The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron)
I thank both Front Benches for their welcomes, in varying degrees and to varying aspects, for the two plans: one to deal with social care into the very far future—something that I would want to emphasise—and the other on electives. I, too, pay tribute to NHS and social care staff, not just for the work that they did through Christmas and the new year but for the work they do and the commitment they show in some very difficult circumstances all year round. That is exactly why we have come to your Lordships’ House and the other place with this Statement.
To start with social care, the noble Lord, Lord Kamall, talked about the agreement that was around in respect of the social care cap, but that really dealt with only one aspect of social care; what we seek to do is something that actually has not happened before, which is a very comprehensive and long-lasting approach that will transcend politics and last, no matter who the Government are, and that is perhaps what has been lacking. Certainly, I would agree that there has been no shortage of ideas in the past 15 years—some good and some, as I am sure some people would say, less good—but what there has been a lack in is a different way of doing things and a different approach, and that is what the independent review led by the noble Baroness, Lady Casey, will seek to provide.
I am glad that both opposition parties have accepted the challenge or invitation from the Secretary of State to participate in a cross-party solution, and I am most grateful to party leaders and spokespersons for that. I want to put on record that the noble Baroness, Lady Casey, is regarded as Whitehall’s number one doer; she is a leading social reformer, and she has served Governments of all political stripes, which equips her very well to talk about building a national care service.
I understand the concerns raised about the amount of time that is being taken. The noble Lord, Lord Scriven, referred to that. Perhaps I can reassure your Lordships’ House that the first report will be published next year, with recommendations that can be implemented as soon as possible. The final report will be later in the Parliament.
I should also say that we have not actually waited. It is important to say that there are a number of things happening right now, because I do not want your Lordships’ House to believe that everything is waiting for the conclusion of the report. I shall run through some of them because I think they are helpful in terms of social care. Legislation has happened for the first ever fair-pay agreement, which will tackle the 131,000 vacancies that social care is currently carrying and is a real problem in providing service. On the budget, I was very glad that your Lordships’ House welcomed the biggest increase in carer’s allowance since the 1970s. There has been an extra £3.7 billion for local authorities and, last week, the immediate release of £86 million for the disabled facilities grant, which will enable some 7,800 home adaptations before April. There has been a whole range of reforms, including the current introduction of new standards.
The noble Lord, Lord Kamall, asked about digitisation. Joining together medical and care records is so important. I know from the report of the House of Lords committee chaired by my noble friend Lady Pitkeathley that the most concerning aspect for those who care for those who need that support is that they constantly have to say what is wrong and what the issues are. Always having to repeat things was the number one issue that that report identified. We are also training care workers to perform more health interventions. I would say that there has been a lot done but that there is an awful lot more to do, which is why I am very glad about this approach. I do not regard this, by the way, as kicking the can down the road; I regard this as realistic for the situation that we are now in. I must emphasise that we really want a cross-government approach that will outlast any Government, no matter who they are, into the future.
On electives, the noble Lord, Lord Scriven, asked about measuring outcomes and ensuring that, in meeting one target, other matters are not overlooked. He makes an extremely fair point, and we will, as part of the ongoing work, look at how we measure and how we avoid the unintended consequences that both noble Lords have referred to. I am grateful for the reminder on that point. It is important, and noble Lords will have heard it said by the Secretary of State, that we take the best to the rest—I think that is crucial. There is some excellent work that goes on across the country, but it is not universal or serving everybody.
On reducing waiting times, the noble Lord, Lord Scriven, used the word ecosystem, which I would absolutely share. For example, the failure of social care currently puts enormous pressure on the NHS. It is an ecosystem, and not always a positive one, I might add. If we go back to November, some 12,400 people every day were well enough to leave hospital but could not do so because it was not possible to discharge them. That is a failure of social care very much linked to the NHS, but we also have an ageing society. By 2050, we will have 4 million more people aged 65 and over than we have now and if we do nothing, for example, on social care, the costs will double over the next two decades. Neither exists in isolation. Social care and the NHS come together.
I say to the noble Lord, Lord Kamall, that this is absolutely a cross-government problem which will require a cross-government solution. Of course, it will be very much part of the 10-year plan and part of our three immediate pillars of change, which are sickness to prevention, hospital to community and analogue to digital.
This is about major reform, not kicking the can down the road on social care and the NHS. I know the noble Lord was not suggesting that of the NHS. On workforce, we are currently making plans which are different from those of the last Government, so we must carefully look at not just numbers but the range of skills and professions needed. This reform requires change. It is not about standing still.
The noble Lord, Lord Kamall, asked how we will keep centres open for more hours. It was one of our manifesto commitments, and we have held many discussions with workforce representatives to seek a wide range of solutions. One proposal, which has been extremely well received, is to offer to pay people overtime to do the work. We are already reducing waiting lists through this. We all know that the current working hours of the NHS do not reflect the reality of people’s lives.
This is a really big opportunity to make a major change and grasp the many nettles. I wish all of it could happen immediately—particularly on social care, as we know that it has taken a long time and many have failed along the way—but it will take time. However, we have the plan and a commitment to support, guide and resource not just the NHS that we need now, but that we will need in the many years ahead.
Lord Laming (CB)
My Lords, the Statement is most welcome, not least the attention given to social care services. I congratulate the Minister and the Government on striking that proper balance between health and social care. The issues are hugely challenging, very expensive and important for the whole of society, especially if the National Health Service is to survive and prosper, for reasons that the Minister has touched on. The issues in social care range from recognition of the very important contribution of unpaid carers to the fact that a large number of local authorities face financial problems which place their future in a degree of jeopardy. The commission to be chaired by the noble Baroness, Lady Casey, will tackle these and many other issues, but we have to get through the immediate situation. Can the Minister assure the House that, in taking the social care agenda forward, from today these matters will be kept in sharp focus and handled with great vigour and determination?
Baroness Merron (Lab)
I am pleased to give that assurance and thank the noble Lord for his welcome for these measures. As I mentioned earlier in response to opposition Front-Benchers, we have not waited. In the last six months, we have made a number of immediate changes. He mentioned carers, and it is worth emphasising that, as I said, the increase in carer’s allowance is the largest since the 1970s. It will mean roughly an extra £2,300 a year for family carers. That is extremely significant. This House rightly presses me on the need to recognise carers, in particular unpaid carers, which we have done. The whole range of measures I described earlier will show our direction. I look forward to the noble Baroness, Lady Casey, publishing her first report next year. Those recommendations will also be there straightaway. We are doing this on all timescales.
Baroness Pitkeathley (Lab)
My Lords, it is indeed gratifying, as the Minister has mentioned, that many of the health proposals take into account the report of the Committee of your Lordships’ House on integrated care, which I had the privilege of chairing. I am going to take it for granted that the issue of unpaid carers will be the focus of the commission’s report, since the whole edifice of social care depends on unpaid carers.
Does the Minister agree that social care and health care work best when you cannot see the join between them? Therefore, are we able to look at employing people across both disciplines—and indeed across the voluntary sector as well, which provides many of these workers—in order that the focus can be on the patient or the user, and not on the institution?
Baroness Merron (Lab)
As the House knows, my noble friend is a great campaigner on this issue. I can certainly assure her that the review will include exploring the needs of the 4.7 million unpaid carers who effectively hold the adult social care system together. On the point about the care workforce, we are already improving career pathways by expanding the national career structure, including new role categories. The suggestions my noble friend makes about a seamless service are quite right. We are a long way from that, but I hope we will be able to get to it, and the workforce will be key in that.
Lord Lansley (Con)
My Lords, may I tell the Minister that the Statement is not an accurate representation of what happened in 2009-10? More importantly, it is now over 13 years since Andrew Dilnot produced his report, and there have been many promises to implement it that have not been kept. There should be no further delay. The Minister should acknowledge that if there is further delay in implementing a social care cap on costs, many thousands more people will face the catastrophic loss of their life savings and earnings as a consequence of meeting those costs. Until we implement the cap on social care costs, we will not know whether it will deliver a market in providing insurance against long-term care costs, which in itself would make a significant contribution towards meeting some of the costs of social care in the future.
Baroness Merron (Lab)
I understand the wish of many, myself included, for more urgent action. However, the reality is that acting in haste will not solve the problem, not least because of the depth of the difficulties we are looking at. The noble Lord is right that many promises have been made—a number by his own Government—but not fulfilled regarding what should happen on the cap. I reiterate the point I made earlier: while I appreciate that there are Members of your Lordships’ House who believe that Dilnot is the answer, it deals with just one aspect, and that is not what we need. As my noble friend just said, we need a comprehensive look at creating a more joined-up service that will work around people, rather than focusing on institutions or one particular problem.
The Lord Bishop of St Albans
My Lords, I am grateful to His Majesty’s Government for trying to get cross-party agreement on this really important issue; it is important that it does not get lost in party politics. It is good to hear about the improvements to the NHS app, which is working quite well in some areas already. However, some people are digitally excluded, and there is a lack of connectivity in rural areas. How are we going to ensure that these groups are not excluded as we go forward with this important work?
Baroness Merron (Lab)
The right reverend Prelate is correct to mention—I have raised it myself—not just the digital exclusion of individuals but connectivity. It is one of the reasons that we will approach this in a cross-government fashion. However, on our move from analogue to digital—the noble Lord, Lord Kamall, rightly mentioned the capacity of the NHS—our view is that it can do so much more than it is doing currently. The Secretary of State said in the other place that restaurants, for example, have been texting customers for many years, have they not? They remind customers about their booking and give them a chance to cancel or change it. That is the kind of connectivity and service that we need from the NHS. I assure the right reverend Prelate that, where people are unable to use whatever the digital solution might be, they will be able to deal with it person-to-person or on paper. We will be flexible enough and actively seek out those who are not, as he described, immediately connected.
Baroness Tyler of Enfield (LD)
My Lords, the Darzi review estimated the impact of delayed discharges at some 13% of total hospital beds. Given this, can the Minister say how confident she is that the immediate steps to improve the rate of discharge from hospital into social care, which she has already outlined, will happen? How quickly will that happen and over what timescale, and what accountability measures will be established at both national and local levels to ensure that those delayed discharges start to come down, and quickly?
Baroness Merron (Lab)
The independent review by the noble Baroness, Lady Casey—in addition, as I mentioned, to producing recommendations that can be implemented straight away next year—is focusing on completing its final report later in this Parliament, so we are looking at the longer term. I cannot give an exact timetable, although I am hopeful that we will be able to update your Lordships’ House with further information, as the noble Baroness quite rightly asked. The matter of discharge requires there being suitable facilities in the community, but we are not in that place, so this will take some time. But I am very hopeful that all of the measures here, and the measures we have taken already, take us further to that point. We will continue to strive on the matter of discharge, because it is a problem not only for the NHS but for patients and their carers and for social care. We are carrying, as we know, a lot of vacancies and a social care system that is creaking at the seams: we must be honest about that.
Lord Patel (CB)
My Lords, I welcome the Statement and many of the proposals in it. We have learned from past experience that all reforms to, and any proposal to change things in, the NHS—and, for that matter, social care, but more so with the NHS—lead to increased bureaucracy but not the benefits that we thought they might deliver. One of the waiting list initiatives is that GPs will have a consultation with hospital staff to try to reduce waiting times and avoid unnecessary duplication. There is some financial incentive attached to that, but it certainly will increase bureaucracy. What modelling has been done to find out whether it will work, whether it will increase bureaucracy and by how much it will increase costs?
Baroness Merron (Lab)
I am grateful to the noble Lord for welcoming many of the measures in this announcement. He referred to the £20 fee that will be paid to GPs to call the consultant where necessary. I understand the concern about increasing bureaucracy, but all these reforms are intended to work the other way. We will very closely monitor them and have very carefully considered them with all those who will be dealing with them. I am actually more than hopeful, because the intention is that allowing the GP, for example, to get further advice, and making sure that people are being seen in the right place, will save money. It will mean that people are not taking up a referral place and that they will be referred for the necessary tests, scans, et cetera without the middle bit, which is a very backward-facing way of dealing with things. We will continue to monitor that to ensure that we are reducing what is currently wasted clinical time, while also preventing unnecessary out-patient appointments. The monitoring should show all of that and I will be very happy to update the House on that. The fee is to ensure that it can happen and is an incentive to do so. Of course, the greatest prize is an increased and speedier service for patients.
Lord Turnberg (Lab)
My Lords, it is pleasing to welcome the proposals from the Government. It is also very pleasing to hear of the immediate things that can be done for social care, because we should not be waiting for the final report.
There are some more suggestions that we could make that do not require any money—that should be music to the Minister’s ear. We do not need more money to reduce the bureaucracy that people in the community are required to go through to gain admission to a care home. It is horrendous. They have a means test and a needs test serially, which can be very bureaucratic and time-consuming, and there are waiting lists. We must reduce that bureaucracy.
The second thing, which the Minister has already referred to, is the value that we place on care home workers. It is good to hear that they will get a rise in their money and that ideas will be put about on their careers, but, unless they have a recognised national qualification and registration of that qualification, career prospects will be limited. We must do more for them to allow them to see themselves in a career that could go on to nursing in the NHS. We must do more in that field if we are to retain these enormously valuable people.
Baroness Merron (Lab)
My noble friend, as always, makes very practical observations. I totally agree with the point about bureaucracy in terms of care homes. I have experienced that as I have power of attorney for an elderly friend, and I constantly wonder: if I am struggling with it, what would it be like for somebody who perhaps is not as used as I am to dealing with forms, organisations and, indeed, bureaucracy? It is extremely troubling. Yes, that will be part of what we will be looking at to improve social care—and also the discharge ability that we were talking about earlier. Valuing care workers, professionalising the service and recognising them are all key. I agree that it should be a natural move from being a care worker into a clinical setting, but we also need to recruit people to be care workers, retain them and upskill them, which is so important.
Lord Bellingham (Con)
My Lords, on the vexed subject of delayed discharge of very elderly patients who have been admitted from care homes, quite often with ailments such as flu, medicine management, wound-dressing management, et cetera, surely the key is to ensure that many of these patients are not admitted in the first place. This follows on from the last question about the training of care workers. Is there an argument for enhancing their training so they become better carers in terms of dealing with these problems? Can the Minister say something about what I know has been tried in a number of care homes: having intermediate NHS beds in care homes?
Baroness Merron (Lab)
Both the points that the noble Lord makes are very welcome and shine a light on the need to be more flexible in the range of services and care provided. It should not be just an either/or. People have intermediate stages. Some of the issues about discharge are about having a position in the middle, which is more about rehabilitation, and having the things in place to allow people perhaps to return home or to some other setting.
There is also the point about having a range of settings. Currently, the offer is perhaps too restrictive, although not in all places, as there are some excellent examples. We must be much more creative in the kind of offer that is available and in the training of care workers, not just for the service that they offer to patients, which is important, but for their professionalisation and their morale in their jobs.
Baroness Hollins (CB)
My Lords, why is there no mention of mental health in the Statement? What happened to parity, I wonder? For example, 12,400 hospital patients a day are well enough to be discharged. I presume that this does not include the 1,500 or so autistic people and people with learning disabilities who are waiting to be discharged from psychiatric hospitals but for whom there is no social care? Community diagnostic centres are mentioned but there is nothing about the need for 24-hour community drop-in centres for citizens who have mental health problems. Social care costs for elderly people may be expected to double, but what about the increasing costs of care for disabled adults of working age?
Baroness Merron (Lab)
The noble Baroness makes very real and important points. Some of the points in the Statement cover mental and physical health but, if I might be honest about the situation, this is only one of the things that we are putting forward. As I said at the beginning of this Statement, how I wish that we could deal with everything immediately. It is not possible. This is just the first stage in the journey that we are on. I hope that the noble Baroness is reassured by the direction that we are taking, the commitments and the work that we have already done on mental health. The Committee stage of the Mental Health Bill next week will also be a very significant step forward. I absolutely accept that there is so much more to do, and we will be getting through that.