(2 years, 9 months ago)
Lords ChamberRead Hansard Text Read Debate Ministerial Extracts
Baroness Thornton (Lab)
My Lords, in the almost five years that I have been doing this job, we have been waiting for a social care White Paper. My noble friend Lady Wheeler, month after month, asked where it might be and was told that it would be in the summer, the spring or the following winter, and it did not arrive. Indeed, in desperation, the House’s Select Committee, chaired by the noble Lord, Lord Forsyth, brought forward its own proposals for the future of social care, and extremely good they are, too. But here we are—the Government are now spoiling us with a third White Paper in a year. However, this one is a disappointment, I have to say, given the importance right now of the future for social care. Given the Government’s commitment to fixing social care, it is even more of a disappointment. We know that integration of health and social care, however it is defined, is extremely difficult, but I fear that its integration will not be delivered by this White Paper. It is long on description and has really great examples and aspirations, but it is very short on actual solutions and action.
Before I ask the Minister some questions that we need to address, I should also say that what is very disappointing in the White Paper is the lack of attention it gives to carers. They are not mentioned very often, even though the NHS and social care depend heavily on unpaid carers supporting people with long-term conditions and disabilities in the community. Some 1.4 million people in the UK provide more than 50 hours a week of unpaid care, and while unpaid carers provide the bulk of care, they are still not systematically identified, supported or included throughout the NHS. We have one system, social care, that recognises carers legally as an equal partner, while the other, the NHS, does not. That has been discussed in your Lordships’ House very recently, in the passage of the Bill before us, and is still not resolved. If there is going to be an integration of health and social care, one of the first things that needs to happen is the integration and legal recognition of the role of carers and our duty to support them and their well-being.
Moving on, it is not clear how this White Paper fits with the Bill before us. Even the experts involved repeatedly trip over the crucial issues, such as the relationship and responsibilities of integrated care boards, integrated care partnerships and integrated care systems, as well as the new joint committees and how they will work with the statutory health and well-being boards, which as we know have no commissioning powers, as the noble Lord, Lord Lansley, has said on at least one occasion. What is the role of health and well-being boards? If they are necessary, why are they not integrated into the system being proposed in the Bill before us? Now that we have a new Joint Committee, my first major question is, how will it work with the health and well-being boards, and with the ICBs and ICPs? Where will the clinical leadership sit, and where is the accountability to local people?
It is not clear how this latest offer fits with the proposals before us today. I suggest to the Minister that this is not really a plan. It is a description, an aspiration, but it is not a plan. It does not tell us which bit is responsible for what. If the new individual proposed in this White Paper is to take responsibility for shared outcomes, who will appoint them? How will they get there? Will NHS England, which is appointing the ICB chair and chief executive, be accountable to this new super-leader? Will they be inspected by the CQC? What if a huge local foundation trust misbehaves? What powers will the new leader have to act? That is why it is not a plan.
The second reason this is not a plan is that it has no workforce component—an issue that we are very seriously concerned with in the Bill before the House now. There is no workforce strategy or a commitment to one. If we want integration, it has to be a workforce strategy that covers health and social care, and it has to be long term.
The aspirations and vision are fine, but we have signed up to strategies before—for example, the NHS plan in the noughties; we thought that would be good. I regret that it almost feels as if this document has been put together as part of finding lots of new things to say to detract from the issues facing the Prime Minister and No. 10, which is a huge missed opportunity.
So, the issues the Minister needs to address include the workforce and the question of how you integrate and pool two systems which operate in different ways. One is means tested, and the other is not. One has national criteria for entitlement, and the other does not. The ways they are governed and funded are totally different, and they are kept going by two separate workforces with no aligned terms and conditions.
The White Paper talks about local initiatives and building things locally, but unless the infrastructure is there to produce the alignment needed, those local initiatives—many of which are very successful—will not be the pattern for how this works. So, I leave the Minister with a series of questions I hope he might be able to address.
The White Paper also does not help children and young people. It does not address the challenge of how to care for and support working-age adults with a disability. As I have said, it does not value or assist the informal workforce or carers. For an NHS under enormous pressure after years of austerity funding and then the impact of Covid, this is a disappointment. I am afraid that I could not decide whether it should get a C or a D.
The Deputy Speaker (Lord Haskel) (Lab)
My Lords, the noble Baroness, Lady Brinton, is taking part remotely. I invite the noble Baroness to speak.
Baroness Brinton (LD) [V]
My Lords, I declare my interest as a vice president of the Local Government Association. Both the Statement and the White Paper set out a laudable ambition to integrate health and social care and communities, but I am afraid that we echo the disappointment of the noble Baroness, Lady Thornton, especially at the glaring omission of children, young people and disabled people who need care.
While reading the White Paper, I had a sense of déjà vu, and I dug out my copy of the White Paper Integration and Innovation: Working Together to Improve Health and Social Care for All, which was published on 11 February last year—almost exactly one year ago. The tone and the ambition were remarkably similar. All noble Lords know that the Health and Care Bill we are debating at the moment sets out in part how the Government believe that the White Paper from last year is going to be turned into legislation and changes in practice. The Minister knows the real concerns across the House about that practical implementation, and I do not believe that this new White Paper takes matters further forward.
From these Benches we also ask: where are carers? There is zero mention of carers in the Statement but 13 in the White Paper, two in the index and two as part of headings. The remaining nine in the text relate only to the people carers care for. There is no formal recognition of the role and no mention of support directly for them as carers. It says:
“People will move seamlessly between health and care settings because people and those supporting their health and care, including … unpaid carers, will be able to see and contribute to their care record and care plans.”
Is that the best on offer for carers—that they will actually be able to see the care plans? They can usually see them now, although most, I must confess, are still in paper format.
That was one example; I want to go on now to a couple of other issues. Much of the paper talks about how data will transform care in the future. On page 14 it says:
“A core level of digital capability everywhere will be critical to delivering integrated health and care and enabling transformed models of care.”
Can the Minister say—because the White Paper is absolutely silent on this—whether there will be funding for fast broadband across the country, especially in rural areas, to deliver that capacity to every single home? Without it, this entire system will fail before it even starts.
The White Paper also says that
“the data and information required to support them should be available in one place, enabling safe and proactive decision-making … We will aim to have shared care records for all citizens by 2024 that provide a single, functional health and care record which citizens, caregivers and care teams can all safely access.”
Can the Minister say how citizens’ data will be protected so that only those who need access to it will see it? As the Minister knows, this is another area where there is real concern over the Bill.
The paper talks extensively about leaders but in a generic way. There are muddles over NHS leaders, social care leaders and leaders of ICBs. Is it referring to council leaders or just leaders? I have to say that the organogram on page 37 makes the classic assumption of councils being single-tier metropolitan authorities, ignoring the plethora of two-tier council arrangements as well as other key stakeholders such as housing associations. It talks about
“3-5 local authorities within an Integrated Care System”.
Even at upper-tier authorities, that number is way too small with the shadow boards at the moment, and dwarfed when you add in district councils, which have key roles in delivering support for care. Unless this is hiding a proposal from the Secretary of State for Levelling Up, Housing and Communities, this is another massive reorganisation for local government.
Housing is vital to the aims of the Bill. The paper says:
“People’s homes should allow effective care and support to be delivered regardless of their age, condition or health status.”
But housing is not mentioned in the “Next Steps” section. I ask the Minister whether there will be specific funding to ensure that housing can be improved at a local level for people who will need it for the next stages of their lives.
The Statement and White Paper recognise the importance of the workforce—in theory. The section in the White Paper talks about continuous development and joint roles, some of which is very laudable, but what is actually happening in the Health and Care Bill at the moment, where the Government will not commit to proper planning for the workforce, makes this unattainable too.
Above all, from our Benches, we want to know where the resources are that will enable this transformation to take place. Even before this week’s announcement about the patient backlog, the levy for health and social care was already prioritised for the NHS. Every time we have asked the Minister when the social care sector will get the resources it so desperately needs—and what they will be—we are told that it will happen at some point in the future.
We need to know when social care and councils will get the support they need, particularly councils with extra responsibilities in this White Paper and the Bill. The LGA has said, correctly:
“Adult social care is in a fragile position, with councils struggling to balance their budgets … A long-term funding solution is urgently needed.”
Can the Minister tell the House what, where and when resources from both departments will be announced and made available to at least give this White Paper half a chance to get going?
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Kamall) (Con)
I begin by thanking both noble Baronesses for their questions. I will try to answer them within the time and, if I do not, will write to the noble Baronesses or others. I will go through some of the issues, first on place-based models.
As we discussed on the Health and Care Bill, ICBs operate at a system level. They will be working with place-based organisations, including health and well-being boards. We expect several models of place-based alignment and governance to emerge and we are not going to be prescriptive about a single model. We are clear that, whatever model is adopted, in the coming years all places must be characterised by clarity of leadership and accountability; a strong shared mission across the sectors, informed by local citizens; a commitment to integration manifested in removing unnecessary boundaries between services and strengthening connections to agencies able to influence the wider determinants of health and well-being; a strong culture of improvement; and a linked sense of urgency about the need to deliver more integrated care to improve outcomes, particularly care quality.
By that we mean that we do not start thinking in siloed ways—of hospitals or primary care, with social care over there. All these White Papers are building-blocks to help explain some of the intentions behind the Health and Care Bill. The Bill itself creates a flexible framework based on the real experience of making effective change happen locally. This flexibility is designed for a purpose: the stronger integration of health and care services. The White Paper picks up that ambition by making clear the strong commitment of the Government to this agenda and our ambition to make progress. The White Paper will ensure that we go further and faster on health and care integration with local authorities and the NHS to make the most of the forthcoming legislation. It does not contradict the Health and Care Bill.
I will pick up on accountability. Three things are different. There is a wider recognition of the demographic challenges we now face, which will increase. We cannot manage it as just health any more or, even within health, primary, then secondary and care over there. The pandemic showed us that some of the cultural and governance barriers to change that seemed impossible to shift have moved. We have seen this work in lots of places up and down the country. There are some model ICSs, which many noble Lords have drawn my attention to, and case studies; we want to learn best practice without being overprescriptive. The noble Lord, Lord Mawson, has talked effectively about place-based organisations many times and getting the right mix of skills and people for a particular place. What works in east London will not necessarily work in South Yorkshire. Some of it will, but some of it will not. We will learn from best practice.
We can be confident that the approach to accountability set out in the paper will work, because it draws on real examples that are already in place. If you ask local leaders what accountability means to them, they will be able to tell you who can ultimately hire and fire them. That is one version of accountability. They will also give you a list of the people and bodies to which they are accountable—partner organisations, local democratic institutions, staff, patients and service users, as well as regulators. We want to make sure that all that comes together to address accountability.
We hope to have shared care records for all citizens by 2024 but, as noble Lords will remember from the debate about data last night or early this morning, we have to get that balance right to make sure that people trust that data will not be shared unnecessarily or inappropriately. One of the key challenges for any integration is that it needs data across primary, secondary, social care and other agencies but, at the same time, we have to allow people to opt out. When people opt out, they might have to re-register a number of times. We want to avoid people, particularly vulnerable people, being asked the same question time and again. We hope that integration and people speaking to each other will help across the health and social care sector.
On carers, I was in fact having conversations yesterday on that subject, and I am going to be doing a round table with a number of noble Lords. One of the issues is making sure that we professionalise and give real respect to the caring workforce. One of the reasons why we set up the voluntary register was to understand the landscape of care, the different qualifications and levels, so that we can get a clearer understanding of what qualifications carers need and how we can make sure that works across both health and social care, so that staff can move between health and social care without feeling that one is better than the other.
We want to build on existing reforms. We want to talk to a number of partners—the noble Baroness, Lady Brinton, mentioned housing, for example—and in the adult social care White Paper we looked at ideas about people being treated at home, some of the things that will have to be done at home, whether that is done at system level and how to make sure that partners are working together.
One thing I will say is that the vast majority of care workers are employed by the private sector. The increase the national living wage means that they will benefit from a pay rise, but we have also put in money. Some private providers feel that they are using private profits to subsidise others. We are making sure there is more money to make sure that we get a better quality of service right across. What we really want to do is say, “Tell us where it doesn’t work and where it breaks down” and to make sure that at the place-based level they are able to work together. We will speak to as many stakeholders as possible and we will continue to ask them to inform us.
I will try not to run over time, but I shall talk about the single accountable person. This will be agreed by the local authority and the integrated care board. An increase in long-term conditions and an increase in the number of people being treated for them means that, increasingly, the co-ordination between the range of services looking after them can fall apart; we know that too many people fall between the cracks. That is why we want to have the single accountable person—so that we can make sure that people are no longer falling through the cracks.
I know I have gone on a bit long, so I will allow other questions to come in, but I hope that addresses some of the concerns.
Baroness Finlay of Llandaff (CB)
My Lords, before I ask my question, perhaps I might formally apologise to the House for an error I made last night in Committee on the Health and Care Bill in responding to the debate on my Amendment 287 on dispute resolution and children’s palliative care. I had missed email correspondence from Together for Short Lives prior to the debate, in which the organisation had offered to discuss my amendment with me. I hope the House can accept my sincere apologies and regret at my inaccuracy. I have had helpful correspondence with the charity today.
I turn to today’s Statement. In my role as chair of the Mental Capacity Forum, I welcome the mention in item 5.14 of training in mental capacity, because there is a tremendous need for training at every level.
I also welcome the concept of personalised care, but I am concerned that the paper before us just does not go far enough. We need to document what matters to a person, and that needs to be an ongoing dialogue, not a tick-box exercise. If we know what matters to a person, that can inform best-interest decisions if the person loses capacity, and it is important for informal carers and family members to know that beforehand. Personalised care must include emotional care.
I am also concerned that there is nothing here about training the unpaid carers. They do not just need training in physical aspects of care; they need emotional training and training in how to de-escalate their own emotional stress, particularly when dealing with mental health issues in the person that they are caring for. There is nothing here about child carers and how information goes to a school that a child is a carer and may be under tremendous stress—or it may be that I have missed it in the documentation.
I hope the paper will stress the importance of people being listened to, which will inform decisions when deterioration happens. I would welcome the Government’s comment on how they are going to train enough people and instigate training across the board, both in sensitive listening skills and in achieving the high aspirations that I think the paper has attempted to set out.
Lord Kamall (Con)
I thank the noble Baroness for her clarification and for notifying me earlier about the issue that she apologised for. One of the issues for us is that we want to make sure that if all the parts of the healthcare and social care systems are talking to each other, and there are accountable people, we hope that people will not fall through the cracks and that there is a multi-agency approach. It will be difficult to be overly prescriptive here, because what would work in one area might not work in another.
The point that the noble Baroness makes about training is critical. In many debates in this House, we have understood that we need to take the social care workforce seriously and give support to unpaid carers of whatever age, whether they are children or family members. Sometimes they are doing it because they do not want their loved ones to go into a home and sometimes they just need a bit of respite. We are looking at a number of issues around carers—first, unpaid carers but, secondly, making sure that being a carer is a rewarding career and is not seen as being at a lower level than, say, a nurse in the health service.
One reason for having a voluntary register, for example, is to understand the landscape and then put in place proper and different educational pathways, and other pathways, into care. Having national qualifications at levels 4, 5 and 6 and so on will show parity of esteem and that this is a worthwhile career. We have the Made with Care campaign to start to encourage more people back. We are looking at a number of different ways to make sure that carers are not just forgotten. If they work in care homes, that is fine, but we want to make sure that there is a real career structure for them, and also that they can move between health and social care, both ways. There may well be nurses or doctors who want to move across. We have to make sure that going from one place to another is not seen as disadvantageous in any way and that the system is truly joined up.
Of course, this is all top level and shows our ambition to integrate. We do not want to be overly prescriptive; decisions have to be made at place level.
The Lord Bishop of St Albans
My Lords, I declare my interests as a vice-president of the Local Government Association and president of the Rural Coalition. I want to pick up very briefly on what the noble Baroness, Lady Brinton, said about rural issues. It is disappointing that there are no explicit references to rural health. One of the concerns of the APPG on Rural Health and Social Care parliamentary inquiry was the way in which inappropriate data, metrics and funding formulas can disadvantage rural areas. National programmes are one thing, but when they are delegated to local areas how are we going to ensure that they are properly rural-proofed and will integrate both health and care?
Lord Kamall (Con)
It is important to stress once again that the key to this is that we cannot overly prescribe from here in Westminster and Whitehall. We must make sure that at whatever place, whether it is rural or urban, the people and patients who are cared for in the system are being understood. One reason why we want one person to be accountable, whether in urban or rural areas, is the fact that they must take responsibility for ensuring that all these things are joined up—not only health and social care as we understand them but technology, housing and all those other issues. I know that the right reverend Prelate and my noble friend Lady McIntosh have often raised this issue. We think that the proposal is flexible enough, whether in an urban or a rural area, to make sure that one person really understands the local area of integration.
Lord Lansley (Con)
My Lords, paragraph 1.11 of the White Paper states:
“Our focus in this document is at place level.”
Paragraph 3.11 goes on to state:
“Success will depend on making rapid progress towards clarity of governance and clarity of scope in place-based arrangements.”
As far as I can see, the Government are proposing that by spring next year such place-based arrangements will be put in place across the country, with a single accountable person to whom my noble friend referred. There is no reference at all to place-based arrangements in the Health and Care Bill. For years, the NHS has been saying, “We are creating integrated care systems but they don’t have statutory cover, so we want legislation that reflects our way of working”. The Government are now proposing legislation that creates a way of working with no legislative cover. I am afraid that this will not work unless the Bill changes to reflect place-based arrangements and a single accountable person, and defines adequately who they are, what their powers are and how their accountability works.
Noble Lords
Lord Kamall (Con)
I respect my noble friend for his willingness to pass on the benefit of his many years of advice to me.
We do not want to get overly prescriptive. We have talked about health and well-being boards and I know that my noble friend has talked about their importance. In the papers I laid in the Library the other day, where we looked at integrated care boards and integrated care partnerships it was quite clear that, in some places where the health and well-being boards may well completely overlap with the ICPs in a smaller area, that will continue to be the place-based level. Where there is a larger system, we expect the integrated care board and integrated care partnership to work with the local place-based organisations underneath them at a more local level. That is what we have been saying all the way through. We want to make use of existing fora. In some places they will overlap and may well end up as the same thing. We will update the health and well-being board guidance in due course to reflect the implications of policies set out in the White Paper and what comes out of the Health and Care Bill when it passes.
Baroness Donaghy (Lab)
My Lords, mine is a simple question. We have two separate pieces of legislation on the same area. How does the Minister guarantee that we will not end up with two contradictory systems?
Lord Kamall (Con)
The only legislation I am aware of is the Health and Care Bill; this White Paper complements that, just as the adult social White Paper does. This is not legislation.
Lord Mawson (CB)
My Lords, I welcome the White Paper and the direction of travel. I thank the Minister and his colleagues for being willing to listen to me and colleagues in the NHS who are involved in actual practical pieces of innovation in this space. It is good to see real examples of the implications for real people in this White Paper. There is also lots of focus on practical and detailed changes—for example, streamlining training and qualifications and shared outcomes. I wonder whether sufficient attention is paid to the social determinants of health and getting upstream with regard to prevention. Is there still too much assumption that the state is doing all the work? The private and voluntary sectors are the major delivers of care. Does the model of partnership proposed fully reflect this? The Minister might like to reflect on that.
Finally, as always, the devil is in the detail and will be all about implementation. One of the ways of achieving this focus is, as I have said before, through establishing innovation platforms that embody the ideas of not only the White Paper but the Health and Care Bill, levelling up and many other current initiatives. Innovation platforms can start to bring together some of these initiatives. It is our experience on the ground that a lot of the public sector systems and processes are not in place and are not fit for purpose. There needs to be innovation in this space. The problem could be an opportunity if we start to join some of this up. How do the Government intend to join up these various initiatives?
Lord Kamall (Con)
In many ways, the answer is not what the Government intend to do but what happens at the place-based level. As the noble Lord has reminded me on a number of occasions, some of the projects that he has been involved in and other social enterprises have been really good at bringing people together. Sometimes it has been led by local councils; sometimes it has been led by social enterprises; sometimes it has been led by networks. I completely understand the premise of the question and agree that it has to be a partnership. It is not just a state, but social enterprises, co-operatives, local movements and local civil society all working together with common aims. Go to any part of this country and you will see a number of these people working together. We have to make sure that there is no overlapping or duplication. This is the real aim of what we are trying to get, making sure that people talk about health and social care but well-being as well.
Lord Davies of Brixton (Lab)
My Lords, the one thing I admire about the document is the way in which the meaningless term “levelling up” has been shoehorned into the text. I want to raise the bundle of issues which have been grouped under the heading of parity of esteem between physical and mental health. It is not an issue we need just to have in the back of our minds; it needs always to be front and centre in the development of policy. More could be covered than is in the White Paper. One of the examples given in the White Paper is of Mandeep. It is well chosen. It is a case of someone with mental health problems and diabetes where there is a success to point to: where joined-up working has reduced the differential in suffering from diabetes experienced by people with and without mental health problems. That is a good example of what can be achieved. I hope that parity of esteem will be central in what the Minister is doing.
Lord Kamall (Con)
I thank the noble Lord for raising the issue of mental health and parity of esteem, not only here but in our debates on the Health and Care Bill, and for our continuing conversations. We hope that we will be able to find a solution to make sure that mental health has parity of esteem. In previous Bills, health has meant physical and mental health, but I recognise the mood of the House when noble Lords ask for it to be stated explicitly somewhere, even in the triple aim. We are looking at solutions for that. He is absolutely right that it is not just about physical health; it is about mental health, about well-being, about tackling inequalities and about disparities. However, we cannot do that from here. We have to make sure that the place-based organisations, working in partnership with integrated care systems, really understand what is happening locally and are best placed to do that.
Baroness Jolly (LD)
My Lords, I welcome the White Paper. How will adults with a learning disability and their carers see a difference in their care and support as a result of it?
Lord Kamall (Con)
That is a really important issue. A single point of responsibility will make sure that these things do not fall between the cracks. It ensures that physical health, mental health and well-being all come together. A number of noble Lords have spoken about social prescribing, for example, and where that has been tried and where it might not work in other places. It is important that by talking about integration we get people thinking about integration at the place-based and the system level, but also that we can learn from good examples of what works elsewhere. That is what we hope to see. Sometimes, you just have to put in on the tin and say, “Think in an integrated way.”