Physician Associates
Baroness Keeley Excerpts(1 year, 4 months ago)
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Barbara Keeley (Worsley and Eccles South) (Lab)
I applied for this debate to discuss the use of physician associates in the national health service and I am grateful for the opportunity to bring this important subject to the attention of the House today.
This issue was raised with me following the very sad death of Emily Chesterton, the daughter of my constituents Marion and Brendan Chesterton, who are in the Public Gallery today. Emily died in November 2022 after suffering a pulmonary embolism. She was just 30 years old when she died.
Emily was a budding actor in musical theatre. She studied at the Liverpool Institute of Performing Arts and performed in numerous productions. She was also a winner of the Hammond House poetry prize in 2018. Emily’s mother, Marion Chesterton, describes Emily as active and always willing to help others.
Emily and her partner, Keoni, moved to London from Boothstown in my constituency to pursue their careers in the arts. They registered with their local GP surgery, the Vale Practice in Crouch End, north London. Emily had been diagnosed with polycystic ovary syndrome and had also contracted covid-19 late last summer.
My constituent, Marion Chesterton, said that Emily had been feeling unwell for a few weeks before she made an appointment at the Vale Practice on 31 October 2022 as she had calf pain and was breathless. Emily believed that this appointment was to see a GP, but the person she was booked to see at the practice was a physician associate.
A physician associate does not have the depth of training that a general practitioner would be expected to have, as they are not a doctor. A physician associate can practise after just two years of training. Importantly, physician associates are intended to supplement more qualified staff, not to replace them.
After a short appointment, the physician associate diagnosed Emily with a sprain and possible long covid. She was told to rest and take paracetamol. At no point during the appointment at the GP surgery was Emily made aware that the person who had diagnosed her was not a doctor.
A week later, on 7 November, Emily began to feel very unwell. Her leg was swollen and hot and she struggled to walk a few steps without becoming out of breath. She made another appointment at the Vale Practice and saw the same physician associate. It appears that this was a short appointment and that Emily’s legs were not examined.
The physician associate suggested that Emily’s breathlessness was due to anxiety and long covid and prescribed propanolol for the anxiety. In messages Emily sent on this day, she described seeing “the doctor” and it appears that she was never told that the person she was consulting for medical assistance was not a fully qualified GP.
In its serious incident report, the Vale Practice states that patients should not see a physician associate twice for the same condition, and guidelines make it clear that physician associates cannot currently prescribe, with any prescriptions needing to be signed off by a supervising GP. It appears that the oversight of prescribing medication was missing and that this system failed in Emily’s case.
Later in the evening of that same day, 7 November, Emily’s health deteriorated while she was out for a meal with her partner and parents. She took a propanolol tablet as advised by the physician associate. Emily’s mother, Marion Chesterton, told the coroner’s inquest into Emily’s death that Emily immediately became drowsy and that they all soon left the restaurant, with Mr and Mrs Chesterton driving Emily and Keoni back to their home in Crouch End.
On returning home, Emily became very ill. Her partner, Keoni, recalled to the inquest that she lost her pulse and he had to perform cardiopulmonary resuscitation on her, which recovered the pulse. Keoni then called an ambulance.
Mr and Mrs Chesterton then returned to Crouch End to be with their daughter. Marion Chesterton recalled that, when she saw Emily, she was squatting on the stairs. She sat with her daughter as they waited for the ambulance. Marion said:
“Emily asked me in a quiet voice to please help her, and I tried my absolute best to keep her calm, stroking her hair, holding and supporting her on the step as best I could, reassuring her that all would be well, not to panic, that I loved her…I noticed that she had lost some responsiveness, that she was extremely clammy, and her lips were turning blue. Her breathing had become very laboured, and she was rasping.”
Mrs Chesterton recalled that the ambulance arrived not long afterwards, around 45 minutes after Keoni made the first phone call. Emily suffered a cardiac arrest on the way to the hospital. Her family had to say their goodbyes while she was still on the machine which was pumping her heart for her.
Keoni recalled that staff at the A&E department at Whittington Hospital, where Emily died, told him that the propanolol tablet “definitely wouldn’t have helped” Emily’s condition. Staff had to give her an antidote to the drug.
The circumstances that led to Emily Chesterton’s death were investigated by a coroner, with a hearing at St Pancras Coroner’s Court on 20 March 2023. The coroner heard from representatives of the Vale Practice, Emily’s mother, Emily’s partner and the physician associate who had seen Emily.
Messages from Emily to her partner and family at the time of her appointments were also shared with the inquest. These messages evidence Emily’s belief that she was seeing a doctor. They also evidence that the appointments with the physician associate were short and that Emily was not examined fully.
The conclusion of the coroner was:
“Emily Chesterton died from a pulmonary embolism, a natural cause of death. She attended her general practitioner surgery on the mornings of 31 October and 7 November 2022 with calf pain and shortness of breath, and was seen by the same physician associate on both occasions. She should have been immediately referred to a hospital emergency unit. If she had been on either occasion, the likelihood is that she would have been treated for pulmonary embolism and would have survived.”
That is a heartbreaking statement, making clear the failings in the health system, which should have supported Emily with appropriate care.
Further failings were evidenced in the incident report from the Vale Practice, which was provided by the practice to the coroner. Failings of the physician associate identified by the GP practice include not introducing herself to Emily during the appointment, not allowing Emily’s partner to accompany her into the consultation room despite this request being made and despite Emily being vulnerable because of her illness, not exploring the potential causes of Emily’s breathlessness, not documenting the severity of covid-19 that Emily had suffered from a month earlier, not exploring why Emily felt “clammy”, not documenting whether oxygen saturation readings after exertion or respiratory rate readings were taken, in line with clinical guidelines, and not referring Emily for an electrocardiogram, blood tests or other clinical investigations, also in line with clinical guidelines.
Crucially, the physician associate did not seek medical advice after seeing a patient who had presented twice in one week with significant risk factors for pulmonary embolism, such as polycystic ovary syndrome, recent contraction of covid, calf pain and breathlessness, and she sent Emily home without consulting a doctor. The practice later raised concerns about the physician associate’s knowledge and understanding of what appropriate investigations she should perform in a patient presenting with symptoms post covid, about her ability to recognise an unwell patient and escalate such concerns to a doctor, and about her over-confidence and lack of insight into the limitations of her own clinical knowledge and practice.
Two weeks after conducting the serious incident review, the practice made a collective decision to terminate the contract of the particular physician associate, as she appeared to be unable to co-operate with the practice’s supervision requirements. Then
“a decision was made not to employ physician associates going forward”.
Despite that, Mrs Chesterton tells me that the particular physician associate is still practising medicine in the NHS in London as a locum. She asks, “How is this possible?”
This case raises serious questions about the wider use of physician associates in the NHS, and particularly about allowing the provision of unsupervised one-to-one consultations in general practice. NHS information says that physician associates are graduates who have undertaken relevant postgraduate training and that they work under the supervision of a doctor. They will have been educated on a medical model with basic medical skills, but they lack formal professional regulation and they do not have prescribing rights. Most physician associates work in general practice, acute medicine and emergency medicine.
The physician associate role was introduced into the UK 20 years ago—I have to say that before looking into this case I had never heard of the physician associate role, but it appears it has been around that long—in an attempt to address workforce shortages in underserved primary care practices. The role was based on the physician assistant role in the United States, which dates back to the 1960s.
Physician associates are expected to be under the supervision of a designated medical practitioner, but that does not appear to have been the case with the lack of supervision that occurred in the case of Emily Chesterton. When qualified medical professionals such as GPs are already stretched, it is easy to see how tasks such as checking the notes and work of a physician associate could be missed.
There is also the problem of the title of the role, which Marion Chesterton told me sounds
“extremely grand, even grander than a General Practitioner”.
She suggested that the name should change to “doctors apprentice”, “learner doctor” or “probationary doctor” to avoid confusion, and it should be made very clear who patients are seeing.
Marion Chesterton also told me:
“We only discovered that the medic treating Emily was not a doctor the week before the inquest. This caused us extreme distress.”
She asks:
“Could something be put into place to keep families fully aware earlier on in the process?”
Crucially, it is very concerning that there is no statutory registration system for physician associates. There is only a voluntary register. In July 2019, the Department of Health and Social Care announced plans for the General Medical Council to regulate physician associates, pending the passing of new legislation. After a consultation in 2021, the timetable for regulation has been beset with delays. The Royal College of Physicians and the Faculty of Physician Associates have called these delays “frustrating and disappointing”. It was not until February this year that the draft legislation was published and put out to a public consultation.
When will the Government respond to the consultation and when does the Minister expect the legislation to regulate physician associates to be debated and approved? It has been, as I said, 20 years since the role was introduced. In 2018, as the Minister may know, the hon. Member for Newton Abbot (Anne Marie Morris) promoted the Physician Associates (Regulation) Bill, a private Member’s Bill. In 2019, the Government committed to regulating physician associates. That was four years ago now.
The Royal College of Physicians and the Faculty of Physician Associates have led the RegulatePAsNow campaign since May last year. The Faculty for Physician Associates said:
“We believe that regulation is fundamental to ensuring that physician associates remain a safe and effective workforce in the future.”
We also know that regulating physician associates has public support. A petition calling for the statutory regulation of physician associates was signed by nearly 6,000 members of the public.
It is clear that the legislation underpinning the regulation of medical practitioners is now in urgent need of reform. The Medical Act 1983 is now 40 years old, and the General Medical Council has described it as
“complex, overly prescriptive and slow to adapt to change.”
It has taken the Government too long to recognise that, and progress is happening at a snail’s pace.
What will the Minister do, from today, to ensure the safety of patients being treated by physician associates? What measures will he introduce to ensure that patients know the role and qualification of the person they are seeing when attending appointments in general practice settings? Those questions are becoming increasingly pressing as more people enter the physician associate role. There are currently more than 3,000 qualified physician associates working in the UK. Although the numbers look relatively small at the moment, the General Medical Council expects them to grow steadily in the next few years, with one study estimating a projected growth of 1,000% per year.
Growth in the number of physician associates will be turbocharged by proposals in the Government’s recently published NHS long-term workforce plan. The plan aims to more than triple the number of physician associates in the NHS workforce in the next 12 years. By 2037, they will total 10,000, with around 1,300 trained annually from this year, and 1,500 trained each year in 10 years’ time. In response to the Government’s long-term workforce plan, Latifa Patel of the British Medical Association said that the proposed wider use of physician associates
“must come with clear boundaries around expectations, and not impact on the training of medical students and doctors.”
The coroner concluded that the poor quality of care given to Emily Chesterton by the physician associate at Vale Practice contributed to her death. That concerns me deeply, and it should concern the Minister, too. The Government must now move quickly to regulate physician associates and learn from the events that led to the sad and tragic death of Emily Chesterton.
I want to finish with the words of Emily’s mother, Marion:
“We feel extremely let down by the care provided by the GP practice. We have lost our precious, beautiful, kind, loving, talented and irreplaceable daughter, and this must not be allowed to happen to any other family.”
Barbara Keeley
I take what the Minister has said about the training and voluntary registration aspects, which I did speak to, but could he comment on the situation we seem to have been in? The GP practice had concerns about the physician associate’s knowledge and understanding of what investigations she should perform, her ability to recognise an unwell patient, and her overconfidence and lack of insight into the limitations of her own knowledge. Those are the issues that the GP practice itself reported. Does the Minister share my concern that it is a very serious thing to have had a system like that, and, surrounding that, to have the fact that the reception function in that practice did not realise that it should not refer an unwell patient to a physician associate twice within a short period of time? If these are meant to be safety measures, they are not working, are they?
Will Quince
I hear what the hon. Lady says. In response to her questions, we very much need to look into the exact details, and I hope I will be able to respond to her with full answers when I have received both the coroner’s report and further information from NHS England regarding the practice itself. On the face of what she has just said, the situation is concerning and it certainly adds weight to her calls for the register to be non-voluntary and for regulation and legislation in this space. I will come on to that issue in a moment, because it is a case well made.
The physician associate role is in no way a replacement for any other member of the general practice team—that is an important point to make. They work in conjunction with the existing team, and are complementary to it. Physician associates can help broaden the capacity and skill mix within the practice team to help address the needs of patients in response to the growing and ageing population faced by constituencies up and down the country, including the hon. Lady’s constituency and, indeed, mine. However, let me be clear: the employment of a physician associate does not in any way mitigate the need to address the shortage of GPs, nor does it reduce the need for other practice staff.
I will talk, not about the specific case that the hon. Lady described—I do not have those details—but about the generalities of the responsibilities of a supervising doctor, which may be relevant in this case. Physician associates are dependent practitioners: they are working with a dedicated consultant or GP supervisor. They are able to work autonomously but, vitally, with appropriate support, and the General Medical Council has published guidance for doctors who supervise physician associates. The supervision of a qualified physician associate is similar to that of a doctor in training or a trust-grade doctor, in that the physician associate is responsible for their actions and decisions. However, the medical consultant or GP supervisor ultimately retains responsibility for the patient.
The hon. Lady has called for regulation. As she alluded to, the General Medical Council is well advanced in developing regulatory processes for physician associates once the necessary legislation is in place, and regulation will give the GMC responsibility for, and oversight of, physician associates and anaesthesia associates in addition to doctors. That will enable a more coherent and co-ordinated approach to regulation and make it easier for employers, patients, and of course the public to understand the relationship between the roles. The hon. Lady asked specifically when that legislation will come forward. We intend to lay legislation before the House at the end of this year, which will allow the GMC to commence the regulation of physician associates by the end of 2024—legislation by the end of this year, and then a year for it to be put in place.
The General Medical Council has published future professional standards for physician associates. Among other things, that includes working within the bounds of professional competence and knowing when to refer, or indeed to escalate, to a colleague within the practice. Those standards also cover communication with patients, including the importance of physician associates explaining what they do and how their role fits in with other members of the medical team. Once regulation commences, the GMC will be able to investigate concerns raised about physician associates, and in serious cases will be able to prevent a physician associate from practising, either on a temporary or a permanent basis.
Barbara Keeley
I want to go back to the point I made to the Minister about the title of physician associate, which I have used a lot and so has he. The point is that it does sound rather grandiose as the name of a role in clinical practice for a person who has trained for only two years, and it is confusing. I have been steeped in health and social care matters in this place—I have been a member of the Health Committee and had Front-Bench responsibility for it—and I had never heard of physician associates, so it does seem confusing. The title itself is confusing.
Will Quince
I thank the hon. Lady for her intervention, and I gave careful thought to the point she raised in her speech. Although the terms she used were doctors in training or trainee doctors, physician associates are not doctors in training and they are not doctors. They are very different, but they are a part of a multidisciplinary team. I will take away what she says. She is right that they have been in place for well in excess of 10 years, but nevertheless there is still a relatively small number of them. However, there are plans to significantly grow their number, so I will take that away.
Personally, as part of my own experience of the NHS, I have never seen a physician associate, but when I have been in general practice, I have often seen a paramedic, a physiotherapist or a pharmacist and they have made their position very clear at the outset of the appointment. I think we need to ensure that, regardless of the title— I will take that away and look in some detail at whether it needs to be changed—they are properly introducing themselves and their role, making it very clear to patients that they are not a doctor but are working under the close supervision of one, and making it very clear that they are not able to prescribe but a doctor can. I think that is the most important point, but the hon. Lady raises a very good point about the title and I will consider that very carefully.
Barbara Keeley
I think this is actually related to the confidence one has or does not have. The Minister says he takes advice from pharmacists, as do most of us, but we tend to know in that circumstance that it is a pharmacist we are talking to. There are receptionists, physios and all these types of people working in GP practices, but this was a person who to all intents and purposes looked like a doctor. That knowledge of the short period of their training, and of what they can actually do and not do, really ought to be more visible.
Will Quince
I hear what the hon. Lady says, and I will certainly take that away and give it considerable thought. If she has any particular ideas in this regard, given her experience on this matter, I would of course be very happy to meet her to discuss this further. It is really important, certainly ahead of legislation, that we get this right.
Before I close, I would again like to reiterate my deepest condolences to the family of Emily, and I thank the hon. Lady once again for bringing this debate to the House. As we develop and progress with changes to the NHS workforce, it is absolutely vital that robust governance and supervision sit at the heart of the multidisciplinary model, because at the heart of everything we do must be patient safety.
Question put and agreed to.
National Carers Week
Baroness Keeley Excerpts(1 year, 5 months ago)
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Barbara Keeley (Worsley and Eccles South) (Lab)
It is good that the hon. Member for Gosport (Dame Caroline Dinenage) has secured this important debate, because opportunities for the House to debate the difficulties faced by unpaid carers and to recognise their contribution are always valuable. However, this cannot be a recognition exercise alone. For too long carers have struggled to get by with little support from the Government, while at the same time providing many hours of highly skilled work. They have been worked to the brink for too long, and many now say that they are fed up with warm words. One unpaid carer, Rachel Adam-Smith, said:
“I cannot believe I am 19 years into my caring role and nothing has changed—other than the fact that I look more exhausted and feel more defeated.
We are given no time to rest, to look after our own health, to take a holiday or even to have a bath. We are all human, none of us are superhuman but unpaid carers are treated as though we are. We aren’t.”
Rachel asks:
“Will it ever change?”
Carers are right to feel disappointed and angry with the Government. As we heard earlier, research by Carers UK shows that a quarter of unpaid carers are cutting back on essentials such as food, and more than three quarters of carers said that the rising cost of living was one of the main challenges they would face in 2023. Gaddum, a charity in Salford, delivers the carers service contract for Salford City Council, which covers my constituency, and it shared with me some insights from a survey of the carers using its services, carried out in February this year. The survey found that 42% of carers’ finances had been negatively affected by their caring commitment, and 84% of carers’ emotional health had been negatively affected. One unpaid carer told Carers UK:
“To date I have sold both of our pensions, shares and insurances to maintain our living standards. They have all gone now so I had to start claiming Universal Credit last year. I have nothing left to sell and I am anxious that we are going to live in poverty for the rest of our lives.”
It is clear that the system of support for carers is not currently working. The financial situation is desperate for too many carers, and the direction of travel for Government policy is deeply concerning. Instead of helping unpaid carers with their unprecedented financial pressures last winter, the Government changed the arrangements for the warm home discount so that nearly 300,000 people with disabilities and their carers were no longer able to claim it. This spring they announced that they would reduce the already pitiful pot of money assigned to social care reform by at least £500 million. Support from the Government is falling away just as more and more carers fear having to cut back on essentials such as food and electricity.
The financial pressures resulting from those and other decisions taken by the Conservative Government have put a real strain on the mental health of carers. Gaddum has told me that carers’ own mental health has been the issue most frequently discussed through casework in the last few years. As the campaigner and unpaid carer Katy Styles recently warned, there is now a risk that carers will become cared for themselves. She said:
“Not only will local authorities and Government bodies be looking after the people that they care for, but also carers who are in a really bad way.”
The We Care Campaign, which Katy founded, does crucial work in amplifying the voices of unpaid carers. We Care is campaigning for more financial support for carers and to secure funding for carers’ breaks. The campaign is also pushing for longer-term solutions, including to the social care crisis, and a crucial national carers strategy.
As the right hon. Lady mentioned, the Government have failed to publish a national carers strategy. They consulted on one in 2016, gaining a lot of responses, yet ultimately the strategy was delayed and then abandoned. Some 6,500 unpaid carers contributed to that consultation, giving up what little time they had to invest their energies in providing details of their day-to-day caring roles. It was dismissive in the extreme for the Government to drop the proposed national strategy. Carers who had contributed to the consultation felt extremely angry. Katy Styles said at the time that:
“Whilst unpaid carers spent precious time informing a Strategy; that time and effort was wasted as that Carers Strategy was apparently scrapped. That’s how much carers’ lives matter.
A national strategy would set the tone on how society should value and support carers. Without a strategy; carers have no hope of being valued and supported.”
Nothing has changed in the past five years to give carers hope of being valued and supported. The 2018 to 2020 “Carers Action Plan” was a flimsy document shamefully void of funding and ambition. We have had nothing of any substance since then.
It is worth remembering that the national carers strategy published under a Labour Government 15 years ago was launched not by a junior ministerial group, as I think is being proposed in this cross-departmental roundtable, but by the then Prime Minister, and signed by all Secretaries of State. That commitment shown by Labour at the time was vital, because I understand that Care Ministers struggle to get that cross-departmental aspect—we have heard about how many Departments are involved.
The other thing is funding. When the strategy was updated in 2008, the last Labour Government pledged £255 million for new commitments to support carers. That included £150 million to increase significantly the amount of money provided by central Government for breaks from caring. The Carers Trust reports that unpaid carers consistently tell it that they value breaks and respite very highly. Carers say that taking a break from caring is beneficial for their health and wellbeing and can allow them to continue in employment. Yet funding for respite care has dried up since Labour’s national carers strategy, with the funding no longer earmarked for breaks as it was up to 2010. The current Conservative Government’s plan in the 2021 social care White Paper for five days of unpaid leave from care is woefully insufficient. It was also disappointing that the Government recently rejected the Lords Adult Social Care Committee’s recommendation on ringfenced funding for breaks. Carers Trust is now calling for a statutory right to respite breaks for unpaid carers across the whole UK.
Carers in Scotland have access to a national scheme giving unpaid carers access to breaks, and Wales will launch a national scheme in June. There should be a national scheme in England too, with local carer organisations as key partners, and it should learn from Carers Trust Wales when designing breaks for unpaid carers. A Carers Trust survey of over 2,500 unpaid carers found that 53% of respondents said a break from caring is what would make the biggest difference. Despite that, research from Carers UK shows that a quarter of carers have not had a single day off from caring in more than five years.
For many, unremitting caring takes a toll on their mental and physical health. Both the GP Patient Survey and 2021 census data show that carers are more likely than those not in a caring role to have a long-term health condition or to have reported “very bad or bad health” and to feel isolated and exhausted. Both studies also showed that the more intense a caring role is in terms of the hours of care provided, the more likely it is that carers will have poorer health outcomes.
The Social Care Institute for Excellence systematic review of evidence on carers breaks found that carers value breaks for a range of reasons: practical, emotional, social and psychological. For some carers, the break has value beyond its allotted time. For instance, looking forward to a break can have the same effect as the break itself. The importance of breaks is to be part of a whole-family approach and as a break from the caring routine, not just having time away from the person. Some carers prefer a break with the person they care for, or as a whole family, but just not when they have to do all the caring.
Stephen Doughty
My hon. Friend is making a crucial point. This is exactly what I saw recently at Tŷ Hafan in Sully in my constituency, where there is the option of hotel accommodation for the whole family on site near the person for whom they are caring, but without them having to undertake the full responsibility for care. A pristine natural environment also provides opportunities for the whole family to relax and get some quality family time together while having a break from their responsibilities.
Barbara Keeley
I thank my hon. Friend; that will sound very good to other carers.
Breaks can have a vital preventive role, sustaining the caring relationship and preventing carer stress, crisis and breakdown. There are key points where, if practical support and information had been provided, the negative impact of caring may be reduced. Breaks can reduce loneliness and isolation, enabling the carer, and the person they care for, to stay connected to family, friends and the things they enjoy.
We must face the fact that there has been a decline in the funding used to support carers breaks. Analysis by the Nuffield Trust of short and long-term data shows that 24,000 fewer carers were receiving breaks in 2020-21 than in 2015-16—a decline of 42%. It is no wonder that so many unpaid carers are exhausted. Claire, a carer from my constituency, told me that in order to attend the carers networking event in Parliament yesterday, the cost of alternative care for her mother was £33 an hour. She told me that there should be an alternative because the excellent Humphrey Booth Resource Centre in Salford has a four-bed unit for people with dementia. However, it cannot be used to offer respite care for Claire’s mother because it has been taken over to help with hospital discharge issues.
Another major issue facing many carers is that GPs and other NHS staff treating the person they care for often know nothing about their caring role, meaning that carers are not offered the support to which they are entitled, as we have heard. Another carer from Salford called Justine, whom I met in Parliament yesterday, told me that at the start of caring for her mother, who has dementia, she was offered no help or advice and did not know where to turn for support. Even when she asked social services for help, turnover of staff meant that different people were asking her to fill in the same forms again and again and that assessments were being done again and again. Justine said:
“You feel like you are treading water all of the time.”
Analysis by the Nuffield Trust shows that there was an 11% drop in the five years to 2020-21 in the number of carers in receipt of direct support. That is the equivalent of 13,000 fewer carers being given the choice and personalisation that direct support is designed to offer. That downwards trend is reflected in local authority gross expenditure on services for carers, which reduced by 11% between just 2015-16 and 2020-21. That has meant a reduction in the support offer available to carers. Local authorities provided fewer direct support payments and directed 36,000 more carers to information and advice only—that is all they got. Carers have since reported finding it harder even to access adequate advice and support, and satisfaction with carer support services generally is declining—hardly surprising.
Carers organisations know that proper identification of carers by the NHS would mean that carers could be supported much more effectively. Identification of carers is something I have campaigned on for many years. In 2012, I brought in a private Member’s Bill on the identification of carers that would have created a duty on the NHS to identify carers and to promote their health and wellbeing. The then Care Minister in the coalition Government would not support my Bill. Indeed, there is so much that could have been done in the past 13 years to avoid the appalling situation that too many unpaid carers now find themselves in, which has been made worse by the cost of living crisis.
We are here today because this is Carers Week, but care does not stop when Carers Week ends. The Government must urgently bring forward a long-term plan informed by carers and understood at the highest levels of Government. Ministers must learn to listen to unpaid carers—not just this week, but every week—and value their lived experience and insights. The We Care campaigner Katy Styles said that there are so many issues for the millions of carers whose voices she tries to amplify, but only a few of them were able to meet MPs yesterday. Katy told me:
“It’s a battle and a fight for everything. It’s grinding us down.”
We cannot continue to leave carers without proper support.
The Minister for Social Care (Helen Whately)
I thank my hon. Friend the Member for Gosport (Dame Caroline Dinenage) for securing the debate, for her powerful opening speech and for all she does as chair of the APPG on carers. This week is Carers Week—a chance to recognise and focus on carers—but as every carer knows, if you are a carer, every week is carers week. I pay tribute to carers and young carers across the country for what they do, caring for loved ones, whether it is their mum or dad, brother or sister, a neighbour or their child, who will often be grown up, day in, day out, all year round.
Over 4 million people in England are unpaid carers. For some, caring may be a few hours a week helping a relative or neighbour with things they cannot do themselves or providing companionship. For others—in fact, nearly one in three, according to the latest census—caring means over 50 hours each week looking after someone. It is not just a full-time job, albeit unpaid, but how they are spending their lives.
My hon. Friend drew on her expertise, as a former Care Minister, and her personal experience. She spoke about how few families are untouched by caring responsibilities, about the sacrifices that carers make and how they are driven by love, but also the problem of exhaustion and burn-out for carers. She talked about the importance of identifying carers, especially young carers. She spoke powerfully about children with experience of dialling 999 because of a parent needing an ambulance but not telling anyone because of the stigma, particularly due to a parent’s mental health needs.
My hon. Friend asked whether we could build on some of the things we did for carers in the pandemic. I know, as I was Care Minister at the time, how incredibly hard the pandemic was for many carers, how isolated many felt and how many felt they did not have the support they needed. I know how difficult it was to work out how we could support carers during the pandemic, but we managed to do some things, such as identifying carers we prioritise for the covid vaccine. I will take away her request to look at how we can build on the things we did in the pandemic.
I know that the hon. Member for Worsley and Eccles South (Barbara Keeley) is a committed campaigner for social care and carers; we often speak in the same debates. She spoke about some of the financial difficulties for carers, the importance of cross-Government commitment to carers, and carers needing breaks and time off from caring.
My hon. Friend the Member for Cities of London and Westminster (Nickie Aiken) spoke about her personal experience of caring for her father. She talked about the loneliness and isolation but how cricket helped, which made many of us smile. She talked about young carers, how the sacrifices they make are often not appreciated and the long-term effects of being a young carer.
I pay tribute to hon. Member for North East Fife (Wendy Chamberlain) for her very important work in steering the Carer’s Leave Bill through Parliament. She spoke about things that employers can do more broadly to support carers and the opportunity of being a Carer Positive employer. The right hon. Member for Hayes and Harlington (John McDonnell) said that he chairs a local carers group, and I give him credit for that, whether or not it is a Labour group. That is a very important thing to do, bringing carers together to support one another and listening to what help they need. He spoke about the difficulty for carers in getting assessments. The hon. Member for Ceredigion (Ben Lake) spoke about the cost of living and the cost of heating homes for carers, particularly in his constituency, where many carers are off grid and use heating oil.
We also heard briefly from the hon. Members for Strangford (Jim Shannon), for Cardiff South and Penarth (Stephen Doughty) and for Livingston (Hannah Bardell) and my hon. Friend the Member for Henley (John Howell). That level of Back-Bench interest in this topic on a quiet Thursday in Parliament shows how strongly people feel, rightly, about the need for support for carers in our constituencies. We also heard from those on the shadow Front Benches, the hon. Members for Leicester West (Liz Kendall) and for Motherwell and Wishaw (Marion Fellows).
I know, from my own experience and from my family, that caring is something we do because it feels the right thing to do. We might not have a choice or not feel we have a choice, but nor can we imagine not doing it—not caring for the person we love. For many people, it is something that just happens to them: they become a carer without really realising it. Suddenly, they are spending hours caring—perhaps all their waking hours, and often in the night as well—without realising that they have become a carer, and without knowing that they might need support or, indeed, that they could get it. That is why recognising carers and helping them recognise themselves is important in its own right. There is a good reason why recognising and supporting carers in the community is the theme of this year’s Carers Week.
Local authorities, the NHS, schools, universities, all public services, and indeed companies need to continue to improve how unpaid carers are identified, recognised and supported in our communities. This Carers Week, I have had meetings with more than 30 unpaid carers, young adult carers and representatives from unpaid carers’ organisations, and both as Care Minister and in my life outside politics, I meet carers all the time—remarkable carers who have shared their stories with me. Those are so often stories of how hard it is to be a carer, although it is also really good to hear some positive stories. For instance, some employers are really supportive of carers and their caring responsibilities. However, sadly, that is not always the case; in fact, just on Tuesday, one carer told me that she is thinking about giving up her job due to a lack of support. Many hon. Members have spoken about that issue today.
On the important issue of juggling employment and caring, I want to highlight the Carer’s Leave Act 2023, which received Royal Assent on 24 May. Eligible unpaid carers will soon be able to take a week’s flexible unpaid leave each year. I am so pleased to see that Bill pass into law to help carers who are juggling work and caring.
This week, I also spoke to another carer about the challenges they are facing in getting the professional care and support they need. That is one reason why the work we are doing on reforming the adult social care workforce is really important. I say to carers, “Please keep on speaking up. Keep on telling your stories, for other carers and to make sure people know what it is to be a carer. None of you are alone.”
In April, we published our reform plan, “Next steps to put People at the Heart of Care”. The enormous contribution of unpaid carers is reflected in that plan, and in writing it, we were thinking about carers as well as those they care for. This financial year, £327 million of the better care fund has been earmarked to provide short breaks and respite services for carers, as well as additional advice and support. We are finalising plans for how we will deliver the additional sum of up to £25 million that we committed to carers in the White Paper, and I will be sharing those plans shortly. I know it is taking time, but I do really want to get it right.
The Health and Care Act 2022 includes provisions for the Care Quality Commission to assess the performance of local authority delivery of adult social care duties. That duty has gone live as of 1 April with our new assurance framework, which will provide a clear assessment of how local authorities are meeting their statutory duties, including those relating to carers, such as whether local authorities are undertaking their assessment of carers’ need for support and then meeting the needs that are identified. That will address one of the questions asked by my hon. Friend the Member for Gosport, along with other Members: how we make sure carers get the assessments to which they have a statutory right, as well as the support they are identified as needing.
We are working with NHS England to streamline the ways in which unpaid carers are recorded in GPs’ health records, and we have written to all GPs in England to communicate improvements to how that is carried out. Crucially, that identification of individuals with caring obligations extends to young carers. Questions designed to identify children and students caring for family members have been added to the school census, and that important data has been published today. We are also making progress on our plans to transform social care data, better joining up the care to people, including support to unpaid carers as well as those they care for.
Meanwhile, we are taking steps to design a new survey to capture the wide range of experiences and needs of unpaid carers across England, and to commission a valuation of the support provided to unpaid carers through the better care fund, including carer breaks and respite. It might seem obvious, but different carers want different things, so it is right that we take steps to understand and build the evidence base of what works and what matters when supporting carers.
Helen Whately
I am really sorry, but I have but a minute left—Madam Deputy Speaker has confirmed that. However, to address the points that the hon. Lady made in her speech, I assure her that not a penny has been taken away from funding for adult social care; in fact, more money is going into adult social care, thanks to the record funding of up to £7.5 billion over two years that we announced in the autumn statement. A crucial part of our adult social care workforce reforms is our reform of the professional care workforce: developing social care as a career for the professional workforce, developing the career pathway and investing in qualifications for that workforce. That is very important to unpaid carers, because the top issue often raised with me by the unpaid carers I talk to is the difficulty of accessing professional care.
To close, I want to say as Minister for Social Care that I care, and I will continue to champion carers’ needs as part of the work I do across Government. I am delighted to announce that I will be convening a roundtable of Ministers to work together across our Departments to identify, recognise and support unpaid carers. I thank all right hon. and hon. Members who have made contributions on this important topic today, as well as Carers UK for its work this Carers Week and its year-round advocating for carers, and the other campaign groups involved in this week, including Age UK, the MND Association, Rethink Mental Illness, the Lewy Body Society and Oxfam. Finally, I say thank you to all carers.
Covid Pandemic: Testing of Care Home Residents
Baroness Keeley Excerpts(1 year, 8 months ago)
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Helen Whately
My right hon. and learned Friend is exactly right; we are having a public inquiry and the Government are fully co-operating with it so that it has all the information required to look through all that happened, to investigate it and, rather than trying to score political points, to truly learn lessons for the benefit of the country.
Barbara Keeley (Worsley and Eccles South) (Lab)
On 2 April 2020, I wrote to the former Health and Social Care Secretary, jointly with my right hon. Friend the Member for Leicester South (Jonathan Ashworth), highlighting the urgent need for testing in care homes for staff and residents and, in particular, for patients being discharged from hospital. I knew at the time, as did other colleagues, that without that testing, care homes in my constituency and those across the country were suffering a heavy toll of deaths of residents. Indeed, one of our care home managers died of covid in my constituency.
Furthermore, at a session of the Select Committee on Health and Social Care in July 2021, I asked the right hon. Member for West Suffolk (Matt Hancock) why the Government had not taken up the offer from care providers of facilities to isolate people discharged from hospital before admitting them to care homes. He told me that he did not know anything about the letter, despite it being sent by Care England. Will the Minister now admit that the Department and Ministers failed to understand and to involve social care in the key decisions about the covid pandemic, and ignored letters offering help that could have saved lives?
Helen Whately
The hon. Lady is right about the importance of testing. It is a view that she has and that I had at the time; some of the exchanges will show how I, as Social Care Minister, was arguing very hard for testing for care homes, as Members would expect. I know that other Ministers and other people were arguing for the things that they had oversight of. Ultimately, of course, the Health Secretary and the Prime Minister had to make decisions, based every step of the way, clearly, on the scientific advice on these things, as we did. To that point, during the course of the pandemic, as the capacity allowed, millions of tests were distributed to care homes. As I have said, as the capacity increased, care homes were prioritised in that process. Specifically to address one of the points she made, let me say that the guidance set out on 15 April was not only that everyone discharged from hospital to a care home should be tested, but that they should be isolated.
NHS Strikes
Baroness Keeley Excerpts(1 year, 9 months ago)
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Will Quince
The right hon. Gentleman says that many who work in the NHS are worried about patients: I spend every single day worrying about patients; I spend every single day ensuring the NHS has the resources it needs to provide the level of care and service our constituents rightly expect. I have a budget, and that budget has already taken into consideration a 4.75% on average pay award, with more than 9% for some of the lowest earners. There is an independent pay review body process for a reason; it is only two months away, in April, and I encourage the unions to take part in it. Of course I meet with unions, and of course I do and will meet with nurses and those who work in our NHS. I believe some of the points the right hon. Gentleman makes are correct, and I know those who work in the NHS genuinely want to ensure we are attracting and retaining the very best; that is all the more reason for us to get it right, and the way to get it right is the independent pay review body process.
Barbara Keeley (Worsley and Eccles South) (Lab)
There were no strikes in the NHS over 13 years of the last Labour Government, and the cavalry is coming to rescue our health service with the next Labour Government. The Minister just asked where the funding is coming from to pay for NHS staff: we will train a new generation of NHS staff paid for by abolishing non-dom tax status so that the NHS has the workforce it desperately needs. Why will the Government not do as the Chancellor has suggested and adopt this policy now?
Will Quince
The hon. Lady says the cavalry is coming; how many more unfunded pledges—[Interruption.] Labour Members say they are fully funded: absolute tosh. I have heard the Opposition spend that non-dom money more times—
Urgent and Emergency Care Recovery Plan
Baroness Keeley Excerpts(1 year, 9 months ago)
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Steve Barclay
I am happy to give my right hon. Friend that assurance. I assure the House that our commitment to the cancer mission and the dementia mission through the Office for Life Sciences is absolutely there. He is right that we are bringing that together in one paper—I think we should take a holistic approach—but I share his ambition on prevention. In early January, I set out a three-phased approach: first, the £250 million immediate response to the pressures we saw from the flu spike over Christmas; secondly, as I announced today, building greater resilience into the system looking ahead to next winter; and thirdly, the major conditions paper on prevention, which is about bringing forward the innovative work that colleagues are doing through the Office for Life Sciences to impact the NHS frontline much sooner than might otherwise have been the case.
Barbara Keeley (Worsley and Eccles South) (Lab)
I want to raise the case of a constituent who described to me the state of Salford Royal’s A&E earlier in January, saying:
“My partner was taken by ambulance yesterday at about 11am. He has a severe chest infection and breathing problems. He was left sitting in a chair on oxygen until 10pm when a trolley was found for him to sleep on. There are no beds available.”
My constituent said that patients and staff
“feel that no one cares”.
After such a long wait, my constituent’s partner was found to have pneumonia and he has been very poorly. Now the Secretary of State is talking about a target of 76% of A&E patients being seen within four hours by next March. Will he tell me and my constituent why he thinks it is acceptable for patients to wait longer than is safe?
Steve Barclay
We are bringing times down; I think the current mean response for C2s is much more in the region of 25 or 26 minutes than it was in late December-early January, because across the UK there was a massive spike in flu. The hon. Lady will have seen exactly the same in the Labour-run NHS in Wales. Over December there was a 20% increase in 999 calls, for example. That is why we need to put in place greater resilience, as the plan I have set out to the House does.
NHS: Long-term Strategy
Baroness Keeley Excerpts(1 year, 10 months ago)
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Barbara Keeley (Worsley and Eccles South) (Lab)
First, I want to share with the Health and Social Care Secretary my constituent’s recent battle to get medicine for his son, who had a high fever and symptoms that could be strep A. Unable to get a GP appointment, my constituent and his son had to travel out of the area to a local walk-in centre. They were then sent to the hospital, where they endured a six-hour wait. When the child was eventually examined, he was prescribed amoxicillin, but it was another long battle to find a pharmacist who stocked the antibiotics needed. My constituent said:
“Even I am shocked with what I have experienced over the last 24 hours.”
More and more people are finding out that the health service is no longer there for them when they need it. When someone has a child with serious symptoms and a temperature over 40°C, they should be able to access care quickly and not be forced to drive around for miles in desperation. My constituent also told me that he ran into several other parents that day who were experiencing the same issues in trying to get appointments and medicine for their children, who were very ill.
Nurses, doctors, ambulance workers, pharmacists, administration support staff and all those who, as part of our national health service, pour their energy into helping people when they are sick are worthy of our deepest respect and our thanks. The NHS crisis is not of their making. It is caused by the inability of the Conservative Government to plan or to support our health services adequately.
Many clinicians and commentators looking at the NHS crisis this week have raised the question of social care. Every year we revisit the pressures on social care and the desperate need for reform. Every year we see the consequences of Government inaction. We have had promise after promise of reform, but that reform is always dropped in favour of sticking-plaster solutions.
This week’s sticking-plaster solution gave the NHS some extra money, apparently to buy care beds. The deeper issue in social care is not beds, but the crisis in the social care workforce, with 165,000 posts vacant, representing one in 10 of the workforce. The NHS can buy beds in care and nursing homes, but that home may not have the appropriate staff available for the needs of the person being discharged. Unsuitable care will only lead to readmissions to hospital, so the cycle carries on. We know that in some parts of the country there are care deserts where there are no care home places. Does that mean that hospitals will start buying care home places tens or even hundreds of miles away?
The scandal of out-of-area placements is already a reality for many autistic people and people with learning disabilities. Chronic underfunding of social care and the lack of appropriate community services have entrenched a reliance on expensive in-patient care for autistic people and people with learning disabilities—care that is often far from home and not suited to the person’s needs. There is no extra funding to solve that problem. Indeed, the budget for those community services has been reduced this year from £62 million to £51 million.
We know that 2,000 autistic people and people with learning disabilities are trapped in that inappropriate in-patient care, which is often found to rely on the overuse of punitive seclusion and restraint. The fact that many placements are hundreds of miles away from family and friends makes the problem worse. Despite the steady stream of scandals, from Winterbourne View 11 years ago to the Edenfield Centre more recently, it is an issue that the Conservative Government choose to forget, even though it is destroying the lives of many of those detained and their families.
Our Opposition motion rightly ends with a call on the Government to
“end delayed hospital discharges…and reform primary and community care”.
Thirteen years of Conservative failure have led to this crisis. It will take a Labour Government to make the NHS fit for the future.
NHS Winter Pressures
Baroness Keeley Excerpts(1 year, 10 months ago)
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Barbara Keeley (Worsley and Eccles South) (Lab)
It is one thing to talk about blocked beds but, as many Opposition Members have said, care is also about staff. How does the Secretary of State expect care homes to cope with this increased pressure when one in 10 social care posts remains empty and when staff feel overworked, underpaid and exhausted?
Last year, a report commissioned by the Department of Health and Social Care found that the rapid discharge of people from hospital to care homes during the first wave of the pandemic, without adequate covid testing, was “highly likely” to have caused some outbreaks. How will the Health Secretary avoid the fatal mistakes of the past by militating against the seeding of more infections in care homes and, as my hon. Friend the Member for Ilford North (Wes Streeting) said, the danger of unsuitable care leading to hospital readmissions?
Steve Barclay
The hon. Lady makes a good point about the risk of introducing infections into care homes, as happened in the past. It is worth the House reflecting on the fact that we are in a very different position from the start of the pandemic. First, we now have vaccines in place for care home residents and staff. Secondly, we now have antivirals. Thirdly, we now have huge knowledge about covid. From an infection point of view, the risk of releasing people into care homes is now in a very different place.
On the wider workforce, part of the reason for the £500 million announced in the autumn statement is to support measures for the workforce, but we are also looking to boost numbers through international recruitment.
Oral Answers to Questions
Baroness Keeley Excerpts(2 years ago)
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Helen Whately
My hon. Friend is absolutely right about patients spending too long in acute care in his own hospital. We know this is affecting other people around the country. I am very happy to meet him and I would very much like to visit his hospital and speak to his NHS, the local authority and other stakeholders to ensure we can improve the situation.
Barbara Keeley (Worsley and Eccles South) (Lab)
Tony Hickmott is an autistic man who was detained in an in-patient unit for 22 years, often in near total seclusion, against his wishes and those of his parents, Pam and Roy. Tony now has his own home in the community, but the NHS spent £11 million on his detention in the last nine years after doctors considered him fit for discharge. Can the Minister comment on the wasted years Tony and his family spent fighting to get him free? What will she do to release the 2,000 other autistic people and people with learning disabilities detained in in-patient settings who would receive far more effective care in the community?
Helen Whately
The hon. Member raises Tony’s individual case, which is very hard to hear about. She and I know there are too many others in this situation. She will know, too, that I listened to this when I was formerly a Health Minister. It is a difficult problem to solve, but we should absolutely continue to work with the NHS, the Care Quality Commission and local authorities to ensure people who are not benefiting from being in in-patient settings are able to get the care and support they need in the community.
Edenfield Centre: Treatment of Patients
Baroness Keeley Excerpts(2 years, 1 month ago)
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Will Quince
The Government are absolutely committed to ensuring that all patients receive safe and high-quality care in all settings. As the hon. Lady pointed out, we are investing more than ever before in NHS mental health services through the NHS long-term plan, which will see an additional £2.3 billion in funding per year by 2023-24.
The hon. Lady asked what work is underway. There is work under way at a national level to improve the way we safeguard patients and ensure they receive high-quality care through a new mental health safety improvement programme, which has set up new mental health patient safety networks across all regions in England. We are reviewing everyone with a learning disability and all autistic people in long-term segregation in a mental health in-patient hospital. The Care Quality Commission is introducing a new approach to inspections from next year, which will be more data driven and targeted, and we have commenced the Mental Health Units (Use of Force) Act 2018.
I can absolutely assure all hon. Members that this Government will continue to work with our partners across the NHS, social care and other sectors to consider what more action is needed to tackle toxic and closed cultures, looking at the available evidence base and, most importantly, hearing from the people affected and their families.
Barbara Keeley (Worsley and Eccles South) (Lab)
NHS guidance has been clear for many years that abuse of this kind, including punitive seclusion and overuse of restraint, should never be allowed, yet it has persisted, as other hon. Members have said, including at Winterbourne View, Whorlton Hall, Cygnet Yew Trees, Cawston Park and now the Edenfield Centre. There will be other places, too, that have not had media attention, but where families of patients are seeing abuse and have no mechanisms to change things.
Harley is a young autistic woman who was detained at the Edenfield Centre and experienced punitive seclusion for weeks at a time. She said in the programme:
“Staff provoke a patient and then my reaction is used against me. But they’re provoking us. It’s disgusting. I’ve been treated like I’m an animal.”
There are over 2,000 autistic people and people with learning disabilities locked in inappropriate in-patient units in this country, often for 10 years or more. The policy of the use of inappropriate in-patient units for autistic people and people with learning disabilities is a choice. They could have support in the community with skilled and experienced staff. Will the Minister promise to end the culture of abuse for Harley and so many people like her?
Will Quince
The hon. Lady is right. I believe what I saw to be disgusting too. She specifically referenced those with learning disabilities and autistic people in long-term segregation. NHS England is undertaking independently chaired care education and treatment reviews for everyone with a learning disability and all autistic people in long-term segregation in mental health in-patient hospitals. A senior intervenor pilot is also underway. These actions will help support people in long-term segregation to move to a less restrictive setting or to leave hospital. A programme of safety and wellbeing reviews for the care and safety of people with learning disabilities and autistic people is now complete, and NHS England will be publishing the findings of a national thematic review later this year.
Ambulance Services and National Heatwave Emergency
Baroness Keeley Excerpts(2 years, 4 months ago)
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Maria Caulfield
Yes, and I thank my right hon. Friend for raising that point. Different response times are required, depending on the reason for the call. Strokes would be a C2 emergency, for which the target is 18 minutes. The latest figures we have are from May, when we were performing better than in April. The figures are not where we want them to be, but we are seeing month-on-month improvements. For C1 and C2 cases, which need urgent treatment as soon as possible, particularly for strokes, every minute counts and we want to see further improvements in those times.
Barbara Keeley (Worsley and Eccles South) (Lab)
The Manchester Evening News is reporting that the North West Ambulance Service has raised its operational pressure level to “critical incident” level, which indicates a potential for failures as ambulance services try to cope with extreme pressure. A&E departments at the Royal Bolton and Stepping Hill Hospitals have admitted that they are extremely busy, with long queues of ambulances at some times. The Minister did not even mention social care in her response, which we know is so broken that it adds to delays and discharges. Twelve years of Conservative mismanagement and neglect have left those services, on which my constituents rely, so vulnerable. What does the Minister have to say to the patients suffering as a result?
Maria Caulfield
I am sorry that the hon. Lady did not hear my response. I specifically mentioned social care as well as the integrated care boards that we have set up to bring health and social care together—I think Labour Members voted against that. As I said, one factor affecting ambulance delays is the bed occupancy issue. Part of that—not all of it—is about delayed discharges and lengths of stay are 16% higher. We have a plan for fixing social care and it is unfortunate that Labour Members voted against it.