Adult Social Care: Challenge Procedures

Baroness Tyler of Enfield Excerpts

Wednesday 19th April 2023 Lords Chamber

Asked by

[Baroness Tyler of Enfield]

To ask His Majesty’s Government what assessment they have made of the Equality and Human Rights Commission’s report Challenging adult social care decisions in England and Wales, published on 28 February; and what steps they will take to make local authority care challenge procedures more accessible and transparent.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

The Government have noted the findings in the report. Encouraging a culture of feedback and learning is vital if we are to improve services and people’s experiences of social care. The CQC’s local authority assessment framework, which went live on 1 April, includes oversight of local authority assessment and eligibility frameworks for adults and unpaid carers accessing social care and support. This includes looking at transparency and accessibility and whether people can appeal decisions effectively.

[Baroness Tyler of Enfield (LD)]

I thank the Minister for his reply. The EHRC report clearly demonstrates the problems facing social care users who have challenged local authority decisions, and it is a pretty bleak picture. But while there is much for local authorities to do to improve their complaints system, there are also important recommendations in the report aimed at government, including making the Local Government and Social Care Ombudsman the statutory complaints authority for social care in England. When and how do the Government intend to respond to these recommendations? Does the Minister agree with me that the shortcomings at local level will be remedied only by long-term sustainable funding of adult social care—not made easier by the Government’s announcement on 4 April, when Parliament was in recess, to hold back £50 million of the money promised to help plug staff shortages?

[Lord Markham (Con)]

First, we will respond in detail to the report the noble Baroness mentions. On funding, as I have mentioned before, the £7.5 billion over the next two years is a 20% increase and is substantial by any measure. I spoke to Minister Whately about this issue this morning, and she was at pains to say that, in terms of funding and overall numbers, everything is in place in this latest programme. Also, £600 million is being held in reserve to follow up in the areas that really need it.

Social Care

Baroness Tyler of Enfield Excerpts

Thursday 30th March 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords—follow that. As the excellent reports we are debating today make clear, we are failing those in our society most in need of our care. As we have heard powerfully in today’s debate, the social care sector is in crisis due to chronic underfunding and the repeated deferral of hard decisions. Fundamentally as a society, we are sending the message that we do not truly value caring and caregivers.

The care that people, both older people and those of working age, need to have a good quality of life is often either unaffordable or unavailable. People who could be supported to stay in their own homes are being moved into residential care and people who are medically ready to leave hospital are unable to, because the care they need in the community is just not there. This has knock-on effects throughout the NHS. We know from the CQC’s latest State of Care report that the health and care system is gridlocked and is unable to operate effectively or, in some cases, at all—as we heard so poignantly from the noble Lord, Lord Polak.

As we have also heard, demand for care is rising as people live longer and often with more complex needs. As my noble friend Lady Barker explained, we now have a growing number of people without children of their own. Recent analysis from the King’s Fund showed that overall requests for social care have hit an all-time high.

At the same time, as we have heard, the workforce is in near meltdown. I want to explain why I use that term. We know that there are severe staff shortages and problems both in retention and in recruitment, which mean that current needs are not being met. Without major change, things are going to get worse as demand grows. As we have heard, according to the King’s Fund, the current social care staff vacancy rate is the highest since records began: 165,000 unfilled posts is a huge number.

Looking ahead, Care England estimates that the number of adult social care jobs will need to increase by 27%, to around 2.3 million, by 2035. In reality, we are looking at the prospect of further workforce reductions over the next 10 years as the current care workforce, more than a quarter of whom are over 55, retire and are not replaced. Poor pay and conditions are key drivers affecting recruitment. One in three care workers is paid the minimum wage, or less as their travelling time between clients typically goes unremunerated. At the same time, other sectors are offering far higher rates for, frankly, less demanding work.

It is a scandal that the social care workforce is among the lowest paid in our economy and zero-hours contracts are prevalent. The Health Foundation has found that staff experience much higher levels of poverty and deprivation than other UK workers and health workers. For many in the sector, career progression is simply non-existent. Given all this, it is not a surprise that the workforce is in near meltdown.

The impact of these workforce shortages on both patients and the wider NHS is devastating. First, increasing numbers of people, especially the elderly, have unmet care needs. Due to a shortage of care workers, 170,000 hours a week of home care could not be delivered during the first three months of 2022. That is seven times more than spring 2021.

Secondly, there is a backlog in initial assessments and long waiting times for many people to have their needs assessed. Shockingly, people are dying while waiting for care. Age UK found that some 37,000 people died in 2020-21 without receiving the care that they were waiting for. According to the CQC’s recent State of Care report, only two in five patients are able to leave hospital without delay when ready for discharge.

Many of these problems, which so many noble Lords have talked about, are rooted in funding, which has been inadequate for many years. According to the Health Foundation,

“When the pandemic hit … government spending per person on social care was lower in real terms than in 2009/10”.


This is compounded by how social care funding is often piecemeal, with crisis cash in winter making planning harder. This is exacerbated by the fact that the actual costs of providing care, either in the home or in running a care home—wages, Covid expenses and the increased costs of food and heating—are rising, but many local authorities are rationing social care to those in greatest need due to inadequate funding from government. This point was underlined last year by the Local Government and Social Care Ombudsman. At an individual level, a failure to introduce a cap on lifetime care costs means that one in seven people over 65 faces catastrophic costs of more than £100,000.

Like other noble Lords, I was particularly alarmed to read recent press reports suggesting that the Government are poised to cut £250 million from investment in the social care workforce in England. I join the noble Baronesses, Lady Andrews and Lady Donaghy, in asking the Minister, when responding, categorially to either confirm or deny that this is the plan.

Of course, all of this results in an overreliance on informal unpaid carers, as demonstrated vividly in the recent report of the Select Committee chaired by the noble Baroness, Lady Andrews. According to Carers UK, in England the number of unpaid carers outnumbered the paid health and care workforce by at least two to one. Many other speakers have pointed this out passionately in our debate today. Millions of unpaid carers are having to bear the negative effects of social care workforce shortages and a lack of funding for social care. This leaves far too many of them with very little support, often feeling isolated and undervalued in the face of the relentless demands of caregiving.

Too many unpaid caregivers face financial hardships themselves, as they receive little financial support. Many find it hard to juggle staying in paid employment with caring. That is why I was so pleased to support the Private Member’s Bill put through the Commons by my honourable friend Wendy Chamberlain MP; it had its Second Reading here recently. It creates a new entitlement for employees to take up to a week of unpaid leave a year in order to provide or arrange for care. Yes, it is a very small step forward in improving employment rights for unpaid carers, but it is important none the less.

The most depressing thing in today’s debate has been the litany of broken promises of reform over the past decade. We had Dilnot, endlessly postponed; and White and Green Papers that never materialised. As my noble friend Lady Jolly reminded us, the Care Act 2014 was a seminal piece of legislation, but key provisions in it have been indefinitely postponed. The Government’s “Build Back Better” plan for health and social care, published in 2021, led to the passing of a law to collect a health and social care levy, but this was then reversed and the charging reforms outlined were subsequently delayed—again.

Despite all this doom and gloom, I want to end with some solutions to add to the others that have been put forward. There are five things on my immediate wish list which I am very much hoping to see in the long-awaited government social care implementation plan.

First, we need to invest in the workforce, pay wages people can live on and offer career progression by professionalising the care sector. That is why I am so pleased that Liberal Democrats are calling for a legal obligation to provide a carer’s minimum wage, to be set at a rate of £2 an hour above the national minimum wage. This much-needed boost is long overdue, and I know others have referred to it.

Secondly, the Government need properly to fund local authorities so they can continue to provide the social care services they are legally required to, and ensure that care homes are paid a realistic rate rather than relying on excessive cross-subsidisation by self-funders.

Thirdly, we desperately need to integrate services, so that there is a joined-up preventive approach which reduces the risk of reaching crisis point and needing care home placement or hospital admission. I hope the development of 42 integrated care systems can help bring this about, but concerns remain that social care sector providers struggle to get their voices heard within these systems.

Fourthly, we must provide more support for informal carers and introduce a statutory guarantee of regular respite breaks for unpaid carers.

Finally, as others have said—including, very powerfully, the noble Lord, Lord Bradley—the carer’s allowance must be reformed so that it no longer discourages carers from remaining in paid work. The carer’s allowance is the lowest benefit of its kind and does not reflect the contribution of unpaid carers; it must be increased.

I therefore ask the Minister: what assurance can he give me that the vital issues that I and others have underlined will indeed be addressed in the Government’s plan?

NHS Staff: Food Banks

Baroness Tyler of Enfield Excerpts

Tuesday 7th February 2023 Lords Chamber

[Lord Markham (Con)]

That is a concern; we want to resolve the pay dispute. I know personally how much time and energy are being put into this from our side as well. Clearly, more needs to be done. We are not there yet, but I am hopeful that we will get there. At the same time, we did try to protect those on the lowest incomes, as I mentioned earlier. Everyone received a minimum of £1,400, which is 9.3%. Clearly, we will need to do more for the next year, but we are trying to protect those in the most difficult circumstances.

[Baroness Tyler of Enfield (LD)]

My Lords, can the Minister tell the House what percentage of NHS hospitals have subsidised canteens that staff can use at the end of long shifts, and how many of these are open in the evening and during the night, when access to reasonably priced hot food is hard to find? If the Minister does not have those figures, could he please write to me with them?

[Lord Markham (Con)]

I do not have those figures so I will happily write to supply them to the noble Baroness. However, I have some examples, such as Newcastle upon Tyne, where they have good free meal cards that they can give out to help people buy their meals discreetly themselves, or the Birmingham Women’s and Children’s Hospital, which has subsidised £2 hot meals that are available at any time. So there are some good examples of what trusts are doing to help people in the space, but I will write to the noble Baroness about the other cases.

Care Homes: Staffing

Baroness Tyler of Enfield Excerpts

Wednesday 11th January 2023 Lords Chamber

[Lord Markham (Con)]

Yes, absolutely. I find—and I talk as a businessman of 30-odd years—that by paying people well, you attract and retain the most motivated staff. It is the best way to run an organisation.

[Baroness Tyler of Enfield (LD)]

My Lords, is it not the case that there will be sufficient staff in the social care sector—both care homes and domiciliary care—only when we have a truly integrated approach to workforce planning across both health and social care? Yes, pay will be absolutely critical, but so will progression and career development opportunities, and opportunities for things like joint posts and rotational arrangements between the two sectors. What plans do the Government have to look seriously at this critical workforce issue?

Hospital Beds: Social Care

Baroness Tyler of Enfield Excerpts

Monday 19th December 2022 Lords Chamber

[Lord Markham (Con)]

I thank the noble Lord. Yes, we are, and I think that is shown by the investment we are putting into place. As I say, that will be up to £2.8 billion next year and up to £4.7 billion the year after, which will be a 22% increase. That shows that we are very serious about this.

[Baroness Tyler of Enfield (LD)]

My Lords, we have already heard about the crisis in the social care workforce. NHS leaders are calling on the Government to introduce a new national minimum care worker wage of at least £10.50 an hour to stem the flow of social care staff to other sectors. Can the Minister say what plans they have to introduce such a minimum wage, which could hardly be said to be stoking inflation at that level?

[Lord Markham (Con)]

Of course, the noble Baroness is aware that it is the third parties, whether it be the local authorities or the private sector, that employ them. But what we have done in terms of setting the national living wage, which I believe is around that amount, is exactly making sure that there is a minimum amount that these people can get. About 65% of the funding going into the system goes through to wages, so the £2.8 billion increase next year will flow largely into wages and salaries.

Children in Care: CAMHS Waiting Times

Baroness Tyler of Enfield Excerpts

Monday 5th December 2022 Lords Chamber

[Lord Markham (Con)]

I have some personal experience in this area, so I agree that we need to see people as quickly as possible. On the investigation, we have recently undertaken a call for evidence, which closed in July with 5,000 responses that we are going through. I think that our response to that will answer many of the questions, but I would be happy to meet the right reverend Prelate and discuss this further when we have those results.

[Baroness Tyler of Enfield (LD)]

My Lords, the Select Committee looking at the Children and Families Act 2014, which I have had the honour to chair, is publishing its report tomorrow, and the frankly dire state of children’s mental health services runs through it like a stick of rock. Our inquiry received harrowing evidence of waiting times of up to two years for children already in crisis; specifically, we heard that there are very long waiting lists for post-adoption trauma support. What are the Government doing to improve mental health support for this particular group of children?

[Lord Markham (Con)]

I will need to write to the noble Baroness to give a specific response in that case. It is an area of concern where I think we are increasing awareness, and any diagnosis needs to start with awareness. By definition, that means that more people are diagnosed or come forward, which is a good thing, but it then means that often it takes longer to see those people—I do not say that as any sort of excuse but just as an explanation. As we increase our understanding in this area, and I think that we would all agree that over the last 10 to 15 years there has been a huge increase in understanding, that means that more people are coming forward, but it means also that we need up our game in terms of supporting them.

Abuse and Deaths in Secure Mental Health Units

Baroness Tyler of Enfield Excerpts

Wednesday 9th November 2022 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

I thank the noble Baroness. I first want to apologise for the failings in the care that Christie Harnett, Nadia Sharif and Emily Moore received. My thoughts, and I am sure the thoughts of this whole House, are with their families and friends. The death of any young person is a tragedy, all the more so when they should have been receiving care and support in a safe place.

The Minister in the Commons is looking much more towards a rapid review rather than a public inquiry, as the feeling is that rapid action is needed. We have seen some good examples of that recently, with Dr Bill Kirkup. It is very much at the top of the agenda and I agree with the noble Baroness; this is the third time I have spoken on similar incidents in the short time I have been here. We clearly need to make sure the proper action is in place to identify these issues.

[Baroness Tyler of Enfield (LD)]

My Lords, when this Question was answered in the other place on 3 November, the Minister said that

“staff shortages often contribute to some of the failings we have seen.”—[Official Report, Commons, 3/11/22; col. 1021]

These are some of the most horrific cases of abuse and death in so-called secure mental health units I have ever seen. Can the Minister say what emergency intervention funding will be made available, as happens with maternity services put into special measures, to ensure that every mental health patient in a secure unit is in a safe place?

[Lord Markham (Con)]

I agree, and I have been asking similar questions around whether we should be looking for a special measures-type regime in this space. To be fair to the new CEO, who has come in from 2020, he has set out a plan and progress is being made on many steps. It is the focus of the Minister to see whether that progress is quick enough. We understand that staffing is a key issue. We have increased the number of staff by 24,000 since 2016, and almost 7,000 in the last year alone. Clearly, part of this rapid review needs to be around staffing.

NHS: Discharge to Assess Policy

Baroness Tyler of Enfield Excerpts

Tuesday 8th November 2022 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, the recent survey conducted by Carers UK, which has already been alluded to, found that 63% of carers disagreed that they had been asked about their ability to provide care. Indeed, the report is littered with harrowing examples of carers who felt that the discharge of the person into their care had happened too quickly, as a result of which their condition got worse and they had to go back into hospital. Can the Minister say how the NHS will collect both qualitative and quantitative data at the point of hospital discharge to ensure that undue pressure is not being placed on families?

[Lord Markham (Con)]

As mentioned, the Carers UK report and its findings made for sobering reading. It clearly shows why it was right to delay the guidance until we had that input; again, that will be followed up at the conference on Thursday. I think we all agree on the premise that we want to discharge people into their home quickly because that is the best place they can be, provided that they are medically able to be there. It is then in their home that the assessment takes place. Clearly, that must happen in a timely fashion and with the carer’s involvement but, again, the survey showed that that is not being done quickly enough in many cases. I accept that there are many things we need to learn from this but I think we can all agree on the direction: it is right to discharge people quickly provided that back-up and support are there to ensure that they have what is needed.

Cost of Living: Public Well-being

Baroness Tyler of Enfield Excerpts

Thursday 20th October 2022 Lords Chamber

[Baroness Tyler of Enfield (LD)]

I congratulate the noble Baroness, Lady Drake, on her excellent opening speech and refer to my relevant interests in the register.

As we speak, we are witnessing political turmoil of a kind I have not seen in my lifetime. Frankly, we are a laughing stock on the world stage. All of this makes me very angry because it is ordinary people who will pay the price, and that is what we are debating. On 23 September we were already in a cost of living crisis, with the highest inflation in 40 years and the nightmare of out-of-control energy prices. Events since then have caused massive further anxiety, fear and distress for millions of our fellow citizens. The cost of living crisis we are experiencing and the impact on public well-being is simply dire. All the research on well-being shows that not being able to meet basic needs has a negative impact on well-being individually, as families, communities and as a nation.

How did we reach this parlous state? It just does not wash to blame it all on Ukraine and other international factors. The market’s response to the so-called fiscal event of 23 September—the completely unfunded and by far the largest giveaway Budget in 50 years—was instant, brutal and devastating, both for the UK economy and us all as individuals. Sterling plunged; gilt yields rocketed; mortgage rates rose by well over two percentage points; and major players in the pensions market came close to insolvency. The outgoing Prime Minister’s much-lauded but quickly junked growth plan led to the UK losing overnight our much-cherished global reputation for fiscal probity and sound financial management.

Instead of it being a case of going too far too fast, the truth is that the growth plan did not survive its first contact with economic reality. The immediate result was to crash the economy. It is ordinary citizens—particularly the most vulnerable and the lowest paid—who are going to pay the highest price. Fast forward a few weeks: the IFS and others estimate that there is a remaining black hole of around £40 billion still to be bridged in the Chancellor’s Budget on 31 October. The Chancellor has said that he will be identifying a mixture of further extraordinarily painful cuts in public expenditure, together with increases in taxation. No matter what the Chancellor does, however, the UK will be paying a significant political risk premium to lenders not just for months but for years to come. One very visible effect of this is that millions will be paying higher mortgages and rents of several hundred pounds a month for years to come. It is no wonder that people are anxious, and public well-being has nosedived.

Jeremy Hunt has stated that he will be keeping the most vulnerable at the centre of his attention, which is clearly right. However, he is still refusing to confirm that universal credit will be raised next April in line with an inflation figure of well over 10%. The energy price guarantee—which, of course, was very welcome—has now been reduced from two years to six months. History will judge both the politics and the economics, and will allocate blame for the mistakes made on 23 September and subsequent events. Today, however, we are focusing on what we can do to support the millions whose already fragile sense of personal well-being has been further battered by all this turmoil and to protect them from the worst effects of that £40 billion of further cuts and tax increases still to come.

The context is not promising. Inflation is at 10%; food inflation is at 14% and real wages for many are at a 40-year low. According to a recent British Psychological Society survey, 55% of people feel more anxious about being able to pay their bills than they did this time last year; more than a quarter said that worrying about money was making them feel depressed; only 27% felt confident that they will get by financially this winter, and 52% said they were concerned about not being able to afford food. Other recent surveys have shown an estimated 11 million people feeling unable to cope. Anxiety about the rising cost of living is estimated to be affecting half the population; 50% of the population report that they have had to reduce expenditure on essentials—food, toiletries and petrol—over the past few months. Use of food banks, as we have heard, including by people in full-time employment, is skyrocketing. Millions are extremely anxious about how they will be able to feed their families and children. An estimated 1 million children are in food poverty and not receiving free school meals. Fuel poverty is estimated to have tripled, with many saying that they feel too scared to open their energy bills.

This cost of living and well-being crisis requires an urgent and meaningful response. This toxic cycle of mental health problems and money worries demands immediate action from the Government, regulators, employers and firms to stop the cost of living crisis becoming a mental health crisis. Many charities, think tanks and external commentators are generating policy responses and ideas. Foremost among these are: raising all benefits, including universal credit and disability benefits, in line with inflation on 1 December; reviewing and then revising in line with inflation all benefits, not only every 12 months but every six months, starting from next April; moving all children from families living in food poverty into free-school-meal programmes; providing further targeted cost of living payments to vulnerable groups still falling through these new safety nets; strongly encouraging mortgage providers and landlords to restructure payments for those struggling with payments, with a view to minimising home possessions and evictions; requiring the appropriate regulators to work with the energy companies to ensure that they make all possible efforts to secure payment restructuring for bill payers and provide a compassionate response to customers; ensuring energy companies make further financial contributions to the financing of the energy price cap; and ensuring—this is very important—provision of adequate and accessible debt advice services and debt relief schemes to prevent people from spiralling ever further into debt.

Finally, it is vital that the Government commit to funding mental health services, as set out in the NHS Long Term Plan, and publish the promised 10-year cross-government mental health and well-being plan and the health disparities White Paper. I hope that, when the Minister winds up, he can assure me that the measures I have highlighted, and others that we will no doubt hear about today, are being urgently considered.

Finally, there is a time when you have to say, “Enough is enough”. So could the Minister also say when this Government will finally do the decent thing and call a general election?

Health and Social Care Update

Baroness Tyler of Enfield Excerpts

Monday 10th October 2022 Lords Chamber

[Lord Markham (Con)]

On the 15 trust areas, I will need to get back to the noble Baroness on whether it is down to demographic factors. I wish to dig into it more and will look at a number of things. I have been told anecdotally that the day of the week makes a big difference to performance and wait time, so that is another area I want to get underneath. In terms of retaining people, as an entrepreneur who has started up many businesses, I know the importance of motivating a workforce. Clearly, if work does not pay—for want of a better word—there is not much motivation to put in the extra hours we require. I will come back to the noble Baroness with more information on that.

[Baroness Tyler of Enfield (LD)]

My Lords, I welcome the Minister to his new role and declare an interest as a non-executive director of the Royal Free London group of hospitals, which includes Chase Farm. I would like to pursue the points made by both the noble Baroness, Lady Merron, and my noble friend Lady Brinton about health inequalities. With an almost 20-year gap in healthy life expectancy between the most and least deprived areas in London, could the Minister say if and when the Government are planning to publish the health disparities White Paper?

[Lord Markham (Con)]

I thank the noble Baroness for reminding me that I failed to reply to that point earlier and for giving me the opportunity to do so, but I will need to investigate further. As I say, I do not have immediate knowledge of this issue, but I undertake to come back to the noble Baroness with a reply.