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.