Care Homes: Staffing

Baroness Watkins of Tavistock Excerpts

Wednesday 11th January 2023 Lords Chamber

[Lord Markham (Con)]

I thank the noble Baroness. I think that the House will recall that I have mentioned on a number of occasions that this is a critical part of the workforce plan. What has become clear, even in the short time that I have been at this box, is that social care is a vital cog in the whole chain, so to speak, which goes right back to ambulance wait times and A&E, because if we do not get the flow going out of the system, we have got problems there. So I can assure the noble Baroness that it is key to my thinking, and to all our thinking.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a future member of the NHSE board. I want to ask how we are going to monitor the advancement from care homes back into domiciliary care, in order to ensure that we do not just move the problem from the hospital to care homes so that, very quickly, there are no beds left in care homes to continue this transfer system. In particular, who is going to pay for the residents in those care homes, and for how long?

[Lord Markham (Con)]

The question is absolutely correct: as I said earlier, less than 10% of these 13,000 people need to be in care homes full-time. The danger is often that once you put them there, they remain. That is why the package is focused on stays of up to four weeks, and absolutely making sure that they are monitored through, because it is vital. It is a step-down situation to help people ease from the acute—where they need a bit of extra support—so that, most importantly, they can get back home as soon as possible.

NHS Winter Pressures

Baroness Watkins of Tavistock Excerpts

Tuesday 10th January 2023 Lords Chamber

[Lord Markham (Con)]

As with my answer to the previous question, I look forward to that meeting and learning everything we can. I will repeat the statistics on that subject that struck me most: of those 13,000 people who are fit to be discharged, we think that only 3% need to be in social care in the long term; 97% could be at home, which is the best and most cost-effective place for them. We need to ensure that the support is in place to ensure that that option exists.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a nurse and as a new appointment to the NHS England board as a non-executive director. There are two things missing from this discussion. First, there has been no reference to people waiting for mental health support. How can we ensure that people in mental health crisis are moved rapidly out of busy A&Es to be supported in quieter environments? There is a very good example across the road, at St Thomas’ Hospital, which is helping the A&E. Secondly, it is high time that we seriously consider giving full-time contracts to care workers in domiciliary services, because, as soon as somebody goes into hospital, the care worker’s hours are cut and, although they know that individual, they very rarely get reallocated to them when they are transferred back out of hospital. The lack of continuity of care often results in readmission, so what will the Minister do to ensure that, in the way that the noble Lord, Lord Turnberg, just outlined, we improve the lot of those particular care workers?

[Lord Markham (Con)]

First, I welcome the noble Baroness to the NHS England board, with high expectation of the value that she will add to it. I am very interested to understand her point further; I will speak to Minister Whately about that and respond to the noble Baroness in writing. Where people have knowledge of a patient at home, they can add that to their care when they come back out again.

Social Care Sector: Staff Shortages

Baroness Watkins of Tavistock Excerpts

Monday 21st November 2022 Lords Chamber

[Lord Markham (Con)]

I thank the right reverend Prelate for the passion that she clearly displays in this field. As I mentioned in my Answer to the Question, we have a national recruitment campaign, and looking at the staffing plan for allied health professionals and what needs to be paid to recruit people in the right areas will be part of that. The national living wage is a start, but clearly we need to make sure that this is an attractive career that people want to join and stay in.

[Baroness Watkins of Tavistock (CB)]

My Lords, I draw attention to my interests in the register. Recently, the coroner in Cornwall ruled that some deaths in the county are probably attributable to delays in ambulance services, which are in turn associated with delays in transfers of care from acute services to care homes. There has been a reduction of more than 600 care bed places in Cornwall in the past four years. This is an example of the challenge that we face. Does the Minister accept that the Government’s objectives for the NHS will never be effectively achieved without resolving the social care challenges, and that the difficulty of recruiting from overseas, particularly in rural areas, should be acknowledged?

[Lord Markham (Con)]

I agree and have often made the point that solving this part is key to the flow and to getting people through discharge quickly, which has a knock-on impact on A&E and ambulance wait times. That is why I was delighted to hear the Chancellor recognise this specifically and mention £2.8 billion of funding in 2023-24, which will account for 200,000 new care packages in this space, as well as £4.7 billion in 2024-25 to resolve the exact problems that the noble Baroness brings up.

Long Covid

Baroness Watkins of Tavistock Excerpts

Thursday 17th November 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

It is a pleasure to follow the right reverend Prelate the Bishop of Exeter, whom I know well and whose speech I completely concur with. Happily, mine does not completely reflect it. I also acknowledge the work of the noble Baroness, Lady Thornton, in getting this debate for us to consider today.

I will particularly highlight the challenges of long Covid on mental health services, healthcare staff and children’s education and health, and therefore need to declare my interests as a registered nurse and president of the Florence Nightingale Foundation.

I note that the lack of consistency on the definition of long Covid makes it difficult to measure and analyse the emerging evidence. Despite this, the NIHR estimates that 1.8 million people in the UK—as others have said, 3% of the population—are experiencing symptoms of long Covid. Its studies published in 2021 showed that up to one in three people who have had Covid-19 report long Covid symptoms, and up to one in seven children. The scale of chronic ill health and disability after Covid-19 has been described as the next big global health challenge. I am not sure that it is the next big one; I think it is the immediate one.

According to the NIHR’s survey of 3,286 people with long Covid, 71% said it was affecting family life and 80% reported that it affected their ability to work. The Ulster University survey of 3,499 healthcare staff demonstrated that 49.3% felt overwhelmed by pressures of the pandemic, with social work and nursing the most impacted.

NHS Check, a study by King’s College London—where I must declare I have a visiting chair—looked at 18 partner NHS trusts and found high levels of distress and symptoms of anxiety in staff working in healthcare. A concerning finding was that there was a high prevalence of PTSD symptoms and self-harm. This has caused long-term absence of staff due to Covid-related sickness, resulting in people at work carrying out jobs out of their skill set and/or being overworked. It is reported that these issues have directly impacted the quality of care and waiting times and, in extreme situations, have led to unsafe practices. Dissatisfied patients have resulted in increased abuse towards healthcare workers, exacerbating their exhaustion and anxiety levels. Those on long-term sick-leave have suffered isolation and financial difficulties, intensified by the recent soaring cost of living, leading to further distress and longer absences from work, and some healthcare workers have lost their jobs due to long Covid.

The impact of staff shortages from long Covid has also led to a breach in some patients’ human rights: namely, the illegal detention of patients. Last week, the Independent reported that mental health patients were being held “unlawfully” in A&Es due to shortage of staff to undertake timely mental health assessments. I must stress that I believe that that has been to protect their safety, but none the less it is a severe problem.

The effects on our children are highlighted in Ofsted’s second report on the impact of the pandemic and school closures. It demonstrates that children have regressed in basic skills, physical fitness and learning, particularly those whose parents were unable to work flexibly—including, of course, health workers. Children were found to show increased signs of mental distress, including a rise in eating disorders and self-harm.

Social isolation and greater exposure to family conflicts have added to children’s mental ill health, leading to an increase in the number of referrals to CAMHS, which has not been matched by an increase in investment in children’s services. A large study by the NHS in 2020 found that mental health conditions among children had risen by 50% compared to three years earlier. I think that will be even higher in the next piece of work on that issue. It is sad that Baroness Sally Greengross is not here to argue for intergenerational fairness on this issue.

These academic studies have shown major organisational changes across the NHS, with substantial physical and mental health challenges for NHS staff and other care workers during the pandemic. Results also indicate the importance to support staff so that they can contribute to service recovery. Therefore, can the Minister explain the Government’s position regarding the implementation of the proposed 10-year mental health and well-being plan for NHS staff and, in particular, the investment to support staff with long Covid?

Will the Government make further contributions to NIHR for global collaborative research to increase our understanding of long Covid and its impact and, in particular, to generate evidence-based interventions that may enable the health recovery and mental resilience of staff impacted by long Covid and support them to return to work, thus ensuring their retention in healthcare practice?

Ambulance Delays

Baroness Watkins of Tavistock Excerpts

Wednesday 9th November 2022 Lords Chamber

[Lord Markham (Con)]

The noble Lord is referring to the whole-system issue here, which I mentioned before. There is a £450 million investment to increase capacity in A&E facilities; that has already worked to upgrade 120 trusts to enable them to offload quickly. There are also 7,000 extra beds, and the £500 million social care discharge fund is all about freeing up more beds so that ambulances can discharge quicker.

[Baroness Watkins of Tavistock (CB)]

My Lords, I must declare that I am a former deputy chair of an ambulance trust that was an exceptional performer but is no longer, associated with the fact that, in some circumstances, it cannot get patients admitted to two of its largest local hospitals in under four hours. The problem is social care, not increasing the number of ambulances on the roads. Will the Government consider much more innovative approaches to respite care support for people who are ready to leave hospital and whose families cannot afford to leave work to look after them but, with incentives, probably could do so? That would be a practical way of moving the system forward at the moment.

[Lord Markham (Con)]

I agree with the noble Baroness that social care is a key solution to all this. As I said, that is what is behind the 13% of beds that are currently blocked and the £500 million spend in this area. However, we can be more innovative. That is what the virtual ward initiative, which I saw working so well in Watford, is about; it has reduced reattendance rates after 90 days from 46% to around 8% for COPD patients. This is an area where we need focus and innovation, and which is very much top of my agenda.

NHS: Nurses

Baroness Watkins of Tavistock Excerpts

Tuesday 1st November 2022 Lords Chamber

[Lord Markham (Con)]

To be very clear, today, there are 29,000 extra, over the 2019 figures. That is more than half way towards the figure of 50,000. I will quite happily write to noble Lords so that they can see the figures clearly in black and white, but I can assure the House that we are talking about increases in nurse numbers. We have achieved a 29,000 increase on the 2019 levels.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interest as a registered nurse and would like to follow on from the noble Baroness, Lady Chisholm. We must grow our domestic workforce in nursing. I do not dispute the figures the Minister has given, but any nurse earning more than £27,000 who trained recently is now repaying 9% towards their student loan, on top of the 20% tax they are paying. I accept that they get a £5,000 bursary a year, but they work extraordinarily long hours compared with ordinary students. It really is essential that we find a way to retain those young nurses who have just trained by doing a debt write-off of their loan after five or six years.

[Lord Markham (Con)]

I totally agree that retention and attracting people into the profession are key. I like to think that we are looking at all these things in the round, taking into account the £5,000 grant, the service they are giving, and their conditions and pay going forward. As ever, this is a moving feast, for want of a better term, so we will keep looking at it to make sure we continue to both attract and retain the domestic and international staff numbers.

Nursing: Recruitment

Baroness Watkins of Tavistock Excerpts

Wednesday 26th October 2022 Lords Chamber

[Lord Markham (Con)]

First, we are actually exceeding the number of leavers. There were 36,000 people who left last year and 45,000 who joined—a net increase of 9,000. That is not to say that we do not want to retain people. I absolutely accept the premise that we do, which is why we have a retention programme in place to ensure that we are able to do so. We also have a restart programme to help people who have left to get back into nursing in a quick and easy way. Overall, the main point here is that the number of joiners is exceeding the number of leavers. We are more than catching the number up; we are exceeding it.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a nurse and the co-editor of the WHO report, State of the World’s Nursing. It is true that we have 9,000 additional nurses, but of the 48,000 who in the last year joined the register for the whole UK—for the four countries, not just England—more than half had trained overseas. Those nurses are very welcome here, but it illustrates that we are not encouraging people who wish to go into nursing to do so, beyond the 72,000 the Minister referred to. That is very much to do with student finance and the lack of apprenticeship opportunities for older people who want to go into the profession. Can the Minister look into increasing those opportunities?

[Lord Markham (Con)]

Indeed, and towards that aim we have set up the nursing associate role, which is a stepping-stone to allow people to ease in and have qualifications on the way to becoming a fully trained nurse. The overall point I make, as before, is that by putting in a £5,000-a-year grant for student nurses, we are recruiting the numbers. I reiterate that 72,000 is a big pipeline but also that it is an uncapped pipeline. The more we can attract, the merrier—whether domestically or, as in the fine tradition of the NHS, from overseas sources.

Health and Social Care Update

Baroness Watkins of Tavistock Excerpts

Monday 10th October 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, I welcome the new Minister and declare my interests, in particular that I share his interest in the nursing profession. I have two questions. One is about the 15 units where particular problems have been identified. Does he think that is to do with demography, particularly older populations, and that we have got the funding calculation right in those areas? Secondly, is he prepared to meet me to talk about retaining people who are currently qualifying who, if they do overtime, are being hit with the 9% repayment for their student loans? This means there is very little incentive for the younger generation to do overtime, despite their being the fittest and probably most able to do so.

[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.

Primary and Community Care: Improving Patient Outcomes

Baroness Watkins of Tavistock Excerpts

Thursday 8th September 2022 Lords Chamber

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to follow the noble Baroness. I congratulate my noble friend Lord Patel on securing time for this important debate and support his proposal for a special committee. I declare my interests as a registered nurse and as president of the Florence Nightingale Foundation.

Other noble Lords have spoken about the medical workforce—in particular, general practitioners—and the need to invest in dentistry services. I will focus on the multidisciplinary teamwork in general practice and community care, with a particular emphasis on nurses, midwives and health visitors. In England, the primary care networks have enabled some community nurses and GP practices to work closely together at a local place level. This is building on a successful neighbourhood model that has been in existence for many decades. However, as briefing from the Queen’s Nursing Institute reminds us, a one-size-fits-all model does not apply because of the variety of geographical neighbourhoods—including rural and urban communities —and the different needs within those communities.

The Fuller stocktake report referred to by other noble Lords gives good examples of where services work closely together, successfully emphasising that the focus in both community and primary care should be on good outcomes for patients, not a one-size-fits-all approach for the sake of administrative uniformity. It is for that reason that the local integrated care boards should ensure that local practitioners, in partnership with the people they serve, are closely involved in determining the shape of local community services. It is widely recognised in government that there is a significant workforce shortage in the NHS, including in primary and community care. Yet everything points to the need for more care to be delivered in patients’ homes and in community settings, and this must be considered in workforce planning.

It is particularly vital that we educate more qualified specialist district nurses to lead and manage teams in the community. This in turn links to patient safety and quality outcomes. Similar investments are necessary in the mental health and learning disability community nursing services. Our extremely esteemed colleague my noble friend Lord Kakkar, who is a surgeon, defined this very accurately in his speech, so it is a pleasure to agree with him. There is significant untapped potential in the nursing workforce and many other healthcare professions including, for example, physiotherapy and occupational therapy. All healthcare professionals should be encouraged to use the skills and knowledge they have to the highest level of practice for which they have been educated. Instead, many feel frustrated that they are not enabled to work to their maximum potential. We need to be clear about career development for healthcare professionals working in community settings. This would aid retention and develop more independent and professional practice, meaning that many patients with long-term conditions would need to be seen by GPs only when their healthcare status changed significantly.

It is argued that the first 1,001 days from pregnancy to the age of two are a period of unique rapid development which lays the foundations for a child’s lifelong mental and physical health. Midwives, who lead interventions, including support with breastfeeding, smoking cessation and parental emotional well-being, have a positive and far-reaching impact on a child’s subsequent health development and life chances. The reverse is also true, and it is often during pregnancy that families get locked into the intergenerational cycles of inequality. For example, babies born to families on lower incomes are significantly more likely to be born underweight, have higher risks of mortality and experience of developmental problems.

The latest NHS workforce figures for England show that there were 541 fewer midwives in June 2022 compared with 12 months earlier. The drop in numbers was particularly pronounced in the north of England—evidence of the need to level up. The most recent Office for National Statistics figures show that 11,000 more babies were born in 2021 than in the previous year, so we have fewer midwives yet more births. The Institute of Health Visiting estimates that there is a shortfall of 5,000 full-time equivalents in England—a loss of over a third since 2015. It is worth noting that there were 536 child serious harm events in 2020-21 including, sadly, some child deaths. This was an increase of nearly 20% on 2019-20.

The health visitor performance matrices from August 2022 show that the lowest-performing local authorities had 4.2% of new birth visits within 14 days and 5% of two to two-and-a-half-year reviews, against the highest-performing local authorities, where the figures were 99.3% and 100% respectively. This means that, in some parts of the country, almost all children receive a two to two-and-a-half-year review whereas, in others, fewer than one in 10 children is assessed by health visitors for what are deemed to be mandated contacts. This kind of postcode lottery should be of significant concern to us all. Health visitors make a difference through improved identification of children with developmental delay and vulnerabilities by supporting families through early intervention and thus improving outcomes.

Does the Minister agree that it would be helpful to harness the skills and experience of all clinicians in the delivery of public health and to locate health and care services in easily accessible and prominent community facilities? This would enable healthcare teams to work closely together and make preventive care easily accessible to all. Early intervention is not only crucial to the health and well-being of families and children but good for community cohesion and economic productivity, as well as leading to savings in the cost of unemployment, crime and mental illness.

Finally, I turn to information from the Royal College of Nursing. In June this year, it reported that over half of nurse respondents in primary care said that there were insufficient nursing staff to safely meet the needs of their patients, and two-thirds said that the skill mix was not appropriate to meet the needs and dependencies of the service users and patients effectively. With advanced skills, registered nurses in primary and community care should be able to lead care for patients who have received accurate diagnosis and treatment plans from GPs and/or hospital consultants. Safely delivering high-quality care improves patients’ outcome and reduces readmission to hospital.

Key to patient outcomes are the structure and processes of health and social care services—and, I would add, housing. Investment is urgently needed to improve the digitalisation of patient records and test results in primary care. Patients want effective healthcare delivered by compassionate, professional, trained staff and to understand their treatment, which assists them in adhering to their own personal care plans. The latest idea in general practice is to be told, “You’ve had this blood taken, but if you don’t hear from us then everything is fine.” None of us trusts it, to be honest.

Local integrated care boards should be involved in planning the most appropriate structures and processes of services to meet their local need, but must also be mindful of ensuring uniformity of access to NHS-funded services in England; I recognise that not all services have to be delivered directly by the NHS. Access to community-based physical and mental health services is as important as the right to an operation or emergency care following an accident. Can the Minister assure the House that this aim will be supported by the Government to improve patient outcomes and reduce the disparity of access to primary and community services in England?

Disabled People: Personal Assistants

Baroness Watkins of Tavistock Excerpts

Wednesday 7th September 2022 Lords Chamber

[Lord Kamall (Con)]

The noble Lord makes an important point about who should be in that room when we are talking about all these issues. Generally, across government, there are a number of joint initiatives in terms of ensuring that we hit our target of equality for disabled people, but as other noble Lords have pointed out, this issue falls between DWP and DHSC. I was surprised when I was briefed on this about where it fell. It clearly must be people in the same room.

[Baroness Watkins of Tavistock (CB)]

My Lords, it was a pleasure earlier to hear the new Health Secretary say that this is the kind of example that she would want to resolve—she did not use a particular one. Could the new integrated care boards not be the trusted sponsor for such personal assistance in each area? It would be straightforward and simple to introduce.

[Lord Kamall (Con)]

On the face of it, that sounds a very sensible suggestion, so let me take it back to the department, and if I am still here, I will respond.