Health and Social Care
(2 years, 4 months ago)
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Baroness Thornton (Lab)
My Lords, I first declare my interest as a serving non-executive director on a local hospital board, which is in the register.
I thank the Minister for the Statement from Friday concerning the winter and the NHS. If the House will indulge me for a moment, I put on record what a pleasure and privilege it has been over these years to have had my honourable friend Jon Ashworth, former Shadow Secretary of State for Health and Social Care, as my boss. I welcome Wes Streeting MP to that position; his huge talent will challenge the health team in the Commons and keep them on their toes, I have no doubt, and I look forward to it.
Today, the Daily Telegraph carried a story saying that 10,000 hospital beds were taken up by patients waiting for home care. NHS Providers has done some research and warned that those beds are mostly currently occupied by elderly people who are medically fit to be discharged, but no care is available to look after them at home. The chief executive, Chris Hopson, said that hospitals are now having to deploy their own staff to take on care duties in the community in order to free up hospital beds.
The lack of social care surely lies at the heart of whether the NHS can cope with the winter pressures, deal with ambulances stacking up, tackle the backlog and deal with whatever Covid, and particularly the new variant, may throw at it. When Professor Stephen Powis, NHS National Medical Director, said:
“NHS staff have pulled out all the stops since the beginning of the pandemic, treating more than half a million Covid patients, while continuing to perform millions of checks, tests and treatments for non-Covid reasons”,
he could have added that they are exhausted and need our support and that of the Government to move forward.
We need to add in the fact that about one in 60 people in private households in England had Covid in the week to 27 November—up from one in 65 the previous week, according to the Office for National Statistics. One in 60 is the equivalent of almost 900,000 people. Although it is true that, thankfully, fewer people are hospitalised and even fewer are in ICU, that is still a significant number. But this rate of infection, with the new variant possibly being even more infectious, means that, apart from anything else, there will be a surge in people being off sick, including NHS and care staff.
It is too easy for the Government to say that the winter crisis and the huge waiting lists are simply the result of the challenges of Covid. The reality is that the entire health and social care system has been left dangerously exposed by this Government’s choices over the past 11 years. Before the pandemic, there were waiting lists of 4.5 million, staff shortages of 100,000 and social care vacancies of 112,000. This week, the National Audit Office starkly detailed that things are set to get even worse: waiting lists might double in the next three years.
Those NHS waiting lists stand at 6 million. Almost one in 10 people in England waits months, or even years, sometimes in serious pain and discomfort, because the Government have failed to get a grip on the crisis. Everyone understands that we are in the midst of a global pandemic that has placed the NHS under unprecedented pressure, but that does not excuse or explain why we went into the pandemic with NHS waiting lists already at record levels and with unprecedented staff shortages.
Of course, the investment described in the Statement is welcome, and the plan recognises the many challenges that the whole sector has faced over the past 18 months. Can the Minister say that the Statement is a credible plan to meet those enormous challenges? If it was a genuine plan to prepare for the winter, why did it arrive on 3 December? For example, I noticed that on one of the hottest days of the year, in August, people from GP practices, primary care networks and federations gathered to start to think creatively about managing their winter pressures in a session hosted by the NHS Confederation. When I served on a clinical commissioning group, we did our winter planning in June—it started in the early summer. The board on which I currently serve has been discussing winter pressures and our winter plans for months.
A serious plan to bring down waiting lists would have the workforce at its heart and would have clear targets and deadlines. A serious plan would recognise that, unless we focus on prevention, early intervention and fixing the social care crisis, there is no chance of bringing waiting lists down to the record low levels we saw under the previous Labour Government. A credible plan to tackle the NHS winter crisis—which was foreseeable and foreseen—would have been published long before 3 December. Without a serious strategy to build the health and social care workforce that we need, the plan is not a plan at all.
The Deputy Speaker (Lord McNicol of West Kilbride) (Lab)
I call the noble Baroness, Lady Brinton, who is taking part remotely.
Baroness Brinton (LD) [V]
I, too, thank the Minister for the Statement and I start by thanking all our NHS and social care staff, at all levels—back room or front line—for all they are doing to keep the NHS and social care going while under the most extraordinary, sustained pressure.
Like others, I am struggling to see what is new in the Statement, which admits that the funding mentioned is not new. Although there is marginally more detail on how some of it will be spent, it is very light on by when the extremely urgent investment will deliver the help that our NHS and the public who use it desperately need.
Repeatedly, the Statement, and the accompanying so-called policy paper, The Health and Social Care Approach to Winter, refer to the urgent need to recruit more staff for both the NHS and the social care sector. However, it reports that currently, the NHS has an 8% vacancy rate at all job levels, and the social care sector, which has had more than 100,000 vacancies for some time, has had a further 3% reduction in staff since March this year.
Although there are proposals to increase staffing, can the Minister please explain where those staff will come from if they have not been able to be recruited over the past few months? How long will it take to recruit them? It is good that money is being put into the workforce, but I struggle with any suggestion that that will help to deal with the current winter crisis. When will the staff who are desperately needed in health and social care be available to join the teams out in the wards?
Both the Statement and the report talk about using locum services for doctors and agencies for nurses and social care staff, but health and social care employers tell the public daily that the extra qualified people are just not there. One of the problems in social care at the moment is that the NHS is poaching nurses from care homes. Please can the Minister explain who is going to fill those roles, given that training those skilled personnel takes a lot longer than a few months?
I echo the comments of the noble Baroness, Lady Thornton, about delayed discharges. We have all been asking the Minister and his predecessor about specific plans to help the social care sector overcome its problems in the workforce, not just for months but for years. The high level of staff vacancies continues to worsen. Can the Government help in the short term? For example, NHS Providers made the very helpful suggestion today that the Government help to fund a winter retention bonus for social care staff. NHS Providers understands that we must get the log-jam moving, and if the only way to do that is for the Government to help, please will they consider that proposal very seriously?
The Statement says that the NHS needs to be able to offer more appointments, operations and treatments, which is absolutely right, including with the NHS itself. However, the capacity to change to innovative ways of working, with a heavy load of staff vacancies and the current sustained 20 months of intense pressure, seems to be extraordinary. To illustrate this, in the second week of November, there were 966,406 more GP appointments in England compared with the same week last year—and we were not in lockdown at that point last year.
The Statement talks about the transformation funding for elective recovery, announced in September. The plan lists the hospitals that have been successful in getting their schemes approved. I know, from experience in my local area in Watford, that some of the modular ward proposals can move ahead very quickly. Can the Minister tell us the likely earliest delivery date for any one of these projects? Once the buildings are there, when will extra staff be available to make these new wards work? We certainly do not want to see a repeat of the Nightingale hospitals.
The plan says that NHS Test and Trace will be carrying out contact tracing, so will the Minister say whether local test and trace will continue? It is noticeable that this was not mentioned at all, yet only two months ago Ministers were saying that this was where the focus of contact tracing would be. May I repeat the questions that I have asked on at least two occasions to the Minister? What is happening to the funding for the local resilience teams for Covid tracing and other pandemic work from April, given that, at the moment, there is no money in the budget whatever for the next financial year?
Last week, the Minister wrote to my noble friend Lady Thomas of Winchester about the delivery of vaccines to the vulnerable housebound who cannot go out either to their GP’s surgery or to vaccination centres. He wrote to her after the Question, confirming that GPs have a duty to offer vaccines to the housebound. He went on to say:
“If there are no GP practices signed up to phase 3, the CCG will make these alternative arrangements instead.”
Today’s Daily Telegraph talks about more than 300,000 people—more than two-thirds of the housebound—having yet to receive their booster doses. This is not hesitancy in people coming forward; it is clear that there is a problem. With many GP surgeries having withdrawn from delivering booster jabs because of their increased workload, can the Minister tell me when CCGs will be setting up these new systems and, most importantly, contacting and reassuring this vulnerable group of people about when they will get a visit from the mobile vaccination team? Putting the booster programme on steroids for all adults is of no use if the most vulnerable are not even being contacted. I look forward to hearing from the Minister. If he does not have the answers at his fingertips, I ask him to write to me.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
My Lords, I thank both noble Baronesses for their questions and for acknowledging that I may not have all the answers immediately; I will commit to write to them if I do not.
I will start with the questions on hospital beds and discharge. We are very aware that we have put in £478 million to get patients out of hospitals, freeing up beds. The NHS is also giving ambulance trusts an extra £55 million to boost numbers. It is our priority to ensure that people are discharged safely from hospital to the most appropriate place, and that they receive the care and support that they need. Our guidance sets out how the health and social care system is continuing to support the safe and timely discharge of people in hospital. People who are clinically ready are supported to return to their place of residence where possible, where an assessment of longer-term needs takes place using the discharge-to-assess Home First model.
New or extended health and care support is funded for up to four weeks, until the end of March 2022. During this period, a comprehensive care and health assessment for any ongoing care needs, including determining funding eligibility, should take place. Since March 2020, we have made nearly £3.3 billion available via the NHS to support enhanced discharge processes and implementation of the discharge-to-assess model. This approach means that people who are clinically ready and no longer need to be in hospital are supported to return to their place of residence. We are also reviewing the way that we look at this scheme and how it works. We are very much aware of the issues raised about how we make sure that people are discharged in the most appropriate manner.
On the issue of investment, a number of trusts were asked to bid for funding, very much on the basis of which of those schemes could be delivered immediately and which were longer-term. Trusts have now been informed that their bids have been approved, and they are beginning to work to deliver them. NHS England and NHS Improvement will be monitoring the programme closely. Schemes were selected that could deliver immediate solutions that will support elective recovery this winter, as well as over the next three and a half years and beyond. This is just one element of how we are looking to make sure that we are dealing with things in the short term.
As the noble Baroness, Lady Brinton, acknowledges, some of these modular systems can come up to speed quickly, and that was considered in the bids that were put forward. Funding was allocated on a regional basis, based on the number of people living in each area, to ensure that funding is equally spread across the country. NHS regional teams identified and prioritised individual schemes and DHSC evaluated and approved them to ensure that the schemes that had the highest potential to help us reduce waiting lists for elective care were selected.
We have looked at a number of areas and, looking at the regional breakdown, we have had about £112 million in the north-east and Yorkshire; £97 million in the north-west; £131 million in the Midlands; £78 million in the east of England; £105 million in the south-east; £69 million in the south-west; and £109 million in London. There are a number of different schemes at various hospitals, on which I would be very happy to go into more detail if asked.
Turning to waiting lists, we need to recognise that 75% of people waiting do not require surgical treatment; 80% of those requiring surgical treatment can be treated without an overnight stay; and 20% of patients are waiting for ophthalmology treatment for eyes, or orthopaedics for bones, muscles and joints. So we are looking at how, on a targeted basis, we can address that backlog. We hope that, with the new diagnostic centres rolling out, we should be able to tackle a lot of that backlog.
Baroness Finlay of Llandaff (CB)
My Lords, I should declare my interest in relation to medicine, the BMA and the Royal College of Emergency Medicine, and I would like to ask about emergency medicine. The winter flow data from the Royal College of Emergency Medicine has data from 40 sites across the UK. They are reporting that, in November, there were 275,596 attendances. Their long hospital stays had increased by 13% to more than 48,000 patients. Their 12-hour stays in emergency departments were twice as high as they had been in the previous year, and that was equivalent to 7.3% of all attendees. Their four-hour performance is incredibly low, at 62%. I know from one department that was built for 28 patients that, on a Monday in November, it had 108 patients in. This becomes unsustainable, and the overcrowding is a danger in terms of Covid and infection. It is also a danger to the welfare of staff because, in this particular department, even the staff toilets were not flushing, so the staff had to leave the department just to excuse themselves.
The estate takes time to rebuild and be repaired. What is being done with projects now to create additional space for emergency departments to manage this overcrowding? Is there targeted money going to make sure that the departments are in a good condition of maintenance for the staff? Separate, but related, to that, is the pension block, which has stopped doctors from returning from retirement and has pushed some doctors into early retirement, being addressed in the long term? It is important that doctors who have retired because their pension pot has reached its limit can be incentivised to come back to take pressure off in GP surgeries and in hospital departments, particularly out-patient departments, by seeing patients where their long-term experience and wisdom can contribute to the clinical services.
Lord Kamall (Con)
I thank the noble Baroness for the points she makes. We are doing what we can to support the dedicated NHS staff in healthcare services. This year alone, we have invested over £15 billion on top of the existing NHS annual budget, and that includes funding to help get patients out of hospital, freeing up beds and supporting hospitals to manage Covid-19. In addition, we are looking at how we can tackle capacity issues on NHS 111 and A&E. We are giving NHS 111 £98 million to boost capacity, help people avoid unnecessary ambulance trips to A&E and take pressure off hospitals. We realise that NHS 111 is often the first port of call to provide urgent medical advice quickly and book time slots for people at their local A&E or appointments at alternative services. We are also delivering the largest ever seasonal flu vaccination programme, so we hope to tackle it on that basis. A number of CCGs and others are having conversations about how we can tackle the pressures on A&E.
The noble Baroness makes the point about staff who, during Covid, went way beyond the call of duty, and we managed temporarily to address those concerns. We are very grateful to staff who had retired and returned, and we are looking at whether that can be a long-term solution. We need to make sure that no one who is willing to come back is disincentivised. I do not have the details at the moment but I commit to write to her.
Baroness Bennett of Manor Castle (GP)
My Lords, the first paragraph of this Statement says that it outlines
“the preparations we are making so that health and social care services remain resilient … and available to patients”.
How does that square with the fate of the residents of Berkeley House in Kent, which was home to adults with severe learning difficulties and autism, who were told at 7.30 in the morning that they would have to leave by 5 that evening? Among them was one resident who had to be sedated to ensure he could safely be moved. Berkeley House is owned by Achieve Together, one of a chain of companies registered through the tax haven of Jersey that ultimately appears to be owned by AMP Capital, a global investment firm based in Australia. How does providing a “resilient … and available” social care system line up with homes such as this being run for profit, not for the public or the residents’ good?
Lord Kamall (Con)
We have to recognise that if we look at the social care system, there are an awful lot of private providers. Quite often, when we look at private providers, it is private patients who subsidise their ability to provide places for state-funded patients. In our health system overall, there will always be a mixed economy, including state provision. Lots of our GPs, for example, are partnerships—they are not state-run, some of them are co-operatives, some are even for profit. When we look at the overall health system, there will be a general balance. I am not aware of the particular case, so I thank the noble Baroness for raising it, but one of the things we are committed to is making sure that we improve services, whether they are state-funded or private, as part of the overall system of healthcare that we have in this country. Clearly, where providers are not providing a service, there will be CQC and other assessments to see whether they are fit.
Baroness Walmsley (LD)
My Lords, Covid-19 is absolutely rife in our schools, both primary and secondary. Teachers are in the front line. There are whole classes and even whole year groups being sent home because the teachers are off sick and they cannot even get supply teachers. A lot of teachers are under 40. Why can they not get boosters? If vaccines really are the answer, during this winter period, that would help more children to be able to stay in school and avoid disrupting their education. Will the Minister tell us about that?
Secondly, I go back to what both noble Baronesses on the Front Bench raised. Where are the social care staff going to come from? When I looked at the paper that sat behind this Statement, I noticed that there was nothing in it about changing the salary level at which visas can be offered to social care workers coming from abroad. Why not? We are desperate for social care workers. Can the Minister tell me—and if he cannot, perhaps he will write to me—what proportion of vacant posts fall below the salary level required for a visa?
Lord Kamall (Con)
In terms of tackling the social care workforce, there are a couple of things: £162.5 million is going on a number of different schemes to make the social care sector an attractive place to work and we are looking, longer term, at professionalisation, so that people feel valued. At the same time, the minimum wage will help lift the pay of many people in social care work, but in the longer term we want to make sure that social care is not seen as the poor relation of other parts of the health service. We want to make sure that we have professionalisation and that it is all joined up. Some of these things will not be tackled in the short term, but we have a short-term programme called Made with Care, which is aimed at targeting and recruiting people to come and work in the social care sector. We realise that we have to do the long-term things, but also to promote short-term measures to tackle the issues we have at the moment. On specific statistics, as I am sure the noble Baroness can imagine, I do not have the details at hand but I commit to write to her.
Baroness Pinnock (LD)
My Lords, I draw the attention of the House to my registered interests as vice-president of the Local Government Association and as a member of Kirklees Council. I want to pick up on issues raised already by the noble Baroness, Lady Thornton, and my noble friend Lady Brinton, and the point that the Minister himself has just made about professionalising the workers in social care. On one hand, as the noble Baroness, Lady Thornton, said, there are no spaces in social care for older people to be discharged into, because of a lack of availability of staffing, and we have heard already about some care homes being closed. The issue at the heart of all this is the great chasm of funding being made available for social care.
In my own council area in West Yorkshire, the pandemic has resulted in a 36% rise in demand for social care by adults in the last year, yet the funding from the Government is nowhere near going to meet that demand. What we have then, as a consequence, is older folk who have first gone into hospital because of ill health, and there is then nowhere available for them to be discharged into to continue their recovery and gain back their independence. The chasm of funding is at the heart of this. Can the Minister confirm that the Government will no longer impose the social care precept on the council tax payer, which, since 2016, has been at either 2% or 3% per annum? This is a totally regressive tax and has cost taxpayers in my part of the world well over £200 a year. What is needed is proper funding from the Government, not the bits and pieces that the Government have announced so far.
Lord Kamall (Con)
When you look at our health and social care sector, you see that one of the issues is a lack of joined-up thinking over the years. We have seen report after report about the future of adult social care gathering dust on the shelves—not forgetting that lots of people who are not older are also in the social care system. The White Paper we published last week was a first attempt to try to tackle the problem long term. We recognise that you have to look at the long-term issue—which, frankly, successive Governments have kicked down the road for years, and not really tackled—and we have made an attempt to do that with the 10-year vision we published last week. But we have also committed to the first three years of funding, to realise that vision. We now have a framework against which to judge future progress in adult social care, so that, overall, it is no longer seen as a poor relation of the rest of the health system and is properly joined up on a number of different levels—not only career paths but also the data that can be shared, so that you do not have the drop-off that happens when someone leaves hospital and enters a social care home and you have to find all that data again; the home is prepared to accommodate that patient with all their specific needs at the beginning.
In the longer term, with increases in technology, we hope that, instead of patients leaving hospital to go to a residential home, they will be able to return to their own home with the help of technology. All that will take time, but we have laid out that vision.
In the short term, we have laid out the winter plan, which includes looking at how we tackle some of these social care issues and how we recruit more social workers via the £162.5 million. The Made with Care plan will make sure that social care seems more attractive. For a long time, no one has really “sold” social care as a career. We want to ensure that it is seen to be just as valid a career as any other and offers a real career path. We also want to see a professionalisation of the industry, so that people feel valued.
Baroness Bennett of Manor Castle (GP)
My Lords, in responding to my last question, the Minister referred to the mixed economy of ownership of healthcare provision. I am sure that he is aware that 84% of care home beds are provided by for-profit providers. Tonight, the “Panorama” programme is looking at HC-One, which is the biggest care home chain provider, with 321 care homes, formed in 2001 from the collapse of Southern Cross. I will not ask the Minister to watch the programme, since I know that he is a very busy person, but will he undertake to look at a summary of it, particularly the fact of the funding of HC-One, which appears to include a £540 million interest-only loan from a New York-listed property company? A great deal of this has been uncovered by the Centre for International Corporate Tax Accountability & Research.
Lord Kamall (Con)
I thank the noble Baroness for sharing all that data with me. The point remains that our system of healthcare will, through CCGs at the moment and integrated care services in the future, continue to commission some from the state and some privately; that is the way it is. What is really important is not who provides it but the care that the patient receives at the end of the day, and the fact that taxpayers are getting value for money. We should judge outcomes, not inputs.