The Long-term Sustainability of the NHS and Adult Social Care

Baroness Watkins of Tavistock Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

I thank the noble Lord, Lord Patel, for securing this debate and for his work as the Select Committee chairman. I particularly congratulate the members of the committee on providing an excellent report, despite the fact that there was no nurse and five medical staff on the review team. The committee has produced a thoroughly excellent report that highlights the fundamental issues to consider if we are to preserve the notion of health- care that is free at the point of delivery, funded through the taxpayer, for future generations. Note that I do not say “the NHS” because, coming from a mental health background, I know that a tremendous amount of good care is provided by a range of charities and voluntary organisations as well as the mainstream NHS; however, it needs to be funded through the public purse.

I draw attention to my interests in the register, particularly as I am a nurse, as noble Lords know. With that in mind, I was initially intending to speak largely on nursing, but many noble Lords have done that so I have added one or two other issues to my speech.

Without doubt, we simply need enough appropriately skilled and motivated staff to provide care in the health service and social care—not just adult social care but children’s social care. This has been highlighted by many noble Lords, particularly the noble Lord, Lord Willis, and my noble friend Lady Emerton. This requires a focus not just on recruitment and pre-registration training but on nurturing and developing the staff we already have. As Public Health England’s report Facing the Facts, Shaping the Future distinctly put it:

“The most cost-effective way to ensure the health and care system has the staff we need is to keep the people we already employ”—


including those of the Windrush generation and their successors, many of whom I have worked with in my clinical experience.

Yet unprecedented numbers of nurses are leaving the NHS for reasons other than retirement—more than 5,000 more, in real terms, than five years ago. The Royal College of Nursing gave powerful evidence to the Commons Health Select Committee earlier this year about nurses feeling undervalued and not supported. Reasons for leaving cited included the pressure of the workload, with nurses often feeling that they are unable to undertake their full role in terms of care and kindness to their patients, but also a lack of flexibility, pay and career development. There have been significant cuts in CPD budgets, which have obviously prevented nurses and allied healthcare professionals in developing further competences to take over some of the roles traditionally undertaken by medical staff.

It is not merely that we need more money but how money is spent most effectively. At the most basic level, we need to support newly qualified staff of all types to ensure that they can undertake their roles safely and with confidence. However, at a time of transformation, with new models of care being introduced, a flexible, adaptable and resilient workforce is key to leading the NHS into the future. Upskilling the workforce to specialise in priority areas and to advance practice and leadership skills, so that people see working in the NHS as a career, not a job, will enhance productivity and facilitate change and improvements. These benefits would represent good value for money.

Much has been said on funding for health and social care. However, I will briefly mention how we might fund it in the future. The NHS is a source of national pride, with near universal support. There is much evidence to suggest that a large proportion of the public are willing to pay more to have a high-quality NHS. However, we need to be careful that whatever we do to increase funds for the NHS demonstrates intergenerational fairness. We cannot expect the younger generation to pay entirely for the older generation. I fail to understand why we could not undertake some of the other issues people have recommended here on older people paying more.

I have raised points about the workforce, but I will take one extra minute to talk about care. If we are to reduce expensive, prolonged stays in hospital that are harmful to patients’ health and prevent unnecessary admissions, and allow ourselves to provide kinder care where people want it, in or near their homes, in a more cost-effective way, we need to think how we can do so. For example, I hear of children in mental health in-patient care being admitted 100 miles away from their homes and families, with essential components of their care and treatment, such as family therapy and liaison with social care, unable even to start until they can be moved closer to home. This is clearly not kind or cost-effective.

I have also just read a very poignant account of the provision of “comfort care” at the very end of life in the obituary of Barbara Bush, the former US First Lady. It noted that she rejected further treatment in hospital and selected a comfort care package at home for her last days. This illustrates how people with sufficient knowledge can plan the most comfortable care in a personalised way. I urge us to think how we might adopt the term “comfort care” rather than “end-of-life care”, because it demedicalises the concept and may be particularly pertinent to people suffering from dementia.

I therefore support the concept that we should pool the risk for all people in terms of social care as well as healthcare. I very much hope that, as a result of this report, we will find a cross-party collaboration that will enable us to get not a 10-year funding plan but a 30-year vision for health and social care.

NHS: Staff Pay

Baroness Watkins of Tavistock Excerpts

Wednesday 21st March 2018 Lords Chamber

[Lord O’Shaughnessy]

I thank my noble friend for making that point. It is not only about the lowest paid staff whom she has described. It is also worth dwelling on the fact that a newly qualified nurse will see a significant increase in his or her pay, which will be 12.6% higher in 2020-21. This is a package which takes account of the fact that starting salaries have been too low. We are trying to address that because it is one of the ways we can attract more people into the profession.

[Baroness Watkins of Tavistock (CB)]

My Lords, I welcome this Statement as a sign that the Government have at last recognised the effect that the pay cap has had on recruitment and retention, in particular in nursing. I hope that this pay increase will lift many nurses out of hardship and improve morale. It is a sign that the Government value NHS staff and I especially welcome the significant increase for newly qualified nurses for 2020-21. These new recruits, who commenced their training in 2017 without bursaries, will be in a far better position—comparable with other graduates in terms of starting pay—as they proceed to repay some element their salary after achieving an income of more than £25,000 a year. My only concern is that the charitable and social care sectors, which employ nurses, will need to match these salaries. How can we ensure that they will be able to do so?

Abortion: Misoprostol

Baroness Watkins of Tavistock Excerpts

Tuesday 20th March 2018 Lords Chamber

Asked by

[Baroness Watkins of Tavistock]

To ask Her Majesty’s Government, further to the Written Answer by Lord O’Shaughnessy on 21 January (HL5321), why there are no plans to enable women undergoing early medical abortion to take the second dose of the medication, misoprostol, at home, if they so wish.

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

My Lords, the Government’s priority is to ensure that women who require abortion services have access to safe, high-quality care. Abortions must be performed under the legal framework set by the Abortion Act 1967. We are not currently in a position to approve homes as a class of place under the Act. However, we will continue to keep this matter under review and assess further evidence as it arises.

[Baroness Watkins of Tavistock (CB)]

I thank the Minister for his Answer, but can he inform the House of the expected timeframe for the Government’s decision regarding enabling women to choose the dignity of being as comfortable as possible in their own homes when they experience medical abortion, rather than some of them suffering while travelling home from the clinic? Journeys of over two hours are not uncommon, particularly for women from rural areas. It is also worth noting that the procedure is endorsed as a safe practice by the World Health Organization.

[Lord O'Shaughnessy]

I thank the noble Baroness for her question. No timeframe has been set for any decision on a policy change. She will understand that any change of policy would need to be done cautiously, in the light of the evidence and of legal developments—for example, relating to Scotland’s decision to name homes as a place. It is on that basis that we will consider any further evidence.

Alcohol: Minimum Unit Pricing

Baroness Watkins of Tavistock Excerpts

Wednesday 28th February 2018 Lords Chamber

[Lord O’Shaughnessy]

I would be very happy to meet my noble friend and the colleague he mentioned.

[Baroness Watkins of Tavistock (CB)]

In terms of austerity, can the Minister justify neglecting the £3.2 billion cumulative reduction in alcohol-related harm over five years that the Public Health England evidence review into the policy cites with an MUP of 60p? That is what would be generated.

[Lord O’Shaughnessy]

As I have said, and reiterate to the noble Baroness, we will look at the impact of minimum unit pricing. We must not just take into account any revenue that we generate and the health benefits that could accrue, but make sure that it provides a fair deal for those who drink sensibly.

NHS: Charitable Donations

Baroness Watkins of Tavistock Excerpts

Thursday 22nd February 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness asks a very interesting question. Clearly these are emerging organisations and most of the charities are attached to hospital trusts—although not exclusively: some are attached to primary care. None of these are yet quite in being. Once they are in being, this will be an excellent suggestion that we should take forward.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain why we should not at least be clearer about what care costs by publishing the tariffs within hospitals so that people understand, if not individually, how expensive some of the day-to-day treatments they get are?

[Lord O’Shaughnessy]

That is an important point. We are not yet in a position where we have mandatory collection of all that unit pricing data. That will happen from the next financial year onwards, so we will be able to publish that data. It is important, though, to resist the urge to send out to people information itemising costs, precisely for the deterrence reasons that I mentioned.

NHS Winter Crisis

Baroness Watkins of Tavistock Excerpts

Monday 5th February 2018 Lords Chamber

[Lord O’Shaughnessy]

This is an afternoon of agreeing to meetings—but, yes, I would be delighted to do so. I am not knowledgeable enough about the issue that the noble Baroness mentioned but, while of course there is a huge difference in the kinds of workloads of those different types of A&E, the target incorporates all of them. They all have the obligation to reach the four-hour waiting time standard and we want to make sure that, whatever the situation and whatever the venue, we can do that.

[Baroness Watkins of Tavistock (CB)]

My Lords, will the Minister explain how, five years after the Francis inquiry, there is a lack of investment in the health and care nursing workforce in England, as outlined in the RCN report published today? That report, Left to Chance, shows that even if we had more beds we would not be able to staff them. In comparison, Wales has invested heavily in new nurses and continued professional development, and is doubling the number of district nurses that it intends to train this year. In England we currently have 4,400 qualified district nurses, but in 2010 we had 7,500. How can we resolve this quickly and ensure that we have more district nurses in training by this September?

NHS and Social Care: Winter Service Delivery

Baroness Watkins of Tavistock Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw attention to my interests as outlined in the register. I thank the noble Baroness, Lady Wheeler, for securing the debate on this important topic and for her excellent speech which, together with that of the noble Baroness, Lady Pitkeathley, and others, covered some areas which I will now not repeat. This topic should be of concern to all parties in this House, given the public’s expectation of access to high-quality provision, not only of healthcare but of social care.

Some 40 or 45 years ago, when I was at school, I read in a series of papers about the scandal in mental hospitals. It really encouraged me to go into mental health nursing and improve the lot of people who now no longer suffer in that way in institutional care. However, in the Times last week, there was the headline:

“A million lonely pensioners left to starve in their homes”.


A group of MPs from across all parties have talked about this. We are beginning to create what we had in institutional mental hospitals 40 years ago in people’s own homes, where they are even more isolated and alone than those who were in the system that I worked to change.

In all four countries in our United Kingdom, patients are waiting in ambulances or on trolleys in A&E prior to the full assessment of their conditions. One reason is that our acute hospitals are full, with bed occupancy rates of higher than 90%—completely different to the international recommendation that 80% to 85% is a safe way to practise. We know, as others have already outlined, that this is frequently because patients who are deemed fit enough for discharge are not fit enough to go home without significant levels of social support and care.

Rural England reported earlier today that, in Cornwall, there are on some days 60 people in hospital who are ready to go home, but part of the problem is that it is difficult to recruit home carers. Is that a surprise, when these carers are on less than £9 an hour and are not paid to travel, particularly in rural areas? At least when I was a district nurse I was paid for my travelling time. Patients are therefore held in ambulances, although with excellent paramedic care and support. Yesterday, South Western Ambulance Service NHS Foundation Trust told me that this costs about £66 an hour for individual ambulances and the clinical crew. Let us compare that to the £9 an hour for carers—if we could just turn the system around, could we not improve for the same amount of money? We know that people wait for long periods for discharge from hospital, which costs a minimum of £450 a day. We need a coherent total systems approach to health and social care. How can we do this? Well, is it not time for the Department of Health and Social Care to reimagine community services, as the recent King’s Fund report suggests?

As a short-term measure, we could set up some pilot sites, with acute trusts given the funds and authority to purchase and maybe even provide community support, including residential and nursing homes, for the first six weeks after discharge. Indeed, we could set up success measures to see whether we can reduce social isolation, enhance older people’s nutrition and thereby reduce admissions.

We need not only to remember that the current situation is affecting social care but to think about the perception of those whose planned operations have been postponed. These elective operations involve both young and older people, perhaps waiting for a simple hernia repair or orthopaedic operation. How do they feel about our NHS? Surely they would rather have innovative solutions than stay with the status quo. The issue of intergenerational fairness and a potential hypothecated tax was raised by the noble Lord, Lord Macpherson. We will turn the next generation off the health service unless we can provide the care they need as well as the care for their grandparents.

What plans are there to consider more innovative pooling of health and social care budgets, to provide the best seamless care for our people, and to reduce the stress caused not only to patients but to NHS and social care staff in our hospitals and community teams who—believe it or not—want only to provide high-quality services to those they serve? These are the questions that our staff want answered and we need to answer to encourage recruitment and retention in our vital services. I have given some of the simplest costs in financial terms that the public would understand, so surely a reorganisation with a community focus for older people’s care may enable better services for the same cost. This of course also includes suitable housing for frail elderly people and, possibly, NHS nursing homes.

Finally, does the Minister agree with a summary in a paper on economics from the BMJ last year, which concluded that spending constraints, especially for personal social care, were associated with a substantial mortality gap? The paper suggested that spending should be targeted on improving care delivery in care homes and people’s homes, and on maintaining or increasing nursing numbers.

NHS: Winter Funding

Baroness Watkins of Tavistock Excerpts

Thursday 11th January 2018 Lords Chamber

[Lord Clark of Windermere (Lab)]

My Lords—

[Baroness Watkins of Tavistock (CB)]

My Lords—

[The Lord Privy Seal (Baroness Evans of Bowes Park) (Con)]

It is the turn of the Cross Benches.

[Baroness Watkins of Tavistock]

My Lords, will the Minister ask the newly named Department of Health and Social Care to consider funding a pilot of four weeks of social care on discharge for frail elderly people to assess whether this would release patient beds and enable in-depth assessments to be made of future needs? This should be done now rather than wait for a full evaluation to be made.

Mental Health Care: Vulnerable Children

Baroness Watkins of Tavistock Excerpts

Tuesday 28th November 2017 Lords Chamber

[Lord O'Shaughnessy]

I ask the noble Baroness to write to me on that specific case. Of course, health services should never be withheld on such a basis; they should be provided on the basis of need, as we all know. I can confirm that the Green Paper will be published before the end of the year.

[Baroness Watkins of Tavistock (CB)]

My Lords, can the Minister explain why some looked-after children who have been on waiting lists for mental health care and are then transferred out of the area for foster care have to start their wait for access to mental health services again, if we have a National Health Service?

[Lord O'Shaughnessy]

I think this picture of a fragmented service is one that the CQC report highlights. One of the ways in which the Government are trying to address that is through incentive payments in the tariff system to make sure that trusts are incentivised to join up care, particularly when children are moving from place to place.

NHS: Wound Care

Baroness Watkins of Tavistock Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, in his absence for bringing this important debate to this House, and the noble Baroness, Lady Wheeler, for her excellent introduction to the issue. I draw attention to my registered interests, in particular as a lifelong member of the Royal College of Nursing and the current president of the Florence Nightingale Foundation.

Other noble Lords have addressed the issue of improving the strategy for wound care through the development of generic national specifications classed as clinically acceptably and fit for purpose for at least seven wound care and dressing categories. This is an entirely logical approach which the nursing profession broadly supports and is actively involved in designing. My noble friend Lord Kakkar outlined the macro- economic costs of wound management. It is estimated by Guest et al that 2.2 million wounds were managed in the UK in 2012-13, involving 18.6 million practice nurse visits and 10.9 million community nursing visits. In addition, significant nursing time is spent in hospitals, care homes and nursing homes managing wounds, not only in the NHS but in the independent and social care sectors. Therefore, any strategy for the future needs to consider the total cost of treating wounds, not the unit cost of products. Cost estimates need to focus not only on the price of wound treatments in terms of assessment tools, such as Doppler machines, medicines and dressings but also on the costs of treatment time from a variety of healthcare workers including, for example, medical staff, dieticians and podiatrists, while recognising that wound management, particularly in community settings, is predominantly a nurse-led discipline. The noble Lord, Lord Mackenzie of Culkein, gave an excellent overview of the challenges, the types of wounds and the expertise that clinical nurse specialists in tissue viability use in leading teams.

Innovation is central for the future, but I want to concentrate on four issues—the prevention of wounds, the prevention of infection, treatment expertise and sound models of care—through the lens of patients suffering from leg ulcers. Leg ulcers are painful, debilitating and frequently lead to social isolation. How then can leg ulcers be prevented? Some, of course, cannot, but with education many can be stalled and healed in their very early stages and others can be prevented very effectively by maintaining skin integrity through improved nutrition and exercise in at-risk groups. Keeping even small cuts clean and covered while healing can prevent infection entering a wound. Most patients want to prevent infection and will be happy to concur with a suggested treatment plan.

However, I want to give noble Lords one example from my practice when working as a district nurse more than 20 years ago. I was working with a woman in her mid-70s who was housebound with a severe leg ulcer that was not healing despite what was then regarded as best practice in terms of treatment, which involved a particular form of medically impregnated bandage being put on the affected leg by a relatively skilled nurse, because such bandages must not be put on too tightly. I was not as busy as most district nurses are today, so I returned unexpectedly at about 4 pm to see how she was doing. The answer was that, despite my having asked her not to, she was huddled by a two-bar electric fire, which was in effect setting and hardening the bandage, thus doing far more harm than good. After further assessment, I appreciated that she felt the central heating was too expensive to run and turned it on only when I was due to visit. A referral to a charity resulted in some extra funds towards her heating and over the next two months, with additional ad hoc visits from me, her leg healed. She was able to get out and help her nephew a bit in his shop, while regularly elevating her leg, and I was delighted to be able to discharge her. My point is that we now have just over 4,000 district nurses in England, but when I was working in practice there were in excess of 7,000 and I had the time to take the approach I have described.

Despite the pressure that district nurses are under today, they continue to deliver high-quality care. Investment in continued professional development is vital for healthcare professionals if they are to keep up to date and deliver contemporary evidence-based practice, yet CPD budgets for non-medical staff have been steadily eroded. A fantastic initiative has developed. It originated in Barnstaple in Devon and has already been alluded to by my noble friend Lady Masham. It is the Lindsay Leg Club Foundation. These clubs are usually led by qualified district nurses and have between 50 and 200 active members who have had or have leg ulcers. The clubs are gateways for input from tissue viability specialists, podiatrists and nutritionists. Initial results show quicker healing and improvement of ulcers and reduced prescribing costs through adherence to approved treatments, some of which are expensive but cost-effective. The clubs empower patients as stakeholders to work in partnership with professional staff, volunteers and their peers. Leg clubs are built around the notion of promoting peoples’ independence and well-being. This new social model of care is proving effective not only in the treatment of the physical wound but in promoting people’s independence and mental well-being by reducing loneliness and isolation.

Any wound strategy needs to consider how we prepare health professionals to work with groups, encouraging self-care as far as feasible, and how to integrate evidence-based practice through the dissemination of new evidence. There is little doubt that investment in the nursing workforce, particularly in CPD, is as important as selecting the best treatment product.

An RCT in Queensland, Australia, concluded that nursing time and related costs decreased by 36% using the leg club model, leading to the cost per healed leg ulcer being reduced by 58%. When I was practising, I undertook single home visits. These will always be necessary for some patients, but I delight in acknowledging that today’s leg clinic model is one that I would now wish to adopt. I believe it would have benefited my patients more cost effectively than the intervention I undertook, particularly in terms of productivity in nursing time.

The noble Lord, Lord Carter of Coles, in his report, recommends the adoption of single integrated performance in care pathways centred on customers, workforce and finance. These should apply not only to NHS providers but to independent nursing homes and the wide variety of social care services involved in delivering wound care prevention and treatment.

As the strategy for wound care develops, will due consideration be given to further investment in the workforce, including district nurse training, further development of nursing associates, continuing professional development, and customer education to ensure our workforce—which includes patients—can continue to lead the way in cost-effective care for wound management, based on new research evidence and treatment, thereby reducing individuals’ pain and suffering associated with chronic wounds such as leg ulcers?