NHS: Long-term Sustainability

Baroness Warwick of Undercliffe Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Warwick of Undercliffe (Lab)]

My Lords, it is a pleasure to follow the noble Lord, Lord Crisp, and I thank the noble Lord, Lord Patel, for providing the opportunity to consider this challenging but vital issue. I look forward to the maiden speech of my colleague, my noble friend Lady Ramsey of Wall Heath.

I shall focus my remarks on care needs, highlighting the crucial interdependence of care and the NHS. I will draw on my experience as a member of this House’s Select Committee on Adult Social Care, so ably and empathetically chaired by my noble friend Lady Andrews, whose report, A “Gloriously Ordinary Life”, was published at the end of 2022.

It is clear to me that, if we are to ensure the long-term ability of the NHS to deliver comprehensive healthcare for all, adult social care is crucial. Fundamental changes to social care funding and provision, in the form of a national long-term plan for adult social care, are a national imperative. We engage with the NHS at all points in our lives, but adult social care is often invisible and off the public agenda until we have a sudden need for it. Yet as our report noted, 10 million of us are affected by it at any one time, either because we receive care and support or because we provide paid or unpaid care. Because we are living longer and with more complex conditions, we are all increasingly likely to be one day included in that number.

Noble Lords will be aware that there is no national government budget for adult social care in England. Services are financed primarily through local authorities, bolstered by large numbers of people who fully or partly fund their own care. As the APPG on Adult Social Care highlights in its recent report Future of Care 5, this piecemeal approach means that social care is particularly vulnerable and will often be the first to lose out when—I say that advisedly—the NHS or local authorities have their budgets cut. The 29% cut in local government funding since 2010 has led to an estimated 12% drop in spending per person on adult social care services.

If we are looking at new models and systems of care and funding within the NHS, we have to change short-term emergency funding. Social care needs a long-term funding plan. As our Select Committee highlighted, improving adult social care should be seen not only as an investment in the NHS but in ourselves, as a resilient and caring society. As the quality and consistency of services has suffered, so has the pressure and demand on unpaid carers risen. Estimates suggest that there are more than 6 million unpaid carers in the UK, and the actual figure is likely to be much higher. Estimates of the value of unpaid care provided by family and friends vary between £100 billion and £132 billion a year. That is an extraordinary contribution to the health of this country and it really needs to be seen to be valued. However, as one carer who gave evidence to our report told us:

“Unpaid carers are often not even considered to be a part of the health sector and yet without them the sector would collapse”.


Despite their numbers, carers feel invisible and many are at financial, emotional and physical breaking point. Hearing the lived experiences of those who gave evidence to the Select Committee was sobering, at times even harrowing. Time and again, they told us of being unaware of what help was available, not knowing who to ask or how to access help, or of not being listened to and being put through tick-box exercises that bore no relation to their actual circumstances or needs. Time and again, these carers were falling between the gaps of a broken system, often over many years.

One parent carer told us that, while her daughter was under the age of 18, she had a central point of contact within the NHS, a paediatrician, who could project manage the different strands of specialism her daughter needed. Once she turned 18, all this fell off a cliff. The distinction made between a health need and a social care need means that unpaid carers, often family members, are on their own, battling to get information and help.

In the Select Committee report, we urged the Government to establish a commissioner for care and support who would be able to raise the profile of social care, act as a champion for older adults, disabled people and unpaid carers and accelerate a more accessible adult social care system. Sadly, this recommendation gained no traction with the Government, but, in light of the overwhelming body of evidence on the need to improve adult social care and advocate for those at the heart of adult social care of all ages, can the Minister give us any assurance that this will be revisited?

[Lord Evans of Rainow (Con)]

My Lords, I am most grateful to the noble Baroness for finishing just before five minutes were up, but she has been the only one. The excellent speech of the noble Lord, Lord Patel, finished two minutes before his allotted time. I gently remind all noble Lords to keep to their allotted time of five minutes. I know that the next speaker will keep to it because he is a perfect timekeeper.

Maternity Services

Baroness Warwick of Undercliffe Excerpts

Thursday 25th January 2024 Lords Chamber

[Baroness Warwick of Undercliffe (Lab)]

My Lords, I thank my noble friend Lady Taylor, for introducing this timely debate. It is an honour to follow the noble Baroness, Lady Cumberlege, with her long and distinguished engagement with many health issues.

I want to highlight some numbers. The Royal College of Midwives estimates that there is a current shortage of midwives across England equivalent to 2,500 full-time staff. While the NHS workforce in England rose by 14.1% between December 2019 and March 2023—that is almost 160,000 full-time equivalent members of staff—the number of midwives over that same period rose by 1.1%, or just 247 additional midwives. The impact of this shortfall, to quote the RCM, is “stark and sobering”.

Staff shortages mean women and their babies are not receiving the high-quality care midwives want to deliver. But it is not just that staffing levels simply have not kept pace with demand. At the same time, a rise in more complex pregnancies—whether due to increasing maternal age, increasing obesity in pregnancy or pre-existing medical conditions, all of which may place women at high risk of complications—has resulted in pregnant women often requiring more care and more time with midwives so that these issues can be picked up.

The last few years have also seen a significant year-on-year drop in students studying nursing, with an inevitable impact on the numbers who go on to midwifery. This is critical because, while steps are now being taken to increase the number of student midwives, the potential positive impact of this is undermined, as my noble friend has said, by too many experienced midwives leaving. Why? It is because they are burned out, insufficiently valued or rewarded, and because they cannot deliver the quality of care they want. In addition, senior midwives are needed to provide oversight and leadership, but this essential career route means losing experienced midwives, which is having an impact on the ability to train student midwives on their NHS placements. Staffing ratios need to reflect the combination of experience and skills needed to deliver care successfully. Within the workforce planning now under way, what review of national staffing ratios is taking place to ensure that we have sufficient staffing and funding for the population that NHS England serves?

The “stark and sobering” truth is that, in recent years, our maternity services have got worse, not better. The Care Quality Commission’s latest maternity survey shows the decline in positive maternity experiences. Confidence and trust in staff delivering care, whether antenatal, in-hospital or postnatal, has fallen over the past five years. Staff availability, and communications and interactions with staff, require improvement. My noble friend highlighted the BBC report from last November, which analysed CQC data and found that 67% of England’s maternity units—more than two thirds—had been rated by the CQC as inadequate or requiring improvement, up from 55% in the previous year. The CQC describes the overall picture as

“one of a service and staff under huge pressure”.

That is a thunderclap of a warning from the regulator.

More recently, we have data showing that the maternal mortality rate in the UK has risen to levels not seen for a decade, and shocking inequalities are contained within these figures. An investigation led by Oxford Population Health found that the maternal death rate was three times higher for black women than for white women, and two times higher for women from Asian ethnic backgrounds. Women living in the most deprived areas had a maternal mortality rate more than twice as high as those living in the least deprived areas.

Alongside the disturbing national data, we have seen catastrophic failings by specific NHS maternity units across England. The independent review of maternity services at the Nottingham University Hospitals NHS Trust is ongoing, while the investigations into maternity care at University Hospitals of Morecambe Bay NHS Foundation Trust, the Shrewsbury and Telford Hospital NHS Trust and the East Kent Hospitals University NHS Foundation Trust all produced recommendations for action, all prompting new oversight groups, strategies and targets.

We now have a national maternity safety ambition to halve the 2010 rates of stillbirths and neonatal and maternal deaths by 2025, which I understand we are not on target to achieve. Can the Minister confirm that? We have a women’s health strategy and the NHS long-term plan—and we finally have a Three Year Delivery Plan for Maternity and Neonatal Services, published in March last year. It sets out how the NHS will make maternity and neonatal care

“safer, more personalised, and more equitable”

for women, babies and families. This is a great ambition—an essential ambition—but where are the building blocks that are needed to achieve it and overcome the stark data I quoted earlier? It seems to me that we have some way to go for this ambition to become a reality.

Midwives who shared their experiences ahead of this debate tell me that they have lost patience with reports and reviews. They say it really is about the numbers: more midwives in the wards means better care for mothers and babies, fewer mistakes, a more positive and supportive culture for midwives to work in and more reasons to stay in the profession. “Invest in more staff as quickly as possible” is the message I received. As we have seen from some of the terrible failings in recent years, ensuring a culture that fosters openness and learning really matters. I was dismayed to find that a number of midwives were not prepared to talk to me because of the negative repercussions for colleagues who had previously spoken out. Donna Ockenden’s review of Shrewsbury and Telford Hospital NHS Trust maternity services, published in March 2022, puts it succinctly:

“Only with a robustly funded, well-staffed and trained workforce will we be able to ensure delivery of safe, and compassionate, maternity care locally and across England”.


I therefore ask the Minister: can he give us any new update on progress on the actions and recommendations in the NHS England Three Year Delivery Plan for Maternity and Neonatal Services? How are they ensuring that recommendations for action will be widely implemented in all maternity services across England? We need to know that we are moving forward. We must do better, and we must do so quickly.

Social Care: Integrated Care Systems

Baroness Warwick of Undercliffe Excerpts

Wednesday 11th January 2023 Lords Chamber

[Lord Markham (Con)]

From my experience I understand that this is a very important part of their remit and role. As we are all aware, the unpaid carer role is vital and historically has probably not been recognised as much as it should have been.

[Baroness Warwick of Undercliffe (Lab)]

My Lords, following on from the question asked by the noble Lord, Lord Laming, what plans has the Minister to encourage ICSs to embed co-production in the design and delivery of adult social care at the local level?

[Lord Markham (Con)]

Each ICB has a slightly different approach to ensuring that it is there and ensuring the kind of co-production with these front-runners that I talked about earlier. It is about trying to see whether there are new and better ways of doing it. Maybe at another time I can talk to the House in more detail about what those six different pilots are doing. It is about taking the comments that I have heard here over the last few weeks about what works and trying to scale them up.

Covid-19: UK Arrivals

Baroness Warwick of Undercliffe Excerpts

Tuesday 16th November 2021 Lords Chamber

[Lord Kamall (Con)]

I share the frustration of the noble Baroness and others. This is not great for our international, global outlook, or for the fact that we want to attract the best students from around the world, not just Europe. We are a global country and we have to address this. I am pushing the NHS on this because it is really important. The problem is the national immunisation management system, to use the technical term, and the inability to validate the data of overseas visitors.

[Baroness Warwick of Undercliffe (Lab)]

My Lords, I can sense the Minister’s frustration in this, but we have been aware of it for some time; this should have been sorted out a long time ago, yet here we are now in November. Does the Minister accept that all departments must play their part in achieving the Government’s aim of increasing the number of international students? Will he assure us that his department will be both flexible and creative—with the emphasis on “creative”—in resolving this and other similar problems that may arise?

[Lord Kamall (Con)]

I assure the noble Baroness that when I was pressing this issue yesterday with officials in preparation for this Question, I stressed the importance of flexibility and creativity. We need to think outside the box on many issues. One issue we are looking at is: if passenger locator forms can do this, why can the NHS Test and Trace system not? I am told that is because it is based on self-certification. I am pushing the NHS to address and analyse the different options as soon as possible. It is really important we send a message to the rest of the world that we are open to the brightest and the best from across the world.

Health Care and Adult Social Care

Baroness Warwick of Undercliffe Excerpts

Wednesday 27th October 2021 Lords Chamber

[Lord Kamall (Con)]

I thank my noble friend for his question and for the advice he has given me to date. Even though I have size 11 feet, I am finding it rather difficult to fill his large shoes. On the funding announced, local authorities have a key role in supporting recruitment and retention in their local areas. We are working with them to make sure that they support local providers by identifying workforce shortages, developing workforce plans and encouraging joined-up services. We also continue to work closely with providers, councils and our partners to assess the situation and consider what further action may be necessary.

[Baroness Warwick of Undercliffe (Lab)]

My Lords, the CQC’s annual report highlights the challenges faced by people with learning difficulties, their families and their informal carers. Does the Minister acknowledge this problem? The CQC accepts that its inspection procedures require more emphasis on the knowledge and experience of family and informal carers, following Professor Murphy’s report on the failures and abuse in Whorlton Hall. How can we hope that the CQC and other agencies in health and social care will give priority to the role of family and informal carers when the Government’s main policy statements and papers still virtually ignore their existence?

[Lord Kamall (Con)]

The Government recognise the valuable role that paid and unpaid carers play in social care. We are looking at how we can make sure that we recruit and retain staff. We understand the challenges that many care homes, quite often those in the private sector, face when trying to recruit and retain staff, given the competitive pressures around the jobs market. The Government certainly take seriously the role of unpaid and paid carers.

Social Care in England

Baroness Warwick of Undercliffe Excerpts

Thursday 14th October 2021 Lords Chamber

[Baroness Warwick of Undercliffe (Lab)]

My Lords, I congratulate my noble friend Lady Pitkeathley on her devastating opening speech, which set out vividly the challenges facing social care and the inadequacies in the Government’s proposed response. I am glad to join in noble Lords’ welcome to the Minister.

This is, I think, the fourth time in the last month that this House has expressed its concerns about the Government’s approach to social care. On Monday, the noble Lord, Lord Agnew of Oulton, introduced the Health and Social Care Levy Bill, when speakers from all sides of the House expressed real anxieties that the Government’s proposals will not address the key issue: that too few people are getting the level and quality of care that they need. Given that this is the Government’s flagship Bill to resolve one of the biggest challenges facing the country, the lack of confidence in your Lordships’ House and elsewhere is desperately worrying. I hope that, in replying to this debate, the Minister will seek to assure us all that the Government are listening to these concerns and that they will be reflected in the next stage of their plans for both resources and social care reform.

Successive Governments have neglected social care, and the pandemic has dramatically shown that the sector has been brought to the brink of disaster. Report after report has shown that many vulnerable people died in care homes because the problems of care homes simply were not part of the Government’s thinking. Millions of unpaid carers were left completely unsupported as support services were withdrawn overnight and they were left to struggle alone as best as they could. The impact of that on carers and those for whom they care has clearly been devastating, although I fear that it is as yet largely undocumented. Carers UK is beginning to gather this grim evidence.

Only today, Skills for Care published its annual report, The State of the Adult Social Care Sector and Workforce in England, which documents the impact of the pandemic. It reports that sickness rates “nearly doubled”,

“occupancy levels in care homes have fallen”

and workforce numbers started to fall from March. It states:

“As of August 2021, vacancy rates are now back above their pre-pandemic levels”


and are increasing. The report estimates that, if the workforce is to increase at the same rate as the proportion of over-65s in the population,

“by 2035 the sector may need 490,000 extra jobs”.

How will they be provided?

I say all this to emphasise the urgency of providing the resources to right this terrible wrong now. It is not clear that the Government’s present proposals will do this, however good their intentions. The NHS clearly needs money to tackle waiting lists; this will help families looking after relatives with worsening health conditions. However, the recent announcement does not suggest that there will be any immediate direct investment in social care. The Commons Health and Social Care Select Committee advised that £3.9 billion is needed just to deal with the sector’s wage increases to the national living wage and ageing pressures. The LGA estimates that £1.5 billion is needed each year just to stabilise the care provider market—the difference between what it costs providers to deliver care and what councils pay.

Where will vulnerable patients from hospitals go if there are no care places? In all the public pronouncements and speeches in the House and elsewhere, the Government have scarcely mentioned unpaid family carers. If they are not mentioned in descriptions of how policies will be made in future, that probably means that they will be left out of the picture altogether. Carers UK is concerned that, although the Government’s proposals will help some families, they will not help carers who need help now. For instance, there is no indication that the levy will secure an immediate increase in funding for breaks or respite support for carers. Nor will it help those with the lowest means who cannot afford to pay for their own services and have no other recourse but help from the state or charities.

Can the Minister tell us whether the Government plan to provide immediate and significant cash injections to local authorities for the delivery of adult social care services, including support for unpaid carers, in the forthcoming spending review on 27 October? How will the health and social care levy deliver the funding for underlying social care support so that carers can juggle care and work? Without this investment, it is unlikely that the Prime Minister will be able to deliver on his promise to fix social care.

In adding one final point on supported housing, I declare my interest as a chair of the National Housing Federation. I have stressed many times in this House the essential role of supported housing in delivering independence and well-being for many people with long-term care and support needs. Supported housing takes the pressure off public services and saves public funds. Housing associations, like care homes, are struggling to fill vacancies. The value of local authority contracts is so low that it is not possible to increase wages or reward staff financially for their dedication and the sacrifice made over the pandemic to keep residents safe. The Government have promised ring-fenced funding for the NHS and social care. Can the Minister consider reinstating the £1.6 billion ring-fenced funding for housing-related care and support services and use the opportunity of social care and NHS reform to prioritise preventive services, give security to people with care and support needs, guarantee funding and enable housing providers to continue responding to the impact of coronavirus?

Social Care and the Role of Carers

Baroness Warwick of Undercliffe Excerpts

Thursday 24th June 2021 Lords Chamber

[Baroness Warwick of Undercliffe (Lab)]

My Lords, the forensic, measured and moving opening speech of the noble Baroness, Lady Jolly, demonstrated that there are a number of pressing issues to be addressed within the wide topic of social care. The Government have committed themselves to resolving the issue of who pays for residential care in old age, and we are all eager to learn of their plans as hundreds of families face this challenge every month. I shall focus in my three minutes on two points: social care provided by the not-for-profit sector; and social care provided by family, friends and others who are unpaid—what is called informal care.

As chair of the National Housing Federation—I declare that interest—I have taken a keen interest in housing associations’ provision of not-for-profit care and housing, and seen the amazing work they do not just for the elderly but for those with disabilities, learning difficulties and physical and mental illness. I echo the call from Anchor Hanover, England largest not-for-profit provider, on the need to tackle the negative perceptions of social care in terms of low pay and lack of career progression. This is not new: before the pandemic, there was a shortfall of 1.1 million care workers in the next 15 years. With a current workforce estimate of 1.6 million, that is a massive challenge. What will the Government do to deal urgently with these negative perceptions and begin to address the shortage challenge?

On my second point, about informal carers, my noble friend Lady Pitkeathley has consistently and passionately advocated their cause in this House; I look forward to hearing her contribution shortly. In my experience, the majority of all social care is provided by family or friends caring for their loved ones. In most cases, they do not even label themselves as carers; they do it because they are husbands or wives, daughters or sons, sisters or brothers. It is what they do, and it is what we do. This vast army of carers increased dramatically during the pandemic. In most areas, services for carers, including young carers, vanished overnight, and there are real concerns that they will not be reinstated. There are an estimated 13.6 million of them, plus 800,000 young carers, yet they are often invisible when it comes to public policy and they have to fight every inch of the way for support, often at the cost of their own health or financial security.

Despite their warm words, the Government entirely missed the opportunity in their health and social care White Paper to recognise the contribution of informal carers. The Minister will be well aware of the mounting criticism of the Government’s response to the pressures on social care provision and on carers as a result of the pandemic. Can the Minister assure us that carers will be specifically included in any forthcoming legislation, and that carers themselves will be directly involved in its preparation? The Government now have an historic opportunity to make changes that will at last deliver parity of esteem between social care and the NHS.

Covid-19: Variant B.1.617.2

Baroness Warwick of Undercliffe Excerpts

Wednesday 26th May 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, there is an enormous amount of data published. I draw the noble Lord’s attention to table 6 in the table test conducted on 28 May 2020, which has an enormous amount of weekly collection data for schools. In that week, 1,967,904 LFTs were taken by schools, and they yielded 1,806 positive results. Those were all examples of where we have cut the chains of transmission. Tests are delivered through a variety of channels, including the community testing channel. Reports on infections in schools are analysed by the tracing programme, and they are then taken through to PHE and JCB. We are looking at ways in which we can aggregate all that schools data into more specific tables. But until we do that, there is already a very large amount of data.

[Baroness Warwick of Undercliffe (Lab) [V]]

My Lords, my noble friend has pointed out that cases are substantially concentrated in school-aged children and young adults, who of course have not yet been vaccinated. Does the Minister agree that it was premature to announce last week that face coverings will no longer be required in secondary school classrooms and communal areas? Does he accept that this policy could drive an increase in infections in our unvaccinated children and young people, as well as in school staff, families and wider communities?

[Lord Bethell (Con)]

I share the noble Baroness’s concern, but I can reassure her on a couple of things. It is, I think, a real tribute to the hard work of parents, teachers and the pupils themselves that the infection rates in schools have been relatively contained, and certainly have not shown the same kinds of behaviours that they did in September of last year. But we remain extremely vigilant, for exactly the reasons the noble Baroness explained. On the question of face coverings, it is a very difficult balance to strike—they are intrusive and disruptive but, on the other hand, they are an effective way of minimising infection. It is an area that we keep a very close watch on.

Health and Social Care Update

Baroness Warwick of Undercliffe Excerpts

Monday 22nd March 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, I simply do not recognise the characterisation that the noble Baroness has just presented. The view of our treatment of the elderly and vulnerable taken by Amnesty during the pandemic is completely inappropriate and inaccurate. Huge steps have been taken to protect those who are vulnerable and elderly. I cannot think of a country that could have done more under the circumstances. I therefore reject its analysis.

[Baroness Warwick of Undercliffe (Lab) [V]]

My Lords, this is a Statement on health and social care. I am astonished that the Minister has confined the Government’s policy on adult social care following the pandemic to a couple of sentences. He must know that most of the adult social care in this country is provided by family carers. They are regularly ignored in such Statements, but many of the 6 million carers looking after vulnerable adults, including those with learning difficulties, have been pushed to breaking point by the pandemic. Is there nothing to say to them about access to support services or respite care and nothing on carer’s allowance? Without support for these essential carers, policies such as enhanced hospital discharge, as mentioned in the Statement, will not be feasible. What is the Government’s strategy for dealing with this crisis in care?

[Lord Bethell (Con)]

My Lords, I endorse completely the noble Baroness’s remarks that we depend on the generosity, public spirit and kindness of family carers who provide an enormous amount of support for their loved ones. Without them, the system could not possibly exist and the world would be a much graver place. I recognise that many carers have been pushed very hard by the pandemic. We have put a huge amount of resource into local authorities, which are responsible for providing support for those families, and that includes the kind of respite support that the noble Baroness has rightly pointed to. I am sure that more could be done and I would welcome any correspondence on this by way of follow-up that she would like to send my way.

Dentists: Covid-19

Baroness Warwick of Undercliffe Excerpts

Thursday 11th February 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, the noble Baroness is entirely right; ventilation is a key issue. I took my daughter to the dentist this morning, and there were indeed long gaps between each appointment. I am not aware of the ventilation system she alludes to, but if the BDA would like to write to me, I would be happy to have a closer look at it.

[Baroness Warwick of Undercliffe (Lab) [V]]

My Lords, can I follow up on the Minister’s point about the new activity target imposed on dentists to reduce the backlog? It seems to have had the reverse effect. It has resulted in one of the biggest dental chains in the country instructing its dentists to focus on band 1 check- ups and reduce urgent treatments to meet the targets, reducing access for those who need it most. Other practices are reported to be doing the same. What assessment have the Government made of the impact of this target on patients who need urgent and complex treatment? Dentists have continued working, like doctors, nurses and other health professionals, in a high-risk environment during the pandemic. But their contribution seems to have been ignored. Can the Minister confirm the Government’s appreciation of the commitment of dentists and their staff during this pandemic?

[Lord Bethell (Con)]

I join the noble Baroness in paying tribute to dentists. As of 18 December, 88% of NHS dental practices were open, and that is a huge tribute to the hard work, determination and skills of dentists. She is right that they offer a spread of services; more triaging is going on, and that has successfully made a big contribution to getting through the lists. As of 13 January, 6.9 million dental patients have been triaged on the AAA service—advice, analgesics and antibiotics—but urgent dental care centres, of which there are 695, have picked up the difficult and time-consuming work for those who have an emergency need.