GP Services

Anne Marie Morris Excerpts

Thursday 5th February 2015 Commons Chamber

[Derek Twigg]

As I will come to later in my speech, there are a number of things that the Government coming into office after the May election will have to deal with to address the sustainability of GP services. They will have to consider whether the training is correct and whether there are enough incentives for young people to go into general practice, or, indeed, other parts of the NHS. That will be an important part of any sustainable plan to make sure we have enough doctors throughout the health service, and in particular GPs. That is a point that needs addressing.

The British Medical Association is also concerned that not enough foundation doctors are choosing to pursue a career in general practice. Application rates for training programmes continue to fall year on year. According to figures from the National Recruitment Office for GP Training, the number of applications for 2014 was 5,477, which was a reduction from 6,034 in 2013. I am told that this is leaving GP vacancies unfilled in parts of the UK: in the east midlands and Merseyside just 62% and 72% respectively of vacancies are filled. To come back to the point Members have been making, 9% of the general practice work force are aged over 60 and 38% are aged 50 or over. Just 27% of the general practice work force are under 40 years of age.

One of the reasons for speaking today is to deal with the access problems. I am sure most, if not all, MPs will have had complaints about that raised with them by constituents and by GPs.

Last year, Healthwatch Halton carried out a GP access and out-of-hours provision survey, and it is important to share some of the key results with the House: 56% of people rated booking an appointment with their GP as “very difficult” or “not easy”; 33% of people rated the length of time it took to get through to their GP practice as “poor” or “very poor”; and 62% of people would like their practice to be open longer, particularly at weekends and in the evenings. That is a particularly important point when considering whether GPs are accessible and we should move to weekend working, which we have had and are debating. However, doing that requires resources. Importantly, a sizeable proportion—32%—were unhappy with the way in which their complaints were handled. That is roughly in line with national findings. On the very big plus side, the general satisfaction level of people with their GP was more than 90%, which is important.

The figures provided to me for Halton by the Royal College of General Practitioners—my constituency covers most but not all of Halton; some is covered by the hon. Member for Weaver Vale (Graham Evans)—show that we have 66 full-time equivalent GPs and that we need to increase that by 24, or 37%, by 2020. In one of the most deprived boroughs in the country we already have a shortage of GPs. My area deals with some of the most difficult health problems—high cancer rates, and high levels of chest disease and of heart disease—so being able to access a GP, and quickly, is very important. Any shortage has an impact on all that.

[Anne Marie Morris (Newton Abbot) (Con)]

The hon. Gentleman makes a good point about access and about the challenges in deprived communities. In Newton Abbot, we have faced a real challenge in trying to replace the services there. Does the research he refers to indicate any difference between rural and urban communities, and between deprived and well-heeled communities?

[Derek Twigg]

I cannot answer the hon. Lady’s question because I do not have those figures in front of me. I am sure that if she talks to the Royal College of General Practitioners or the BMA she will be able to find all those figures. I am sure she understands that I represent one of the most deprived urban constituencies in the country and so I am going to focus on that, as I am sure she would focus on her constituency.

Let me re-emphasise a point I made earlier: whoever forms the Government after 7 May, they will have to come forward with solutions to the mounting pressure on general practice and the NHS overall. There needs to be long-term, sustainable investment in GP services in order to attract, retain and expand the number of GPs. Retention is just as important as recruitment—a point made in the comments about GPs retiring early.

--- Later in debate ---

[Anne Marie Morris (Newton Abbot) (Con)]

There is absolutely no question but that we all have a huge respect and admiration for our general practitioners. They do a fantastic job, and I am immensely proud of our GPs in Devon. Indeed, my GPs do the out-of-hours services themselves; they created Devon Doctors. Although it is accessed through the 111 service, we all love it because we see it as our doctors.

It is unquestionable that GP services are currently challenged—in large part because there has been an awful lot of change. As previous speakers have commented, there are simply more people; we are building more houses; there are more homes. Although being able to live longer is a wonderful benefit, the fact that we have more elderly individuals with more complex needs puts a different level of pressure on GPs trying to deal with this challenge.

The issue of GP numbers is a complex problem. The issue involves training places, attracting people and a whole range of other things. As others have dealt with the matter very competently, my comments will not focus on that particular challenge, but I would reiterate some of the comments made by the hon. Member for North East Derbyshire (Natascha Engel) about the challenges of keeping partners and passing partnerships on to the next generation. The hon. Lady was right that the burden of paperwork and bureaucracy acts as a deterrent, and that being a locum provides a much easier lifestyle.

Capital cost is a major issue. I understand that in the old days a loan could be acquired through the primary care trusts—not directly, but there were schemes to enable people to buy into a practice so that the partner could retire—but that that option is no longer there. That shows that there are problems beyond the bureaucracy and red tape—particularly about financing the challenge of GP numbers.

One of my greatest concerns is about rural and deprived communities. I would like the Minister to undertake a proper analysis of where those deprived and those rural communities are. I am absolutely convinced that it is possible to work out what is where, and consider the quality and adequacy of the GP services within those different areas. We need to unpick the problems before we can ever find solutions.

I believe that we need a new model. This has been talked about for many years and under a number of Governments, but I am hopeful that, under Simon Stevens’s leadership, we will come up with something fit for purpose, on which all parties can agree. He is already indicating some changes. I would certainly not advocate another major reorganisation, but he is looking sensibly at the use of GPs in hospitals and similar issues. As I say, we need a new model.

Clearly, we need to consider the possibilities for integrating within primary care and across primary and secondary care. I do not believe in a one size fits all, but we need to look at a variety of models. I am pleased that in my local community, whether it be NHS, social care, the third sector or indeed the private sector, they are all working together to give the quality of care that constituents need. That is greatly to their credit.

I am pleased, too, that in Newton Abbott we have had funding from a pot of £3.5 million for a pilot scheme on dealing with the frail and elderly. It deals with how to look across the spectrum to ensure that these individuals can, with the right sort of support, stay for longer in their own homes, which is clearly better for them as well as reducing pressures on A and E. I very much look forward to seeing the results from that.

The overall model needs to take integration into account, because for too long primary and secondary have been seen as separate sectors, never mind their separation from social care. We need to look, too, at a new physical model. We talk about public health—a responsibility now given to our county councils or unitary authorities—and we need to consider what we can do to keep people healthy and fit. The concept of a hub is important, where medical care and social care, perhaps along with a gym, could be provided. We need something to pull all those things together—a way forward in some areas. I would like to think that that could be a practical solution in one of my towns such as Kingsteignton. It is challenging to find somewhere for a new GP practice: one integrated in that way would enable us to support the serious funding challenges . I would love to think that NHS England has limitless pots of money, but that is simply not true. That is why we need to involve the private sector—providing the gym or other attribute—in making the new hubs work.

We also need to look at non-physical structure, by which I mean telemedicine. A particular challenge for rural communities is how to use telemedicine more effectively. That could be an additional challenge, of course, because it depends on whether we have the internet and whether individuals know how to use it. It is a challenge that we need to take seriously none the less. We must be careful to ensure that we do not say, “If you live in a rural community, you can have just telemedicine”. That would be a great mistake. One of the greatest fears of my local rural community is that as it becomes more sparsely populated and people become older, they will effectively be forgotten. That would be absolutely wrong. Telemedicine has a place, but it cannot be the only solution.

The main challenge is to meet the need for a long-term plan. I hope the Minister will tell me that he and NHS England have a vision of how to deal with—or at least look at—urban and rural issues, how to deal with deprived and less deprived communities, how to deal with the physical versus the non-physical solution and how to deal with the issue of integration versus stand-alone. We must ensure that we have space and place for the new solutions and the new models.

One of my deepest frustrations is that a good local authority will take into account the housing numbers and the need for a new hospital or a new GP surgery, but because the NHS is not a statutory consultee of the planning process, it is not properly thought through. The challenge is to get the NHS involved. The average GP and indeed the CCG have enough on their plate without getting involved in planning issues. That said, it is crucial for us to get this right, because otherwise we shall be landed with huge challenges. New homes will be built, and there will be no local GP services. Our local plan for Kingsteignton, which was completed recently, provides for a substantial number of new houses, but does not reflect the clear need for additional general practices. We need to find, somewhere in the area, a new space and a new place.

When it comes to planning applications, the NHS is—again—not a statutory consultee, and therefore faces considerable challenges. The number of houses involved in an application can suddenly start to increase exponentially. In the north of my constituency, in the Dawlish and Starcross area, we were to have 1,000 new houses; now we are to have more than 2,000. The local general practices are very worried about how they will cope. Having looked at their existing sites to see how they can develop them, they apply to the council for planning permission, and they cannot get it. They are feeling incredibly frustrated, because they want to provide a service, but there is absolutely no way in which they can do so.

In the case of a development in Newton Abbot, a surgery has relocated, which is great—the accommodation is much better and more fit for purpose—but the issue of bus services has been overlooked, and many people have complained to me that it has not been thought through. That is partly because the NHS has simply not been involved, in any guise.

Local residents are deeply concerned about the changes, and I am regularly approached by patient groups who say, “What are we going to do? We absolutely need to support our local communities, but we cannot see a way forward. We face challenges because existing practices cannot expand, because we need funds so that new partners can replace those who wish to retire, and because the grand plan has not been thought through and our local NHS body has run out of money.” Although the financial year has not yet ended, there is no money, and if we are to have a new general practice, we must find another way of securing that money.

There is a huge fear that if the Government cannot come up with a better way of dealing with those challenges, large private organisations such as Boots will suddenly become the new general practices. Boots currently provides flu vaccinations and the like, but it is clear that it is only one step away from starting to look into how it could provide GP services alongside a supermarket or health hub. Access is obviously important, but the fear is that people in rural areas and the elderly who cannot get to Boots will not receive those services.

We need a plan, and that plan needs to be articulated. We must have a strategy to establish how we are to plan for all this—“plan” as in “planning”—and patients and residents must be involved in the decisions. At present, they feel that they are out of the loop. There is a real fear among rural and elderly communities that they will lose out, and we absolutely must ensure that that does not happen.

Health

Anne Marie Morris Excerpts

Monday 9th June 2014 Commons Chamber

[Anne Marie Morris (Newton Abbot) (Con)]

The Gracious Speech was an extremely fine speech, but I would have liked more work on the care agenda. The Care Act 2014 made a very good start, but there is more to be done. This concerns me particularly because Devon has the highest number of over-65s in the country, and my constituency has a very large chunk of that population.

By 2035, 25% of the population will be over 65, 620,000 will be in care homes, 50% will have a sight impediment, and 75% will have a hearing impediment. Today, one in five over-80s has dementia, and that figure is set to double within the next 30 years. The demand is not going to diminish, while the supply is a real challenge for our society as a whole. Seventy-five per cent. of current need is met informally through the voluntary sector and by families. We must give thanks for that, but we then need to think about the financial contribution from the state. The NHS budget, which is now 8.4% of GDP, is in absolutely the right place—that is exactly what we should be spending given the current state of our finances—but the social care budget is decreasing and has decreased by 10% in real terms since 2010, if Age UK’s figures are correct. The reason is cuts in council funding. In my rural constituency, council budgets have been seriously hit, and I see the consequences day in, day out. Day centres in Devon are facing closure and support for supported living is being ripped out. This is a matter of great concern that must be addressed quickly.

I welcome the 2015-16 better care fund of £3.8 billion, but will it be enough and will it be too late? Age UK says that £3.41 billion more is required if we are really to meet the need. I am a great believer that we do not solve everybody’s problems through money, so we must look at what we need to do. There is nothing more important than health and dignity in the ageing population. We need to look at what we, in a civilised society, believe good care should look like. We need a proper debate about who pays. Is it the individual, their family, or the taxpayer? We need to look at who delivers it. Is it the family, the voluntary sector, or the state? Clearly, it must be all those.

The Care Act made a good start. It provided uniformity in the funding structure, consolidated the assessment process, capped costs, recognised carers and the need for support, put a duty on local authorities for care and well-being of our older population, introduced safeguarding adult boards and the star rating system—very good steps forward—and recognised that prevention is better than cure. In some ways, however, it was a missed opportunity. The commissioning process that decides what is ultimately purchased is not overseen. We still have a postcode lottery against which people’s only recourse is an individual appeal. We still have a conflict of interest in that our councils can commission and provide care, as many do. That has to change. On quality, star ratings are a good move. Let us remember that this is about relativity, not absolute quality. What are we paying for—brass or platinum? There is, as yet, no reassurance that wherever anybody lives they will get the fair share of care that they deserve.

Staffing issues were not addressed. Best practice as regards staff and patient numbers is a ratio of 1:5, but the reality is more likely to be 1:7 given the budgetary constraints. No thought was given to trying to deal with some of the training concerns. Skills for Care is a voluntary programme. If we are going to make something really work, there has to be some stick and some carrot. I am pleased that we have a studio school in Torquay that meets some of the training needs and that the University of Surrey will introduce a proper foundation degree in 2015, but more is needed.

Integration could have been addressed. This is not just about money; it is also about health and wellbeing boards. The King’s Fund suggested that there should be a requirement that providers are engaged in health and wellbeing boards. At the moment, only 30% are so engaged, and that needs to change. I am very pleased that in Newton Abbot we have a pilot on the frail and elderly that deals specifically with integration.

There has been a missed opportunity for change, and change must come soon. We need to think about how to fund smartly. How can we increase the amount available to councils? After all, prevention is better than cure; otherwise A and Es and the NHS pay the price. How can we better support families to care for their elderly as we help them to care for their children? What can we possibly do in terms of time, flexibility and tax support? How can we support the voluntary sector? There is not an inexhaustible supply of volunteers, and they are fed up with the form filling that makes their lives burdensome. How can we reduce the capital burdens that councils face when having to deal with providing care? The capital cost of the homes and day centres is driving the closures. Let us work with social enterprise, housing associations and others to look for a better model.

Let us improve quality and remove the postcode lottery. Let us, as we can under the Care Act, ask the Care Quality Commission to review the whole commissioning process. Let us look at what is provided by our county councils, what value for money we get, and whether it is the same across the country. What are we paying for? Are we finding that people in one county are getting bronze and those in another, where more money is allocated, are getting platinum? That cannot be right. Let us look, once and for all, at splitting purchasers from providers as we have in the NHS. Let us get rid of the potential bias that exists in this regard. Let us review the make-up of health and wellbeing boards and make sure that providers serve on them.

Without proper resource, and that means people, we cannot get this right. We need to ensure that more nurses are trained and that they get the respect and the pay that makes them want to work in social care as much as they want to work in the NHS. Let us produce a proper career path that drives respect and reduces the fear they live in that they are going to be criticised for trying to do their best in an impossible situation. Let us enforce the best practice ratio of 1:5. Let us look at how we are going to fill the gap whereby unless one gets to a level of substantial need one will not be funded by the state. There is so much to be done and so little time. This has to be a priority for Government this year.

Care Bill [Lords]

Anne Marie Morris Excerpts

Monday 16th December 2013 Commons Chamber

[Anne Marie Morris (Newton Abbot) (Con)]

For my constituents this Care Bill is one of the most important pieces of legislation we have seen in my time in Parliament. That is because the west country attracts a lot of people wanting to retire to our very beautiful countryside. In Newton Abbot, 23% of residents are over the age of 65, compared with the national average of 16.5%. Social care is therefore a very important issue for us.

I congratulate the Government on what they have done, because they have introduced an holistic framework that sets the scene for ongoing legislation to flesh out that framework. They have listened to Dilnot and to Francis and that is very much to their credit.

Integration of health and social care has been the watchword on everybody’s lips. All Members will have come across examples in their surgery case loads of where that does not work, and I am very pleased to see the integration—the balancing provision—that we already have in the Health and Social Care Act 2012 now reflected in this Bill.

On the adult safeguarding framework, I say well done! This is crucial. This is the first time we will have had anything like this for vulnerable adults. In my constituency, I am regularly addressed by carers who are frustrated not only by the challenges of those they care for but by the lack of support they receive. The Bill will provide the answer in the form of care plans and proper assessments. It is not often that individuals come to me who have fallen into the gap between the care plan for a child and the plan for an adult, but it does happen, and I am pleased to see that the Bill will mean that that will change.

One of the big challenges is dealing with the cost of care, and it is to the Government’s credit that they have started to look at that difficult question. How much is it right for the taxpayer to pay, and how much for the individual? This is a good Bill, but there are many things that I am sure all of us would like to see added, improved, amended or clarified. For me, one of the challenges is the role of the local authority in its commissioning and provision of care services. It seems bizarre that it should do both, because that must surely give rise to a conflict of interest. How can it commission and provide? The conflict was recognised in the NHS, and a split was introduced. It is now time to introduce such a split in this regard as well. Now that local authorities will have a key oversight role, it would be madness not to review that situation.

An important change involves the concept of true integration, and the challenge will be to identify the stakeholders who should be included in that integration. Clearly, it must involve the NHS, the local authorities and housing, but one area in which there is often no acceptance of stakeholder responsibility is that of transport. Transport to get people between care homes and hospital appointments has almost reached crisis point in my constituency, and there is huge reliance on the voluntary sector to fill the gap. There is clearly some provision for the NHS to provide that transport, but the rules are so broad that, when times are tough, transport provision becomes limited.

So who provides the transport? The volunteers in my constituency are brilliant, but they can afford only so many vehicles that are equipped to take wheelchairs, and there are only so many drivers. That issue needs to be properly addressed. In the guidance on integration that is to be given to local authorities, the NHS and other stakeholders, we must look seriously at the transport question and ensure that appropriate responsibility is taken for it and that it is properly funded. We cannot assume that the voluntary sector will continue to fill the gaps.

The assessment will form a critical piece of the jigsaw, and the Government are to be commended for trying to clarify the process, to avoid confusion and to get agreement on this. I understand their need to limit mandatory provision by a local authority to those in substantial need and above, but I fear that there could be confusion over the interpretation of the word “substantial”, and I would welcome clarification on that from the Government, in guidance or elsewhere.

Having looked at the definition of substantial need, we then need to consider who is to be involved in agreeing the care package. This is about the process of assessment, and it will be crucial for all the stakeholders to be involved. I have seen diverse levels of application in my local authorities. In some, this is very much a matter for the local authority, and it can sometimes almost seem as though a care package is being imposed on an individual. In other authorities, however, the individual, the carer, the family and the care home are all involved to ensure that the package is understood, agreed, accepted and fit for purpose. It would be extremely valuable if guidance could ensure that that always happened, when the Bill becomes law.

Having assessed the individual’s need, we need to ensure that the quality of the provision is fit to meet that need. I welcome the introduction of the new, almost Ofsted-like categorisation of quality, which will give us a real insight into what is on offer, and what “good” and “average” look like. That in turn will give rise to further questions. Once we know what they look like, we shall have to answer a much more difficult question: to what level should the taxpayer pay, after which there should be a personal top-up? That issue can be addressed only when we have some experience of those categorisations.

If there are to be different levels, the option of a top-up has to be real and available. It clearly exists, but I have seen a reluctance to make it happen in practice in some local authorities. In some ways, that is understandable. The contract is with the local authority and the care home, and not with the relatives or, more usually, the individual picking up the extra cost. The local authority will be concerned that, should there be a problem of affordability for the caring relatives, it would be left to pick up the bill. The top-up therefore needs to be reviewed. If it is to be available, it must be meaningful, and that might involve looking at whether relatives can be part of the contractual arrangement.

In the longer term, following the successful passage of the Bill, there is a lot more that could be done. The Bill will undoubtedly put in place the framework, and we can then begin to look in more detail at the strategies needed for those living in their own homes with support. Historically, we have asked what we should be doing for those in residential care or in hospitals, but once we have the framework, we will have the opportunity to look at a much more concrete strategy. That is something I would very much like to see.

Given the financial circumstances in this country at the moment, we can afford to support only those with substantial needs as a minimum requirement, but the Bill makes provision for local authorities to offer advice as well as providing services, and we should perhaps give more support to those who have only moderate needs. Their needs could be better explored, and they could be better championed and provided for.

The final word needs to be that change is not just about legislation. This is also about a culture change. That will always be a challenge, and it is incumbent on all of us in the House, whatever happens to the Bill, to follow it up and ensure that it becomes something meaningful in practice that will benefit all our residents, who very much deserve it.

Community Hospitals

Anne Marie Morris Excerpts

Thursday 6th September 2012 Commons Chamber

[Anne Marie Morris (Newton Abbot) (Con)]

I congratulate my hon. Friend the Member for Totnes (Dr Wollaston) on securing this debate. We are discussing an important topic and there are many wide-ranging issues to be addressed. I also congratulate the Minister on having been appointed to her new role. We all look forward to working with her.

Community hospitals do not just provide excellent clinical medical care. They are also places where patients feel the warmth of the community, which adds to a sense of well-being that is also part of their recovery. One reason why people feel so strongly about having community hospitals close and accessible is because it means friends and relatives can attend, which helps to make patients feel well. That is not just emotional clap-trap.

My hon. Friend the Member for Totnes put her finger on a key point when she said that this is about the community and trying to extend and expand the range of community services that are available. My community hospitals in Teignbridge are going from strength to strength, and there is a move towards integrating social and health care. That will be the salvation of community hospitals in the future. I support my hon. Friend’s comments about volunteers, too. The league of friends and the community transport in my three hospitals are first class. Without them, our community hospitals would not be nearly as successful and happy.

My three hospitals are quite different, but they all have minor injuries units and X-ray facilities, and provide a variety of services to the old and the young. Dawlish was the first private finance initiative hospital ever built, and patient surveys consistently put it in the top three of the 22 Devon hospitals. Remarkably, Teignmouth still has an operating theatre, as well as a physio unit funded by the league of friends—well done! Newton Abbot got the 2007 PFI deal of the year. Unusually, it has a maternity unit, as well as a first-class stroke unit.

My hon. Friend the Member for Totnes also raised the important issue of ownership. I raised this matter last year in a Westminster Hall debate. It is crucial that we get clarity about how ownership is to be managed once the asset is transferred from the primary care trust. In the case of Teignmouth hospital, the property is owned outright by the PCT. As I understand it, that property will be transferred to NHS Property Services Ltd. My local community has put in £850,000, so how does it feel about that? What will happen on future fundraising? Will the money just go into a central pot? What terms and conditions will be imposed on the service provider?

The situations at Newton Abbot and Dawlish are much more complicated, because those hospitals are the subjects of PFI contracts. That means that the buildings are owned by a private contractor and are, in effect, rented out to the service provider subject to two charges, an availability fee and a service charge, both of which have historically been extraordinarily high. In those cases, the contracts will be transferred to the NHS Commissioning Board. That raises a number of legal questions about the validity of the transfer, given the nature of that contract, and about the ability of the new owner to renegotiate the contract. Why do I talk about renegotiation? I do so because it is well known from evidence in the press that some of the charges that have been levied are disproportionately high. What can we do to enable such a renegotiation? Clearly it will be completely inappropriate for a local trust provider to undertake such a renegotiation, so will the NHS Commissioning Board do it?

My hon. Friend the Member for Hereford and South Herefordshire (Jesse Norman) has been brilliant in raising a campaign to look at renegotiating these contracts. The Government have already started to look at the whole management issue of these contracts to see whether costs can be cut, and they reckon that a substantial saving has been made and 5% savings can be achieved. They have established a fund of more than £1.5 billion for this; that is the amount that any one trust can get over 25 years to assist with the blighting cost, but that can be obtained only in exceptional and historic circumstances. The fund has been used, but generally that has been in much larger cases involving much bigger hospitals; I cannot see a community hospital being able to pass the test of having exceptional and historic problems. So what can the Government do to help those hospitals blighted with the burden of a PFI contract? I have heard of hospitals that, under the service charge, have had to pay £333 just to change a light bulb. I am pleased to say that that was not the case in my local hospital, but my goodness me that sort of situation has to change.

[Guy Opperman]

My hon. Friend rightly raises the issue of PFI and asks what the Government can do. I would venture to suggest that the previous Health Secretary’s decision to approve the county council’s assistance to the health trust so that it could buy out the PFI contract that was crippling Hexham hospital is exactly the right way forward. Under that approach, a PFI arrangement is bought out and a much better financial basis is put in place—an ongoing future financial basis approved by all.

[Anne Marie Morris]

My hon. Friend makes absolutely the right point, but the tragedy is that few communities can afford that sort of buy-out. As he rightly says, if we could achieve that, it would undoubtedly be the answer.

All we need from the Minister is some clarity as to exactly how these properties are to be transferred; what the position with the local community will be when properties are owned by NHS Property Services Ltd; and what the position will be on the PFI contracts when they get passed across to the NHS Commissioning Board. Clarification on those matters would be helpful and it is now urgently needed, because local trusts that are looking at continuing to run these hospitals need certainty about what they are going to be including in their budgets, and the sorts of figures that the availability fee and the service charge take out are phenomenal. The availability fees at my local hospitals range from 18% to 35%; that is the fee simply to repay the funding costs of the overall PFI arrangement. The service charge can also be high, reaching 18% to 20%. Set against that, private investors are currently seeing returns of up to 50%. That is huge and it seems unreasonable. The previous Government entered into a voluntary arrangement whereby any excess profits, particularly as a result of contracts being bundled by external private bodies, should be shared between the taxpayer and the private investor.

All those tools, which are available for the Government, need to be used. We need certainty and manageable budgets so that our community hospitals can thrive and so that money is available for what we really need—the services.

Care (Older People)

Anne Marie Morris Excerpts

Tuesday 6th September 2011 Westminster Hall

[Anne Marie Morris (Newton Abbot) (Con)]

This is an important issue and probably one of the most important topics that we as a Government and a Parliament will need to consider. On current estimates, the number of 85-year-olds will double by 2026, so it is a serious issue and I congratulate my hon. Friend the Member for Chatham and Aylesford (Tracey Crouch) on securing this timely debate.

Dilnot focused on the financial issues and found that the current system is not fit for purpose. I think that there is another issue in relation to quality. The Government clearly want to ensure that we have a system that, ultimately, is fair, affordable and sustainable. They want to invest in a system that will ensure that we have more care and support in the community, so that we can keep people in their own homes rather than force them into residential care as the only option. However, if we want that quality, we need to ensure that there is proper monitoring and proper regulation. Although I am not a great fan of over-regulation, we have to bear in mind in this particular argument that we are dealing with consumers who are often not very vocal or not able to be very vocal. Therefore, it cannot necessarily be assumed that the way in which a market would normally self-regulate will be the way in which this market will regulate itself.

My comments are based on conversations I have had with the Care Quality Commission, a number of local authorities and private providers. I have a long-term interest in the issue. I was a county councillor and chairman of the health overview and scrutiny committee, and in Devon we currently have the largest number of retired individuals in the country. I will turn first to residential care, then to domiciliary care, look at how they are regulated and monitored, and raise some concerns that need to be addressed by the Minister.

Residential care is commissioned by the local authority. Although provision is monitored by the CQC, the commissioners, per se, are not. I have a concern about that, because it is the local authorities that are determining whether to commission in their own homes—where one might argue that they have a conflict of interest—or in the private sector. What I have found particularly disturbing is the price that is paid for each of these contracts. I hear that local authorities—I give this by way of an example—are paying £700 in the public sector, compared with £350 for a private provider. Whatever the savings might be, there is no way that, for half the price, the same quality of care can be provided.

There is no standardisation of contract in the current system. Although choice is clearly important, I think that, for a consumer who has a difficult time getting their voice heard, it is difficult to ensure that they get consistently good quality. If we are to ensure that there is real choice, genuine quality and fair pricing, we need to look seriously at how the commissioning bodies—the local authorities—might be monitored and regulated in future. I believe that the Government have looked at HealthWatch as a possible source. My concern about HealthWatch is that, first, it does not yet exist and, secondly, it seems to have been conceived as a reactive rather than proactive body.

The provider of residential care is, principally, either the local authority or the private home, and here CQC does monitor. Although the intention was to set out a new framework that, rightly, was more outcome-focused than process-focused, the challenge for the care homes is to comply with this new care quality regulation. I have talked to a number of homes and the majority have indicated that they expected a light touch from Government. They expected that they would be able to provide evidence of compliance and that there would not be many onerous visits. I hear that there are many visits, which surprises them and surprises me. They are saying that it is taking up an awful lot of administrative time. Given that, as a Government, we are committed to cutting red tape, something is clearly not working somewhere. The position needs to be reviewed. Clearly, it is important, because we need to guarantee quality, but let us find a way of doing it better. The other concern that homes have expressed to me is that, with the new outcome framework, there is no guidance as to how to meet the new requirements. In the old days, the CQC used to provide guidance, but now it does not see it as within its remit.

Domiciliary care is, perhaps, one of the most tragic and most important areas of concern. Commissioning of domiciliary care is done by local authorities. Here again, there is no monitoring and, I understand, no regulator; I would love to hear the Minister tell me that I am wrong. I cannot therefore see how we can ensure that our local authorities are really making sensible, informed choices about how they award contracts for domiciliary care. Indeed, I have heard stories of local authorities trying to take out costs and to subcontract their role to lead providers, who then take on the role of subcontracting further to find individuals and more providers of domiciliary care. In all that process, the quality control and the quality test seem to be lacking. I have talked to providers in the private sector who have seen some of what goes on, and the stories are horrifying.

Let me give one example. A provider indicated to me that she had gone into the home of an elderly person who was having to be put on to the toilet. The lady was literally sitting in her chair eating her sandwich lunch and the providers came in and lifted her up in a way that is apparently not appropriate or correct from a nursing perspective. They put her on the toilet, went out, smoked a cigarette and came back in. The sandwich was still in that poor old lady’s mouth. They then took her and stuck her back in her chair. That does nothing for the dignity of the older person.

The provider of domiciliary care is sometimes the local authority but, increasingly, it is the private sector. Unlike the residential end of care, there is no Care Quality Commission monitoring domiciliary care and I understand that there are also no spot checks. Although there is an obligation on local authorities to have a watching brief, what I am hearing anecdotally shows that very little of that is actually happening.

The concept of e-monitoring was introduced to try to assist with that. The idea behind e-monitoring is that, when someone goes in to provide care in a home, they pick up the phone in the individual’s residence and log in. When they have finished dealing with the client, they log in again through the telephone. However, the reality is that once someone has logged in, frankly, they can do almost anything. As in the case I mentioned, that could be putting a lady on the toilet and then disappearing outside and having a cigarette. Therefore, e-monitoring is not an effective way forward. The other thing happening is that, because there is no monitoring of quality, cost rules and consequently quality are going down.

I shall make this a very short contribution. In conclusion, the Minister should carefully consider having a regulator to deal with the monitoring process for commissioners both of residential and domiciliary care. In addition, certainly with regard to domiciliary care, some urgent and immediate action needs to be taken to examine current practice.

Reform of Social Care

Anne Marie Morris Excerpts

Monday 4th July 2011 Commons Chamber

[Mr Lansley]

I share with my hon. Friend the feeling that if we can improve the quality of end-of-life care and give people an understanding of the recent great developments in symptom control at the end of life, people’s perception of the decisions that they might have to make about end-of-life care might change, and that might give them greater confidence that they can have what most people would regard as a good death.

[Anne Marie Morris (Newton Abbot) (Con)]

I welcome the Dilnot report’s many practical suggestions, which will be very important in Devon because it has the highest level of retired people—22%. With regard to the need for any new funding proposal to cover a range of different provision, given the change in relation to when people need to go into residential care, the contracting will need to be looked at carefully. Does the Secretary of State agree that if we are to have contracts, they need to be standardised? For example, the contracts that councils enter into with care homes are not standard, so although in theory they offer the same quality of care—

[Mr Speaker]

Order. I am extremely grateful to the hon. Lady, but I think that that is an excellent subject for her to pursue in an Adjournment debate, and I feel sure that she will.

Social Care Services

Anne Marie Morris Excerpts

Tuesday 17th May 2011 Westminster Hall

[Alex Cunningham]

It most certainly is. My hon. Friend says that social care accounts for £1 in every £4, and a 16% cut represents a considerable reduction in the amount available to spend on social care.

ADASS also concludes:

“savings on this scale simply cannot be achieved through doing the same things more efficiently or by trimming management costs”.

As for the money that has gone to PCTs, can the Minister tell us, hand on heart, that he has any idea how much of it will be spent on social care this year? Given the revolution unleashed by the Health and Social Care Bill, PCTs have had other issues on their mind as they have sought to protect services during a transition period that will see them abolished. More importantly, this transition period threatens to reverse the progress made on health and social care over the past few decades. I just wonder what guarantees there can be that we will have properly commissioned and funded care once PCTs have gone and have been replaced by consortia that do not have the expertise and understanding of our community’s wider health and social care needs.

Media reports just this weekend outlined the profits that some think can be made from the health and social care system, effectively taking hard cash from the front line. The Prime Minister’s senior adviser, Mark Britnell, told a New York conference attended by the giant private health care providers that dominate in north America that the changes over the next two years will provide a “big opportunity” for the profit-making sector. As I am sure hon. Members will know, no one can make profits without taking cash out of the system. I look forward to hearing what reassurance the Minister can give those who will be hardest hit. What is his guarantee that profiteers will not have their way with the NHS and related social care services?

I know that Ministers get fed up with MPs from the north highlighting the divisions in our country, but the BBC is highlighting them now. In a survey released last week, it identified a new north-south divide, with social care spending this year falling in the north while actually rising in the south, although I will question the value of that so-called rise later. The BBC’s findings reflect the differential impact of the cuts, with councils in the midlands and the north more reliant on central grants and thus hardest hit. The findings may also reflect demographic differences and the effect of falling property values on people’s ability to self-fund.

In the north, spending will fall by 4.7% in the current financial year alone. Then there are deprivation factors to be taken into consideration. Local authorities in the most deprived areas—many are in the north, but they are elsewhere as well—have the worst mortality figures and the highest incidence of long-term ill health, but they are suffering the deepest cuts in spending power. Front-loading the cuts means that huge changes must be brought in quickly, giving little time for consultation with staff and service users over the best way to minimise the impact on front-line services. That said, I would not like anyone to get the impression that things are rosy in the south. The 2.7% increase in spending in the south is about half the rate of inflation and does not keep pace with need. Nor will it be enough to prevent real people from losing real support—support that, in the Chancellor’s words, they depend on.

My main purpose in securing the debate, however, is to consider the human impact of social care cuts, not just to debate dry spending figures.

[Anne Marie Morris (Newton Abbot) (Con)]

I note what the hon. Gentleman says about funding. He briefly mentioned the issue of commissioners and quality, which is clearly as important as funding. Does he share my concern that the changing role of the Care Quality Commission, which will now monitor providers rather than commissioners, will mean that there is a gap and therefore a risk that commissioners will not be held to account and provide good-quality care?

[Alex Cunningham]

Yes, I agree that there is a considerable risk. I should say that I have been much impressed by the role played by local authorities in health scrutiny. I hope that the Minister will answer the hon. Lady’s question directly later.

The successful judicial review against Birmingham city council’s adult social care cuts looks set to be hugely significant. The Minister might be tempted to hide behind a carefully drawn veil of localism, but does he really consider it acceptable that Birmingham should seek to withdraw support from 5,000 people? Many of those people could be in a situation where abuse or neglect have occurred, or will occur, or they could be unable to carry out the majority of their personal care or domestic routines. They will be the real losers in all this.

Does the Minister consider it acceptable that 2,145 elderly and vulnerable people in Lancashire will have all care and support removed, as part of cuts that are the subject of another judicial review? Does he consider it acceptable that desperate families are being forced to go to the High Court to try to prevent devastating damage to their quality of life or that of family members?

In West Sussex, the “Don’t Cut Us Out” campaign has brought people together to campaign against eligibility cuts. If Members visit its website, they can read testimony from Tony, who has limited mobility. He must carry an oxygen cylinder wherever he goes and he is susceptible to blackouts and periods of deep depression. He will lose all the benefits and support currently provided by West Sussex county council. He says:

“My current care package...provides for 13 hours of care support each week and has kept me out of hospital for much of the last two years, saving the Country hundreds of thousands of pounds. Before, I was in hospital for six months at a time, and once discharged was being re-admitted every two weeks or so. I can’t imagine what my life will be like without this support.”

Back in the north, local people, service users and staff have been campaigning to halt the closure of Leeds crisis centre and the threat to mental health day services in Armley and Hunslet. At a packed campaign meeting organised by Unison, a campaigning trade union of which I am proud to be a member, a service user said, “I am saving the council money by using these services; when living in London, where there weren’t these services, I had many hospital admissions; I have had none since living in Leeds.”

Mencap provided me with a graphic example of what the cuts mean for George and his daughter, who are from Rotherham. George’s daughter has profound and multiple learning disabilities. Due to her disability, she is doubly incontinent and requires the use of many disposable items of medical equipment. She lives with her dad, and as part of her care package, the council picks up all body and medical waste from the household. The waste includes faeces, urine, blood and vomit. Mencap says that Rotherham council has gone from collecting the hazardous waste once a week to once every 14 days and has reduced the amount that it picks up by 50%. The council has also stopped providing specialist waste bags for the disposal of the waste, leaving the family to cover the additional cost themselves. That bodily waste now goes into black bin bags mixed with household waste, which are sent to landfill. These stories illustrate the fundamental truth: these cuts are a false economy with devastating human, social and economic costs.

In a recent national survey by a group of charities, including Carers UK and the Alzheimer’s Society, half the respondents said that increased charges for care meant that they could no longer afford essentials such as food and heating, and more than half said that their health had suffered as a result. We must consider the services run by voluntary organisations—dare I say it?, the big society—that offer early help for people who do not necessarily qualify for assessed council support. Day care centres, meals on wheels, support groups and drop-in centres are being cut because they are losing grant funding.

Jackie Dray used to run four support groups called “Elders with Attitude”—I love that name—in Birmingham, but she was told in March that her £30,000 council grant was to be cut altogether. She now runs only one group and is desperately looking for alternative funding. She said:

“They are cutting luncheon clubs or groups like mine that could make a difference between somebody remaining in the community or sinking into clinical depression and residential care. For a small amount of money, you could delay the point at which people have to go into hospital. I see a lot of clinical depression in carers and cared-for alike. People are teetering on the brink. There’s a lot of frustration, worry, lack of sleep.”

Before we can consider the future of social care services, we have to consider the consequences fully.

While we await the Dilnot commission report on long-term funding and the Government’s response to the Law Commission review, the Government are, in effect, already re-engineering the infrastructure of care and support. As services are razed, my fear is that capacity is being lost, services are being withdrawn and staff are being lost—capacity and skills that cannot easily be recreated. The Government are seeking to soften people up and lower their expectations, to get them to accept a return to reliance on family and buying from the open market with their own funds, or a patchwork of precarious charitable provision from a third sector suffering its own cuts and challenges.

I want to turn to the ideal, which I thought all the parties shared, of personalisation in adult social care. I fear that that ideal is being lost. The cuts mean that the policy, which promised much, is fatally undermined. Social workers and care managers tell their union that they are being expected to reassess personal budgets with a view to cutting them. I know that they need to consider value for money for all care packages, but they believe that they are expected to make cuts to get the budgets down.

A forthcoming report on a survey that Unison conducted with Community Care will highlight the fact that the paperwork and bureaucracy associated with personal budgets is excessive and inaccessible for service users. I question the Minister’s decision to prescribe from Whitehall that personal budgets be provided in the form of direct payments. That appears to be at odds with his claim to be a champion of local determination and removes choice from people who wish to have a managed budget. It appears to be linked to the aim of completely withdrawing state provision. Individuals will be expected to navigate the market or take on what many will see as the onerous and stressful responsibility of becoming an employer. I urge him to reconsider the prescription of direct payments, as there is evidence that it will restrict choice, but more importantly, distress some of our most vulnerable people, who already have enough challenges in life.

As we contemplate the future of adult social care services, there can be no under-estimating the scale of the challenges that we face as a society: by 2041, the number of adults with learning disabilities, we are told, will have risen by 21%; the numbers of young people with physical or sensory impairments by 17%; and disabled older people by a massive 108%. We all know that the number of dependent older people is set to increase hugely. The Association of British Insurers says that currently 20% of men and 30% of women will require long-term care at some point. If we add to that the challenges of the increasing number of young adults with complex needs who will need very expensive care packages for decades; the 170,000 people with a learning disability who Mencap tell us live with parents and carers who are already over 70 years old; the growth in the number of people with dementia, which the Alzheimer’s Society says is set to soar by a third to 1 million people by 2025; the costs facing authorities due to alcohol misuse; and the number of people with obesity-related problems, then we can see that the Government’s proposals are destined to fall well short of what is needed.

The director of children, education and social care for Stockton-on-Tees borough council, which serves people in my constituency, says that we have to be mindful of the knock-on effect of the reduction in other funding streams that impact on adults—the independent living fund, the Supporting People programme and affordable housing funding. She tells me that some of the funding streams that have historically been linked with it are being reduced or ceasing, while her department works to maximise people’s independence.

[Alex Cunningham]

That is very much the case. A stream of people have come to our surgeries or to see us in Parliament, and there seem to be so many attacks—left, right and centre—on some of the most vulnerable people in our society. As my hon. Friend says, something needs to be done if we are to arrest this situation.

The director of children, education and social care for Stockton-on-Tees borough council says that the result of the cuts, if we have limited extra care and supported living options, will be a further over-reliance on residential provision. An integrated health and social care facility and extra care scheme in Billingham in my constituency was an important part of my council’s strategy for supporting people, but the Government refused the private finance initiative credits to make it happen. Would the Minister prefer his granny, mother or other elderly relative to be forced into residential care when they could have been supported in their own home or an extra care facility and had the independence that I know most older people want?

Another area of concern is the shortfall in funding to support carers. Yes, I know that the Government allocated a welcome £400 million for carers’ breaks, but other funding managed by PCTs to support adults and their carers is not ring-fenced in any way, and although some flexibility is needed, carers, who are often seen as the poor relation, could end up all the poorer.

The sector skills body estimates that the social care work force needs to double by 2025, yet it is a sector characterised by labour shortages, low pay, poor prospects and a poor image. Some 60% of care workers hold no care qualifications, and only 20% have a national vocational qualification level 2; only 10 % have an NVQ level 3. Before anyone intervenes on that point, I should say that I believe that previous Governments, including our own Labour Government, could have done more to address that issue. However, it is not just Governments’ responsibility; other organisations, including service providers, should play their part in driving up qualification standards and meeting the costs.

Is the provision made by such organisations being properly managed or being left to the market? In Stockton, we have over-provision of residential care places, some of which are under financial pressure, including those owned by Southern Cross, which is seeking £100 million from investors to secure its future. Surely we need some kind of controlled management or strategic planning to get this right and ensure that standards are maintained.

We must look to the future of adult social care. We need immediate action to lay the groundwork for genuine reforms to flourish. The Chancellor said that his cuts would not touch front-line services; he should be prepared to say that he got it wrong. There is an urgent need for a new plan that looks again at the local government settlement and works with local authorities to ensure that front-line services are funded to meet need. Everybody agrees that we must do more to give early help because it prevents dependence and saves money on acute care, and yet those services are first in line for the chop. Will the Minister genuinely and strenuously consider the recommendation of a duty to provide early help for adult services such as that which Professor Munro made for children’s services?

The Minister must reconsider the equation of personalisation with the transaction of receiving direct payment. Personalisation is not about ticking boxes and having the right number of people receive direct payment. Trying to make it work in the context of the cuts requires him to spend time talking to practitioners and service users about what is happening on the ground and what they think the priorities should be. We need to get it right for individuals.

We need an improved and comprehensive work-force strategy covering training, development and qualification standards as a condition of provider registration and a commitment to working towards a living wage for all care workers. We must work with work-force representatives to boost the autonomy and confidence of practitioners. I am sure that the Minister will welcome, as work-force regulators have, Unison’s duty of care handbook for health and social care staff. The handbook aims to promote awareness among workers of their duty of care and other professional duties, and of how to raise concerns about poor practice.

Costs, too, need to be addressed urgently. The Association of British Insurers says that the average cost of care in residential homes in the UK is approaching £25,000 a year, with people in England spending an estimated £420 million a year on private home care. This question was not sensibly debated during the general election. We need cross-party co-operation to reach a long-term sustainable solution to the problem.

[Anne Marie Morris]

The hon. Gentleman raises a question about care homes and fees. Does he agree that one way to solve the problem would be to introduce a standard contract? At the moment, there are great differences in provision; there is no consistency in standards, which means that one person’s care can be very different from another’s.

[Alex Cunningham]

During my time I have visited many care homes, and I have seen many variations in quality and standards. I have seen some places where elderly people were highly motivated and excitedly engaged in activities and others where people were sitting in seats glued to the television—at least, I think that they were glued to the television; they certainly seemed to be in another world. I agree with the hon. Lady that we need a solution of exactly the sort that she outlines.

There is an overwhelming desire to end the postcode lottery for care. It is important that when people move around the country, they should receive the same standard of care without their cases being constantly reassessed. Recommendations made by the Law Commission for national eligibility criteria and carer assessments are a start in plotting a way forward. We must end the cost-shunting and turf wars between health and social care over continuing care assessment and funding. Do the Government still intend to allow the Law Commission to draft a Bill to simplify the legislation, and if not why not?

When Dilnot reports, we need to hear from Ministers a genuine commitment to cross-party engagement on long-term funding. The Minister must realise that a voluntary insurance market, like that described by the Prime Minister’s senior adviser this weekend, will not be acceptable to a public worried about the workings of the discredited financial services sector.

As well as a new funding system, we need to review the quality standards of service regulation, with greater emphasis being placed on the importance of providers having a stable, highly skilled and confident work force. The quality of care is all about the quality of relationships, but for as long as we have a 25% turnover of care staff we are letting down the hardest hit, who deserve much better.

The future of social care and its funding is not a matter only for this generation or this Government. We all have a responsibility. I hope that the Minister accepts that the Government should not go it alone, but should work with everyone involved to find the kind of long-term solution that will help to ease the anxieties of an increasing number of disabled and elderly people.

I end with a question for the Minister. If we are all in this together, why is it that adult social care is the hardest hit? Is it not the case that the most vulnerable are taking a disproportionate hit? I hope that the Minister will accept my points and other constructive points made during this debate, and that he will answer our specific questions. He should reflect on the unfairness of what is going on. He should realise that despite all the statements, funding is not meeting today’s needs and that current plans will not address the increased demands of the future. I hope that he will tell all those who receive adult social care services that he will make changes to current and future plans to ensure that the most vulnerable have a quality of life that most of us take for granted.

--- Later in debate ---

[Catherine McKinnell]

I agree that that is a great concern, which is why the Minister must take on board the deep concerns that are being expressed today. In any event, reforming the law will still not be enough.

I am pleased that, as a result of the Tyne Tees investigation, the Care Quality Commission has agreed to review its reports and to conduct unannounced assessments on the homes in question. However, I am concerned that it appears to have required a television programme to spur the Care Quality Commission into action. By placing their loved ones in residential care, people are putting huge amounts of trust in a service. They rightly expect that the Care Quality Commission is adequately monitoring, regulating and inspecting all care homes on a frequent basis.

[Anne Marie Morris]

The hon. Lady has made some extraordinarily good points, and the Care Quality Commission certainly needs more help to do an effective job. Now that we have an outcome-based set of performance criteria, homes need to be given guidance on how to comply with them. In my meetings with the Care Quality Commission, it says that it no longer gives advice, which means that it is an uphill battle for any home to ensure that it provides the quality of care that is needed and that it complies with the new criteria.

[Catherine McKinnell]

I agree that the Care Quality Commission should take a proactive approach to improving the quality of care in our adult services.

Another worrying statistic is that on-site inspections in care homes have fallen by 70% since the Care Quality Commission was introduced in October 2010. That must worry anyone who lives in a care home or who has a loved one in a care home.

Will the Minister consider the following issues because they are crucial to the future provision of social care services? What further steps can the Government take to ensure a much greater level of protection and safeguarding for vulnerable elderly people in residential care? What measures will he take to ensure that the culture of fear that was spoken about by people participating in the Tyne Tees reports is broken down, so that care workers, relatives and residents feel confident and safe in raising concerns about the standard of care? What steps is he taking to improve the status, pay and training of care home staff, who are doing an incredibly difficult and important job? How will he ensure that the swingeing cuts to local authority budgets over the coming years do not detrimentally impact further on the quality of social care being provided to elderly people, particularly at a time of ever-increasing demand?

--- Later in debate ---

[Mr Anderson]

The privatisation of home care services in this country has been a complete failure and a nightmare. I have represented home care workers for many years and have seen the service deteriorate. We had a dedicated work force who had a set list of clients whom they went to see day in, day out. They built a relationship with that person and their family. When those jobs were contracted out, it was said, “We will send worker A on this day and worker B on that day.” The home care worker lost that direct link with not just the family but the wider team within the authority. That team would work together and take a holistic view and work better for the person concerned. It is clear that services are being contracted out to save money. If we save money, services will not be as good.

It is clear that we will see problems being stored up if we lose public sector capacity in home care services. At the moment, some 31,000 residents are being taken care of by Southern Cross Healthcare. Their homes now hang in the balance as a result of reckless business practices and local commissioning, which has allowed the organisation to become so dominant in the market. Southern Cross and Four Seasons—the big two in residential care—have operated casino-style finances, and both are now teetering on the brink of collapse. A toxic cloud, formed by irresponsible borrowing, weakening demand, council cuts, the slump in care home property values and the collapse of favourable credit facilities, now hangs over the heads of frail elderly people and their families at a time of insecurity and when they need real security.

How has it come to this? How has RBS, a state-owned bank, become the biggest shareholder in Four Seasons in exchange for writing off debts of £300 million? Would taxpayers’ money not be better spent directly on care homes run by democratically accountable councils, rather than being tied up in byzantine financing arrangements?

Across the social care market, research by Community Care suggests that one in five providers expect to go out of business in the next financial year. The regulator describes the home care market as a cottage industry of small, often barely viable providers alongside a few giants such as Care UK, whose chairman kindly provided £21,000 to fund the personal office of the Secretary of State for Health—perhaps that is one reason Care UK is doing so well.

If Southern Cross, Four Seasons or indeed local providers collapse, how will local authorities find new homes for people when they no longer run them? When home care providers default, as they often have and might in future, how will local authorities fill the gap if they have scrapped their own home care teams, which is happening up and down the country?

What about the quality? Care Quality Commission data show that privately provided care services are less likely to be rated “good” or “excellent” and five times more likely to be rated “poor”. I know that the Government do not like targets or standards, but when their own commission is saying such things its message should be listened to. Private providers consistently score lower on a range of indicators of quality and safety. When we look at the employment practices of some providers, we cannot be surprised that home care workers do not stay in their job. They are not paid for their travel time between visits, and they have to provide their own mobile phones and pay for their uniforms. They suffer from underpayments; they often have zero-hour contracts; and they sometimes have to pay towards the cost of administering their own time sheets. No wonder people do not see it as a job for the future or a career that it is worth investing their time and talents in. We need real regulation of employers to stamp out employment practices that have impacted so badly on home care users and, through them, on staff.

Where are we today? We have a Government who want more from staff for less; who want more work by fewer staff, because they are making 500,000 public sector workers unemployed; who want more pension contributions from less pay and for poorer pension provision; and who want people to spend more time at work by making, in particular, women work until they are 66 years old, with less time at home and in retirement.

What did we get last week? The Chancellor has a new red tape initiative. What is he going to do when people are losing their jobs? If there is a chance of redundancies being managed sensibly, what does he talk about? He wants more chances of people being sacked, with less chance of real support by limiting the time to consult. People will have more chance of being made redundant and less legal support to challenge decisions taken by their employer.

The CQC sees a vacuum in regulation and in the checking of safety and quality of care. The CQC’s risk-based approach is resulting in a dramatic drop in inspections. A freedom of information request by Community Care found a 70% drop in CQC site inspections in the past year alone, at a time when more people are in need of care.

[Anne Marie Morris]

I thank the hon. Gentleman for being so generous in giving way. The statistics are interesting, but care homes in my constituency of Newton Abbot complain that more visits are being made. I spoke to the CQC just this week and it said that it was making on-site visits to every home within its purview in the south-west. There might be a regional difference, but in the south-west, where there are a huge number of elderly people, the number of visits is going up, not down.

[Mr Anderson]

I thank the hon. Lady for that. More inspections are good: we want inspections that work; otherwise, we will get into the problems that my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell) mentioned.

Staff and service users fear that there is an over-reliance on provider self-assessment and secondary sources rather than direct inspections. There are fewer indicators and data sources for adult social care providers than there are for NHS providers, yet the methodology is common. Alongside a “lighter touch” approach from the regulator, local authorities are cutting quality assurance departments, which, as Community Care showed, means fewer local checks on the quality and safety of care being provided.

Some of the changes that the unions and workers at the CQC would like to see, which I agree require serious and urgent consideration, include reinstating and strengthening the requirements on the types of incidents and issues that must be reported to the regulator. These should again include medication errors, significant injuries, accident and emergency admissions, safeguarding referrals, matters where staff are subject to disciplinary action or dismissal and unusually high staff turnover. Those are all indicators of things that might be going wrong, but they are not being recorded as they should be. A minimum frequency should be set for how often a service is visited.

I have no doubt that the hon. Member for Newton Abbot (Anne Marie Morris) is correct about the experience in the south-west, but it should be replicated across the country because it would give people greater confidence that things were being done properly. There should be a greater range of tools so that service users and employees can make their concerns known to people who can affect outcomes. We want to encourage people who want to blow the whistle where necessary, and give people whose relatives are in care confidence that, if they make a genuine complaint, the care will not be reduced.

I hope the Minister will look at my points, provide answers on the failures of private adult social care providers and say whether anything can be done to make the CQC more representative. For years, adult social services have been regarded as the Cinderella service, which is a disgrace. People are in care not because they want to be but because they have to be, so I hope we will work together to try to make adult social care something this country can be proud of.

Health and Social Care Bill

Anne Marie Morris Excerpts

Monday 31st January 2011 Commons Chamber

[Anne Marie Morris (Newton Abbot) (Con)]

One of the concerns that I have come across is from health professionals who would be delighted to see red tape removed. I have spoken to directors of nursing who spend more time on red tape than they do with their patients, and they are deeply frustrated. Does my hon. Friend agree?

[Nadine Dorries]

Absolutely, and the Bill will address that, in as much as care will be more easily accessed by the GP and the patient, in a much more streamlined process.

When nurses sat their medical exams 62 years ago, when the NHS was first established, the answer to each question had to begin and end with the words: “Reassure the patient”. It did not matter what someone said in the answer; if they did not emphasise the fact that the patient had to be reassured, they failed. That has gone. That demonstrates exactly how the patient has become invisible in today’s NHS.

I support the Bill because I support GPs working in consortia. A common myth—an urban myth—that we have heard in the few weeks leading up to this debate, and which has been thrown at us from the Opposition Benches, is that GPs are simply not up to the task of becoming business managers. The truth is that they already are business managers, because they all manage their own businesses. They will not be working as individuals or in individual practices; they will be working as part of a consortium, which is quite different from the impression given by the Opposition. Right now, 141 pathfinder consortia are demonstrating that they are ready and able to take on commissioning, and that they endorse patient involvement in the decision-making process. As a result of the “any willing provider” provisions, there will be a genuinely wider choice of care options available to the GP and the patient.

I would like to rebut the argument that the private sector will come in and undercut the NHS. That is complete nonsense. There will be no undercutting of the NHS whatever. Services will be—[Interruption.] I can only say that Opposition Members have not read the Bill, because there will be a tariff. Charities and the private sector will be able to provide services, but with a tariff. I shall give an example. If a patient requires a surgical procedure, which they discuss with their GP, and the local hospital has no bed available for six weeks, two months or however long, but if the local private hospital can provide a bed the next morning at the same price, are the Opposition really saying that an ideological obstruction should be put in the way of that patient being admitted to that private bed for that procedure the following day?

--- Later in debate ---

[Sarah Newton]

As someone who represents a rural area of Cornwall where GPs’ delivery of pharmaceutical services is vital, I think that that is an extremely good idea.

Secondly, the new responsibilities of Monitor and the Care Quality Commission will make possible independent regulation of both quality and safety of care and value for money. I have observed the problems that have occurred in recent years when managers have evaluated their own compliance with standards. Good decisions can be made only with sound evidence. The powers of the National Institute for Health and Clinical Excellence and the Information Centre will be enshrined in legislation for the first time, and their independence from Government will thus be guaranteed.

Thirdly, the Bill creates a new role for local authorities in public health. Directors of public health, jointly appointed by Public Health England and local authorities, will play a leading role in the discharging of authorities’ public health functions. Arguably, it was the initiatives of local authorities in past centuries—such as the introduction of fresh water, drains, sewage management and the controlling of vermin—that led to some of the most significant improvements in life expectancy.

[Anne Marie Morris]

Is not one of the real strengths of making public health part of the role of local government the fact that housing, which is a critical issue to public health, can be viewed in the round?

[Sarah Newton]

I entirely agree with my hon. Friend, who has anticipated a point that I was about to make.

The returning of more responsibility to local authorities—along with the considerable social determinants of health for which they are already responsible, such as the availability of good-quality housing and the regulation of places of work, environmental health and leisure services—has the potential to improve health outcomes, and to close the ever-widening gaps in health equalities in this country.

The Bill will ensure that every upper-tier authority establishes a health and wellbeing board consisting of the director of public health, GP consortia, children’s services, adult services, care providers from all sectors, and local health watch organisations. Such boards should provide local leadership and a strategic framework for the co-ordination of health improvement and the addressing of health inequalities in their areas. The joint strategic needs assessment will be integral to the process, and will influence the commissioning of services. The local health and wellbeing boards will, in effect, hold the ring when it comes to the health and care services provided in their communities. Local authorities will maintain and extend their role as scrutineers of all services, whether they are commissioned locally or nationally and whether they involve health or social care. They will also be able to commission complaints and advocacy services from any provider, rather than just from the local or national health watch.

The Local Government Association has warmly welcomed the proposed changes. The best local authorities have good experience of working with public, private and not-for-profit organisations as well as the charity sector in delivering integrated care. They are used to planning person-centred and personalised care.

I believe that—along with the changes that the Secretary of State has already made to the operating framework of the NHS in relation to the reconfiguration of services—the Bill, when effectively implemented in communities across the country, will lead to greater openness, greater accountability, and greater confidence for all those working in health and care, as well as for the ordinary people up and down the land who have lost so much confidence in the way in which decisions are made. These changes will take time, but I am confident that within the next four years, when we ask the people of this country, “Do you feel that decisions are being taken about you and with you?”, many more people will say “Yes” than would do so if asked that question today. That is a result that I shall be proud to have played my part in achieving.

--- Later in debate ---

[Nicky Morgan (Loughborough) (Con)]

Thank you, Madam Deputy Speaker, for allowing me to contribute to the debate on a Bill that is essential to implementing the coalition Government’s policies. I had intended to say what an excellent debate we have had so far, with some thoughtful contributions from all parts of the House. The hon. Member for Wolverhampton North East (Emma Reynolds) made a thoughtful contribution, but I am afraid the hon. Member for Eltham (Clive Efford) let his side down completely with his offensive remarks about how Government Members view the national health services.

Although she is not in her seat, I congratulate the hon. Member for Oldham East and Saddleworth (Debbie Abrahams) on her contribution to the debate. I did not agree with it, but she gave her speech extremely well.

I welcome the Bill. It is essential that more power is given to front-line doctors, who are best placed to understand patient needs. It is a tragedy that Opposition Members seem to think that GPs are not capable of stepping up to the mark and taking on those responsibilities. From the conversations that I have had with my GPs, I do not understand why the Opposition believe that; they will be proved wrong.

I support the focus on clinical outcomes. I think that GPs are interested in taking on commissioning and the proposed changes. Three consortia in Leicestershire and Rutland have stepped forward so far. My primary care trust is working extremely closely with them, particularly on transferring community services, and I welcome their close working relationships.

The GPs commissioning arrangements will mean that GPs listen to what patients want. GPs will be responsible for community services in Leicestershire and Rutland, including the walk-in centre in the middle of Loughborough and out-of-hours services, which have not been mentioned in the debate. One of the things that patients feel most passionately about is the fact that some GPs, particularly in the part of the country I represent—I cannot speak for everywhere—are not responsible for delivering out-of-hours services. What patients say to me more than anything else is that when they call someone in the middle of the night, they want their GP or someone who has access to their records to answer the telephone, not a call centre.

[Anne Marie Morris]

I absolutely support what my hon. Friend says. I have the very good example in my constituency of Devon Doctors, which is effectively a not-for-profit organisation that provides all the out-of-hours service and gives the people of Devon exactly what she has suggested.

[Nicky Morgan]

I entirely agree with my hon. Friend. It just shows that GPs, if they are given the responsibility, will step up to the plate and deliver what their patients need.

In the limited time available, I wish to focus on what the proposed changes will mean for mental health services. I speak as a member of the all-party group on mental health, and as someone with a family interest in mental health issues. The NHS in England spends more on mental health services than on any other disease category, including cancer and heart disease, and one in four people will experience mental ill health at some point in their lives. The public health strategy has so far not been mentioned in the debate. I entirely welcome the Government’s emphasis on public health and the emphasis on good mental health as well as good physical health. I recently spoke with Charnwood mental health forum, which is based in my constituency, whose members told me that prevention of mental health problems and supporting people who are perhaps heading down the road to depression and more serious conditions is incredibly important.

There are four keys areas that I want to mention in the time available. My first point, which has already been mentioned by the Opposition, is that we must ensure that GPs get proper support to commission effective mental health services and other specialised services. That support can come from the national commissioning board, third sector organisations and patients. That is why I think GPs will step up to the plate, because they will ask their patients and listen to them when designing and commissioning services.

A recent Rethink survey of GPs found that 31% of GPs did not feel equipped to commission mental health services, compared with 75% who felt that they could commission diabetes and asthma services. It also revealed that 42% of the GPs said that they had a lack of knowledge about specialist services for people with mental illness, and 23% said that they had a lack of knowledge about mental illness in the first place. I will cite a recent case study from my Loughborough constituency, in which I was told that one of my constituents was suffering from complex mental health conditions, but his GP appeared to have no knowledge of personality disorders and saw the problem as largely behavioural. The relationship between the constituent and the GP deteriorated and therefore the local Rethink carers group stepped in to help find another GP. With consortia, a GP in a different practice could have that specialisation, and the first GP, realising their limitations, could speak with that other practice and engage with carers groups, such as Charnwood mental health forum or Rethink to ensure that there are special services available for patients.

Public Health White Paper

Anne Marie Morris Excerpts

Tuesday 30th November 2010 Commons Chamber

[Mr Lansley]

I bow to my hon. Friend in his understanding of local government. My experience and understanding of local government is such that I know that the people involved are very concerned about improving health in their communities, and these resources will be available for that. Those people will not only be accountable to the people who elect them but accountable through the incentive mechanism of the health premium for the delivery of improving outcomes in the reduction of health inequalities. They will have an in-built incentive in the funding system to use those resources to deliver the outcomes that are collectively agreed, co-produced with local government. If they do not do so—if they spend the money elsewhere—they will not see the increase in resources that would otherwise flow.

[Anne Marie Morris (Newton Abbot) (Con)]

Given the Secretary of State’s support for Sure Start, will he clarify his plans for Home-Start, as several families in my constituency are concerned that it will lose funding?

[Mr Lansley]

I will write to my hon. Friend about that. We are very clear that we are going to introduce a universal health visitor service, which has been lost in recent years. That element of universal support to all families when babies first come home is an absolutely integral part of getting them on the right path. We think that not just targeted but early support for all families will have disproportionate benefits in the long run.

Accident and Emergency Services

Anne Marie Morris Excerpts

Tuesday 14th September 2010 Westminster Hall

[Anne Marie Morris (Newton Abbot) (Con)]

This has been an interesting debate and I commend hon. Members on their contributions. It is clear that accident and emergency is close to all our hearts. I am particularly blessed with two very good district general hospitals—one is at Torbay and the other is the Royal Devon and Exeter hospital. I am extremely fortunate. However, there are three minor injury units in the smaller towns of Newton Abbot, Teignmouth and Dawlish. The challenge for me is in many ways an echo of the points raised by my hon. Friend the Member for Southport (Dr Pugh). Clearly, the issue is access. I am concerned to ensure that we use the minor injury units to their fullest extent. For my constituents the journey to Torbay or the Royal Devon and Exeter is quite a long one. My concerns, on which I hope the Minister will look favourably, are that we should think about making better use of the minor injury units. If we do so, we shall help the overall NHS budget very much.

I do not know how many people realise that the number of people who attend A and E is growing faster and faster. In just the past three months of this financial year, 5.49 million people have been seen at A and E. Mathematically, extending that over the year gives a figure of 22 million people visiting A and E throughout the country. That breaks last year’s record of 20.5 million. Such a figure would mean 40% of the population visiting A and E at least once, assuming that each individual who visited was responsible for only one attendance. That is a huge figure. The challenge for the Government and the country, given the current economic climate, is how we afford that. One of the issues is the number of people who inappropriately attend A and E—not through any fault of their own.

Just going through the door at an average hospital costs the NHS £100. By comparison, the average cost to go through the doors of a minor injury unit is £50. Those figures are averages, but the cost differential is significant.

[Dr Pugh]

The hon. Lady has mentioned the statistics and the increased number of inappropriate self-referrals. She is probably also aware, because she is extraordinarily well informed on the issue, that GPs are referring more people than hitherto to A and E. Therefore primary care—the GP setting—is not the answer. The answer is probably the minor injuries unit.

[Anne Marie Morris]

I thank the hon. Gentleman for that valuable contribution; I agree with the earlier comments that the answer is probably an appropriate network of different provision. However, we need that to be clearly signposted. That is the way forward.

The challenge for the Government and the Minister is to quantify the percentage of people who present at A and E who would be better dealt with in, for example, an MIU. People have tried to quantify that, but the figures vary wildly, from 60% to a more modest 10% to 30%, which is the latest finding of the Primary Care Foundation. Further work on that would be very worth while. However, the Minister could sensibly consider several steps now, even before that investigative work, to examine how we can manage A and E attendance more effectively. The figures show that 20% of presentations at A and E are alcohol-related. We all know that is a huge burden on the NHS and the country as a whole, because of crime and other issues. Minimum alcohol pricing and improving education in schools might make a significant difference to the Minister’s problem.

Secondly, I suggest that the Minister and his colleagues consider the availability of other services, such as dental care, in communities. Often, it is because there is not adequate NHS dental care that patients present themselves at A and E units. A and E services are cheap, they are there, and they are now. If we could fix that situation it would make a big difference. Such problems cannot be the right reason to attend A and E. Although the PCTs have tried to assist the public’s understanding of where to go for which service, it is abundantly clear that they have failed. People know about 999 and A and E, and that is where they go. We need to find a much more effective way of educating them. I commend the Minister on the commencement of the 111 service, which is excellent, if we can educate people to use it appropriately.

The Minister might also like to take into account how we give prominence to and promote MIU services. However, to do it effectively we need to ensure that across the country everyone knows what the service is and that it is consistent—for example, that opening hours are consistent. In my constituency, it depends on which MIU someone attends; if they turn up at Dawlish after 6 o’clock, the door will be closed, but that would not be the case if they turned up at Newton Abbot. It is equally bizarre that for someone who needs an X-ray, the X-ray unit is not coterminous with the MIU opening hours. Those are exactly the sort of things that put people off going to an MIU. In that regard, some steps forward would be extremely helpful.

If I may, I shall take the opportunity to refer to a couple of helpful things that my local health community is doing in my constituency. First, in Torbay hospital, local GPs attend A and E at the point of entry, so, rather than going through standard A and E routes, some patients see GPs, which reduces costs. The second good initiative in my constituency comes from our mental health practitioners recognising that, often, a stay in hospital is extended because someone has the symptoms of depression. Devon Partnership NHS Trust, which is responsible for mental health care in my constituency, has placed mental health care practitioners in hospitals to assess individuals, and, as a result, is beginning to reduce the time that individuals stay.

I am grateful to hon. Members for their contributions and to the Minister for his attention. I commend to him the idea of looking further at consistency in MIUs, how to reduce alcohol-related admissions, using mental health care practitioners to reduce the length of stay in A and E, and making other services, such as dentistry, available, as they should be, to avoid people unnecessarily going to A and E.

[Dr Pugh]

On alcohol-related admissions, which the hon. Lady mentioned twice, one problem that besets many A and Es is repeat customers—chronic alcoholics who appear again and again. Clearly, alcohol pricing would make little difference to them, so a linkage between A and E and other services in the community is normally required in those contexts. In many parts of the country, that linkage simply does not exist, which creates repeat custom for A and E.

[Anne Marie Morris]

I have finished my speech.

[Katy Clark (in the Chair)]

Gordon Birtwistle.