NHS Plan: Consultation

Baroness Pitkeathley Excerpts

Monday 2nd December 2024 Lords Chamber

[Baroness Merron (Lab)]

I can confirm that both the online portal and the “workshop in a box” to which I just referred will be available in easy read and British Sign Language versions, and in other languages. Attention has been given to those for whom English is not their first language; in-person events can be tailored to their needs—for example, by having smaller groups. The staff to whom the noble Baroness refers are a major group being asked to provide input; indeed, they are taking part in online workshops and can respond online.

[Baroness Pitkeathley (Lab)]

My Lords, does my noble friend the Minister agree that one of the groups that sometimes finds it difficult to interact with health service professionals is unpaid carers? Despite the huge contribution that they make, they often have their needs ignored by those providing services. Does she therefore agree that it is very important that the voice of the unpaid carer is heard in the consultation process?

[Baroness Merron (Lab)]

I agree with my noble friend: we have to hear from unpaid carers, because that will strengthen the exercise. We are constantly monitoring which groups are responding and which are not, and that allows us to tailor our approach to the underrepresented groups who are not coming forward. If that includes unpaid carers, the consultation absolutely will make special, tailored efforts to reach them.

Carers and Poverty: Carers UK Report

Baroness Pitkeathley Excerpts

Thursday 21st November 2024 Lords Chamber

Asked by

[Baroness Pitkeathley]

To ask His Majesty’s Government how they plan to respond to the Carers UK report Poverty and financial hardship of unpaid carers in the UK, published on 12 September, and in particular its findings that 1.2 million carers live in poverty and that the poverty rate for unpaid carers is 50 per cent higher than for those who do not provide care.

[Baroness Pitkeathley (Lab)]

I beg leave to ask the Question in my name on the Order Paper and remind your Lordships that today is Carers Rights Day.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Baroness Merron) (Lab)]

My Lords, from these Benches I pay tribute to the memory of our dear and noble friend Lord Prescott.

I thank Carers UK for its report, which, importantly, as my noble friend said, is raised on Carers Rights Day. We will take the findings into account as we continue to support unpaid carers, whose major contribution I pay tribute to. We have announced an increase to the carer’s allowance earnings limit. Carers can earn around an additional £2,000 per year. This is the biggest uplift since the allowance was introduced in 1976. Furthermore, we will review the implementation of carers’ leave.

[Baroness Pitkeathley (Lab)]

My Lords, I readily acknowledge the welcome concessions by the Chancellor in the Budget and thank my noble friend for her response. There is never any difficulty in getting recognition for our moral obligation to carers, but figures published this morning by Carers UK remind us of their contribution to the economy. They show that the value of their support is worth £184 billion per year in the UK—directly comparable to the spending on the NHS in the four nations, which is £189 billion. I hope my noble friend understands that it is against this background of their huge economic contribution that we ask for entitlements for carers and for recognition of their rights to lead an ordinary life, to combine paid work with caring, and to not to be condemned to a life of poverty because of their caring responsibilities.

National Carers Strategy

Baroness Pitkeathley Excerpts

Tuesday 19th November 2024 Lords Chamber

[Baroness Merron (Lab)]

I do have to say to the noble Baroness that I have not committed to a national carers strategy. However, in our joined-up approach, we will certainly be looking at what is needed. That will be very much part of our considerations on the workforce strategy, which Minister Karin Smyth will be leading on. It is crucial to the delivery of services.

[Baroness Pitkeathley (Lab)]

My Lords, would my noble friend agree that one of the major problems suffered by carers is recognition, not just by other people but by themselves? They say, “I am a wife”, “I am a husband”, “I am a mother”, “I am a daughter” or “I am a son”, not “I am a carer”. Therefore, a very high-profile national strategy led from the very top—previously, two Prime Ministers took this on board—would be extremely useful in helping carers recognise themselves and therefore putting them in touch with services that could support them.

[Baroness Merron (Lab)]

My noble friend, who is a very impressive campaigner on the rights of carers, is right to talk about recognition. Of course, if one does not understand that one is a carer, it is hard to access support. I certainly agree on that point. There is guidance, for example, to support GPs in recording which of their patients are unpaid carers, to ensure that they get access to the support they need. Importantly—this has been raised a number of times in this House—in respect of young carers, there is guidance for GPs and it has recently been added to the school census, so young carers can be identified in order that there can be an assessment of needs. So it is true that we need to identify in order to support. Part of that is people recognising themselves as carers.

Cancer: Older People

Baroness Pitkeathley Excerpts

Tuesday 19th November 2024 Lords Chamber

[Baroness Merron (Lab)]

I am glad that the noble Lord is, as he describes himself, a happy statistic. We are all grateful for that. I certainly share the view that there are a number of ongoing chronic conditions and impacts on other aspects, such as people’s mental health. The cancer strategy needs to look at this in its development, and I am grateful to him for highlighting it.

[Baroness Pitkeathley (Lab)]

My Lords, as another happy statistic, I ask whether my noble friend thinks that older people are perhaps more reluctant than our younger friends to mention symptoms and are more inclined to say, “Oh, it’s nothing; I’ll get over it”. Would more public education programmes be useful in this regard?

[Baroness Merron (Lab)]

I am glad that my noble friend is also a happy statistic—although I see all noble Lords as more than just statistics. She makes a very good point but it is not just about those who are older; many people are reluctant to consider taking action when they have symptoms. My request to them is that they do not wait and that they act. That is how we get things diagnosed earlier, to provide the right support and care. There is a lot of embarrassment about certain symptoms and I make the plea that people should not be embarrassed. Certainly, as she suggests, the new cancer strategy will take account of how we educate people as well as diagnose and treat them.

Hospices: Funding

Baroness Pitkeathley Excerpts

Thursday 24th October 2024 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I am grateful to the noble Lord, Lord Farmer, for securing this debate and for his excellent speech reminding us of the philosophical basis of hospices. My remarks are focused more on the practical.

In the past six months, I have visited two friends who were in hospices as their lives came to an end. Both were being cared for in the way we would all like in similar circumstances—with skill and compassion and with support for them and their families. However, in both cases the hospices were operating only at half-pace. Each had 50% of its beds unoccupied for lack of money. It was also a source of regret to the staff that they had not only had to close beds but to curtail the outreach services which are so vital to patients and their families—proof, if any were needed, of the crisis in funding faced by hospices. Emergency funding is needed now to supplement the extraordinary fundraising effort volunteers and support groups put in, but this is a short-term solution. In no other area of health would we tolerate such dependence on charitable activity.

Hospices need to be incorporated into the NHS and dying needs to be seen as as much a part of life as being born. This does not negate in any way the voluntary principle on which hospices were founded—I had the privilege of meeting Dame Cicely Saunders and talking to her in the early days of the movement—but builds on it, harnessing that support and good will and enabling anyone who is need of a hospice place, or indeed hospice services in their own home, to access them. I hope that the assisted dying debate, as it proceeds, will highlight the need for more and better palliative care. Of course, hospices are not the only places providing such care, but many of them have expertise and experience from which the whole of the NHS could learn, and I hope that this learning will be encouraged by the Government. That expertise goes beyond the specialist medical care to manage pain and other symptoms over the short stays or those of longer duration with which we are familiar. It also includes research and innovation to improve palliative care services wherever they are provided.

We should not forget hospices’ important links with their local community, for which they are famed. They mobilise volunteers and voluntary efforts so that local communities are familiar with their services and able to access them, for the benefit of patients and their families when their own time comes. Many a bereaved person has been helped to recover from their grief by, in turn, becoming interested and involved in volunteering at a hospice—a two-way street, indeed.

NHS: Independent Investigation

Baroness Pitkeathley Excerpts

Tuesday 8th October 2024 Lords Chamber

[Baroness Merron (Lab)]

I am very pleased to see the noble Lord in the rudest of health and to hear of his positive experience. Of course, there are many positive experiences every single day, and the noble Lord is quite right to remind us of that and of the need to thank the whole NHS staff team who make that happen.

On the point about the NHS being broken, I understand the noble Lord’s view. However, I think it is important that we lay it bare and say what we have found. Having read the report by the noble Lord, Lord Darzi, I find it hard not to conclude that there are fundamental points within the National Health Service that are just not working. Of course there is good practice and there are brilliant outcomes in some areas, but it is not universal and that is what drives us to make that point. I hear what the noble Lord says. However, it is important to be honest, and that is what we have said we will be, uncomfortable though it might be at times.

[Baroness Pitkeathley (Lab)]

Does the Minister agree that integration between the different branches of the NHS, or rather a lack of it, is one of the problems? It is particularly a problem for patients. It works best when you cannot see the joins between various branches—when you cannot tell who the community nurse is working for, whether it is the hospital nurse and so on. Those are the things that puzzle patients. In thinking about the workforce, therefore, will the Government look at ways—for example, joint training—in which we can better integrate the staff, so that they work less in professional silos and much more across various branches of the NHS?

[Baroness Merron (Lab)]

Yes, I certainly agree with my noble friend about the need for better integration. Joint training is a very practical example and will be part of how we develop the workforce, because silo working clearly is not working, as we can see in the current state of affairs, particularly if we look at the relationship between the National Health Service and the social care service. It is not seamless, and individuals are suffering for that, so I very much agree with my noble friend.

Palliative and End-of-life Care: Funding

Baroness Pitkeathley Excerpts

Wednesday 4th September 2024 Lords Chamber

[Baroness Merron (Lab)]

I certainly take on board the point that the right reverend Prelate makes. It is the case that the amount of funding that charitable hospices receive varies by ICB area. That, in part, is dependent on the breadth of a range of palliative and end-of-life care provision within the ICB area. I can assure your Lordships’ House that my colleague, Minister Kinnock, the Minister of State for Care, has recently met with NHS England, and discussions have started on how to reduce inequalities and variation in access to services and their quality.

[Baroness Pitkeathley (Lab)]

My Lords, does my noble friend agree that when end-of-life or palliative care is delivered at home, the principal deliverers are usually the family—the unpaid carers—of the patient? Does she agree, therefore, that they must be considered in this equation to get them as much support as possible, and that they ought to be given as much information as possible about the patient’s prognosis and the treatment plan, bearing in mind the sensitivities associated with such information?

NHS Continuing Healthcare

Baroness Pitkeathley Excerpts

Monday 2nd September 2024 Lords Chamber

[Baroness Merron (Lab)]

It is crucial that we provide the right support to children and young people. NHS England’s regional teams are working with local systems to explore the delivery of continuing care to that younger group. It is important to say to your Lordships’ House that we do not currently collect data on, for example, children and young people, but we will be doing so from April next year. That will help us capture evidence, which will enable us to improve things in the way the noble Lord and his all-party group want to do. We continue to welcome views from stakeholders and partners in this regard.

[Baroness Pitkeathley (Lab)]

My Lords, I wonder if other noble Lords share my experience of people who should have continuing care never even being told about its existence. As the noble Lord, Lord Crisp, said, the criteria are obscure, but they are even more obscure if nobody tells you that you could be eligible. Would the noble Baroness be sympathetic to the idea of being much more open about the existence of this facility to both patients and their families?

[Baroness Merron (Lab)]

I thank my noble friend for that observation and certainly agree that, in all these areas, it is very important that people understand what might be available and how they might best apply. As I said to the noble Lord, Lord Crisp, the assessment is potentially a gateway to other NHS funding. I feel quite strongly that that needs to be clarified, so that people know what they are going into. I will take my noble friend’s comments on board and discuss this within the department.

Integration of Primary and Community Care (Committee Report)

Baroness Pitkeathley Excerpts

Thursday 9th May 2024 Lords Chamber

Moved by

[Baroness Pitkeathley]

That this House takes note of the Report from the Integration of Primary and Community Care Committee Patients at the centre: integrating primary and community care (HL Paper 18).

[Baroness Pitkeathley (Lab)]

My Lords, many of your Lordships will know that for a long time I have been concerned with health and social care principally though the experience of carers. I have lost count of the number of times I have heard carers say something like, “What I don’t understand is why it doesn’t all fit together. How come the GP didn’t know that Mum was being discharged from hospital? Why did the community nurse and the social worker not know each other? Why have I got to give Mum’s details over and over again to different people?”

So when I was asked to chair a House of Lords special inquiry into integrating primary and community care, I was delighted. I express my most sincere thanks to the 12 cross-party members of the inquiry, most of whom are speaking today, for their knowledge, skills, commitment and wisdom. Most unusually, we had—for reasons beyond anyone’s control—three changes of clerk during our deliberations, so I acknowledge the ongoing support of Chris Clarke and, most of all, Matthew Burton, who was and is a shining example as our policy analyst. I am most grateful to our special advisor, Professor Gerald Wistow, whose long experience in both the health and social care fields was invaluable. I welcome, too, the other speakers in our debate and am grateful that the noble Lord, Lord Jamieson, has chosen this one in which to make his maiden speech.

The inquiry took evidence from 70 witnesses, we had 76 written submissions, and we undertook two visits to projects in areas where integration is definitely benefiting patients. Defining integration is not easy, but we took as our definition something from a government policy paper that had been in use for years before that:

“the planning, commissioning and delivery of co-ordinated, joined up … services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole. Everyone should receive the right care, in the right place, at the right time”.

I guess no one in this Chamber will be surprised that our inquiry found that there is a very long way to go to achieve this, and that patients are constantly being inconvenienced or endangered, or missing improved long-term health, because they are not receiving joined-up care in the right place and at the right time. Poorly co-ordinated care significantly undermines the quality of patient experience in the NHS and can have profound consequences for long-term health.

The inquiry heard of patients suffering vision loss, or facing critical delays in treatment, due to the mishandling or loss of records between services. Patients in care homes frequently endured inconvenient and unnecessary trips to see their GPs or to hospital appointments. Consultants did not talk to each other or consult about patients, resulting in the absurdity of a patient seeing three separate consultants for the three injuries sustained in one fall.

Community nurses were unavailable and rarely in contact with other professionals. Complex care is fragmented across various services, which do not co-ordinate with each other to plan overall patient care and recovery, let alone to take responsibility for the preventive services which we all know are the long-term key to a viable NHS. Social care was not actually within the committee’s remit but witnesses frequently referred to the lack of integration between those two elements as an even more serious problem than the intra-NHS difficulties.

The inquiry identified four key obstacles to integration which could be addressed. I will refer briefly to each of them, with our suggestions for tackling them. The first was structures and organisation. The Health and Care Act 2022 encourages local autonomy and subsidiarity to encourage interservice relationships, but designing a universal policy has proved difficult. The imbalance of power and representation in ICBs, ICPs, local authorities and the voluntary and community sectors limits integration. Of course, it is relatively early days, and almost all our witnesses said that they must be given more time to mature.

We do not propose further reorganisation but suggest that the membership of the governing bodies should be widened and accountability enhanced through better inspection. Health, social care and voluntary sector leaders should work together as equal partners, as they are likely to possess a real understanding of their respective communities. This would encourage integrated policy-making and service provision, as well as a more preventive approach to public health. Importantly, there should be a single accountable officer at place level, specifically charged with working with local leaders.

Our second obstacle was contracts and funding. The NHS allocates an excessive amount of funding to reactive hospital care at the expense of preventive primary and community care. That is a strong statement, but it was not our conclusion: it was the opinion expressed by all four former Health Ministers and Secretaries of State who gave evidence to us. They were from different parties and were Ministers in different circumstances, but they were adamant on that point. Too much money goes to hospitals. Service contracts lack incentive for multidisciplinary care and reform is needed to ensure that this is incentivised.

Co-location encourages better communication and easier access for patients, but the existing GP contract and partnership model hinders this, as does the fragmented funding across different health disciplines. Of course, there is the huge divide between local authority-funded care and that funded by the NHS. The better care fund has made attempts to bridge this gap, but joint funded mechanisms need to be significantly enhanced. The better care fund should cover a larger proportion of relevant NHS and local authority expenditure, and the fund’s statutory responsibilities should be devolved to place-based commissions. This would enable decisions on joint funding to be taken by those with a better knowledge of local needs.

The third obstacle we encountered was data sharing. Single patient records have not been universally adopted, and full implementation faces issues of interoperability and widespread IT inadequacies. For example, we came across people putting the same data into three separate computers because the machines do not talk to each other and the systems are not connected. More frustration was expressed by our witnesses on the inadequacy of connectivity than almost anything else. As well as the technical issues, data sharing is hindered by cultural and perceived legal obstacles. The DHSC should publish guidance that clarifies how data and privacy laws apply to patient data, so that everybody is clear about their responsibilities.

Our fourth obstacle was workforce and training. Staff shortages make integration more difficult; of that, there is no doubt. When you are up to your eyes on the front line, have you time to develop new ideas for integrating? Specialised staff are not trained sufficiently in the work of other disciplines, and there are of course hierarchies of professions and services. Integration needs to be included in all initial clinical training, and clinicians should be introduced to other services by job rotations. Better training for social care workers would enable them to work more effectively with primary and community care workers, and social care must be included in the NHS long-term workforce plan.

Mindful always of the current problems faced by the NHS, we were aware of the shortages of people and resources that undermine integration, however good the intentions of individuals. We emphasise that better integration will reduce the long-term stress on the NHS, as it leads to more holistic and preventive care over time and encourages a problem-solving approach to work that ignores or bypasses artificial professional divisions. Our visits to Coventry and Pimlico provided us with evidence that real integration happens where you cannot see the joins between the professions.

In summary, trusting and constructive working relationships are essential for integration, together with aligned contracts and funding, as well as seamless data sharing. These were the focus of the 16 recommendations that we made to the Government as our inquiry ended. The Government’s response was delayed and when it came, it was very disappointing. In fact, it did not even give the usual “accept” or “reject” response to the individual recommendations, apart from one very lukewarm acceptance. In short, the Government’s response says that everything is under control and all the issues we raised are being addressed.

I will give an example. We found co-location to be extremely beneficial for integration and recommended that the Government should

“investigate different ownership models for GP practices”

and

“their co-location with other community services”.

The Government’s response concedes that co-location can be good but is not required. Although the Government say that NHSE and the DHSC are investigating

“new models of primary care estates”

there is no further information about that, and no timescale is given.

On another of our recommendations—for a single accountable officer—all the Government say in response is that some progress has been made and that a single accountable officer is “one way” of ensuring integration. That is another lukewarm response, which is in direct contradiction to the Government’s previous statements and commitment in the integration White Paper that a single accountable officer must be appointed.

For social care, we make what seem to us to be very sensible, cost-effective suggestions about multidisciplinary teams and joint training, as well as amending the workforce plan to include

“a strategy for increasing the size of the social care workforce”

so that it is sustainable in the future. Again, the Government’s response is immensely disappointing, merely saying that they will “consider” how they will

“support better integration of health and care to create a more flexible, agile workforce”.

In conclusion, I emphasise that the special inquiry was very clear about the purpose of integration: it is not an end in itself, but a means of achieving patient-centred care, reducing inequalities and getting a better balance between community-based care and hospital-based care. Despite endless commitments over many years to the importance of integration, I am sorry to say that the Government’s response to our report is a missed opportunity to show commitment and to bring about important changes, many of which are simple and virtually cost free—I emphasise: they are simple and virtually cost free.

The Government merely fudged their response. They lack any sense of urgency to deal with problems that will only become more urgent as our population ages and lives longer, with more comorbidities. We called our report Patients at the Centre. I am yet to be convinced—although I hope that the Minister may prove me wrong—that the Government are really committed to ensuring that patients are at the centre of primary and community care. I beg to move.

--- Later in debate ---

[Baroness Pitkeathley (Lab)]

My Lords, it is the end of a long day, and I will be brief. I thank everybody who has spoken. It was a particular pleasure to hear the maiden speech of the noble Lord, Lord Jamieson, and I look forward to hearing from him a great deal more in the future. I said that I remain to be convinced by the Minister, and I must say that he has made a good fist of it: I feel a bit more convinced now than I did by the Government’s response about the commitment to integration.

What I do not think that he or the Government, or perhaps many other people, have yet done is make this crucial leap of thinking: integration is not an end in itself but only a means to give patients a better experience. If that sounds a bit vague, let us also remember the practical outcomes which come from giving patients a better experience: you prevent unnecessary hospital admissions, as noble Lords have heard; you head off at the pass preventable illnesses, so you save money, and it is a very good investment; and you make use of the most precious of all resources, the patient’s own experience. Nobody knows better about their health than the patient, but they so often feel disempowered because no one listens to them. I hope my colleagues on the committee will remember the nameless professional who said to us that it really did not matter if patients had to tell their story lots of times to lots of different people, because it helped them get their story straight—come on. Those are the kinds of attitudes that we have to overcome. Integrated working in productive teams helps staff retention because staff are happier and more satisfied; integrated training spreads skills and knowledge in a very cost-effective way. I hope the Minister and his colleagues will keep our recommendations under review. Many of them are, as we have emphasised, easily done and at low cost.

We have talked about integration for so many years—for too long. As one of my colleagues said, it is not rocket science but it does require changes. These are not only changes in the way we distribute resources but changes in the mindsets of professionals at all levels in ICBs, in NHSE, in the DHSC and in political parties. The matter is urgent: with every day that goes past, the health of our nation becomes worse. The rewards are great for everyone, but most of all for patients, if we really do manage to put them at the centre.

Motion agreed.

NHS: Long-term Sustainability

Baroness Pitkeathley Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, it is an honour and pleasure to follow my noble friend Lady Ramsey, and to be the first to congratulate her on her truly memorable maiden speech. I should not be surprised that she has made a remarkable speech, because she is a remarkable person who brings a wealth of experience and achievement in public service to your Lordships’ House. As a barrister working in local authorities, as chair and non-exec on many health agencies and as an upholder of standards in public life, she has already achieved a great deal. Indeed, the range and breadth of her experience is so great that she could have made her first contribution in a variety of debates. I am sure your Lordships will be glad that she chose this one. As we have heard, she brings willingness, commitment and enthusiasm to continuing her work in this latest phase of her public service. Her colleagues on these Benches, and throughout your Lordships’ House, will be grateful for her presence, and look forward to many more memorable contributions.

I thank the noble Lord, Lord Patel, for this debate and for his indefatigable pursuit of improvements in health and social care. Like many noble colleagues, I could give examples of where great care is happening, and my own recent experience could not be improved. The use of technology to make appointments and to deliver care was fantastic, as was the skill and understanding of all the professionals with whom I came into contact. However, too often patients report very differently. As we know, 24% satisfaction with the NHS is nothing to be proud of.

I have lost count of the number of health debates in which I have taken part in my 27 years in your Lordships’ House, and in every one there has been agreement about what is needed to provide the comprehensive and timely care that we seek. We always agree on two things—first, that we need more preventive services, as the noble Lord, Lord Patel, and others have reminded us. We treat people too late and allow their conditions to become chronic, so that major interventions are needed when small ones would have sufficed. We do not treat the broader picture: we do not look at the lifestyle issues and diets that cause the conditions or the poverty that is the reason why people eat the wrong food, which in turn causes diabetes, the need for new joints and the disabilities that mean people cannot work or have a tolerable, pain-free life. Still less do we think of surveying living conditions, such as putting in a handrail and getting rid of the rugs that cause falls, which in turn create huge amounts of work for the NHS and distress for an older individual.

The second area on which we have always agreed is that we need more integration. I shall have more to say to your Lordships’ House next month, when the report of my Integration of Primary and Community Care Committee is debated, but, for now, I agree with other noble Lords that the NHS allocates an excessive amount of funding to reactive hospital care at the expense of preventive primary and community care. This was not just the conclusion of my committee but the strong opinion expressed by all former Health Ministers and Secretaries of State who gave evidence to it. They were from different parties and Ministers in different circumstances, but they were all adamant on this point, as many noble Lords will be in today’s debate.

The mismatch in the levels of funding and importance that is so clear in the NHS is even more significant when it comes to social care. We are all victims of the historical accident that means that local authorities fund social care. Nobody knew that we would live so long and have so much need for support in 1948, but we have made only pathetic or failed attempts to rectify that situation. I know that the Minister would not call the better care fund either “pathetic” or “failed”, but it is, at best, a sticking plaster to cover the basic flaw in our funding system.

Unless we get better integration between health and social care, we will never deliver comprehensive care, and the divide will continue. To overcome that divide, we have to address the join between the NHS and local authorities and areas where professional silos and the arrogance that goes with such divides have not been eradicated. We never seem to have found the ability to translate local success into national guidelines. The “not invented here” syndrome stymies all attempts at change.

Do not get me started on the main providers of both health and social care. I am grateful to the noble Baroness, Lady Warwick, for mentioning unpaid carers. It is not the NHS or local authorities but family carers who provide, willingly and with love, billions of pounds of care—estimates vary, but it is well over £150 billion, or the cost of a second NHS. Does it not make sound economics, as well as moral good sense, to support them better than we have ever succeeded in doing? They are the best-value service any nation could want. Yet what do we hear? We hear of carers being persecuted, even prosecuted, for invertedly going £1 over the earnings limit on the derisory amount of the carer’s allowance. We hear of carers being forced to abandon paid employment, building up future poverty for themselves and future liabilities for the state. We hear of carers being ignored, having their skills knowledge and experience dismissed and not being consulted, with their own health needs going unrecognised. Carers are, and will continue to be, the bedrock of health and care services, and I hope that the Minister will confirm the importance of recognising that.