Agency Nurses

Baroness Pitkeathley Excerpts

Wednesday 10th January 2018 Lords Chamber

[Lord O'Shaughnessy]

It is that last issue that we are trying to address. One factor is that there is now an hourly rate price cap on agency spend, precisely to drill down into that issue. The reason that the number of agency staff went up was in response to the Francis review and what it said about safe staffing levels in the service. The immediate response was to deal with that through agency staff. That was expensive, of course, which is why we have had to push down those costs. Nurses have to come from somewhere, and my noble friend is quite right that using existing nurses and support from nursing banks is one way of meeting demand with better value for money.

[Baroness Pitkeathley (Lab)]

My Lords, I noted carefully the Minister’s words about 10,000 extra nurses on the wards. Can he update the House on the position for community and district nurses?

[Lord O'Shaughnessy]

The number of those nurses has fallen—as have the numbers in mental health, which is worth pointing out—and we are trying to address this. I think I made a slip of the tongue a moment ago when I said that £5,000 more will be spent each year on training nurses; I meant that there will be 5,000 more student nursing places.

NHS: Staff

Baroness Pitkeathley Excerpts

Thursday 30th November 2017 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I congratulate my noble friend Lord Clark not only on securing this debate but on his tenacity on this very important subject of NHS staffing. I endorse all that he said about the potential difficulties into the future—the near future of an institution which is so dear to so many of us and to which many, like me, owe their lives.

As my noble friend reminded us, this week has seen renewed fears about the safety of the care provided in our accident and emergency units, and other units, because of the lack of fully trained staff. There was also a disturbing statement earlier this week about the state of maternity services and the shortage of midwives. But I am going to widen this debate, as others have done, by focusing on another issue which fundamentally affects the efficiency—indeed, the very existence and continuation—of the NHS: social care. We need to consider other major workforces in conjunction with discussions about NHS staffing levels. I think there are three separate ones: those who work in the social care sector, the unpaid family carers, and the staff and volunteers in the charitable and voluntary sector.

It is simply impossible to consider anything to do with the running of the NHS without looking at the social care which precedes, follows or substitutes for NHS care, especially hospital care. Lack of adequate social care means more pressure on hospitals—often unnecessary pressure, as most people prefer to be cared for in their own homes; and if given proper support, they never go into hospital in the first place. Moreover, the levels of readmission rates if people are discharged without proper planning and follow-up are truly shocking, and we must be concerned about the pressure which families face if they are not given proper support with the care that most of them are only too willing to provide.

I have been concerned with social care for more than 30 years and have lost track of the number of times I have heard Ministers and others say that health and social care must be considered together, that we must have integrated services and that we must have staff who work across both disciplines. I have heard the noble Baroness, Lady Emerton, say that on many occasions. I thought it was axiomatic, but how wrong I was was proved by the Chancellor in his Budget last week. I could not believe that he failed to mention social care once. There is overwhelming consensus that the care system for older people and disabled adults is in crisis, but the Chancellor simply left it out.

Social care, which is always means tested, as we know, is provided by councils whose grants have been cut, and as a result the spending on social care has fallen by 30% in some areas since 2010. Three independent think tanks have produced a joint estimate that last week’s Budget will leave a £2.5 billion funding gap by 2019. Already, 1.2 million people are not getting the care they need, even with the enormous contribution of the 6.8 million family carers. The vast majority of care and support is provided not in hospitals and care homes but behind closed doors by family, friends and neighbours, and this is another huge workforce that we have to consider when we look at staffing levels in health and social care. Your Lordships will be fed up with hearing me refer to the value that this workforce provides but I am going to say it anyway—it is £132 billion every year, the cost of another NHS.

The number of people providing unpaid care has increased by about 1 million over the past 15 years, from 5.8 million to an estimated 6.8 million. It has far outstripped population growth. The number of carers grew by 11% over a decade. Families are caring more, not less, and therefore it is not good to hear Ministers even glancingly say that families should be taking more responsibility, because they could hardly take more than they are doing. Two years after the Care Act put in place stronger duties on local authorities to support carers, those new rights are not improving the lives of many carers in England. Carers’ assessments, which were put in place to look at the impact of caring on carers’ health and well-being, are too often failing to be put in place, and breaks and support are just not there. Some 40% of carers responding to Carers UK’s State of Caring 2017 survey said that they had not had a day off for more than a year. Imagine that, not having a day off for more than a year. In the context of this debate, the high rates of women carers and those in their 50s who are employed within the NHS means that supporting carers at work is particularly important for the NHS. Earlier this month, the Health Secretary himself highlighted the importance of flexible work and care leave for those juggling caring and working in the NHS.

The Autumn Budget did not provide additional support for social care in the short term to address the social care crisis and the predicted funding gap which I and others have mentioned, of £2.5 billion. The Chancellor offered a short-term fix to the NHS in his Budget—a sticking plaster, as it has been called—but did absolutely nothing about the long-term sustainability of health and social care funding. Sarah Wollaston, the chair of the Health Select Committee, said:

“We are failing to take the long view and see how serious the situation is. Health and social care is like a balloon—if you squeeze one part, another part pops out. The idea that you can fix the system in this way is nonsense”.


So here we are again. We have been here many times before, and it still seems many miles away from a solution to these problems. The history of our attempts is not edifying. Different parties calling each other’s proposals a death tax or a dementia tax is not helpful, and there have been endless commissions, royal and otherwise, all of which are languishing on the shelves of various Secretaries of State. The Minister will tell me that another consultation on social care funding is pending. My reaction? Oh please, not another one. Since 1997, there have been four independent commissions and five government papers on funding reform. As I said in my contribution to the debate on the Queen’s Speech earlier this year, we know the questions—we just need the answers.

I understand that the Government have now abandoned their commitment to the Dilnot commission proposals. Are we to start again then from scratch? Is all the work that the noble Lord, Lord Warner, and others did going to waste? Can the Minister please enlighten us? Have the very welcome plans for a carers’ strategy gone to waste in rather the same way? We have been working on that for some time, but we now understand that it will be rolled up with the social care consultation, which itself has been delayed, as the noble Lord, Lord Warner, reminded us. How the First Secretary of State could announce a consultation on proposals to reform social care without mentioning the contribution of 6.5 million carers is, frankly, beyond me. Discussions about a refreshed carers’ strategy have been going on for more than two years, and 6,000 carers sent in their views, at the Government’s request. Will the Minister tell me what is happening to those views, submitted by carers in good faith?

I know that last week, for Carers Rights Day, the Minister in another place announced there would be a carers’ action plan in the new year. That is a very welcome, although suspiciously late, initiative—perhaps to correct the unacceptable omission in the announcement by the First Secretary of State. None the less, I do not want to be churlish, and it is very welcome. But can the Minster tell me more about this proposed action plan and how carers and their representatives will be involved?

Finally, I want to refer to the workforce which operates in the voluntary sector. In the field of health and social care, charities are major players, providing care, developing innovative solutions to long-standing problems and representing those who have difficulty speaking for themselves. They often provide such services under contract from the local authority or a health agency, and are increasingly struggling to do so. As the Select Committee on Charities, which I had the honour to chair last year, said,

“there has been pressure on charities to reduce ‘back office’ costs and an increasing expectation that all money donated should go to the frontline … Charities cannot operate unless their core costs are met … commissioners should have regard for the sustainability of the organisations which they commission … and … realistic and justifiable core costs should be included in contracts, just as would happen in the private sector”.

Nobody would question that in the private sector.

My committee also recommended that the Government need to improve the way they consult the charity sector when developing new policies. We said:

“Poor consultation and ill-thought-through policy proposals have caused serious unease and disruption to the work of charities. We recommend that the Government reviews its approach to engagement with the charity sector before policy announcements are made, with a view to ensuring that charities feel better informed about legal changes which may affect them and have a greater opportunity to provide input on new policies”.


Although I still await the government response to the Select Committee’s report, I am glad to note that the Government have accepted this recommendation and that the Minister in another place has announced a cross-departmental initiative to improve communication. I am not expecting the Minister here to be able to respond to that, because I dare say it will not be in his brief today.

I support entirely my noble friend’s concerns about the NHS workforce but ask that the Minister also take into account the urgent needs of the social care workforce, including the unpaid carers and those who work in the voluntary sector.

Child and Adolescent Mental Health Services

Baroness Pitkeathley Excerpts

Monday 30th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight the fact that we need more staff to meet the mental illness burden in society, which is sadly growing. I hope that she will have seen that Health Education England has announced that there will be 21,000 more mental health staff by 2021, of which 13,000 will be qualified clinical staff, including 700 more doctors. The warning she has made has been heard loud and clear and those changes have been made.

If I may, I would like to use this opportunity to say that I made a mistake in my previous answer, when I talked about there being 21,000 people eligible for flu jabs. If that really was true, that would be a poor place to be. It is actually 21 million, which is slightly more reassuring.

[Baroness Pitkeathley (Lab)]

My Lords, I would like to ask the Minister about the 700,000 young carers, who often have severe mental health needs because of the stress of the duties they undertake, as he will know. We had high hopes of specific action for young carers in the refreshed carers strategy, but I understand that this is being rolled up into the consultation on the social care Green Paper. I am concerned and would like to be reassured that the Government have not abandoned the long-awaited carers strategy. If we are waiting for the social care consultation, how will he ensure that the mental health needs of young carers are urgently addressed?

[Lord O'Shaughnessy]

I know that the noble Baroness cares passionately about this group of people. My understanding is that those policy issues are being considered in the round with the social care consultation. I shall write to her to clarify that point. She might like to know that, in the upcoming Green Paper on children and young people’s mental health, there will be an expansion of some of the work that has already gone on around providing mental health first aid and various other things in schools, which will capture some of the young people that she is talking about.

Care Homes: Hospital Discharges

Baroness Pitkeathley Excerpts

Monday 16th October 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord is right to highlight the issue of community nurses, where in particular there has been a reduction in numbers even though the total pool of nurses has increased in recent years. He will hopefully have noticed an announcement at the Conservative Party conference from my right honourable friend the Secretary of State about more nurse training places—25% more—to address the kind of issues he is talking about.

[Baroness Pitkeathley (Lab)]

My Lords, with the pressure on hospitals to discharge people and the lack of nursing and residential care beds, does the Minister agree that undue and unfair pressure is sometimes put on families and carers to accept discharge in an unsuitable situation? Last week, I spoke to an 87 year-old carer, herself frail and with severe angina, who was induced—I use the word advisedly—to accept discharge of her 91 year-old husband, still immobile after a fall, with a promise of visits from a community nurse twice daily. Of course, those visits have not yet materialised.

[Lord O'Shaughnessy]

I am sorry to hear about that particular issue. I obviously have not seen the details; perhaps the noble Lady might write to me about it. Clearly, nobody should be induced or otherwise forced to accept the care of somebody for whom they are not capable of caring. Looking at our growing and aging population, I think we all accept that the number of operations and admissions going through the NHS is increasing. We need much more capacity in the system, whether in nursing and residential homes or, increasingly, in domiciliary care.

Adult Social Care in England

Baroness Pitkeathley Excerpts

Tuesday 10th October 2017 Lords Chamber

[Lord O’Shaughnessy]

The noble Baroness makes an excellent point. We will certainly look at those funding models. Co-ordination, as we have been saying, is the way forward, because if you are a user of care in your eighties, you may be visiting a GP, you may be based in a nursing home, and to you, it ought to be one system and you ought to be travelling through it smoothly. Of course, we know that that is not the case at the moment, and the noble Baroness is quite right to highlight that there are great gains to be made, whether from having pharmacists in nursing homes or from having GPs coming to visit. Her point about technology and data is a good one. We still have an argument to win in reassuring people that their data are safe within the NHS so that they can be confident that they are used wisely for their direct care. That is the policy area I am now responsible for, since the election, so I am focused on providing that reassurance so that we can unlock the kind of innovation she is talking about.

[Baroness Pitkeathley (Lab)]

My Lords, is the Minister able to give us any idea about when we may see the Green Paper for which some of us feel we have been waiting 40 years? Will it contain any revisiting of the Government’s response to the so-called Dilnot proposals about a cap on social care costs, about which there was so much confusion in the general election?

[Lord O'Shaughnessy]

I am sorry to disappoint the noble Baroness but I am not able to give her any more details on the timing of the consultation.

Health: Sepsis

Baroness Pitkeathley Excerpts

Thursday 14th September 2017 Lords Chamber

[Lord O'Shaughnessy]

That is absolutely right: there was an issue with coding. The noble Lord will be pleased to hear that from April this year NHS Digital published new guidance on coding for sepsis to deliver exactly the kind of improved reporting he wants.

[Baroness Pitkeathley (Lab)]

My Lords, as a survivor of total-body sepsis, I very much endorse what my noble friend Lord Turnberg said about the speed and danger of this illness. What was so difficult for both my family and the professionals who treated me to understand was that it could lead to a total failure of all the body’s organs—as it did in my case—within, literally, hours. The urgency of this must be emphasised in any public awareness campaign.

[Lord O'Shaughnessy]

I am very sorry to hear that the noble Baroness suffered that but am obviously delighted that she is still here. Just to re-emphasise the point about speed, I encourage noble Lords to look at the quality standard because it is very stringent about the speed at which treatment must be administered. Of course, the critical thing is making sure that there is proper triage and assessment ahead of that. That is where we still need to make some progress.

Adult Social Care Services

Baroness Pitkeathley Excerpts

Thursday 6th July 2017 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, the Minister has reminded us just how many consultations there have already been on this subject, most of them not moving us very far forward, sadly. It is welcome news, therefore, that the consultation will focus on solutions, not just problems. Does the Minister agree that if we are doing this for the long term—and it essential that we are—a whole-population solution and, dare I say it, a cross-party solution is required?

[Lord O'Shaughnessy]

The noble Baroness is quite right. We need to move forward on the basis of consensus, which is one thing that has been lacking in the past. There is no doubting the point we have reached: we cannot wait any longer and we need to move ahead. That is why we will do so, on the basis of consensus.

Queen’s Speech

Baroness Pitkeathley Excerpts

Thursday 29th June 2017 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, in the 20 years that I have been in your Lordships’ House I have spoken in and led many debates on social care. Each time my hopes were raised by the interest in the subject, and subsequently dashed because no real change came about. But the last time I led such a debate, in December last year, I ventured to express some hope. That was because, in spite of the terrible headlines and analysis we were constantly seeing—“Social care is at a tipping point”, “Bed-blocking crisis reaches a new high”; your Lordships will be familiar with the headlines—there seemed at last to be some agreement across all sectors about the extra resources needed and about the fact that healthcare cannot be sorted out and delivered efficiently without the same attention to social care.

Alas, the election and its aftermath have dashed my hopes once again. It was very welcome that the Conservative manifesto focused on social care, even though the proposals were so poorly thought through. The belated pledge to introduce a cap on the lifetime costs of care—also pledged, I remind noble Lords, in the 2015 manifesto—offered the prospect of protection from the catastrophic costs faced by many. Now, though, there seems to be doubt about these proposals, and the agreement with the DUP has apparently taken up all the money that was due to be allocated in this area.

So we are left with a single line in the Queen’s Speech about a consultation on social care—to add to the endless consultations we have already had. The royal commission, the Wanless review, the Dilnot commission, the Barker review—I could go on. Is that what the Government intend: another fruitless exercise, as all of those have apparently proved to be? For heaven’s sake, we know what the problems are; we do not need another consultation to tell us. If we need a consultation at all, we need it on the proposed solutions to the problems.

So I am going to help the Government take a short cut. There is no need for us to spend time finding out the difficulties; I can tell them what they are now, could probably could any Member of your Lordships’ House. I am going to give the Government some simple “dos and don’ts”. I shall start with the “don’ts”. “Don’t” use the consultation as a delaying process; deal with the shortfall in funding now. As we have heard, it is at least £2.5 billion, four out of five councils do not have enough provision and at least 1 million people in urgent need of care are not getting it. That is in spite of the enormous efforts of the dedicated staff who work in this field and of the vast contribution of the unpaid—usually family—carers, whose contribution, I never tire of reminding your Lordships, is worth over £130 billion to the economy.

“Don’t” assume that this is just a problem with an ageing society. Of the people receiving long-term care in the last financial year, nearly 33% were under 65.

“Don’t” rely on a sticking-plaster solution. The Government talk endlessly about the benefits of the better care fund, but I am tired of being offered that by successive Ministers as a solution every time I raise the issue. Of course we should be trying to do more with less and promoting efficiency and collaboration, but basically we manage demand at the moment by ignoring it and putting undue pressure on family carers, 2 million of whom take on these responsibilities each year and are usually shocked to find how little support is available to them.

I now turn to the “dos”. I have only two: do be honest and do be bold. First, on honesty, no Government, of whatever colour or combination, have ever made it crystal clear to the public that responsibility for paying for care and for arranging it rests with individuals and their families, with public funding available only for those with the least money and the very highest needs. As a consequence, no one prepares or plans for care, and they have to scrabble about doing it when a crisis arises and the awful truth dawns on them. In addition, the expectation has grown that savings and the considerable assets now contained in property can be passed on to family without being touched. We must rethink this and be honest about it.

Secondly, we must please be bold. The Conservative manifesto committed to act:

“Where others have failed to lead”—


so now is the time for action. Every independent review of the last 20 years has recommended that the future funding of social care, as well as healthcare needs, should come from public, not private, finance. The needs of individuals cannot be divided up neatly into health or social care needs, as those of us who have tried to fathom the difference between a health bath and a social care bath have long acknowledged. Now is the time for us as a society to acknowledge that the funding cannot be neatly divided, either.

To those who say that this is not the time, with public finances in such disarray, all the Brexit difficulties and so many other problems around, I remind noble Lords that our forebears tackled reform in the middle of a world war when the country was pretty well bankrupt and not the fifth-richest nation on earth. We must embark on a frank and open debate about how to fund health and social care on a sustainable basis into the future. We must remind everyone that such a debate will not be settled in a single Parliament, so we need to secure cross-party consensus on shared principles to guide that reform. We have enough research and excellent material to enable us to do so; we just need the will. We know all the questions about social care. We just need the answers and the solutions. Will the consultation consult on proposals and solutions?

NHS: Sustainability and Transformation Plans

Baroness Pitkeathley Excerpts

Monday 20th March 2017 Lords Chamber

Asked by

[Baroness Pitkeathley]

To ask Her Majesty’s Government what assessment they have made of the impact of any hospital closures resulting from the implementation of Sustainability and Transformation Plans on Accident and Emergency departments.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, sustainability and transformation plans, or STPs, are about local health stakeholders coming together to make sure that NHS services are placed on a sustainable footing and are being transformed for the future. Any significant changes outlined in the STPs will have to meet the four reconfiguration tests of strong public and patient engagement, a clear clinical evidence base, support for patient choice and support from clinicians.

[Baroness Pitkeathley (Lab)]

I thank the Minister for his reply but, in view of the problems about which we heard in the last Question and the fact that accident and emergency departments and other hospital services deal with many social care needs, does the Minister agree that it is vital that there is sufficient capacity in the community to manage the demands for community services which closures will inevitably cause, and that this must be established before any closures take place? Will the Minister therefore tell the House specifically when, by whom and how this assessment of the adequacy of community services will take place?

[Lord O'Shaughnessy]

As the noble Baroness has pointed out, it is important that there is sufficient capacity in the social care service and in the NHS. In fact, the NHS accounts for more of the delayed discharges, for example, than does social care. Simon Stevens, the head of NHS England, has been clear that, in addition to the four reconfiguration tests, any bed closures would need to show that there was redundancy in the system, that there is alternative provision—to come to the noble Baroness’s point—and that there is clear potential for efficiency. It is clear that the STPs must be able to plan ahead and provide alternatives if there are going to be changes to A&E or other services.

Social Care in England: Older People

Baroness Pitkeathley Excerpts

Monday 20th March 2017 Lords Chamber

[Lord O'Shaughnessy]

I of course associate myself with the comments made by the noble Baroness and apologise for not saying so before. However, I am not going to sing in tribute.

Around 17% of the care workforce comes from abroad and some 7% of the total are from the EU. The key is to make sure that we have, as far as possible, a care system that attracts workers domestically. We are doing that through improving the training packages available and through better pay under the national living wage, which I mentioned.

[Baroness Pitkeathley (Lab)]

My Lords, we heard this morning that the domiciliary care scene is under pressure and many domiciliary care agencies are in fact not tendering for contracts. The care home sector is also under pressure. The people who are not giving up, as the Minister points out, are the family carers— 6 million of whom are picking up the pieces from an inadequate social care system. May I press him a little more on the carers strategy, please? It was due to be published last September. Has he a date yet?