NHS: Long-term Sustainability

Baroness Cavendish of Little Venice Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Cavendish of Little Venice (CB)]

My Lords, I pay tribute to the noble Lord, Lord Patel, his tireless work for the NHS and, as the noble Lord, Lord Carter, called it, his Olympian view across the system that he shared earlier. I too will focus on only one or two things. I am very glad that the Messenger report has been mentioned, and I echo the noble Lord’s question to the Minister, because it is two years since it was written. Gordon Messenger, as someone who served in the Army, really does know how to run a system.

I will talk briefly about two things beyond hospitals that other people have already talked about: prevention and social care. On prevention, to echo some of what the noble Baroness, Lady Boycott, said, my simple question to the Government is this: when will they fully implement the 2015 obesity strategy, written under the Cameron Government, which included, for example, broadcasting bans on unhealthy food? I would have thought that that would be a very simple question to answer. It has now been quite a long time since that report was written.

On social care, I was intrigued by something that the noble Lord, Lord Patel, said, which I had not expected him to say: he spoke warmly about long-term care insurance. I thought I would take my cue from that and talk a little about it. In the past few years, we have seen many interesting proposals for better funding of personal care. We have seen the cap, led by Andrew Dilnot, which is due to come into force in 2025 but on which I note that there is spectacularly little activity. I think that there is an opportunity now, post-Covid, with a public who are much more aware of the value of social care than they were before Covid. This has become a politically salient issue in a way that it was not before, because so many people have seen what care workers really do and how many of them stepped up to the plate. We saw people moving into the homes of older and disabled people, leaving their own families and putting themselves at risk. That made a big impact in a way that it had not before. The truth is that you do not understand what social care is unless you or a relative are in receipt of it. The vast majority of people in this country still do not really know what it is, but the polls show that people are increasingly aware that it is complex, patchy and deeply unfair. People are increasingly prepared to say that, yes, we need more money but we also need a new look at the system.

As others have said, the single-payer system for the NHS is the right and only answer. I do not think that that should be reopened, as the noble Lord, Lord Patel, said. However, there is an opportunity to look for a different model for social care. On the long-term care insurance point that the noble Lord made, Germany and Japan, two countries that I have studied in depth, spent several years having a deep conversation with their voters about a long-term care insurance system—it is slightly different in each place—in which everybody pays something in and everybody is able, if they need it, to take something out. That is a simple, transparent and sustainable approach that we do not have at the moment. What we see at the moment are battles over continuing healthcare, where the primary health need is not defined, and 40% of care home residents paying all their own fees and cross-subsidising other people with less money. I could go on, but we are all aware of the depth of unfairness in the current system. I simply ask whether the Government have any plans to look at other possibilities beyond the simple cap on care.

One of the problems—and I think one of the reasons why Andrew Dilnot, a great man, is so frustrated, and why successive Governments have not implemented the policy—is that it is very hard politically to describe to people a cap that is not a cap; it does not cap the bed and board costs. Imagine being a politician on the doorsteps trying to sell people what is ostensibly a cap on what they need to spend but it is not. It is very hard to deliver that. The other issue is that while it would obviously help people facing truly catastrophic costs, it would help only quite a relatively small number of people. Therefore, there is an opportunity to have a much bigger and wider conversation. However, I am afraid that that would mean going to the heart of an issue that is dear to many voters in this country, which is the question of their primary asset: would they be prepared, and should they be made, to sell their home to pay for care?

I note that Boris Johnson changed his language on this over time. He discovered—as everybody who looks at the issue does—that you cannot get a sustainable funding system while making no claim whatever on the homes of people who, yes, have saved to buy that home but, yes, may have also been lucky that their home value has increased. Will the Government consider, or do they have any plans to consider, looking at that alternative to the Dilnot cap?

Health and Care Bill

Baroness Cavendish of Little Venice Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Cavendish of Little Venice (CB)]

My Lords, I welcome much in this Bill, especially the provisions on childhood obesity, and I welcome the end to the 2012 Act clauses which obstructed collaboration between primary and secondary care and community services. I congratulate the noble Lord, Lord Stevens of Birmingham, on the work that he did to formulate so much of what is in this Bill and on his maiden speech.

However, as we scrutinise the Bill, there are a number of things that we should look at. The noble Lord, Lord Lansley, will be surprised that I am going to agree with him on something for once, but I wonder what the philosophy is that is going to drive up standards of patient care. Competition in the form we used it did not work for the reasons discussed, but the danger of the new ICS structure is that we could create local monopolies and will not be focused enough on what really matters, which is driving up patient care. We need to think about how we define what we mean by success for the ICS and how we define failure. That failure regime is not clearly enough set out in the Bill. I also think that FTs should keep their independence, which Clause 54 would seek to remove.

Essentially—the noble Lord, Lord Mawson, made this point eloquently—we have best practice all over the place in this country. We have wonderful people doing wonderful things in the NHS and social care. Everywhere you look, you can find somebody brilliant, often working against the system, who is getting it right. Our problem is that we never seem to be able to spread that best practice to anywhere. The argument for ICSs is that they are bigger, they will contain more ambition within them, and so we will be able to drive their ambition in that way and bring the laggards with us. I think that will be largely true, but we need to make them entrepreneurial. A number of noble Lords in this debate have proposed all sorts of extra people who might sit on these boards. I would only warn that talking shops really do not get things done; we have far too many of them already and I hope that we will be able to keep these things relatively slimline.

As many speakers have said, the biggest limiting factor in the NHS and care at the moment is staff. I would support a new amendment to Clause 35. I suggest that we consider removing the reference to the OBR which Jeremy Hunt made in his amendment; that would make a big difference. I do not think that it is necessary for the workforce strategy to be consistent with fiscal projections, and I hope that might be considered by the Minister.

As the noble Baroness, Lady Harding, and others have said, we also urgently need to retain staff. We need to train them; yes, HEE needs a bigger budget, but we need to retain the wonderful people that we have. If there is any chance within the structure of this Bill to remove every impediment possible to resolve the pension issues for GPs and to reduce paperwork wherever we can, I urge that we should take it.

We need much better data sharing, but when I was working as a temporary adviser to the DHSC last year, I had a worrying conversation with a wonderful receptionist in a care home. She said to me, “I haven’t been able to talk to a single family today; I’ve got grieving families trying to get through to me on the phone. They can’t get through because it is clogged up with people from local authorities, people from the Department of Health, people from Public Health England, who are calling me to find out the data.” That was a major failing in the pandemic, and we are in danger of making the same mistake again. We must commission for outcomes, but we must find ways to measure them which do not mean multiple agencies—I should have added the CQC, on which I used to sit, to that list—ringing up front-line staff, who have better things to do. We would raise the morale of front-line staff if we stopped asking them to input data into systems again and again.

I want to make two further points. First, if we are serious about parity between mental and physical health, I suggest that we use that phrase to replace “health” in the Bill wherever we can. Finally, Covid-19 has of course exposed what we have long known about health inequalities in this country. I urge the Minister to consider whether the triple aim could be expanded more explicitly to focus on health inequalities.

Social Care and the Role of Carers

Baroness Cavendish of Little Venice Excerpts

Thursday 24th June 2021 Lords Chamber

[Baroness Cavendish of Little Venice (CB) [V]]

My Lords, I congratulate the noble Baroness, Lady Jolly, on securing this important debate. I think all the speakers know what all the issues are. I shall not try to tackle the whole issue of social care in three minutes, but I shall make two points.

My first point is on the paid workforce. The pandemic brought a new influx of workers into the social care sector, many from the hospitality industry, so some of the statistics we are hearing today are probably slightly out of date, but that does not mean that there are not huge issues of retention and attrition. It is important to think about how we are going to keep that new group of people and the existing staff, who have shown in this pandemic that they are extraordinarily dedicated. We need to emphasise that care is, as others have said, not low-skilled. The further you are from a hospital setting and that kind of supervision, the more maturity you need to handle the very real challenges you face in going into someone’s home, trying to figure out what they need and trying to connect with children with learning disabilities, elderly people with dementia and so on. We have heard a great deal about funding in this debate, and it is vital, but we also need to think about what we want to spend the money on. I do not think that throwing more money into an unreformed system will give us the quality of care that we all want.

I want to talk a bit about commissioning. We need a care service which does not just work on a time-and-task basis but gives front-line staff the autonomy to assess what they think is needed and to do what they think is right. Their vocation is to care. Many who drop out of the social care workforce are some of the best people. They have real problems because they are underpaid, but they also have emotional problems because of not being able to give the care needed. We ought to allow that autonomy. We ought to commission for outcomes and not always ask staff to refer to a social worker if they want to change a care package by as little as 15 minutes. That would be a revolution in the way in which we provide care. In Holland, a million patients are cared for by staff who organise themselves and who do what they think is needed. They provide far higher satisfaction levels. They have enabled some vital cost savings, ploughing back money into the service and into staff wages. In this country we do not learn enough from other places. I ask the Government to look at that. Yes, we need better pay, training, career progression and much else that has been mentioned in this debate, but we also need staff autonomy.

Older Persons: Human Rights and Care

Baroness Cavendish of Little Venice Excerpts

Thursday 16th November 2017 Lords Chamber

[Baroness Cavendish of Little Venice (Non-Afl)]

My Lords, I thank the noble Lord, Lord Foulkes, for securing this very important debate with its enormous number of issues.

I do not feel I can follow that powerful argument by the noble Lord, Lord Lipsey, without addressing it, because he has an enormously important point to make. I shall make one suggestion, which I was going to make anyway, because this issue of intergenerational equity, and the triple lock that was referred to earlier, is becoming increasingly toxic in our political life and is dividing the generations. One way through it would be to look in the round at all the benefits that go to the over-65s. We need to take the pensions, the bus passes, the personal independence payments, the care allowances—a huge number of benefits go to certain people in that age group—and set them against the increasing lifetime costs that those people face, especially the group who develop multiple chronic illnesses quite early. I suspect that many of the 1.9 million that the noble Lord, Lord Lipsey, referred to may be in that category. They develop those illnesses at quite an early stage, they find it difficult to continue to work and they are stuck in what I agree is a completely different group. I just wanted to make that point.

I sat on the board of the Care Quality Commission for two years between 2013 and 2015. I assure the noble Lord, Lord Foulkes, that we inspected care homes, though perhaps not regularly enough. As other noble Lords have mentioned, the CQC has uncovered some absolutely terrible and shocking cases of abuse. That does not mean it is perfect, but at least there is now a mechanism. I was also the author of the independent review into the 1.3 million unregistered workers in health and social care. As the noble Lord, Lord Balfe, said, they are, on the whole, deserving of our respect. One thing I was trying to do in the report was raise their status and recognise what they do. This is far too often still referred to as “unskilled”, but is actually deeply, deeply skilled and requires enormous maturity. I am glad to say that the Government have implemented some of my recommendations on training and the care certificate. I encourage them to keep moving forward on the idea of there eventually being one workforce across health and social care.

Some excellent examples of progress are now being made, particularly in Manchester, in pooling budgets and services for the over-65s. One of the missing pieces, however, will be that single workforce, with a common skill set and training. Partly as a result of the multiple chronic illnesses I referred to earlier, there is now a blurring of the lines between the jobs of healthcare assistant, district nurse and domiciliary care worker. It is increasingly difficult for people in the domiciliary care space who are going into homes where medical needs are quite acute. I would encourage more work to be done on developing that sort of joint training. We might perhaps consider including in this some of the relatives and volunteers who do so much of the caring work. They might benefit from some of that basic training and gaining that status.

I have two more points to make, the first about continuity of care. This has not been mentioned and is often overlooked. It is particularly important for frail elderly people, whether they are in a hospital ward or at home. The constant turnover of people in home care is obviously a difficulty for the sector, which is partly to do with money. However, in hospitals a bit more work and consideration need to be given to nursing shifts where, for some unknown reason, the same people reappear in a different part of the hospital for their next shift. That would make a substantial difference to a lot of very confused elderly people who are disoriented and some of whom have dementia.

Lastly, I entirely agree with some of what was in the report about negative stereotypes. There has been a lot of research in the US showing that negative stereotypes about older people being a burden influence enormously the way they feel about themselves and actually accelerate the process of ageing. Those of us in the media need to take more responsibility for the way we sometimes describe people without thinking. This is not malicious—it is just the way people talk in society—but the more that those in this House can do to challenge specific examples of it, the better off we will all be.

Social Care

Baroness Cavendish of Little Venice Excerpts

Thursday 1st December 2016 Lords Chamber

[Baroness Cavendish of Little Venice (Con) (Maiden Speech)]

My Lords, I am proud to stand here today as a Member of this House and make my maiden speech. I would like to thank noble Lords on all sides of the House for so warmly welcoming me and the staff for being so magnificently kind and helpful.

Being here is an honour far beyond anything I expected, not least because many of my illustrious predecessors as head of the Prime Minister’s Policy Unit served there far longer than I did—I only count myself lucky that I got out before most of my failings could be exposed. I am especially grateful to the noble Lord, Lord Adonis, and the noble Baroness, Lady Hogg, for their unfailingly generous and always-discreet advice when I was in No. 10. I am also grateful to the noble Baroness, Lady Hogg, for being my supporting Peer, along with my noble friend Lord Bridges of Headley, who is surely this House’s best hope for delivering a Goldilocks Brexit.

I would like to mention one very special aspect of this House, which I came to appreciate when I was a journalist. In some of my darkest moments, when I have been campaigning on an issue and felt that no one was listening, I have sometimes received unexpected encouragement from Members of this House who I have never met—either notes or, sometimes, very useful pieces of information. I cannot tell your Lordships what a difference that has made.

The most astounding example of this landed on my desk one day from the late Lord Rees-Mogg. I was campaigning to open the family courts to the media, and we were being prevented from publishing some of the cases that I believed were miscarriages of justice. Lord Rees-Mogg wrote a letter urging the Times to publish and offering to go to jail instead of me should we be found in contempt of court. The noble Lord said in the letter that he was so old that he thought he probably would not be jailed for the offence, but that if he was jailed, it would help our cause. Luckily, we never had to call on him, because in fact the Brown Government agreed to change the law, but I have never forgotten the spirit that that letter represented.

I am grateful for the opportunity to speak in today’s important debate, and I know that I need to be brief. Too few people in this country are aware of how fragile the social care system is, of what they can expect if they become old and unable to look after themselves and, as others have said, therefore of what provision they need to make for themselves. I think this is partly because we humans do not like to contemplate our own mortality; we do not think it will ever actually happen to us. But the lack of public understanding of this issue is one reason why social care lags down the political agenda behind the NHS, which is experienced by a much wider group of people.

The social care workforce itself is also misunderstood. When I conducted a review of support workers in health and social care for the Department of Health in 2012 I met far too many care workers who said, “Well, I’m only a carer”. Actually, to go into an elderly stranger’s home and cope with whatever you find there, to feed someone who cannot swallow properly and to lift someone with dignity is a hugely skilled task that requires considerable maturity. Too often we still refer to those tasks as “basic” when actually they are anything but.

I am proud to have been part of a Government who introduced the national living wage, which may help to reduce some of the cripplingly high turnover that we see in the sector. But I also think we have to recognise the cost pressures that this is now putting on providers. As the noble Baroness, Lady Browning, said earlier, the fact that self-funders are subsidising local authority payers in some cases is not only beginning to become apparent to people and making them quite angry, it is also of course an enormous financial problem for deprived areas that do not have self-funders and are increasingly trying to make ends meet.

“Integration” is a great word. We probably all know that some version of integration is vital to address these challenges, and heroic efforts are being made in parts of the country, especially Manchester, to do exactly that and to make the health and social care system work as one. But I am afraid that in too many places integration is still just a word; delayed transfers of care are blamed by the hospital on the local authority, and by the local authority on the hospital. The truth is that until we have greater integration of the money we are not going to break through this problem—and we all know how complicated it is to integrate the money.

One aspect that I will raise is the need to create a much more integrated workforce. Even if we integrate the money, we have to have an integrated workforce in health and social care. As the population we are dealing with becomes frailer, with longer-term health conditions, we are seeing a blurring of the old lines between residential care, nursing care and hospitals. I am pleased that the Government are rolling out the training that I recommended in the care certificate; I hope it will start to break down some of the silos. But I also ask the Government to consider extending that care certificate to volunteers, who already play a vital role in this area and could do so much more to help join up some of the health and social care pieces.

The CQC’s latest State of Care report makes some very good arguments for integration that I do not have time to go into here, but all noble Lords know what they are. It was a great privilege for me to sit on the board of the CQC under the chairmanship of my noble friend Lord Prior, and I salute it for its work in raising standards. The challenge of regulating the sector is enormous because of the sheer number of providers. However, I am not sure that the CQC, the CCGs, the local authorities and other public agencies fully appreciate the cumulative burden that they collectively place on providers, especially small providers, which are often the most caring, with the multiple demands that they make on them. I have watched weary staff filling in form after form—each one almost the same as the last but, maddeningly, slightly different—when they ought to be looking after mothers and grandmothers. I make a plea today to the Department of Health and those public agencies that they get together and agree a single set of data to require from providers. At a time when services are under such pressure, that is the least we could do to ease some of the pressure on them.

I entirely agree with the noble Baroness, Lady Pitkeathley, that we need a more honest debate. Those who are in this Chamber have a much better understanding than the vast majority of those outside. We owe it to those mothers and grandmothers to have that debate because, if they are not our mothers and grandmothers today, they will be tomorrow.