NHS and Social Care: Winter Service Delivery

Baroness Hollins Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Hollins (CB)]

My Lords, I remind the House that I am a family carer, retired psychiatrist and a past president of the British Medical Association, whose work I will refer to during my speech. There has been a lot of talk and publicity about the pressures on what are termed acute services. We have all seen the television images of trolleys and the problems in accident and emergency and so on; they make headlines and they are provoking debate—and I welcome today’s debate. One solution will indeed be a focus on the problem of delayed transfers of care back to the community. Without taking attention away from these important areas, I want to highlight similar concerns within mental health services, which seem to me to be as acute in nature as those described in general hospitals—although, in truth, they are not just confined to winter.

The British Medical Association’s bed occupancy report highlighted particular problems with high bed occupancy and delayed discharge in mental health settings. It identified the main reasons for delayed discharge as being a lack of suitable community services or facilities to support patients at home and a lack of available beds within local community or specialist facilities. Of particular relevance, given the ongoing review into the Mental Health Act, the BMA report noted an association between the reduction in mental health beds and the increase in the number of patients admitted following detention under the Mental Health Act, with the balance shifting towards a more acutely ill in-patient population. It seems sometimes that people have to be sectioned to get a service, even if perhaps that might not otherwise have happened.

In December 2017, the mental health charity Mind published its survey of over 1,000 people discharged from mental healthcare facilities and reported that patients found planning for their discharge was rushed and unsatisfactory, and that around half of patients experienced inadequate planning and support with housing and finances before discharge. If I had more time, I would give noble Lords some examples. Given these issues, it is surprising that the framework in the care Act for addressing delayed transfers of care seems to overlook patients with mental health conditions. One of the mechanisms to promote integration and co-operation between the social care sector and the NHS is the system of local authorities reimbursing the NHS for a delay in transferring care. This system is viewed as an incentive to improve joint working between health and social care. However, the provisions do not apply to mental health care, which is explicitly excluded from this framework. In fact, I understand that the only way a mental health patient may benefit from this framework is if they are unfortunate enough also to develop a physical illness that requires treatment under an acute medical consultant, but of course, ensuring adequate care planning for someone with a significant long-term social care need who also has an acute medical condition requires additional time and skill.

By no means do I think that fining local authorities is the sole mechanism for integrating social care and the NHS. The issue is rather more complex than such a blunt measure could resolve. However, that it is excluded from this framework suggests something about the way mental illness is prioritised compared with physical illness. If increased integration and co-operation between the health service and social care is what is needed for physical illness, why is it not also prioritised for mental illness? If the reimbursement provisions in the care Act are felt to drive integration and co-operation for those with physical illness, why not apply it to mental illness also?

While my amendment to the Health and Social Care Act 2012, on parity of esteem, may have helped to raise concerns and awareness of mental illness and parity of service provision, and outcomes are now regularly raised as critical goals in a modern health and social care system, this debate highlights yet another area where it is partly missing. Although I am very grateful to the noble Baroness who initiated the debate for referring to these issues, what worries me when we hear talk of winter pressures, black alerts in hospitals and crisis management is that it is in this environment that those with the most complex health and social care difficulties can be overlooked. Whether we expected such problems in advance or not, this is not an environment where we can deliver the best care for the most vulnerable people. Care services for vulnerable adults need to be part of a long-standing sustainable system. We cannot rush their discharge just because it happens to be winter. In fact, it is at this time when we should be most careful about discharge planning. Do we have more social workers, community mental health workers, community care placements and district nurses during the winter season in order to pick up the work from the overstretched general hospitals, or do we just settle for less robust discharges? If the latter, then clearly, those with complex mental and physical needs will suffer most—the very people who often find it hardest to make their voice heard.

A sustainable health and social care service cannot run at two different speeds: one for summer and one for winter. Careful, considered, joined-up care is needed all year round. This care does not suddenly appear when a winter crisis is identified.