(8 years ago)
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Baroness Pitkeathley
That this House takes note of the challenges in the current system of social care and of proposals for reviewing it and for longer-term reform of the system.
Baroness Pitkeathley (Lab)
My Lords, here we are again. This is not the first time I have led a debate on social care in your Lordships’ House and I have been wont to call those who join me the usual suspects, because we are the relatively small band who bang on about this subject whenever we get the opportunity. There are new faces as well as old ones here today. It is particularly welcome that the noble Baroness, Lady Cavendish, has chosen this debate for her maiden speech, to which we all look forward.
I have to tell your Lordships that it makes pretty depressing reading to go back to the other debates on social care in which many of us have participated, because the problems remain the same and so little progress seems to have been made. If I felt that before all the other debates—in nearly 20 years in your Lordships’ House, I have rather lost count of the number of times I have focused on this—how much more I feel it this time, when endless reports and newspaper articles are telling us all how bad it is. Your Lordships will be all too familiar with some of the headlines of recent weeks. One said that,
“social care is at a tipping point”,
another that it was “Slow, patchy, cruel” and that social care funding is “not fit for purpose”. Others said that the bed-blocking crisis hit a new high and that local authorities,
“join NHS chiefs in call for extra … funds”.
It may surprise your Lordships to know that I have managed to find some comfort in these terrible analyses, because perhaps they show that at long last there is agreement across all areas about what the problems are. That will be evident in the briefings which your Lordships have received for this debate. It is not as though we have not agreed before, but perhaps not so strongly and not across all areas. When even the chief executive of the NHS, not to mention the chair of the Health Select Committee, and two former Secretaries of State say that if there is any extra money it should be put into social care, maybe we are at last ready to address the issues.
Am I being too hopeful? Perhaps. Certainly, the announcements we were hoping for in the Autumn Statement provided no comfort by their total lack of appearance or even mention. I bow to no one in my desire to have better broadband in rural Herefordshire but, really, can we get our priorities straight? How the Chancellor could ignore the pleas from all sides is beyond me. His decision has been met with incredulity and dismay and called shameful. Nevertheless, I am determined to spend less time today on the problems of social care, which are well known to your Lordships anyway, and more on what the possible options are.
Let me summarise the problems and leave others to elaborate. There is a shortfall in social care funding of about £2.5 billion between what is available and what is required. Four out of five councils do not have enough provision, especially for care at home, and at least 1 million people are going without the care that they desperately need. Much more stress is falling on family carers, who increasingly find it difficult to cope. The results of these shortfalls are all too apparent: too many people end up in acute and very expensive hospital care in hospitals which are already bursting at the seams, even before winter pressures begin to bite.
The situation is bad for everyone. It is bad for councils, which will face legal challenges if they are unable to meet the obligations placed on them by the very welcome Care Act; it is bad for the NHS, as hospitals fill with people who could and should be treated at home; it is bad for care homes that increasingly find it difficult to balance the books, with the resulting threats to the quality of care which recent TV programmes have illustrated; it is bad for family carers. In short, it is bad for anyone who cannot afford to pay for their own care. Even if you are a self-funder, it is bad for you because you have to contribute to underfunded local authority places if you are in a care home. So much for the so-called society “which works for everyone”.
I could go on with endless examples of the bad but I will not. I turn instead to offer options, in the hope that the culture in which we operate is finally changing enough to encourage bold and courageous action. They say that humans and cultures never change unless we are forced to do so. If that is the case, we are forced to do this now before the whole system is not just at tipping point and in crisis, but in danger of breaking down completely. I should say here that I always worry about the danger of too much criticism sapping the morale of the dedicated staff who work in social care and do their best. They are usually paid at the very lowest levels. We owe it to them as much as to the frail, old and disabled to think boldly.
We must first tackle the different methods of funding health and social care, which have been so difficult to overcome and such a barrier to the co-ordination and integration of health and care services. In 1948 when the system was established, men died on average at the age of 66, one year after retirement, and women at about 68. There was no need for the type and range of care we now need. It did not matter so much that while health was free at the point of delivery social care was always means-tested, because you were not going to need very much social care. Social care has been paying the penalty ever since for those decisions, which at the time they were made were perfectly logical. What we need now is a decision of the level and quality that our forebears made then in relation to the NHS. But this time it must be about reshaping health and social care around today’s needs, not those of the population of post-war Britain.
Various attempts have been made and we all remember them: the royal commission, the Wanless review, the Dilnot review, the King’s Fund commission on the future of health and social care and the Barker commission—but no government response has been sufficient. It is evident that what is really needed is a long-term, cross-party approach which takes an open and honest look at the system and, above all, is open and honest with current and potential care recipients about what they can expect.
I think we are now at a crossroads and can make one of two decisions. We can go on as we are, muddling along, trying to do more with less, managing demand by just not meeting it. That is how we are managing demand: we are just not meeting it. I remind your Lordships that, of the more than 1 million people who it is estimated are not receiving care, most have already been assessed as having high-level needs, because helping those with moderate needs is already a thing of the past in most areas. We can keep promoting independence—that is always a good thing—we can keep trying to get individuals to manage their own care better and, above all, we can keep trying to integrate the budgets for health and social care. There are some excellent examples of integrated care at local level which, no doubt, noble Lords will illustrate, but the overall picture is patchy and still too cautious and too hedged about with suspicion and lack of willingness to give up power over budgets, still less to transfer it to other professionals. A single pooled budget for the health and social care needs of a whole population would enable NHS and social care providers to agree the very best use of the public pound and to focus on services which reduce the need for long-term care.
I am sorry to go down memory lane, but I have been talking about this, as have many other people, for almost 40 years—it is probably over 40 years, in fact. My first book was published in 1978. It was about hospital discharge for older people. Funnily enough, it showed that proper co-ordinated care can happen only if there is a single budget in the control of those who provide the services, free from political control and including the contribution of the private and voluntary sectors too.
If we are going to go on with the current system, if we are going to go on trying to muddle along, then I must make a plea for honesty. No Government—and I include my Government in that—have ever made it clear to the public that responsibility for paying for care and for arranging it rests with individuals and their families and that public funding is available only for those with the least money and the highest needs. Most people are aware that NHS care is generally free at the point of use, but their understanding about social care is far less clear, and people therefore have inappropriate expectations. If I had a pound for every carer who has said to me, “My mum has paid taxes all her life, and I can’t understand why her house has to be sold or all her savings used to pay for her care”, I would be a millionaire. That carer is a perfect example of a person who is just about managing, caring for her mother and probably teenage children too, trying to balance paid work with caring responsibilities and so on.
As we are not transparent, no one ever prepares or plans for care, and they have to scrabble to arrange and pay for it at a time when they are anyway distressed by the very need for it. If they are not prepared to reform the system, the Government must surely be prepared to promote clearer public understanding of how the system works and what people can expect and, more importantly, what they cannot. People plan ahead for pensions, and it is possible they could similarly plan ahead for care, but only if they know they have to.
However, it will not surprise noble Lords to know that this sticking-plaster solution is not my preferred option. I believe we must embark on long-term reform of the system because this problem is not going to go away; it is only going to get worse. All international evidence shows that spending on health and social care rises inexorably as the population grows and ages. The question is not whether these costs will arise, but how they will be met. Will they be met by the public purse or by private individuals? We can talk for ever about achieving more with less and delivering better value, but that will never release resources of the scale required to meet the widening funding gap.
Every independent review of the past 20 years has recommended that in future funding of social care, as well as healthcare, should come from public, not private, finance. The needs of individuals cannot be divided up neatly into health or social care needs, as all those of us who over many years have tried to fathom the difference between a health bath and a social care bath have long acknowledged, and now is the time for us as a society to acknowledge that the funding cannot be neatly divided either.
We must embark on a frank and open debate about how to fund health and social care on a sustainable basis into the future and remind everyone that such a debate cannot be settled in a single Parliament, so we need to secure cross-party consensus on shared principles to guide that reform. We have enough research and excellent material to enable us to do so; we just need the will to do it. We know all the questions about social care, so let us not embark on any more questions about what social care needs. What we need now is answers.
To those who say that this is not the time to do this with public finances in such disarray and with so many other problems, which we have just been hearing about in the previous debate, I remind your Lordships that our forebears tackled reform in the middle of a world war when the country was pretty well bankrupt and not the fifth-richest nation on earth, which we keep being reminded that we are. The Wanless review called for this debate 10 years ago. It has never been more necessary, and it is now even more urgent. I beg to move.
Baroness Browning (Con)
My Lords, I congratulate the noble Baroness on bringing this subject to the Floor of the House. I expect I am one of the old faces she mentioned who will be termed one of the usual suspects on this subject. I refer to my interests relating to this debate as set out in the register. Like the noble Baroness, I feel there is a touch of déjà vu about this. We know about demographic trends, the demands of an increasingly elderly population and the whole range of things which cover the gamut of the need for social care, and we have talked about them in this House for decades. Yet somehow, every time we have a debate about this, it is almost as though this is something new that has suddenly come from behind and we are rather astonished to find it is such a problem.
It is now a real problem. There are concerns about care services moving out of the sector. The Local Government Association has raised its concern about people closing down businesses and withdrawing their services altogether at the very time that demand is increasing and we know that it is going to go on increasing. I have a lot of sympathy with what the noble Baroness, Lady Pitkeathley, said about the way in which we look at the funding of this. Funding is at the core of a lot of the challenges we face. Local authorities purchase in bulk. They have the advantage of that negotiation. Self-funders are usually individual people, families who, when mum has a stroke, suddenly find almost overnight that they have to provide nursing or residential care. These are the challenges individual families face almost on a daily basis across the country.
I say to the Minister that I still find it bizarre that we have this subsidy in residential care in the care sector whereby self-funders subsidise those for whom the local authority purchases care. There is never any discussion around this. We do not talk about how fair it is. There is no discussion about the fact that individuals who find they have to self-fund are not paying just their weekly fees, but are also subsidising the person in the next room, or possibly even more than one person. I really think it is time that we exposed how the funding system for care works. It is like having a secret tax that nobody knows about. I find that quite abhorrent.
I agree with the noble Baroness about the need to examine what is expected when people have assets. As a Member of Parliament, I will never forget a couple who were quite elderly themselves—in their sixties—sitting in my surgery virtually in tears at the fact that they were going to have to sell mum’s home because she now needed nursing care unexpectedly, when they had understood that that was likely to come to them. In the context of understanding the responsibility of providing for care, I say to my noble friend that there needs to be joined-up thinking across government. I was quite shocked that when the pension rules were changed so that people with private pension pots could draw down huge amounts of capital from what they had saved over the years, although provisos and bars were set in place to make sure that they had enough to live on, there did not seem to be much discussion about how much of their capital assets they would dispose of, and the whole subject of the amount of capital they would need in order to pay for their long-term care did not really seem to be part of any discussion.
I have one other thing I would just ask my noble friend. Joined-up government is so important, and the weakness has always been between health and social services in terms of agreeing who pays for what. Can my noble friend give the House an update on the sustainability and transformation plans, which should be well under way? It seems to me, if I have understood them correctly, that there is potential here, not just in terms of planning but in terms of finding the resources to implement the plans. We hear a lot about these plans, but I am not sure that everybody really understands what contribution they will make to joining up health and social services, and I hope my noble friend will refer to them when he replies.
Baroness Bakewell of Hardington Mandeville (LD)
I draw your Lordships’ attention to my interests, as entered in the register, as a district councillor and a vice-president of the LGA.
I am grateful to the noble Baroness, Lady Pitkeathley, for securing this important debate and agree with much of what she said. This subject is at the top of everyone’s agenda up and down the country. Many were expecting some sort of recognition of the crisis in social care in the Autumn Statement, particularly as the sector was calling for £1 billion to be invested to stabilise the situation, but there was not even a passing reference. It is astounding that the Chancellor does not regard it as important enough to tackle. Having said that, I look forward to all the contributions this afternoon and especially to that of the noble Baroness, Lady Cavendish of Little Venice.
Government data show that 32 care home businesses failed in 2010. That figure went up to 74 in 2015, while 34 have failed in the first six months of this year. These range from family-owned businesses to nationwide operators. A total of 380 homes have closed in six years, and the care industry is in turmoil. Care homes are enduring an unprecedented squeeze on their finances. Local authority fees have reduced by 5% in real terms over the last three years, while care costs have risen at a faster rate than inflation, particularly staffing overheads. Last year’s 2% rise in council tax for social care was insufficient. The living wage, although to be welcomed for hard-pressed vital staff, has not helped care home budgets.
Four Seasons, the biggest care home operator in the UK, with more than 400 properties, recorded a pre-tax loss of £264 million last year, which includes write-down on the value of its care homes. There are many other similar examples. In Somerset, the county council has a panel which looks at all new packages of care and is currently proposing to reduce 75% of packages for budgetary reasons. Despite this, Somerset’s overspend will be £9 million. Adult social services are having to compete with children’s services, which are also predicting an overspend but are in line for some of the £5 million contingency fund which has been earmarked for them.
The facts are stark. Local authority grants have suffered cuts of approximately 40% since 2010. Despite this, the vast majority of councils have protected services for vulnerable people. Local authorities have substantially reduced the point on the safe hierarchy at which residents will be eligible for care, as we have already heard. Many now provide support only to those assessed as in critical need. There are some councils on the cusp of major service failure due to the funding crisis. What plans do the Government have for picking up the pieces?
Apart from last year, council tax has been frozen for several years, with government incentives, thus curtailing local authorities’ ability to predict and solve their own problems. Should there be another 2% precept for social care in 2017, this will help only marginally, as the problem is now, not next year. As we all know, there are increasing numbers of older people, and this results in more demands. We are now seeing care homes refusing council contracts as local authorities cannot afford to pay enough. Many older people, funding their own care, are subsidising local authority contracts, as the noble Baroness pointed out.
One consequence is more elderly people being admitted to A&E as preventive care is not available. This then puts more pressure on the NHS. Integration of social care with the NHS could be part of the answer, and I look forward to the work my colleague in the other place, Norman Lamb, is doing towards a commission on this subject. But extra funding will be needed to make this happen. The better care fund is a move towards this, but the funds needed are large, and the better care fund is small. Inadequate funding of care means elderly people are ending up in hospitals, adding to the strain on the NHS, as elderly people admitted after falls and infection then become stuck in those hospitals.
My noble friend Lady Pinnock, who is unable to be with us today, tells me that when she was leader in Kirklees, they built two care units to act as post-hospital or return-home places, some residential and some day care. Both of these units can no longer be resourced by the council because of cuts in funding. Council leaders believe the Chancellor’s claim of investing £3.5 billion by end of year is inaccurate. Better-off areas where people can pay will manage, but deprived areas are doubly hit as they cannot meet their own costs.
I leave your Lordships with the personal story of a lady who did have someone to help her have a bath, who has had her hours cut and been told a strip wash will do. Is this really what we, as a nation, mean by dignity in old age?
Baroness Cavendish of Little Venice (Con) (Maiden Speech)
My Lords, I am proud to stand here today as a Member of this House and make my maiden speech. I would like to thank noble Lords on all sides of the House for so warmly welcoming me and the staff for being so magnificently kind and helpful.
Being here is an honour far beyond anything I expected, not least because many of my illustrious predecessors as head of the Prime Minister’s Policy Unit served there far longer than I did—I only count myself lucky that I got out before most of my failings could be exposed. I am especially grateful to the noble Lord, Lord Adonis, and the noble Baroness, Lady Hogg, for their unfailingly generous and always-discreet advice when I was in No. 10. I am also grateful to the noble Baroness, Lady Hogg, for being my supporting Peer, along with my noble friend Lord Bridges of Headley, who is surely this House’s best hope for delivering a Goldilocks Brexit.
I would like to mention one very special aspect of this House, which I came to appreciate when I was a journalist. In some of my darkest moments, when I have been campaigning on an issue and felt that no one was listening, I have sometimes received unexpected encouragement from Members of this House who I have never met—either notes or, sometimes, very useful pieces of information. I cannot tell your Lordships what a difference that has made.
The most astounding example of this landed on my desk one day from the late Lord Rees-Mogg. I was campaigning to open the family courts to the media, and we were being prevented from publishing some of the cases that I believed were miscarriages of justice. Lord Rees-Mogg wrote a letter urging the Times to publish and offering to go to jail instead of me should we be found in contempt of court. The noble Lord said in the letter that he was so old that he thought he probably would not be jailed for the offence, but that if he was jailed, it would help our cause. Luckily, we never had to call on him, because in fact the Brown Government agreed to change the law, but I have never forgotten the spirit that that letter represented.
I am grateful for the opportunity to speak in today’s important debate, and I know that I need to be brief. Too few people in this country are aware of how fragile the social care system is, of what they can expect if they become old and unable to look after themselves and, as others have said, therefore of what provision they need to make for themselves. I think this is partly because we humans do not like to contemplate our own mortality; we do not think it will ever actually happen to us. But the lack of public understanding of this issue is one reason why social care lags down the political agenda behind the NHS, which is experienced by a much wider group of people.
The social care workforce itself is also misunderstood. When I conducted a review of support workers in health and social care for the Department of Health in 2012 I met far too many care workers who said, “Well, I’m only a carer”. Actually, to go into an elderly stranger’s home and cope with whatever you find there, to feed someone who cannot swallow properly and to lift someone with dignity is a hugely skilled task that requires considerable maturity. Too often we still refer to those tasks as “basic” when actually they are anything but.
I am proud to have been part of a Government who introduced the national living wage, which may help to reduce some of the cripplingly high turnover that we see in the sector. But I also think we have to recognise the cost pressures that this is now putting on providers. As the noble Baroness, Lady Browning, said earlier, the fact that self-funders are subsidising local authority payers in some cases is not only beginning to become apparent to people and making them quite angry, it is also of course an enormous financial problem for deprived areas that do not have self-funders and are increasingly trying to make ends meet.
“Integration” is a great word. We probably all know that some version of integration is vital to address these challenges, and heroic efforts are being made in parts of the country, especially Manchester, to do exactly that and to make the health and social care system work as one. But I am afraid that in too many places integration is still just a word; delayed transfers of care are blamed by the hospital on the local authority, and by the local authority on the hospital. The truth is that until we have greater integration of the money we are not going to break through this problem—and we all know how complicated it is to integrate the money.
One aspect that I will raise is the need to create a much more integrated workforce. Even if we integrate the money, we have to have an integrated workforce in health and social care. As the population we are dealing with becomes frailer, with longer-term health conditions, we are seeing a blurring of the old lines between residential care, nursing care and hospitals. I am pleased that the Government are rolling out the training that I recommended in the care certificate; I hope it will start to break down some of the silos. But I also ask the Government to consider extending that care certificate to volunteers, who already play a vital role in this area and could do so much more to help join up some of the health and social care pieces.
The CQC’s latest State of Care report makes some very good arguments for integration that I do not have time to go into here, but all noble Lords know what they are. It was a great privilege for me to sit on the board of the CQC under the chairmanship of my noble friend Lord Prior, and I salute it for its work in raising standards. The challenge of regulating the sector is enormous because of the sheer number of providers. However, I am not sure that the CQC, the CCGs, the local authorities and other public agencies fully appreciate the cumulative burden that they collectively place on providers, especially small providers, which are often the most caring, with the multiple demands that they make on them. I have watched weary staff filling in form after form—each one almost the same as the last but, maddeningly, slightly different—when they ought to be looking after mothers and grandmothers. I make a plea today to the Department of Health and those public agencies that they get together and agree a single set of data to require from providers. At a time when services are under such pressure, that is the least we could do to ease some of the pressure on them.
I entirely agree with the noble Baroness, Lady Pitkeathley, that we need a more honest debate. Those who are in this Chamber have a much better understanding than the vast majority of those outside. We owe it to those mothers and grandmothers to have that debate because, if they are not our mothers and grandmothers today, they will be tomorrow.
Lord Patel (CB)
My Lords, it is a pleasure and an absolute privilege to follow the noble Baroness, Lady Cavendish of Little Venice. On behalf of the whole House, I congratulate her on a brilliant, thought-provoking and only marginally controversial maiden speech. We would have been surprised if it had not been thought-provoking, from someone who had been a director of the No. 10 Policy Unit, and if it had not been challenging or a little controversial, from someone who has written so many articles; I have scanned through upwards of 450 of them.
Some noble Lords may remember the noble Baroness as a campaigning journalist with the Times, and latterly with the Sunday Times, when she campaigned about the practices of the family courts regarding children. At the time, those who opposed her branded her as confused, biased, salacious and even malicious, but she was proved right and legislation was brought in to change the situation. In policy terms, she obviously convinced the Prime Minister and Chancellor that sugar and fat are bad for us, hence the legislation that has come forward relating to the sugar tax. We hope she will deal with some other matters in future, such as alcohol.
I found her writings interesting. If she goes back to journalism, particularly to the Times, it will be interesting to see how her articles on climate change contrast with those of the noble Viscount, Lord Ridley. In my view, the noble Baroness is the country’s best social analyst and thinker. No doubt we will be privileged to listen to her in future.
Noble Lords might wonder if there are any chinks in her armour. I found one, and I think it is from a reliable source. I do not think she campaigned to ban homework but she certainly thought about doing so when she forgot to take her son’s homework when they went to a literary festival in Cheltenham—I see that she suddenly remembers. The thought about banning homework may have come from François Hollande, who tried to ban it in France.
I hope the noble Baroness will speak often in this House. I encourage her to do so; I suspect she will be challenging, thought-provoking and entertaining to listen to. For today, I have the privilege of welcoming her to the House, and I look forward to hearing more from her.
I turn to my small contribution relating to social care. I currently chair your Lordships’ Committee on the Long-Term Sustainability of the NHS. Witness after witness has told us to concentrate on social care and, as the noble Baroness, Lady Cavendish, alluded to, have a wider public debate about social care and its implications. The noble Baroness, Lady Pitkeathley, and others have referred to how a lack of social care and the problems associated with it are currently killing the NHS. Hospital beds are blocked by people who should be in social care.
With regard to the workforce, we have heard evidence suggesting that by 2037, the gap in the workforce will be around 1.1 million if we have zero immigration or, if we have full immigration, 370,000. That is a huge gap in the social care workforce. On funding, the evidence we have heard from several witnesses is that the gap will be between £2.8 billion and £3.2 billion per year. That may not seem a large sum in terms of our national debt of trillions of pounds, but none the less it is a considerable gap in the funding, particularly of the local councils that have to deal with this.
So with that in the background, we need a solution that must involve the public. We must have a debate about the role of the state, of individuals, of the family and of the community in the provision of social care, and how individuals are going to take responsibility for their social care in future.
A Guardian article in October suggested that the Government have no intention of implementing Dilnot, but the Minister may correct me on that. If that is the case, a different solution needs to be found. In my view, the solution must be some commitment from the individual. It can only be through insurance. Insurance companies have hitherto not been encouraged to provide that and have never shown any enthusiasm to do so.
National insurance, as operates in Germany or Japan, is another way. In Germany, individuals pay 2.35% of their salary, which next year will increase by another 0.25%, which provides social care—although not all of it is provided; the public understand, and are encouraged to take out top-up insurance to cover for what state insurance does not cover. The Japanese system is interesting, because, over the age of 40, it is related to your income. You pay about 2%, related to your income, but it covers the totality of social care, including building modifications, appliances that are needed, respite care and all that. That is on top of the tax-funded health insurance, which covers most of the rest. Although I have not witnessed it, I am told that it works very effectively. However, part of its effectiveness is because of the responsibility that their family and communities take.
Will the Minister tell us, first, whether there is an intention to implement Dilnot? If not, given the crisis developing in social care, which some say is a bigger crisis than the pensions crisis, is any thinking going on as to how we will deal with and fix this crisis? Perhaps I may suggest that here is an opportunity for some bold thinking for a Prior solution that could be synonymous with the Beveridge solution and that fixes the social care problem for the long-term.
Baroness Gardner of Parkes (Con)
My Lords, I congratulate the noble Baroness, Lady Pitkeathley, on securing this topical debate and am very aware of the many years that she has devoted to this field. To say, as everyone has, what challenges there are is a complete understatement. It is in such a state at the moment that it is very difficult to know where to go and how to deal with it.
I attended a meeting which the noble Baroness held recently for carers. It was interesting because I tend to think of carers as people who work in the care industry, and her people were alarmed that someone such as me was there, who was interested in people who are working as employees in the care industry. There has to be closer liaison between these two groups. Voluntary carers are fantastic in all they do, but I remember knocking on doors and speaking to people who said they were completely worn out and did not know how much longer they could continue because they had been looking after their elderly mother and were already pretty elderly themselves. That is when the care worker comes in to give respite care or to help out on some occasions. The two need to work together: the huge number of individuals related to people or caring for them voluntarily and the other side.
One problem that stunned me in the meeting was that when people in ordinary employment went to their employer and said that they now had to take on a caring responsibility for a relation, their employer did not want to know them much longer, because they thought it would interrupt their work. I could understand it because, from running a dental practice, I know that if someone goes on maternity leave and you have only two people, you are in a difficult position while one is away. You wondering whether she will come back; you have to hold the vacancy for a long time; and then she decides not to come back after all that. It is not easy. Nevertheless, there must be a change of attitude of firms so that they can make provision for their staff to be able to help a family member who really needs it.
Care workers usually work in what is run as a business and acts as an agency for a local authority, but whoever is doing the work shares the same aim, and respite care is important. The loss of cottage hospitals means that there is now no interim stage: people have to go from a hospital where they are pushed out, often in the middle of the night, when care workers are often the only people who can be there to receive them at home and see that they are safe.
We must be quite sure that the care industry is working correctly. I spoke to one person who was with her friend and someone was due to arrive to give her lunch at 12 o’clock. There was no sign of them, but the one due at 2.30 or 3 arrived and gave her lunch. Then the other one turned up and said that she had just come to sign to say that she had given lunch. Then they said, “What do you mean: you have given lunch? The next person has given the lunch”. That must be checked on.
When I was chairman of social services on a local council, we checked on those things. Someone dropped in at random to check whether you were actually on the job. It is important to ensure that one carer does not come in to find that the other has left someone in an appalling state and done nothing that they were meant to do. That is very unfair and random checks would deal with it.
People want to live independently and they want to die in their own beds. This was said to me by Essex County Council, which sent us a very good paper. I followed up and spoke to Councillor Madden, who was very interesting. He said that they had developed what is called a “good life” conversation. First, they ask: “What can you still do for yourself and what help do you really need?”. Then they look at what they can do to help them get back to where they were, if there is a prospect of that. Otherwise, they just have to go on with it.
I have no time to say more, but much more could be said. I hope that we will hear many other points brought out by other speakers this afternoon.
Baroness Farrington of Ribbleton (Lab)
My Lords, I thank my noble friend Lady Pitkeathley for her introduction to the debate and the noble Baroness for her maiden speech, which leads me to the point I wish to raise. I want to speak to the Minister about the huge looming health costs to be faced by carers. I remember a child carer, a school friend of mine, who never had lunch because she had to go home to an incontinent mother. She had to go home to wash her, clean the sheets and come back to school. Schoolchildren are suffering. There is a picture that all of us, as we get older, become pleasant, reasonable old people. We do not. Some of us—I count myself among them—become irascible, demanding and difficult.
I wish to draw attention to the problem of carers so that the Minister can take an argument about not building up another problem for the future if we do not look after the health of carers. This debate could have taken place tomorrow in the most reverend Primate the Archbishop’s debate on the role of people in the community. Many carers are informal carers. They are members of the family, neighbours or people who fit it in. These people are being put under intolerable pressure.
I have sat with a carer when the patient was asked if they would like to go to home. They said yes. The patient knew that they could not cope on their own. The carer was in tears when she was asked by the hospital, “Will you be able to look after her?”. She had to say no. Two years later, that carer had a stroke herself, in her early 60s. The pressure of being a carer is horrendous, whether they are children or older people.
The Minister and the Government are looking at what they propose to do about benefits for younger pensioners—in your Lordships’ House, “younger” is a flexible term—and what benefits they get, including increases to their pension. I sadly do not have living parents or parents-in-law, so I make no plea for myself. My worry is that, among the so-called “younger pensioners”, there is a group of people who are holding our society together. They are the people who are carers, who support voluntary groups in our communities and who are members of voluntary associations, churches or informal groups of people. I think that the Government should look at who the real carers are. I agree with the noble Baroness that we often undervalue the work and professionalism needed by those who are employed as carers, but we also undervalue the commitment of those who are working hard.
All of us in this Chamber have a responsibility to speak up for those in greatest need. I know that many Members of your Lordships’ House have faced the problem of being the first pit-stop for caring in their own families and I know that many Members are committed to helping friends and former colleagues here. I hope the Minister will believe me that, if we do not do something, we will have bed-blocking by former carers who have been taken ill because we have put too much pressure on them. These are the people who make us the civilised society that we are and we ought to ensure that they do not become bed-blockers because we are trading on their good will and generosity too much by not tackling this problem.
I will read what the noble Lord, Lord Patel, said about insurance. It is interesting that, as I have got older, every birthday I get a letter from insurance companies asking me if I want to take out a policy to pay for my funeral. I have never yet had a letter from anybody offering to sell me a policy for when I become old, difficult, irascible and immobile. Perhaps the insurance companies are missing something there. I have not known them miss anything before—perhaps, I say to the noble Lord, Lord Patel, it would not be financially viable for them.
Lord Bichard (CB)
My Lords, I draw attention to my interests as set out in the register. I thank the noble Baroness, Lady Pitkeathley, for giving us this opportunity to discuss a desperately important issue and I congratulate the noble Baroness, Lady Cavendish, on a maiden speech that was well-informed, challenging and constructive. I would have expected nothing else; I know that she will be a real asset to the House. She is a very welcome new member of the usual suspects club.
There is no one who can deny that social care is in crisis: significant increases in those needing support, both young and old; too many providers failing; too many commissioners feeling disempowered by a lack of resource; too few people seeing social care as an attractive career option; and clients who are not “just about managing” but struggling to survive. We cannot leave it like this; we need to change. I want to throw a few ideas into this debate about how we might change.
I am not someone who believes that resources are ever the complete answer, but I could not start without saying that the social care sector has suffered disproportionately from recent cuts. Some urgent investment is needed now, as well as a long-term resource plan. That is what we argued in the Barker commission report a year or so ago and the situation has deteriorated further since then. It is possible to do it and, as we said in that report, to look again at the priorities for investment and to change them. That is what we need to do.
But, as I say, this is not just about money. I have been struck increasingly by the number of users who tell me that they do not get what they need in the form that they want and can access, because they were never involved in how the services were designed, shaped and prioritised. That needs to change. Frankly, to provide services in a time of austerity which people do not feel are a priority is an affront to our society. We could perhaps start by involving them in the way that we deliver care support. The current arrangements involving attendance allowance—lower and higher levels—domiciliary and residential care and continuing healthcare are confused, wasteful and distressing for many clients. We have reorganised much else in the benefits system but not this confused and stress-laden mess. We could, and we should, if we wanted to.
People will only receive whole-person care if we, the bureaucrats—in my case, a former bureaucrat—and politicians learn to work better across organisational boundaries. The rhetoric of integration has taken root. Yes, we do need one budget and integration, but the user’s experience is often that nothing much has changed as a result of these words. That is because we have not started looking from the point of view of the client. We have convinced ourselves that bringing two large bureaucracies together will inevitably lead to better services and less waste, but it will not. Two large bureaucracies brought together can be even more inaccessible and wasteful.
No one has mentioned today the possibility of the digital dividend. There are some fantastic examples already out there. They are not rocket science, but the problem is that although there are great examples, they are not uniform—they could be, and should be by now.
Do we not need to do something more to help providers, many of whom have either failed or are on the brink of failure? The CQC has shown that providers who need to improve find it extremely difficult to do so. They do not know where to go or where to get the money. Is this not one of those occasions where the Government could just offer some assistance? We used to have something called Business Link, which helped small and medium-sized enterprises. Are we not now in a crisis where we should have something similar for providers in this sector?
We have a crisis in the workforce. This should be the noblest of professions and yet most people would rather stack shelves in the supermarket than work in this profession. It is possible to change this. I chair the Social Care Institute for Excellence and we are doing some really interesting work with JP Morgan in east London, trying to involve people who have been in the system to come and work in the system. We need government to be giving more support to those sorts of schemes.
As someone said a moment ago, we need to look at how we can better involve the community. We have got into a state of mind of thinking that we have to live in a centralised, state-based, dependent culture. That is not the case; social care requires communities to be involved, but somehow we have lost the knack of realising that potential and helping some of the charitable groups in our communities to be involved.
I do not see at the moment that there is a strategy for social care. There needs to be one—the sustainability and transformation plans are not providing it. I ask the Minister: why can we not have a five-year plan for social care to sit alongside the five-year NHS review?
Baroness Redfern (Con)
My Lords, I declare my interests as set out in the register. I congratulate my noble friend Lady Cavendish on her maiden speech, which was very welcome.
I welcome the opportunity to take part in the debate and thank the noble Baroness, Lady Pitkeathley, for tabling it because I feel passionately about the sustainability of our NHS, which is of vital national importance to all of us. I acknowledge people’s expectations of ever-higher standards in the NHS. I too welcome the Government’s commitment and investment of new money, but at the same time we cannot simply call for more when current health arrangements can in some circumstances be a little institutionalised in terms of assessing funding and staffing requirements.
If we are to have a first-class NHS and a fully integrated social care system for the future, much work needs to be done to explore the opportunities offered by new technology and data sharing to improve the way public services work and address the needs of our increasing population. The technology revolution is very real and should enhance more productive use of our scarce healthcare resources now and in the future. We should also invest in transdisciplinary research capacity and use the evidence gained from that to the full, thereby avoiding duplication.
New ways of working and new technologies are out there and our workforce needs not only to catch up with them but also to speed up their use. I understand that that takes time, and time is a very precious commodity. However, if we focus on innovative high-tech solutions, involving redesigning workflows, we will see rewards in terms of improved patient care. Investing in this area will, importantly, improve patient outcomes and save time and money. It is a case of saying, “We understand and we get it and we should go for it”. Initiatives are available that encourage innovation and take-up of digital technologies, with pump priming of financial incentives to enable bodies to undertake a shift in culture and forge ahead and be bold in developing services.
As regards saving to spend, many estates and buildings in this sector have become outdated and, unfortunately, are inadequately maintained. In some cases there are huge maintenance backlogs. They present opportunities to raise capital for reinvestment in the NHS through selling off prime estates where buildings are no longer fit for purpose. The land can be exceptionally valuable in many cases. It makes sense financially to acquire these capital receipts. Collocating brings improved closer clinical interaction. That again benefits NHS patients and the workforce.
The importance of working collaboratively in back-office services cannot be stressed enough. It again offers scope for more efficiency. Again it is important to make sure that the workforce understand it, are up for it and can relinquish the desire sometimes to be too protective of their own back-office functions. Everyone needs to be on message. We want a first-class NHS service and a fully integrated social care system for our population.
Viscount Hanworth (Lab)
My Lords, many of the providers of residential care are on the verge of bankruptcy. They are unable to meet their mounting expenses, while the budgets of local authorities, which are responsible for paying for care in many cases, have been savagely cut.
The failure of the Government to address this problem is in spite of numerous warnings. One such warning was the collapse of the Southern Cross Healthcare Group in 2011. The group was the largest provider of care homes and long-term care beds in the United Kingdom, operating 750 care homes, with over 37,000 beds and with a staff of around 41,000 employees. The company was founded in 1996. It grew rapidly through acquisitions that were financed predominantly by a sale-and-leaseback strategy, which placed its residential properties in the hands of investors in return for large capital sums and at the cost of payments of rent on those properties. Already by 2004, its acquisitions were subject to an investigation by the Office of Fair Trading. In 2011, the company was in crisis on account of its inability to meet its annual rent bill, and it was begging the Government for support. In the event, the Government did not have to intervene, for the reason that the ownership of many of the care homes was transferred to the landlords, some of whom had links to social care provision and many of whom did not. Before its collapse, the value of the shares of Southern Cross fell drastically, and its market value was reduced from £1.1 billion to £12 million.
Another Government of a different political persuasion might have seized the opportunity to acquire the assets of the conglomerate at fire-sale prices, thereby returning the provision of social care to the public domain, where it had resided preponderantly before the era of privatisation. The ownership of care homes is now in the hands of venture capitalists, whose interests are confined to the financial returns of their holdings. The current crisis points to a further round of divestment with an even greater consequence than the failure of Southern Cross. The failed conglomerate was founded on the supposition that a steady and a reliable income would be forthcoming from local authorities. The sure-fire returns would have allowed a high degree of financial leverage on the basis of which there could have been further acquisitions. The fallacy of this supposition has now been demonstrated conclusively with the consequence that very little private capital will be forthcoming in future to sustain the sector. However, there are signs of a pushback from the private owners of care homes, and some are even investing to improve their services significantly. By so doing, they should be able to attract rich patients whose wealth would preclude them from receiving support from local authorities. What is now in prospect is a two-tier care system for the elderly. For the rich, there will be comfortable residences. For the rest, there will be what should best be described as poor homes.
The crisis in social care will be solved only when adequate financial support is forthcoming, and it is important to attempt to envisage how this could be achieved. First, we should observe that the manner in which we end our days is the subject of a lottery, but it is a lottery that has no winners. Some people will take their leave suddenly and without much forewarning. Others will experience a lengthy senescence, which is often a miserable one. If the present inadequacies of the care system continue to worsen, then such people will be amongst the greatest losers.
The appropriate way in which to finance this lottery is by an insurance scheme. In common with the noble Lord, Lord Patel, I propose that every income earner should contribute to a fund in the proportion to which they pay income tax. The fund in question should be used for the sole purpose of social care. The tax to sustain it should be set to a level that is appropriate to the nation’s need for social care, and the determination of that level should be the responsibility of an independent commission.
There have been proposals in the past that Governments have chosen to ignore. Those of the Dilnot commission are still hanging over us. The commission proposed a limit to the amount that any individual should contribute to their care over their lifetime. It also suggested increasing the wealth that an individual might own before being asked to contribute to the cost of their care. Both of these suggestions have found favour with those who wish to preserve their wealth to pass it on to their inheritors. I declare that I am not greatly sympathetic to this motivation.
Be that as it may. I suggest that matters of inheritance should be rigorously separated from the question of how to achieve adequate financing of social care. Much of the difficulty that we face in connection with social care is a consequence of the pernicious confusion of two issues that should be dealt with quite separately.
Lord Warner (CB)
My Lords, with the possible exception of the Minister, I am sure we are all grateful to the noble Baroness, Lady Pitkeathley, for providing us with yet another chance to tell the Government what a dire state publicly funded adult social care is in. It is also good to welcome the noble Baroness, Lady Cavendish, to this gathering of the usual suspects, with her excellent maiden speech and her great expertise.
We have now a Chancellor who, we are told, is impressed by data, so I will give just a few figures, even though these stats have not done much to convince his predecessors. In the 2011 Dilnot commission report—I declare my membership—we told the Government that adult social care was underfunded by at least £1 billion a year. Since 2010, another £5 billion at least has been taken out of the system. According to the experts—I am still rather inclined to listen to them—the deficit next year will be around £2.5 billion. Whatever the precise figures, there has been a funding shortfall for over a decade; it is getting worse; great damage is being done to vulnerable people, service providers and the NHS; and the Government have no credible solution.
Although the problems are not of the Government’s making, they are the people now in charge, and I point out to the Minister that the system could well fall over on their watch. The Autumn Statement is a missed opportunity, and the Prime Minister needs to tell her advisers to come up with something more convincing than telling us that social care faces challenges. Her spads should read the briefing we received for this debate, particularly the evidence from the LGA—now Conservative-controlled—and from the regulator, the CQC, which is hardly a vested interest. The LGA makes it absolutely clear that it will not be its fault if, as is highly likely, there is a serious collapse of publicly funded social care in the next couple of years. The CQC points out that for the first time new nursing home providers are not coming into the market and big players in that market are handing back contracts to local authorities. Make no mistake—the rush for the exit has started from publicly funded adult social care providers of all kinds, and their lack of trust in a credible rescue plan means that they will take a lot of convincing to return. A failure to resolve this long-running social care funding crisis quickly has massive implications for the sustainability of the NHS.
Even if they are tempted to avert their gaze, the Prime Minister’s advisers should, even now, think about what is likely to happen in the shorter term. First: a good old-fashioned NHS winter crisis this winter, continuing almost indefinitely up to the next election, with rising avoidable death rates. With hospital bed occupancy already well over 90%, that is now almost inevitable. Secondly: a regular TV diet of ambulances queuing outside hospitals, unable to deliver patients; 24-hour A&E trolley waits for elderly patients; cancelled operations and a whole host of interviews with doctors, nurses and others about the impossibility of their jobs. Thirdly, the Government can say goodbye to delivery of the five-year forward view, which the NHS England chief executive made clear depended on properly funded social care. They can also expect a flow of social care scandals and the CQC reporting next year a further reduction in the providers of publicly-funded social care.
However, this gloomy forecast need not happen. We do not have to watch the NHS collapse under the weight of work it should not be doing. It is much cheaper and better value to put social care on a more sound and sustainable footing than simply propping up the NHS to cope—and it is better for patients as well. Therefore, here is the Warner five-point plan for doing something now. First, commit to the annual funding for social care being increased at least in line with that for the NHS. Secondly, guarantee the funding for social care for at least five years, starting in April 2017. Thirdly, scrap the bureaucratic and small better care fund and use the money as part of a five-year social care renewal fund of at least £6 billion, with £1.5 billion of this going direct to local government in each of the first two years—but on condition that it is used for speeding up hospital discharges and preventing admissions.
Fourthly, we should commit to implementing the Dilnot proposals already enshrined in the Care Act 2014, and we should do so in 2018-19 with properly funded local government administrative costs. Fifthly, to oversee all this, we should speedily convert the Department of Health into a department of health and social care, with all social care responsibilities transferred to it from the DCLG, and we should make it responsible for an integrated health and care budget. At least that would give us a bit of time for longer-term planning. The Prime Minister could then say that she was helping not only the JAMs but the NAMS—the “not actually managing”.
Baroness Verma (Con)
My Lords, I thank the noble Baroness, Lady Pitkeathley, for initiating this debate, and I congratulate my noble friend on her maiden speech.
I declare an interest as a social care provider. I started the business 16 and a half years ago and have seen many changes in the sector, none of them for the better. It is right and proper that we value care workers, but we cannot do that if we do not have the funding, the time or the ability to recognise their work, which is so important that it would put much more pressure on the NHS if it was not done.
During the years that I spent on the Front Bench, I was unable to speak. Now that I am able to do so, I say to my noble friend the Minister that the NHS is a precious commodity which we all value but, as the noble Lord, Lord Warner, said, it needs to be combined with social care. We need to place social care and the health service on an equal footing. It is not just the elderly who have need of social care; many disabled people and young people are dependent on care workers to support them to live independently.
It has been said that we are the fifth largest economy in the world. If we are to muster a service that is reflective of our society, we must recognise that we need to pay the right price for the right care. I agree completely that we need the living wage, and I would pay care workers even more, but we have to recognise that, while we put the NHS on a very high pedestal, we do not do the same with social care. We need to reduce that gap and equalise the two.
In recent years, the social care businesses delivering domiciliary care have seen added administration costs—there are extra things that care staff and office managers have to deliver—yet there has been no indication of how that is going to be paid for by local authorities. Local authorities claim, rightly, that they do not have the funding. If there is to be funding for social care, it needs to be ring-fenced so that it cannot be diverted to other areas where local authorities face pressures.
In recent years we have had to implement electronic monitoring. To the noble Lord who thinks we are not monitored properly, I say that the social care sector is very well regulated and monitored. Of course, there will be the occasional bad apple, as there will be across all sectors, but I can tell the House that, having worked with and listened to my care staff and managers, I understand the frustrations of having to deliver good-quality care to people. Those care workers, who often will be the only contact that people have throughout a whole day, have to rush through delivering a package of care because the time they can spend on each visit has been so greatly reduced. This is an unacceptable way of treating the most vulnerable people in our community.
I urge the Minister to bear in mind that the social care sector looks after a lot of people, and not just the elderly, although the elderly make up a large proportion of those who end up using the NHS because often they do not get sufficient assistance in their homes. I urge the Minister not to look at integration for the sake of integration but to understand that there is a balance to be struck. Good-quality home care and rest home care prevents people ending up in the very expensive National Health Service.
Baroness Walmsley (LD)
My Lords, this has been an excellent debate with many thought-provoking speeches, including, in particular, that of the noble Baroness, Lady Pitkeathley, in introducing the debate and that of the noble Baroness, Lady Cavendish.
Yesterday morning, there was a story on Radio 4’s “Today” programme that neatly illustrated how problems with social care affect the whole health and care system. The story was about ambulances and the fact that in the past year 500,000 extra hours were spent by ambulance crews waiting outside A&E departments, unable to discharge their patients, while other serious and urgent cases stacked up awaiting their arrival. The head of emergency medicine for the NHS gave an account of new ways of working that may help put a sticking plaster on the problem. However, the story illustrates very clearly the interaction between the various parts of the health and care system.
Of course, the reason ambulance crews have to wait so long is that A&E departments are full, unable to move their patients to beds in the wards because they are full too. One of the reasons that the wards are full is the delays in discharging patients to appropriate care in care homes or their own homes with a suitable package of help—and we know that people go to A&E, where the lights are on, because they cannot get an appointment with their GP. Nearly 570,000 bed days were lost in acute hospitals during the second quarter of 2016-17 as a result of delays in discharging patients, with problems in arranging social care now the main reason given by hospitals for these delays. This comes at a cost to the NHS of £820 million a year. The story illustrates why we need to sort out social care, apart from the need to ensure that elderly and disabled people get the care they need in a timely and dignified way.
The Care and Support Alliance of 90 charities points out that, as well as relying on help with everyday tasks such as washing, dressing and eating, social care plays a vital role in supporting recipients and their carers to move into, or stay in, employment, and in preventing avoidable expenditure, particularly in other parts of the health service. The charity Sense, which works for deafblind people, points out that in the past year alone 11.4% fewer people with sensory impairment were able to access services. This has greatly curtailed their community involvement and life chances.
The whole system is like a pack of dominoes that will fall with a great clatter unless something is done. That is why I, along with others who have spoken today, was shocked and horrified that, despite all the evidence that has come forward about the dreadful state of care funding, the Chancellor said not one word about it in the Autumn Statement and provided not one extra pound. The interoperability of all parts of the system of health and social care indicates strongly the need for a cross-party consensus on how we fund it in this country—I welcome the support on that from the noble Lord, Viscount Hanworth. While I look forward to the report of your Lordships’ ad hoc Select Committee on sustainability in the NHS, chaired by the noble Lord, Lord Patel, we need to go much further, as my right honourable friend Norman Lamb has so often proposed. We need to look at all the options: insurance schemes, the German scheme, the Japanese scheme, general taxation and national insurance.
The nearest thing we have to an independent commission is the King’s Fund and the Nuffield Trust, which work together and with others to inform the debate. Since the disaster of the Autumn Statement they have said that they now expect a funding gap of at least £2.4 billion in social care next year. That means that the intense pressure on services will continue to grow, increasing the burden on older and vulnerable people, their families and their carers, as the noble Baroness, Lady Farrington, has told us.
In its recent report on the sector, the CQC said that social care is at a tipping point. The CQC does not often use such language, but it should know, since it inspects all the services. However, it did report that 72% of settings were good or outstanding, and that is a credit to all those working in the sector who do their very best for the service users despite all the problems. The facts, however, are dismaying. Following multiple cuts to local authority funding over the past six years, 26% fewer older and vulnerable people are receiving services, while demographics mean that demand is rising. Because the potential for most local authorities to do any more within existing resources is limited, my colleagues in local government tell me that they will soon struggle to meet even basic statutory duties.
As we have heard, companies providing places in care homes are handing back contracts to local authorities because they cannot provide adequate care—the sort of care they want to give—with the funding that they get. Some are concentrating on self-funders. Indeed, self-funded service users are subsidising state-funded users in some places, and I agree with the noble Baroness, Lady Browning, that that is not fair. The national minimum wage—I still refuse to call it a national living wage because one cannot live on it—is putting enormous pressure on already small margins. Aside from the quantity of care available, good-quality care matters for many reasons, not least of which is that good care homes, working with their local GPs and community pharmacies, keep people out of A&E and other hospital departments.
Domiciliary care fares no better. Fifty-nine councils have had home care contracts terminated, affecting nearly 4,000 people. Three large national domiciliary care providers with multiple contracts have withdrawn from the market or are planning to do so. The critical condition of home care services threatens to undermine policies to support people at home, which, as we have heard, is where most people prefer to be, near their families and friends who can often help with care and are happy to do so within their capabilities. An estimated 1 million people now have unmet needs for care and support in England and research on disabled adults suggests that at least two in five are not having their basic needs catered for.
The new 2% precept increase that local authorities are allowed to raise does not help deprived areas where the majority of care users are state-funded and low council tax receipts from low-value properties will not raise anything like the amount of money needed. In those places, the potential for cross-subsidy from self-funders is minimal too. Besides, the precept, if fully applied overall, will raise only two-thirds of the cost of the increase in the national minimum wage in a sector where most employees are on that level of pay. At the same time, the Government have delayed until 2020 the implementation of Part 2 of the Care Act 2014, which introduces a cap on care costs and changes to means testing. These are reforms proposed by the Dilnot commission in 2011 and this breaches a Conservative Party manifesto commitment. So can the Minister say when it will happen, since many people are now doubtful as to whether these reforms will ever see the light of day?
The King’s Fund believes that our starting point for reform should be the Barker commission recommendation of a new settlement for health and social care, based on ending the historical divide between the two and moving to a single budget and single local commissioning of services. I agree with that, but there is also a very large elephant in the room, and that is the looming Brexit. We spoke about this at length in last Thursday’s debate. A damaged economy, resulting in a lower tax take, and uncertainty about the future of the many thousands of care staff who come from other EU countries cast an enormous shadow across an already staggering system. When will the Government do the right thing and offer them certainty?
It cannot be right that the care and support received by older and disabled people increasingly depends on where they live and how much money they have—a postcode lottery—rather than on their real needs. Although additional funding is badly needed in the short term, in the long term reform is what is required. The only game in town on that front at the moment is the sustainability and transformation plans, funded by the Better Care Fund, but there is evidence that, first, the emphasis is on sustainability rather than transformation and, secondly, that local authorities, patients and care providers are the last ones to be consulted on the plans. How can services be integrated when crucial parts of the system are not being properly consulted and funds that should be used to develop and pilot new ways of working are just being used to prop up budgets in deficit?
As the King’s Fund said:
“England remains one of the few major developed countries that has not reformed the way it funds long-term care in response to the needs of an ageing population … A number of commissions and reviews have been set up over the years and made recommendations about how to place social care on a sustainable footing. However, successive governments have failed to grasp the nettle”.
I am a gardener and I know the value of nettles: they support wildlife and you can even make nourishing soup out of the small leaves at the top of the plant. So will the Government grasp the nettle, because they may find it good for them?
Baroness Wheeler (Lab)
My Lords, I too congratulate my noble friend on her usual robust and forthright introduction to this debate, providing a clear strategic overview of the options we face that is firmly rooted in the day-to-day reality for older and disabled people and their carers, and on telling it like it is. Indeed, the Minister knows well how it is because he has acknowledged several times the scale and seriousness of the funding issues faced by social care, and he surely knows that the Government’s remedy for this, of the 2% local authority precept and money in the Better Care Fund starting next year, are nowhere near enough and do not provide the urgent resources and investment that social care needs now.
Before last week’s Autumn Statement, a chorus of health and social care leaders, councils, private and voluntary sector providers, think tanks, staff unions and patient organisations pleaded for urgent action by the Chancellor. The Guardian summarised the cost of what is needed for a “basic” rescue of social care at £1.3 billion, the same sum as the Chancellor actually allocated for roads. A major Statement about the Government’s financial programme, policies and priorities making not one mention of social care was a devastating blow for staff and providers, for the now 1.2 million people needing but not getting basic care and support to help them to stay living independently in their homes or in the community, and for those desperately struggling to pay ever-escalating care home fees.
Today’s debate has provided a clear overview of the current state of social care and the impact of what have now been nearly seven years of substantial cuts to local council budgets. The Minister has himself estimated that the decline in real-terms spending on social care from 2010 to 2015 is 12.8%. We have ranged across concerns about the provision of community support services, domiciliary and residential care and the interface of social care with hospital and primary care—the subject of my recent debate on the now record 1.15 million delayed hospital transfers, at least a third of which are caused by the unavailability of social care support. The noble Baroness, Lady Walmsley, set out the figures for this, underlining the cost of £120 million a year to the NHS compared with the estimate by the National Audit Office of what community care costs would be—namely, £180 million.
We all join with my noble friend Lady Pitkeathley in taking some comfort and solace from the consensus on the urgent need to address the social care funding crisis. The medical profession, together with Conservative, Labour and Liberal Democrat leaders in local government, have warned that the safety of millions of elderly people is at risk and that,
“the vulnerable will increasingly struggle … to meet basic needs such as washing, dressing or getting out of bed”.
We on these Benches strongly support the need for the fundamental long-term reform called for by my noble friend and to join up care services, from home to hospital, with properly integrated health and social care budgets.
In this regard, perhaps I may commend as a contribution to these issues a recent report by the Commission on Care entitled, Towards a New Deal for Care and Carers, which crucially looks at how the social care system is working in England from the point of view of care recipients, particularly older people, patients, carers and women, who we know because of their role as the main providers of paid and unpaid care, have been disproportionately affected. It is increasingly self-funders and unpaid carers who are having to fill the gap between diminishing publicly funded care and the growing care need.
The need for an urgent review cannot be more clearly evidenced than in residential care, as a number of noble Lords have pointed out. The sector is home to 425,000 residents in around 18,000 homes across the UK. One in six residents is over 85 years old, an age group set to double by 2035. Care home residents have a prevalence of long-term conditions, in particular dementia, stroke and diabetes-related conditions. Many residents can have up to six co-morbidities. Some 75% of the residents in the top three care home providers are publicly funded. Noble Lords have observed, and Age UK has pointed out, that throughout the sector self-funders of care are getting a raw deal and are helping to keep homes viable and in operation. They are stuck in the middle and unfairly being asked to pay the price for a failing care system. How long can this system of providing residential care survive without going under?
The public focus and concern has been on the precarious financial state of the large-scale providers, but we know that 75% of them are in fact local provider organisations in small group homes being run by just the owners themselves. Care England has estimated that local council fees paid to care home providers average out at about £2.30 an hour and warns that small homes will be the first to go to the wall if extra funding, particularly for the implementation of the national living wage, is not provided.
Does the Minister agree that the current system of funding for residential care needs urgent and thorough review and reform? What plans do the Government have in place in the event of the financial collapse of a large-scale provider? Is he confident that the CQC risk mitigation monitoring of care home balance sheets is a sufficient level of scrutiny and safeguard to avoid a repeat of the disastrous Southern Cross home closures?
On domiciliary care there is clear and compelling evidence that the current system of providing this vital care just is not working. The latest figures in this Sunday’s Observer showed alarmingly that in 48 councils at least one company that provides care for the elderly in their own homes has ceased trading over the last six months. Also in that period, 59 councils have had to find new care arrangements after providers have handed back contracts because they cannot make ends meet on the money that councils are able to pay.
Last month, we saw the home care provider Mitie announcing withdrawal from its home care business, with its CEO, the noble Baroness, Lady McGregor-Smith, a Member of the House of Lords from the Benches opposite, underlining that the prices requested by local authorities for care,
“made it impossible for Mitie to carry on”.
Mitie’s press release quotes the noble Baroness as emphasising that councils and the health service were not to blame for the care crisis because employment costs, including introducing the national living wage, had gone up by a third in the past three years as funding had dropped sharply. She said:
“Care workers should be paid significantly more but someone has got to pay for it. If we are serious about social care in the UK it needs significantly more than the funding that has been suggested”.
On the Dilnot report, I can take the unusual step of answering noble Lords who have questioned the Government’s promises about implementing Dilnot. In last week’s debate on the implications of Brexit, the Minister confirmed that the Government are committed to implementing Dilnot by 2020 and that next year and the year after would see the work on implementation begin and on refreshing the strategy. I look forward to hearing more about this from the Minister.
In last week’s debate, we also had the reminder of the shocking figure of the annual turnover of care staff of 37%, which was one of the most depressing moments, underlining how far we still have to go to attract and retain staff in this vital job, and to make them feel valued as an essential part of the care team. In this regard, I join with other noble Lords in congratulating the noble Baroness, Lady Cavendish, on her excellent maiden speech, in particular on her description of the work of care staff who visit day to day in people’s homes. I can particularly attest to that as a carer of someone with a severe disability who has carers in their homes every day. I thought it was a very apt description.
Finally, I come back to the 6.5 million unpaid carers in the UK who are increasingly having to prop up a care system in crisis and provide more and more carer hours than ever before, much of which should be provided by trained care staff. My noble friend Lady Farrington spoke movingly about this. We are told that supporting carers is a key government priority. The national carer strategy is being revised and updated. The Minister has promised to write to me about this, but unless the strategy addresses the everyday support that carers need to help them care for their loved ones—such as assessments and care plans that result in actual service support, funding for local carer support organisations that build local community advice and help for carers and are there when carers need them, and the regular respite care that is so vital when you are a 24-hour, seven-day-a-week carer—then it will just be fine words. My local council, Surrey, which has previously led the way on carer support services, is having to cut carer support services by 33% over the next three years. A recent FoI request from Revitalise showed 42% of English councils had made cuts to respite care for carers.
This has been a key debate and has underlined the consensus we all still desperately need and which we hope will lead to the Government providing the extra funding that is needed now and into the future. The social care system is complex, difficult to understand and access, especially for the people it needs to be supporting, and is failing across community, residential and domiciliary care, despite the commitment and efforts of providers, staff, volunteers and carers. It needs fundamental and urgent reform, and long-term funding that truly meets the cost of providing good-quality care.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, I join everyone else in thanking the noble Baroness, Lady Pitkeathley, for introducing the debate, which is very important. It is not easy to respond to, to be honest. I acknowledge that there are great pressures on care providers. We saw queues in A&E on the news last night. There are delays in people getting discharged from hospital. In its recent report on adult social care, the CQC found that the market was approaching “a tipping point”. In addition, as has been mentioned, the Autumn Statement did not make any specific announcements on health and social care. So there is no question but that adult social care is under huge pressure. However, that does not mean that we should become so utterly depressed that we do not see that some good things are being done as well. Many councils have risen to the challenge of achieving significant savings while setting balanced budgets, keeping council tax low and maintaining satisfaction in services. The CQC notes that,
“despite increasingly challenging circumstances, much good care is being delivered”,
and there was encouraging evidence that improvements were taking place. Nearly two-thirds of users of social care services have said that they are satisfied or very satisfied.
It is not all bad—there are some bright lights out there. We all know that there are some wonderful care homes, domiciliary care agencies and social care workers. As the noble Baroness, Lady Wheeler, did, I empathised very much with the words of my noble friend Lady Cavendish, who talked about people being “only a carer”. I agree with the noble Lord, Lord Bichard, that in many ways it is the noblest profession, very much unsung. Over time, the care certificate and the living wage will be able to transform some of those roles and give them greater status, as well as providing them with greater pay. In response to my noble friend Lady Cavendish, I say that we are looking at a single data source for data provided by care homes and others who provide social care. Extending the care certificate to volunteers is an interesting idea.
The noble Lord, Lord Patel, raised the issue of Dilnot. It is still our intention to implement Dilnot at the end of this Parliament, as I said in a debate a week ago. It will be interesting to see the results from the noble Lord’s Select Committee. Its views on insurance will be interesting to read.
I want to spend most of my speech talking about the strategic issues that underline the word “integration”, which has dominated our discussions on the subject for many years; I think that the noble Baroness, Lady Pitkeathley, said that she wrote a book on this in 1978. We had case management in the 1980s, inter-agency working in the 1990s, and integrated care pathways in the 2000s. Successive Governments have tried to bridge the gap. With great blowing of trumpets in 2000, the NHS Plan talked about integrating health and social care. The better care fund, which came out of the coalition Government, was the first national, mandatory integration policy. This year, it has a mandated minimum spend of £3.9 billion. Interestingly, it looks as though it will be up to £6 billion through local authorities voluntarily pooling resources into it. There are some examples around the country—I could give details on Northumberland, North East Lincolnshire and Plymouth—of the better care fund resulting in a change. It is not the bureaucratic change referred to by the noble Lord, Lord Bichard, although that is always a risk if you pool resources. If you pool two enormous bureaucracies, you can end up with an even bigger mess than you started with, but there is evidence on the ground that the better care fund is achieving some results. Of course, the Care Act 2014 placed a statutory duty on local authorities to promote integration. So there is no lack of rhetoric on this matter.
These efforts have not been enough, however, and all Governments—the coalition Government, our Government, the previous Labour Government—have to accept that we have brought in other policy changes that have worked in completely the opposite direction. The creation of foundation trusts, brought in by the party of the noble Baroness, Lady Wheeler, the proliferation of CCGs, brought in by the coalition Government, and, of course, payment by results have all had the effect of making the system less joined up and more fragmented and have diverted resources away from community and primary care—exactly where we want them—into secondary care. Integration is still possible in our fragmented system, but it is incredibly difficult. In practice, it requires exceptional leadership, preferably based on long-standing, trusting relationships, which are rare in many parts of the country.
The Five Year Forward View explicitly recognises this. I shall quote from it because it is worth reminding ourselves of the strategy we are embarked upon:
“The NHS will take decisive steps to break the barriers in how care is provided between family doctors and hospitals, between physical and mental health, between health and social care. The future will see far more care delivered locally … The traditional divide between primary care, community services, and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three … Increasingly we need to manage systems – networks of care – not just organisations. Out-of-hospital care needs to become a much larger part of what the NHS does”.
I think most of us who have taken part in this debate would say amen to that.
Underpinning all this work on integration is the difficult question of relationships between organisations. As the King’s Fund said last November:
“NHS organisations need to move away from a ‘fortress mentality’”,
with individual organisations protecting their own interests at the expense of the system as a whole. This is the classic “tragedy of the commons” in which individual interest destroys collective and community interest. This separation is not just a legal separation, it is budgetary, it is financial, it is institutional and, most importantly and most difficult, it is cultural. These barriers will not melt away overnight, nor will they be transformed by us passing new legislation: politicians should take note of this.
How do we put this into practice? NHS England’s planning guidance for 2016 states that sustainability and transformation plans,
“will be place-based, multi-year plans built around the needs of local populations. STPs will help drive a genuine and sustainable transformation in health and care outcomes between 2016 and 2021. They will also help build and strengthen local relationships”.
Planning by individual institutions for a year in advance will increasingly be supplemented and replaced by planning by place for local populations for a number of years in advance. For too long, the NHS has emphasised an organisational separation and autonomy that does not make sense to staff, to patients or to the communities they serve. The Government recognise, as NHS England recognises, that the process of developing STPs has been easier in places where there are strong existing relationships. As Sir Bruce Keogh says, different areas are starting in different places and they will finish in different places at different times.
Jim Mackey, the chief executive of NHS Improvement, has said that the STPs are a process, not an event, and we expect local organisations to continue to work closely together to address local health and care needs, but the STPs are bringing together health and social care on the ground. They are not perfect and they will not solve this problem overnight, but they are starting to have an impact. Different organisations are sitting down together for the first time ever and thrashing out some very difficult long-standing problems.
The next theme I want to explore is devolution because that probably has the best chance of driving towards better and more integration across boundaries and more widely across the public sector. We recognise that this process will not be easy but the direction of travel is right. To paraphrase Nye Bevan, when a bedpan is dropped on a hospital floor in Salford, its noise should resonate in Manchester Town Hall, not Westminster. Devolution should be seen as more than a shift from central to local government. It should enable communities to be directly involved in designing responsive and personalised services. Devolution will make care more accountable to local people.
The first and probably the biggest of these devolution arrangements is Greater Manchester, which has already been referred to in the debate, with the Greater Manchester Health and Social Care Partnership now taking responsibility for implementing its five-year strategic plan. The chair, the noble Lord, Lord Smith, said only a month ago that,
“the progress we have made has been revolutionary for the region”.
That progress has been made possible by the unprecedented partnership shown by working with all 37 organisations involved. It works because Manchester has long-established and well-respected leadership.
NHS England has agreed that Greater Manchester’s partners should make their own decisions on how to spend their £450 million transformation fund, which covers more than 2 million people. The new governance structure has both strategic oversight for all matters relating to health and social care services and the accountability to make big, bold decisions that can truly deliver the levels of transformation we are seeking to achieve. We are looking for transformation as well as sustainability. The same is beginning to be true for Birmingham and Solihull STP, for example, which is another STP that is led by a director of social services. The foreword to the STP plan states:
“The STP is an iterative process, and this is the start of a longer transformation journey. It’s not a short term plan—this is for long-term, sustainable change over 5 years and beyond”.
So the STPs, for all the shortcomings that some of them have, are a step in the right direction towards bringing together health and social care at local level. Picking up the point made by the noble Lord, Lord Bichard, I believe that over the next few months we will see a much greater involvement of local users and local people in structuring those STP plans.
There are two important preconditions for the success of this programme. First, too often social care is seen as the poor relation or simply as a means by which we can reduce demand on the NHS. This is to hugely undervalue and undermine the contribution that those working in the service make to the well-being of users, and the importance of social care services in their own right. Any approach to integration that fails to recognise this and instead seeks to draw in social care services just as a means to reduce NHS demand cannot be right. So when we consider how best to bring health and care services together, it is important that local areas fully appreciate the role of social care and the spectrum of services it provides. It would be wholly wrong to see social care solely as a means to reduce A&E admissions or delayed transfers of care from hospital.
Secondly, we need to be careful not to fall into the trap of thinking that better health can be secured just through integrating health and social care services, when in reality the factors that contribute to a person’s health are much more complex and wide-ranging than those within the scope of health and social care alone. The Marmot review and many other commentators since have been clear that health inequalities arise from a complex interaction of many factors—housing, income, education, deprivation, social isolation and disability—all of which are strongly affected by a person’s economic and social status and well-being. Plans to integrate services around people’s needs should consider the wider determinants of poor population health and factor them in.
The five-year forward view sets out a non-partisan strategy for what needs to be done to ensure NHS sustainability and drive improvements in the health and social care system. The STPs are putting that plan into practice. I accept, as I did at the beginning of my speech, that this is taking place against a very tough financial background. Some will argue that it makes it more difficult; I would argue that change will happen only if organisations are forced to change in order to survive. Change is necessary to meet the needs of today’s population in a way that delivers care that is both better and affordable.
I have not given up hope at all on this. The short term does look bleak and I acknowledge the huge pressures on social care—but, for the first time, we have a strategy that is actually being put into practice. It will not deliver all that we need to do in the space of two or three years, or even within the length of the five-year forward view, but if we can show that it works in some parts of the country, we have a much stronger hand to go back to the Treasury and say, “We need some more money to finance these STPs”. But we have to show that it can work at some pace and to some scale.
Baroness Pitkeathley
My Lords, we have had an excellent debate and I thank all noble Lords who have taken part, especially the noble Baroness, Lady Cavendish, for her thoughtful speech which makes us eager to hear more from her. The topics covered today have been as wide-ranging as the issue itself but there has been agreement about the crisis which exists, if not yet on how to address it.
I did not of course expect the Minister to announce from the Dispatch Box the great public debate that I have called for today. Many others have called today for such a debate and it is of course way above his pay grade—but that does not mean that I resile one iota from the calls for that debate. We must have it; it is inevitable and it would be better to have it sooner than later—before the system really does collapse, as many people have warned us it will.
The Minister has had many suggestions and, with his usual courtesy and honesty, has certainly addressed some of them. I welcome his focus on the strategy and I certainly acknowledge the progress made, as he reminded us, with some STPs. However, a couple of examples that I have had remind us that the STPs should not be about just health and social care but should include carers and the voluntary sector. It is important to bear that point in mind as we go forward with the STPs.
The emphasis has been on the interdependence of the health and social care services, as well as on the needs of users, carers and care staff. I get the impression that the time is right, and I think that the Minister has confirmed this. The people at the top—even, dare I say it, at No. 10—have realised that something must be done. If you have a philosophy which says that the Government must work for all and that you must help people who are “just about managing”, or even the “not managing at all” as the noble Lord, Lord Warner, reminded us, I hardly think that you can avoid addressing this issue. If that is the case and there is agreement that something must be done, I hope that this debate can be required reading. Readers will find calls for more resources but I do not want that to frighten them off, because they will also find in this debate a wealth of practical and deliverable suggestions on how to address these issues. So although I am a bit depressed, I am not totally depressed. Like the Minister, I am not without hope and I certainly hope that by the next time the usual suspects meet here to discuss this, we will have made some more progress. I beg to move.