to cope with this bulge we know is coming.
Lord Kakkar: What would you say is the single most important impediment to ensuring that that integration takes place effectively over the medium term?
Chris Hopson: Without doubt, the way that the system currently operates. Our chief executives will tell you the regulatory system is based on silos, the culture is based on silos, the way they are measured is based on silos and the way the money works is based on silos. I am sure my colleagues will want to talk about this as well, but the acute sector is currently funded by payment by results. Effectively, there is an incentive on them to pull activity into the hospital as a means of maximising income. Most people who want to create an integrated health and social care system know you need to move to a whole-population capitated budget. The joke we have in our office is that almost everything about the existing system is locking people into the existing silos—the culture, leadership training, performance management, regulation and existing governance structures. The people making most progress towards integrating health and social care at a local level are doing so despite the existing system.
The Chairman: The message has come across quite clearly that you are seriously taxed by the current system.
Chris Hopson: Yes.
Bishop of Carlisle: You have given an answer to the question I asked and I am interested to know if the others agree. We have heard at various times in this Committee that the integration of health and social care will not produce monetary savings but will improve the quality of the service and care. I just wanted to clarify that.
Rt Hon Stephen Dorrell: That was a point I wanted to pick up out of what Chris said because everything else he said in his last answer I broadly agree with. There are two points to be made about the impact of more integrated services. The first is that there are better outcomes for citizens. The second is to be careful about this argument that there are no savings. The reason is there is a saving in an acute hospital only if you remove the capacity. What happens when you have more joined up services that sustain people for more fulfilling lives outside hospital is that they have a better life and we do not close the capacity but use the capacity for somebody else. That is not the same thing as saying “no savings”.
Margaret Willcox: I agree. There is no international evidence because that has never happened. People do not close the door behind them, they just develop something else as an alternative. We would say that the key to it is through commissioning collaboratively and jointly in an integrated way. We are not just matching provision in one culture in the local authority with one culture in the acute hospital or the CCG. In health there are 25 or 30 different cultures. Every department, as you know, has its own way and its own thoughts and behaviour. It is a completely new culture you need to develop and not try to mix the existing ones, otherwise you will have one predominant feature. It is very trite to say it, but the bottom line is trust. When people trust each other and are allowed to test that trust, you can pull off good integration.
The Chairman: In that context, Baroness Blackstone has a very important question.
Q97 Baroness Blackstone: Could you each say in just a couple of sentences what your key suggestion for change might be on which the Committee can make a recommendation to support the long-term sustainability of the health service?
Chris Hopson: My view would be that we need to keep a taxpayer-funded system but increase the funding coming in, in which case we need to think much more carefully about how we build a national consensus around that increase in funding. That requires a much better quality of public debate about what the funding levels for the NHS should be and what the consequences of not increasing funding might be.
Rt Hon Stephen Dorrell: There are two elements to a sustainable health and care sector. The first, to go back to the argument with which I began, is that there is public support for and interest in, and a long history of those things, a growing health and care sector. We have to convince ourselves and the public that our policy structure can deliver that. It is a growing sector. The reason I emphasise it is that we are constantly told that if you draw a straight line through the graph for umpteen years it takes 100% of GDP. If you think about it, that is true of any growing sector in the economy. We should be seeking to facilitate the growth of this sector as part of a growing economy. Of course we should want to deliver it efficiently in a way that reflects the needs of citizens, which is why I focus on the need for empowered local government as a key partner in that process.
Margaret Willcox: In support of both, we would say that there is a recognition that health and social care are inextricably linked and they are also inextricably linked to our economy. Therefore, the conversation we need to have with the public is: what do you want us to do when we are working and paying our taxes? How do you want that to work? What do you want us to do when we provide that service for our families, and what do you want us to do when we need it for ourselves?
The Chairman: Thank you all for coming today. We have had a most exciting session. I have allowed it to way, way overrun and I hope that is not going to restrict our next important session. Thank you very much.
Rt Hon Stephen Dorrell: Thank you for your tolerance of our long-windedness.
