PARLIAMENTARY DEBATE
NHS Funding Bill - 4 February 2020 (Commons/Commons Chamber)

Considered in Legislative Grand Committee (England)

[Dame Rosie Winterton in the Chair]

In that context, we are concerned that there will be a temptation, as there has been, to dip into capital budgets to paper over the cracks on a day-to-day basis. We have seen that happen five times in the last decade. This means that we now face a maintenance backlog that has spiralled out of all control, topping £6.5 billion. That is an 8% increase on the previous year, when the cost was just under £6 billion. In dollars, that might get us one Steve Austin, but it is not enough to fix the NHS—I suspect that that reference might not mean much to anyone under 40, although I understand that there will be a reboot later this year, so it might become a bit more relevant. However, the point is that this figure has been rising each year for the last six years and it is now 60% higher than it was in 2013-14. It is very clear that the backlog has risen much faster than the resources that have been made available to tackle it.
Over half the backlog represents high and significant risk. That accounts for an increasing proportion of the total backlog figures. High and significant risk represented about 34% of the backlog in 2013-14, but last year—2018-19—it had gone up to 53%. It is getting bigger and all the time, it also becomes riskier.

Let me now say a few words about new clause 5 and inflation. I am conscious that a number of other Members wish to speak, so I will be fairly brief. The new clause is a safeguard to deal with a mistake made in the Bill. Because the amounts are presented in cash rather than real terms, the figures may not end up being as big as they at first appear. While inflation is now relatively stable and within a reasonable range of the Bank of England’s target, I do not think that anybody—particularly at this time—can confidently predict the rate at which it will be running at in two, three or four years’ time.

If we do not have the additional doctors and nurses available to provide the care that we want to be provided, money will disappear very quickly and we will not see any benefit for it. If we want to get back to those waiting time standards—and no one would want to do that more than I do—we have to look at the issue of capacity, and in two areas in particular.
First, are we actually training enough additional doctors and nurses? I introduced some big increases—a 25% increase in doctors being trained—and of course because it takes seven years to train a doctor, they will not start to come through until towards the end of this Parliament. The Government have announced a big increase in the number of nurses that they want to recruit, but training new nurses takes three years. Looking at whether those numbers are right will be absolutely essential if we are to break the cycle of winter crises. Essential to that is to ensure that we have an independent estimate of the number of doctors, nurses, physiotherapists and allied health professionals that the NHS actually needs and a Government who sign up to training those numbers.
If that number is the result of a negotiation between the Treasury and DHSC, the Treasury will negotiate those numbers down because it always sees training more doctors and nurses as building up a cost pressure for the future. Actually, it is the opposite: if we do not train enough doctors and nurses, the NHS ends up having to pay extortionate agency rates and locum doctor rates, and it ends up costing the NHS more. I would like an answer to the question of whether we are even now training enough doctors and nurses, and I would like to know what the NHS actually believes is the answer to that question. I would also like to know that the Government are committed to doing that, and I very much hope that when we have the people plan, there will be an independently audited projection of the number of doctors and nurses required.
The final point I wanted to make is about—

Parity of esteem is not as simple as how much we spend on physical health and how much we spend on mental health. That is clearly a guide and an easier thing to measure, but it seems to me that if we really mean parity, we should look at not only at the inputs—the money we put into the system—but the outputs. Are we seeing an improvement in access to mental health services? Are we seeing fewer people not being referred with the speed that they and the system expect? What outputs should we look for, and should they not be measured in some way in an annual statement?
New clause 9 would go further than the Opposition amendment, which looks to measure inputs and money, and would require the Government to do something broader and ultimately more meaningful to the British people, whichever quarter of the United Kingdom they come from.

New clause 10 is fairly ridiculous as it is a rehash of the argument that we had at the back end of last year—[Interruption.] It has not been selected. You agree with me, Dame Rosie, so I do not need to talk about how ridiculous it is. [Interruption.] Forgive me. Dame Rosie has no view, and it is important to put that on the record.
In the context of the Bill, we must remember what we are here for. I speak with generosity to Labour Members who I know care deeply about the NHS, but we are not here to try to score points; we are here to improve the state of our NHS. Everybody recognises that this is a good Bill, yet many of the amendments appear designed to create some sort of artificial dividing line between Members on this side of the Committee and that side, regarding who cares the most about the NHS or mental health. I urge all hon. Members to remember that the purpose of this Bill is to increase funding to our NHS and improve our mental health services, and I therefore do not support the amendments.

My third and final point is another that many colleagues on both sides of the House have made already. The CCGs, which make these decisions on behalf of communities, are accountable to no one and, regrettably, take no notice of what local communities say. They might conduct a consultation, as with the Shropshire reconfiguration, but they take no notice of what local people say. They certainly take no notice of local representatives—of the MPs and local councils—and sometimes they appear disinclined to take much notice of the Secretary of State. I am very grateful to him for spending a great deal of time trying to resolve this issue, although the CCG was not particularly impressed with his proposal, which I thought was excellent and would have benefited my community.
CCGs often operate as if they were directors of a FTSE 100 company, with all the trimmings but without the checks and balances that shareholders provide. Without accountability we see abuses of power, conflicts of interest and a failure to serve local communities. It is almost impossible to remove a non-performing chief executive or board, and in any event they just pop up somewhere else with their golden handshake and gold-plated pension still intact.
I genuinely believe that we now have a window of opportunity to solve the Shropshire reconfiguration, and I deeply hope that Ministers can help us to bring it to a long overdue conclusion. If we can learn anything from our experience, it is that we have a decision-making structure in the NHS that does not serve the communities it is intended to serve and which is not accountable to us, and if it is not unaccountable to MPs, to local councils or to individual residents and patients, there is a problem. We need a full examination to ensure that what has happened in Shropshire does not happen again. I am hopeful for my constituents and neighbouring Shropshire MPs that there is a solution on the horizon, and one that would be a positive outcome for all our communities.
That said, our communities should not have had to resort to crowdfunding a legal action against the CCG or the Government, or to protests, marches and petitions, and they should not have had to endure six years of uncertainty or to write thousands of letters to their MP. As the Government embark on this welcome capital expenditure programme—a truly historic investment programme that we all welcome on both sides of the House—I hope they will look at what has happened in the NHS Future Fit process in Shropshire and learn the lessons of that experience so that those mistakes are not repeated.
To conclude, I reiterate what a pleasure it is to take part in a debate where everybody is trying to get the best outcome for their constituents, the country and the NHS in terms of the service it delivers to all our constituents.

I want to talk about some of the incidents that I have come across in Fareham over the past few months. Tragically, several young people took their own lives last year. As I said earlier, I recently met educational professionals who are increasingly worried about how long it is taking young people to access mental health support, counselling or other support through CAMHS. Children or young people are presenting with problems such as anxiety, low-level depression or self-harm, but they are not necessarily meeting the eligibility criteria required by CAMHS, so they are not being accepted for treatment by the services on offer. That leaves them to fall into a treatment gap, which is a problem in Fareham and around the country. Young people are presenting with complex needs that do not necessarily fit into the diagnostic box, and I hope that measures are in place to provide more accessible lower-level care and treatment to meet that demand.
The other issue that young people, their families and teachers, and medical professionals in Fareham are reporting to me is the time it takes to get an initial counselling or therapy session through CAMHS. Young people sometimes have to wait months before an initial meeting, which can have a devastating effect on someone who might be fragile or facing challenges. They may end up dropping out of school, for example, but they may have stayed in school had there been some intervention, or they may increase their level of self-harm or become suicidal within that timeframe. It is tragic that systemic challenges mean that we are unable to reach maybe the easier-to-treat cases in an appropriate timescale. It is incumbent upon me to highlight the challenges we are facing in Fareham, but I am glad that this funding and this commitment to mental health, particularly children and young people’s mental health, will go towards improving some of those systemic problems, such as resources and waiting times.
Turning to some good news in Fareham and the progress being made to address the treatment gap, I am pleased to welcome a new community support project in Fareham and Gosport that has been set up to supplement the existing health service. It is run by the Southern Health NHS Foundation Trust and the Princess Royal Trust For Carers, and a consultation is under way to assess how it can focus more on day-to-day mental health challenges and provide lower-level support for people who do not necessarily fulfil the eligibility criteria that I set out. That might be someone who has lost a job or is facing some financial difficulty, and this support can help them to get through a troubled time and prevent them from deteriorating.
The project will support people on a one-to-one basis and will serve to ease pressure on other services. It aims to nip mental health problems in the bud before they get worse, with a focus on prevention and on flexibility. I really welcome the initiative and hope that if it is successful in Fareham and Gosport it will be rolled out further afield in Hampshire.
I also want to talk about the Southern Health NHS Foundation Trust, which provides mental health services in Fareham. I want to update the House on the good progress that Southern Health has been making. I have been campaigning for many years—in fact, it was one of the first issues that hit my in-tray when I was first elected in 2015—about the systemic and structural problems endemic in the health trust, which was, frankly, failing its patients back in 2014 and 2015. Its leadership has been overhauled and it has had huge interventions from NHS Improvement, as well as a lot of monitoring from the various regulatory bodies in relation to its history of treatment of people with serious mental health problems or with disabilities, including avoidable deaths. Several inquests have concluded that Southern Health did bear blame for those deaths.
I am very glad to report that last week the CQC reported that Southern Health trust should be rated as good, and that is a vast improvement on previous years. It is a vote of confidence in the leadership team, and it is a real step forward in providing confidence to the thousands of people who work for Southern Health, and of course, above all, those patients who are under its care. In terms of leadership, safety, caring responsiveness and the extent to which it is patient-centred, Southern Health was rated as good. I have to say, however, that some areas still require improvement—for example, the effectiveness of services.
I have worked with many families whose young relatives have taken their own lives under the care of Southern Health, and I know they have been significantly involved with helping to get improvements in Southern Health. I know that they will be pleased by last week’s CQC rating, and I want to congratulate those families on all their input and their work on this issue. I also congratulate the leadership team at Southern Health.
Lastly, I want to talk briefly about Fareham Community Hospital in Fareham, which has been my pet project. It is a wonderful facility in the heart of our community, but it is sadly under-used. Last year I conducted a wide-ranging consultation with hundreds of local residents and many stakeholders, and I authored a document on the conclusions: the Minister is welcome to read a copy, maybe tonight or tomorrow, if he would be interested. It sets out a plan, based on the results of that consultation, for how we can better use Fareham Community Hospital. One of our recommendations is that it would be a brilliant location for a mental health hub in our community. We have a great facility, which is well located and in good condition, but in the light of the demands and challenges in the local area with young people’s mental health there is a great opportunity here for more funding and more co-ordination so that Fareham Community Hospital can be better harnessed, so that our young people, and also other people who need mental health support, can use the facility and capitalise on it in the most effective way. I hope that bosses at the CCG and those who make the decisions will that bear in mind.
I applaud the Government for their commitment to the funding in the Bill, and I oppose all the amendments.

May I welcome the Bill in general before dealing with the amendments I wish to speak about? It provides useful and good clarity for all the hospitals around the country, which need to ensure that they have appropriate funding in the coming years. I also welcome the clarity on the revenue side for hospitals such as Chesterfield Royal Hospital, which serves my constituency. It is looking for additional support on not only the revenue side, but the capital side, although I know that this is not the debate for that. I will not be supporting amendment 3, but there is a lot of merit in it, if only to ensure that if we do get our urgent care village at Chesterfield Royal Hospital, we could thus ensure that the money is in place and is ploughed into proper capital upgrades for the hospital in the future, for the benefit of everybody in north Derbyshire and my constituency.
I also welcome the Government’s commitment in recent months to the output point that my hon. Friend the Member for Sevenoaks outlined. That was done to some extent during the general election campaign, and I look forward to the continuation and extension of that in the coming months and years. I am pleased that we are in a debate on the NHS and healthcare that, as my hon. Friend the Member for Telford (Lucy Allan) said, has been relatively friendly and has come away from the usual histrionic fireworks that sometimes accompany this issue. It is helpful for us occasionally to step back and have this kind of debate on the NHS, given that we are all committed to improving healthcare in our constituencies.
I wish to discuss two of the amendments briefly, picking up on this point about outputs. The hon. Member for Ellesmere Port and Neston (Justin Madders), speaking from the Opposition Front Bench, was right about the need for accountability and the need to ensure that the money being committed in this Bill is spent wisely and appropriately, as was my right hon. Friend the Member for South West Surrey (Jeremy Hunt), who is no longer in his place but who talked about this not just being about money, and my hon. Friend the Member for Newton Abbot (Anne Marie Morris), who is also no longer in her place but who was also keen to highlight the importance of outputs. For reasons I will talk about if I have time at the end, it is particularly important for me, on a personal level, that we focus on outputs.
First, let me turn to new clause 4, which I am keen to examine. I congratulate the Opposition Front-Bench team on beginning the long road back to sense—I hope they do not mind my describing it as such—with their welcome return to an interest in healthcare outputs rather than solely in inputs or methods. That is something to welcome, but the problem, and the reason I cannot support these proposals tonight, is that the Opposition continue to mix up the point about targets and outputs. Targets are not ends in themselves. Targets are indicative, much as we wish them to be hit and important as they are, to ensure that they give us good guides as to what is happening in our hospitals and healthcare system. They are different from outputs. In time, I would be keen to see Opposition Front Benchers moving further down that metaphorical road towards recognising that the outputs are the most important thing: people getting well, staying well for longer; going home and living longer and more meaningful lives with their families and within their communities.
The new clause also slightly misses the point. I infer, as clearly one can, that it starts from a position of directly relating the requests made to set out things from the perspective of money. I do not doubt that money is vital in this discussion, which is why we are bringing forward this Bill, but it does slightly become a blunt instrument. An opportunity is missed to recognise that this is not simply about money. The inputs into our healthcare system are incredibly important, but so are the structure, the model, the operations, the behaviour within it, the technology and the prioritisation chosen by all that vast behemoth of bureaucracy around the NHS. We have to ensure that there is a recognition of the importance of that, and that there is a real effect on the output at the end and on making sure that people stay better for longer. On that basis, I cannot support new clause 4.
New clause 11 is a similar attempt by the Opposition to ensure annual reviews of the adequacy of the financial movement forward. My challenge is that there is a definitional problem. The new clause would require the consideration of
affect outcomes. There is an interesting question about the definition of “service delivery”, whether it is a rather narrow assessment or could encompass everything that the NHS ever does, and whether that would provide any benefit to the House or anybody who used the assessments. There is also a question about the complexity of analysis of service delivery in the first instance and how that can be defined and assessed. As a former management consultant, I am all in favour of complex analyses, but ultimately they have to provide a utility appropriate to what we are trying to do and to the ultimate objective and end point.
Although I again compliment the Opposition on moving closer towards output-based consideration, new clause 11 also starts from the position that money alone is the ultimate arbiter of whether our healthcare system is successful. Again, it is not just about money, as important as that money is; it is about organisation, people, motivation, workforce, demand, prioritisation, processes and how technology and innovation are changing things. If we do not recognise that, we are missing out a substantial portion of the debate that will be vital in the next 20 years to ensure that our healthcare system is fit for purpose.
Ultimately, why does this all matter? Why does speaking at a relatively technical level about outputs, structure or processes matter as much as inputs and money? Because, as other people have said, this is about real people—it is about making sure that people live for longer. We have all seen examples, when people come to see us at our surgeries, of where the NHS works wonderfully, but in our heart of hearts we all know examples of where the NHS has worked less well. That focus is sometimes as important as the money.
Let me give the House a personal example. My family, including myself, have had three occasions or reasons to get involved in the NHS over the past few years—indeed, over many years. The NHS saved my life on multiple occasions when I was growing up, and it also saved my father’s life when he had a double heart bypass around 10 years ago. It did less well with my mum when, a few months after I came to this place in September 2017, she was diagnosed with ovarian cancer, about which I have spoken in Westminster Hall. That was an error, errors happen—there are humans in the process—and we have not taken it any further because of that. My mum is still here and I am very happy about that, but ultimately my mum did not have a good experience. If we just focus on money, we miss out on cases such as my mum’s.
We have been lucky in my family, but ultimately there will be constituents of ours who are not lucky. That is the point: I am grateful for the money that is going in, but it has to be well spent. If this place does not consider the outputs—if this place does not understand where the money is going and how it is used—there will be people who do not get through it in the way that we want them to. We all want to stop that, which is why it is really important that we focus on outputs as much as inputs.

New clauses 4, 5 and 11 focus on whether the allocations are sufficient. At their heart is the question of whether the quantum is appropriate and will meet the needs of the NHS. Although I understand the sentiment behind these new clauses, they are unnecessary. The chief executive of the NHS said in 2018, after the announcement of the settlement:
We are giving the NHS the funding that it believes it needs.
There is already a clear duty on the Secretary of State for Health to lay before Parliament and publish an annual mandate to NHS England. The mandate sets objectives that NHSE must seek to meet in the year ahead, and its budget for doing so. That budget includes funding to meet all of NHSE’s statutory duties, including duties under the NHS constitution. The Secretary of State has a further duty to keep performance against the mandate under review, and must also publish his annual assessment of this performance in Parliament, with Parliament entitled to table debates and questions on the matter as it so wishes. Therefore, although I appreciate the purpose behind these new clauses, they would serve no useful additional purpose. Parliament already has ample opportunity to review NHSE’s budget, to consider whether it is sufficient to deliver on the objectives that the Government have set and to hold the Government to account. I will touch a little more on this when addressing new clauses 9 and 2 later.
I turn to new clause 5 and the concerns that the Bill enshrines the NHS budget in cash terms—a point that the shadow Minister has reasonably put to me and to the Secretary of State on previous occasions. Like Government departmental settlements, the NHS budget is set in cash terms. This is essential to deliver certainty and predictability. However, responding to changes or fluctuations in expected inflation rates is part of the normal course of business, and would be addressed and scrutinised as necessary through fiscal events such as Budgets. We do not need to legislate for that separately. Furthermore, the House should remember that what we are proposing is a floor, not a ceiling. We are retaining the flexibility for an increase in funding in a range of scenarios. Nothing in the Bill prevents that at any future point.

Three hours having elapsed since the commencement of proceedings, the debate was interrupted (Programme Order, 27 January).

New clauses 1 and 2 added to the Bill.
Brought up.
Question put, That the clause be added to the Bill.
The Deputy Speaker resumed the Chair.
Bill reported, without amendment (Standing Order No. 83D(6)).
Bill, not amended in the Legislative Grand Committee (England), considered.

More than four hours having elapsed since the commencement of proceedings in the Legislative Grand Committee (England), the proceedings were interrupted (Programme Order, 27 January).
Question put forthwith (Standing Order No. 83E), That the Bill be now read the Third time.
Question agreed to.
Bill accordingly read the Third time, and passed.
Motion made, and Question put forthwith (Standing Order No. 83A(7)),
Question agreed to.