Branded Health Service Medicines (Costs) Regulations 2018
Baroness Wheeler Excerpts(5 years, 10 months ago)
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Baroness Jolly (LD)
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this slightly interesting regret Motion.
It is clear that the issue at stake is the appropriate treatment of hypothyroidism. We have to trust clinicians to prescribe based on what they consider is best for their patients, as the noble Lord, Lord Turnberg, said. I have done an awful lot of reading about this over the last few days, and, although it depends on which article you read, it seems that a significant number of women have this condition: one figure I was given was 10%. In fact, for the last 25 years I have been diagnosed as hypothyroid. I take T4— levothyroxine—which is cheap as chips and costs the NHS about £1.30 every month. But of course, not everybody responds to that, and the alternative is the very much more expensive T3. Some 10% to 20% of patients diagnosed with hypothyroidism come into this category. It is therefore important that the patient receives the right drug. We have heard completely unacceptable tales of patients, as a result of decisions made by clinical commissioning groups, surfing the internet to see what they can get. I did exactly the same last night—having a look to see what I could get—and, again, the T3 was ridiculously expensive, whereas T4 was hardly worth buying online as you could get it very much more cheaply.
What is to be done about this? I was going to explain what it is like when you develop hypothyroidism, before you are diagnosed, and so I thank the noble Lord, Lord Borwick, because his description was lovely: “pathetic, befuddled and exhausted”. I went to see a doctor because my brain was in a fog. I explained it to him and he said, “What do you expect? You work full time and you have two toddlers”. So I was sent away. Curiously enough, at a family event—a lot of my family are doctors or nurses—my mother-in-law asked me, “How long have you had a thyroid problem?” and I said, “I didn’t know I had a thyroid problem”. I went to see my GP, who said, “No, you haven’t got a thyroid problem at all. Who said you had one? Gosh—what does a paediatrician know about it?” Eventually, I had to leave my practice and go to another one to get a diagnosis. I am sure that that is not normal, but it was quite an interesting experience for me. Since then, I have been as fit as a flea. The medication works like a magic charm; very quickly you feel normal and well again. So I cannot overstate to Members of your Lordships’ House how important that prescription was.
I emphasise to the Minister what other noble Lords have said today. We must use the purchasing power of the NHS to drive down the costs of T3 in order to make the argument go away. That might be done by effective negotiation, as the noble Lord, Lord Lucas, said, or in another way, but it is completely scandalous that patients have to buy their own drugs online, and CCGs should therefore review or rework their guidelines as a matter of urgency. Drug companies must not hold the NHS to ransom over the cost of medication that will make patients feel absolutely well again.
On the issue of the costs of medication, one of the non-medical side-effects of having a diagnosis of hypothyroidism was that any other drug I had became free. It is on a list of conditions which, if you have them, mean that any other medication you need becomes free. At that time I was in my early 30s and working. It was very nice to have free prescriptions; I tried to pay for them but they would not let me. However, it means that for the NHS, an awful lot of money is spent inappropriately. Can the Minister give an indication of whether the department has any indication of how much this costs the NHS? I am happy for the NHS to pay for my levothyroxine, but it should not have paid for all other medication I was in receipt of—although, now that I am old, it comes free anyway. How sustainable is this in the current climate, and when was the principle last reviewed?
My takeaway issue for all this is that, whatever happens, we should ensure that the cost of T3 is driven down. However, I would also like the Minister to take this other issue away and—not as a matter of huge urgency—come back to me with some answers.
Baroness Wheeler (Lab)
My Lords, I thank my noble friend for tabling this Motion and for his excellent speech setting out the concerns we all share about NHS patients getting access to the drugs they need and how a number of CCGs are in effect placing a ban on expensive branded medicines—in this case ignoring NHS England’s advice concerning T3 in the treatment of hypothyroidism. I look forward to the Minister’s response to the key questions put forward by noble Lords on this issue.
The Motion has the full support from these Benches. I also commend the work of the British Thyroid Association and Thyroid UK in highlighting this issue, and the very helpful information on their websites, as well as the expert explanation from my noble friend Lord Turnberg on hypothyroidism. The websites include case studies of patient voices which clearly show the impact and suffering of patients who are either denied T3 or who are taken off it because of a decision made by their CCG. It is especially upsetting when patients who have successfully taken the drug for a number of years suddenly have to go back on to a drug, mainly T4, which they already know does not provide them with the treatment they need or will make them ill again. The case studies refer to both the T4 drug and the natural desiccated thyroid—NDT—drug, which I understand is the treatment given before T4 came on to the market but which is not now available in the NHS as it has to go through the Food and Drug Administration process, and it is not known when the branded NDT products will be licensed.
My noble friend and other speakers described their concerns over current CCG decisions that go against NICE guidelines and the advice of NHS England, and the increasing rationing of key services, so I will not repeat them and will await the Minister’s response. The NHS England recommendation and guidance on T3 needs to be clear and unambiguous. I hope that the Minister will acknowledge the confusion and concerns, and will ensure that NHS England informs CCGs that they must both comply with their guidance and amend it to end the scope for CCG misinterpretation. I hope that he will also acknowledge that access to T3 on the NHS is a matter of urgency for many patients and that he will give serious consideration to the call from Thyroid UK and ITT for the procurement of T3 from outside the UK for NHS prescriptions until its UK cost comes down.
On the regulations, I note paragraph 4.7 of the Explanatory Memorandum, which deals with provisions of the Health Service Medical Supplies (Costs) Act 2017 that have been included. This includes the promise of the annual review of the operation and objectives of the statutory scheme which is to be published and put before Parliament. Can the Minister tell the House what the current thinking is in terms of the review process and timing, and say when he would expect the first review to be completed?
The impact assessment also states that the implementation of these regulations will generate a saving of £33 million to the NHS between April 2018 and March 2019. The Department of Health and Social Care says that this will enable the provision of additional treatments and services estimated to provide NHS patients with an additional 2,213 quality-adjusted life years, valued at £133 million. Can the Minister explain to the House exactly how the Government have calculated the savings, and can he give more details of how this money is to be spent in the NHS?
The Explanatory Memorandum also says that the regulations set out other instances when the Secretary of State can give a direction specifying the maximum price of drugs—for example, when there are supply issues with respect to a particular branded health service medicine and the Secretary of State is satisfied that a new temporary minimum price needs to be provided to help resolve the supply issue. Can the Minister explain to the House how the Secretary of State is to decide on the temporary minimum price?
Finally, in respect of the provisions in the regulations for manufacturers and suppliers to pay 7.8% of their net sales income to the Government, the impact assessment provides for those in the PPRS with annual NHS sales above £5 million to make percentage payments based on the difference between allowed percentage and actual percentage growth in NHS expenditure on branded medicines. Can the Minister provide more clarity on how this 7.8% figure has been reached?
Carers: Back Pay Liability
Baroness Wheeler Excerpts(5 years, 11 months ago)
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Lord O'Shaughnessy
I thank my noble friend for raising the issue, which we are looking into. The point here is that the change in policy has come about because of decisions made by employment tribunals and a clarification of the law, and the job of government is therefore to help providers to comply with the law. That is how the scheme has come about, and why extra support is being looked into. We are working closely with providers to try to understand the scale of the liability and how it affects organisations differently—we think that up to two-thirds are affected. We will also make sure that any intervention that might follow—I stress “might”—is proportionate, fair and legal.
Baroness Wheeler (Lab)
My Lords, Jeremy Hunt told MPs last week that a lot of work was going on in government on this issue to,
“understand the fragility of the current market situation”.—[Official Report, Commons, 8/5/18; col. 520.]
However, we already know that the viability of nearly 70% of the disability care sector is threatened by the sleep-in pay crisis, as last week’s survey by disability charities shows. Homes will have to be sold or more local authority contracts handed back. Is this not enough evidence of the desperate state the care sector is in and why the extra funding is needed from the Government to ensure that already low-paid staff are treated fairly and receive the money they are owed?
Lord O'Shaughnessy
The noble Baroness makes an important point about the attention my right honourable friend the Secretary of State is giving this. We are taking this issue seriously, and she is quite right about the number of organisations that are affected. As I said, a scheme already exists which allows providers to defer any payments, and we are investigating whether any further interventions are necessary during that period when they can defer them.
The Long-term Sustainability of the NHS and Adult Social Care
Baroness Wheeler Excerpts(6 years ago)
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Baroness Wheeler (Lab)
My Lords, I, too, congratulate the noble Lord and his committee on this excellent report. The debates on the long-term future of the NHS and social care at this time, as we approach the 70th anniversary of the NHS, are invaluable, particularly as recognition of the need for long-term funding solutions is under the spotlight more than ever before. We also have the very welcome recent evidence from last year’s social attitudes survey that shows that the majority of voters now back a tax rise to fund the NHS. The Government’s response to the committee’s report, a year after its publication, has been described as anodyne, pedestrian and underwhelming—and those are the kind descriptions. In truth, it contained very little that could not have been said three months after the report was published. The Minister has been very apologetic on many occasions about the delay, so perhaps we might be rewarded today with an actual explanation as to why it took so long to say so little.
Noble Lords have spoken on the key funding, structural and workforce issues arising from the report. I want to speak about these in the context of the future of stroke services. I know that the noble Lord, Lord Patel, will welcome this, as it is an issue close to his heart, and I commend the key role that he has played in this House in support of improved stroke care.
Stroke is the fourth-largest single cause of death in the UK. It occurs approximately 152,000 times a year in the UK, there are over 1.2 million stroke survivors, and it is the largest cause of disability. Over half of all stroke survivors have some form of disability. Every year, 80,000 people in England are admitted to hospital after having had a stroke. Stroke costs the health and social care system over £8 billion a year, but research by the Stroke Association shows that when informal care and lost productivity are factored in, this spirals to £26 billion. Without action, this is expected to at least double or triple by 2035. Indeed, the quality of stroke prevention and care in England is a strong barometer of how our health and care system is working, as it is both a medical emergency and a long-term condition. As the committee’s report underlines, reorganising and centralising stroke services reduces disability and can save lives.
The 10-year National Stroke Strategy, brought in by the Labour Government in 2007, has led to major improvements in stroke prevention, treatment and outcomes. But progress has stalled as a result of funding cuts, CCGs not giving stroke reconfiguration the priority or support it needs, which results in huge variations in services across areas, and little attention being given to the whole stroke care pathway—and because of the Government’s mistaken refusal to update the strategy forward into 2018 and beyond. However, the news that NHS England, along with the Stroke Association and others from across the health and social care system, are now working in partnership to develop a new national plan for stroke in England, is welcome. It is essential that this plan is prioritised and effectively implemented to provide the leadership and direction needed to achieve better treatment, care and outcomes for those affected by stroke. Can the Minister update the House on progress on the national plan and on the timeframe for its development and publication?
While reconfiguration of services is planned or under way in many areas across the UK, progress is slow and patchy, with huge challenges in persuading local commissioners to prioritise these services, and persuading communities and patients that reorganisation works. In reality, much of the change is still small scale and limited in scope, such as shutting one unit and diverting ambulances to hospitals with better stroke facilities and staffing. Although 32 STPs have used the opportunity to review acute stroke services, most of these reviews have yet to be actioned and only four consider the whole stroke pathway. The committee’s report makes it clear that the jury is still out on the current effectiveness of STPs, and this is certainly true of their likely impact on stroke reconfiguration and services. As both ADASS and the Local Government Association have pointed out, STPs’ main focus is on NHS transformation, not on social care. The LGA sums it up, saying that,
“there has been little meaningful consideration of adult social care as a vital component of a resilient and sustainable health and care system”.
Can the Minister say how this is being addressed as STPs are taken forward?
Sadly, for stroke survivors the care pathway is the area that has seen least progress in recent times. For comprehensive post-acute stroke care, such a pathway means early supported discharge, long-term neurological rehabilitation, vocational rehabilitation, exercise programmes, vascular risk reduction advice and support, and long-term follow-up and intervention for patients whose functional ability deteriorates. Nearly half of all stroke survivors who responded to the Stroke Association’s recent survey say they felt “abandoned” after leaving hospital and lack confidence and information about how to navigate the post-acute pathway; two-thirds did not receive the vital six-month review of their care needs. Forty per cent of stroke patients are eligible for early supported discharge, which reduces the length of hospital stays and provides intensive multidisciplinary stroke-specific rehabilitation at home. But two out of 10 hospitals in England, Wales and Northern Ireland do not offer ESD, and it is not being commissioned by many CCGs despite national guidance. There are long waiting times in most areas for key post-stroke psychological and emotional support; on speech and communication, the average wait to start speech and language therapy is 22 days, varying from 8.5 days to two months between the best and worst-performing areas. These are precious lost days that can have a lifetime impact on the ability to communicate after a stroke.
On carer and family support, shockingly, one in three areas in England, Wales and Northern Ireland does not provide support for carers and families of stroke survivors. As a carer of my partner who is a stroke survivor of 10 years, I cannot stress enough how important being part of the local stroke community is to the well-being of stroke survivors, particularly those with severe disabilities.
In my area, we are lucky to have a stroke group just down the road, run and funded by the Stroke Association. We also have an amazing local charity called TALK, which provides support with speech, memory and communication difficulties. It is run by volunteers but against increasing odds. It was recently given one month’s notice by the CCG that its small grant is to be stopped this month. When we talk about NHS and social care sustainability, surely these are exactly the sorts of services where local authorities need increased national funding so that they are able to provide support.
Many of your Lordships know that I always have lots to say about stroke but in the time left I shall make just a couple of points. I really welcome the committee’s frank assessment and criticism of the current absence of coherent health and social care workforce planning. I hope that the Minister will today acknowledge this, look at the problems that are occurring and commit to a long-term workforce plan covering both health and social care. There are lots of examples of staff shortages in stroke services which I do not have time to go into. Again, I support what noble Lords have said about the need for increased social care funding.
Thirdly, straying a bit from the committee’s report, the excellent “Children get dementia too” adverts on the Tube have prompted me to remind the House that children get strokes too, because the debates in this House have led to some progress being made. Childhood strokes affect around five out of every 100,000 children a year in the UK. People do not think that children have strokes, but they do, as the families of children who have had major strokes in the womb before birth or later in their teenage years know all too well. Awareness raising, more support for carers and families caring for children who have had a stroke, and much more research into childhood stroke, are needed.
Finally, I join other noble Lords in giving wholehearted support to the committee’s recommendations on prevention and public health, and the need to move from an “illness” to a “wellness” service. For stroke, this is very important, and there is a need for better screening and diagnosis of atrial fibrillation.
In summary, stroke embodies the challenges of planning for population health and delivering integrated, accountable care, and it requires the joined-up health, social and voluntary sector support called for throughout the committee’s report. I look forward to the Minister’s response.
Domiciliary Home Care Support
Baroness Wheeler Excerpts(6 years ago)
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Baroness Wheeler
To ask Her Majesty’s Government what action they are taking to ensure the provision of domiciliary home care support, in the light of the decision by Allied Healthcare to file for a company voluntary arrangement.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)
My Lords, the law is clear that, if services may be disrupted due to business failure, the Care Quality Commission will notify local authorities so that they can put appropriate contingency plans in place. In respect of Allied Healthcare, no such notification has been made to date. The public should be reassured that the Care Quality Commission has been monitoring closely the situation at Allied Healthcare and will continue to do so.
Baroness Wheeler (Lab)
My Lords, Allied Healthcare is the latest hedge-fund-owned care provider to have to take drastic action to keep up the huge burden of paying off loans to its creditors. The precarious finances of many domiciliary care companies has already led to large-scale provider closures and to companies handing back contracts in almost half of councils, and we know that residential care is in a similar position. The CVA means that Allied Healthcare has four weeks to come to an arrangement with its creditors. Its closure would have serious consequences for continuity of care and the safety of its 13,500 clients, including many vulnerable older people and people with learning difficulties, and for its 8,700 staff. With local authorities unable to pay fees that cover the actual cost of care or meet the implementation costs of the national minimum wage, let alone address the potential £400 million of deserved back-pay costs for staff sleep-in payments, what reassurances can the Minister give that councils will be able to discharge their statutory duty to deliver care if Allied Healthcare collapses? Does he really think that this is the way to fund the care that people in need of support in their homes deserve?
Lord O'Shaughnessy
I thank the noble Baroness for the opportunity to provide that reassurance for people using and benefiting from the care provided by Allied Healthcare. I want to reassure them that the Care Act 2014, passed by the coalition Government, gives local authorities responsibility for continuity of care if a business were to fail. Of course, we are not in that position with Allied Healthcare, because it still has to go through the CVA process. I can reassure people that the LGA has said that councils have “robust”—its word—plans in place to ensure continuity of care if that is required. I put that on record for those who may be worried about it.
We know that extra funding is needed in the sector. Over three years, through a number of means including extra money through the precept and direct funding to local authorities, the Government have increased by about £9 billion the funding available for social care, which we know is required. I also point out that, if you look at domiciliary care provider numbers, you will see that there are 50% more than there were eight years ago. We know that markets have entrants and that providers are exiting, but we have more providers in the market and more packages being delivered than ever before. Ultimately, the backstop is that local authorities have that responsibility to provide continuity of care.
Health: Online Services
Baroness Wheeler Excerpts(6 years ago)
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Baroness Wheeler
To ask Her Majesty’s Government what action they are taking in response to the Care Quality Commission’s report, The state of care in independent online primary health services, published on 23 March.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)
My Lords, the online provision of primary care is a development with the potential to improve patient outcomes. However, it is important that these services are regulated and inspected properly. The CQC will continue to hold online providers to account while sharing good practice. Following its report, we are considering what further action is needed to ensure that the right balance is struck between the provision of safe, effective care and encouraging further innovation.
Baroness Wheeler (Lab)
I thank the Minister for his response. We are strongly in favour of technologies and innovations that help to provide the widest possible access to primary health services, particularly when getting a timely GP appointment is so difficult for thousands of patients. The CQC inspection role is crucial but there is no disguising the serious issues to be addressed and resolved. These include checking patients’ identity, sharing information with the NHS GP and the safe prescribing of medicines. Some 43% of companies are failing to meet regulations for keeping patients safe and there are particular concerns about inappropriate prescribing of antibiotics and medicines and about managing long-term conditions. How will the Government ensure that the lessons from the first phase of the CQC inspection are learned, and will they pledge to take swift action on the problems now before the service is further rolled out?
Lord O'Shaughnessy
I thank the noble Baroness for raising this important issue. She is right that the CQC report identified some serious issues among this group of online providers, which of course operate in the independent sector. She mentioned safety and safeguarding, and I would add to that. It is worth saying that there were some positive responses, in terms of 97% of the providers being caring and 90% of them responsive, so some strengths were identified as well as weaknesses. Obviously the CQC retains the ability to take regulatory action. As it sets out in the report, it has done so to ensure that standards improve, and in general they improve from one inspection to the next. However, this is of course the independent sector. We are looking at the lessons for the provision of NHS services. The biggest one of those that comes out of the report is around data sharing: to ensure a clear flow of data between an online provider and a GP, if they are different, so that any problems can be spotted early on. That is particularly important for safety.
HPV Vaccinations
Baroness Wheeler Excerpts(6 years, 1 month ago)
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Lord O'Shaughnessy
My noble friend makes an important point, that vaccinations against the HPV virus brings wider health benefits beyond defending against cervical cancers. It is important to state that it is not my judgment that matters here but that of our expert group, and in its interim advice it did not recommend an extension of the HPV programme to boys as being cost effective, not least because of the high levels of immunity and uptake among girls, with the indirect benefit that that has. But that was its interim advice; the final advice is being considered at the moment, and I can tell the House that that advice and the underlying assumptions on cost benefit will be published when the decision is made.
Baroness Wheeler (Lab)
My Lords, last year’s interim statement referred to by the Minister mentions referring the issue of equality of access to the HPV vaccine to the Department of Health for consideration. Has that referral been made? Given that the clinical benefits of gender neutrality have been so widely advocated by top medics over a very long period, is the department treating this with urgency? When is a response expected, and has any legal advice been taken on whether the current situation of only directly protecting girls and gay men constitutes discrimination by gender or sexual orientation?
Lord O'Shaughnessy
The noble Baroness is quite right that equality is an issue, and an equality analysis will take place. That can be completed only once we have the final advice from the joint committee. I can also promise her that we will publish that analysis, so that will be able to be scrutinised. As for legal advice, it is subject to threats of judicial review at the moment, so I cannot go any further than that, but I can promise that equality considerations are very high on the list of the issues that we are dealing with.
Health: Medical Respite for Children
Baroness Wheeler Excerpts(6 years, 1 month ago)
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Lord O'Shaughnessy
The noble Baroness is quite right. Many of the children we are talking about are receiving continuing care to meet all their needs, and delivering that is very complex. A national framework for continuing care is being revised at the moment, and it will provide the picture for the skills mix that is needed at local level to ensure that these children are properly served.
Baroness Wheeler (Lab)
My Lords, my question is on the specific issue of parent carers, for whom funded respite care is vital to both themselves and the children they care for. The Minister mentioned the continuing healthcare framework guidance coming into force in October, which makes clear CCGs’ responsibilities to fund respite care for parent carers and breaks for families of severely disabled children. The High Court judgment clarifies the law and makes this duty clear now. What action have the Government taken to ensure that CCGs act on the Nascot Lawn judgment now?
NHS and Social Care: Winter Service Delivery
Baroness Wheeler Excerpts(6 years, 3 months ago)
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Baroness Wheeler
That this House takes note of the impact on front-line social care of Her Majesty’s Government’s NHS plans and the delivery of services over the winter period.
Baroness Wheeler (Lab)
My Lords, the most appropriate place to start this debate is with the WhatsApp open letter of 12 January to the Prime Minister from the heads of 68 accident and emergency departments in England. Its signatories included St Thomas’s in London, Heartlands in Birmingham, Addenbrooke’s in Cambridge, the Royal Liverpool, and Frimley Park, where Mrs May issued her new year apology for cancelling 55,000 non-elective surgical operations. With figures showing over 300,000 patients waiting more than four hours in A&E, a record half a million-plus emergency admissions, and 75,000 patients waiting more than 30 minutes in the back of an ambulance, these front-line doctors wrote about the hundreds of patients a day, some of whom were dying prematurely, being treated on corridors and about patients sleeping in clinics turned into stopgap wards.
One of the main purposes of the messaging was to swap practical tips about how to become “corridor specialists” as hospitals become overwhelmed with patients. This speciality includes the Red Cross delivering tea and blankets and sitting with patients waiting on their own. I can think of nothing worse than, for example, being a sick, elderly patient on a trolley without a carer or friend to stay with them, speak up for them or make sure they are being looked after. For the A&E doctors, their reality was that the Government’s winter plans,
“have failed to deliver anywhere near what was needed”.
Their key demand was more hospital beds and an urgent boost to social care. The president of the Royal College of Emergency Medicine warned:
“Our emergency departments are not just under pressure, but in a state of emergency”.
All this, of course, has a huge knock-on effect on social care while arising from the Government’s failure to fund and provide the everyday healthcare and community support, for millions of people who need it, which could stop many of them turning up at A&E and occupying hospital beds in the first place.
We know that the Minister’s response will be his repeated mantra about the extra £337 million the Government made available to trusts this winter and the £1 billion extra in social care funding allocated in the 2017 March Budget. Of course extra funds are welcome but, first, trusts were not told about their allocations until a few days before Christmas, so effective on-the-ground advanced planning was severely hindered as they had no idea of what money there was to spend. Secondly, the Government’s instruction was for half of the £337 million to be spent on servicing trust debts, not on emergency planning. Thirdly, such debts will be further increased by the cancellation of 55,000 non-elective surgical operations. Finally, as all the health think tanks, specialists and everyone involved in the provision and delivery of NHS and social care services have attested, the extra funding was simply nowhere near enough even to begin to redress the huge cuts that have been made in NHS funding and local government funding of social care over the past eight years.
The Government need to acknowledge and own up to the scale of the crisis. The Minister knows that the Budget did not provide extra funding for social care in the short term or address the predicted funding gap of £2.3 billion by 2020. Specifically on A&E care, can the Minister tell the House how the Government will assess the actual impact that providing additional funding in November and December had in dealing with the worst winter crisis the NHS has faced in decades?
On social care, as the very comprehensive Lords Library brief for today points out, we talk of adult social care mainly in terms of the needs of older people, but it also includes care and support provided to physically disabled people, people with learning disabilities, people with mental health problems, drug and alcohol misusers and the carers involved in caring for them. That is the scale of the demand and the need that has to be addressed. I will focus today on carers and older people.
I am a carer, as many noble Lords will know. Emergency care, hospital admission and then discharge is a make-or-break time for carers and their families. Many people become carers for the first time when this happens, as I did. It heaps pressure on families and, despite all the guidelines, most discharges take place with little notice, particularly when there is a national directive to free beds to make way for winter. If you speak to carers, particularly if discharge takes place when the patient is medically unfit or without the proper facilities and care available at home, they will tell you that this is one of the most traumatic times for them.
The number of carers is increasing every day. It is now estimated at 6.8 million, an increase of 1 million over the past 15 years. As Carers UK has stressed, families are caring more, not less, as some would have it. On top of this, we see in the press that carers have been asked by one trust to collect their elderly from hospital to help with the discharge process and ease the winter crisis. Is this really where society wants to head?
For carers, frequent GP and hospital visits, providing and arranging transport and so on are a routine part of looking after partners or relatives with disabilities or co-morbidities or of caring for frail and elderly people. Cancelled operations mean desperately trying to reinstate the cancellations in domiciliary care support made for the hospital stay and, of course, dealing with huge upset and disappointment.
There is the added winter threat of norovirus or flu and the impact this will have on carer and cared for or on both together. Where there is a carer involved in A&E corridor waits, they will be there with their loved ones, doing their best to care for them in very difficult circumstances and sharing their anxiety and concern. Acknowledging the vital role carers play as partners in the health and social care system has to be backed up by providing the resources that are needed to undertake the caring role.
Can the Minister update the House on the call to action that the Government have promised in place of the national carers strategy refresh that carers were expecting two years ago? It was due in the new year and we are nearly at the end of January. Can he tell us when it is to be published and ensure that it provides the support and resources that carers need?
As Labour has emphasised, the winter crisis has consequences not only for those in urgent need, but for everyone using the NHS. The panic cancellations of elective operations and outpatients clinics in the face of hospitals running at full capacity will have a major impact on the many older people who rely on NHS services to stay well and on their carers. As Age UK has stressed, waiting for a hip or cataract operation or having an appointment postponed will leave many people experiencing pain, discomfort and anxiety. It will result in a need for more support in the home or from primary care and could even accelerate people’s need for urgent and emergency care.
The noble Baroness, Lady Campbell, wanted to participate in this debate today, but had a previous commitment. She asked me to raise the key issue of the impact that the winter crisis has on people with acute, long-term conditions and disabilities, such as muscular dystrophy, cystic fibrosis or acute asthma, who, if they go down with flu or chest infections, need emergency care in specialised respiratory units. The availability of these beds is increasingly under pressure because hospitals are unable to discharge severely disabled people occupying those beds back into the community if they require more social care support than they had before. She faced this very perilous situation three years ago when her local specialist unit was full to the brim for many days and a suitable, high-dependency placement could not be found, and she lives in fear of that every winter. Will the Minister undertake to write to her on the urgent measures and steps that will be taken to ensure that people with acute and long-term disabilities receive the integrated and joined-up care they need?
Planning for winter means planning across health and social care. As NHS Providers said last year:
“Too often winter pressures has just been about acute hospital capacity. Last winter showed that ambulance, community and mental health capacity are just as important, as is primary and social care capacity”.
Social care’s extra £1 billion pounds last year was designed to reduce delayed transfers of care and free beds, but only 28% of trusts managed to secure any commitment from hard-pressed local authorities to spend the money on delayed transfers. Most would have simply been unable to meet that commitment.
Over last winter the lack of capacity to deal with expected demand across the whole system was clear: 64% of trusts lacked ambulance capacity; 71% lacked acute capacity; 76% lacked community capacity; 80% lacked mental health capacity; 91% lacked social care capacity; and 92% lacked primary care. Can the Minister explain why the Government’s winter crisis plan for this year did not take account of all these factors? Was this really the effective planning the Government insist went on? Will the lessons be learned for this year’s promised winter crisis ministerial review?
On delayed transfers we know that the NHS needs to get its act together. More than 58% of delayed transfers in November 2017 were attributable to the NHS, mainly through patients having to wait for further NHS non-acute care; 34% of delayed transfers were due to social care. What was the main reason? It was patients awaiting a care package in their own home. Financial penalties on local authorities or instructions to trusts to use the limited extra funding to reduce their debts do not address the crisis in either sector. As the Local Government Association puts it, delayed transfers,
“are a symptom, not the cause, of the pressures on the NHS and in many cases the solutions will lie in investment in prevention, primary care, community services and hospital avoidance schemes ... There cannot be a sustainable NHS without a sustainable adult social care system”.
We know that as a result of the cuts to local government, the availability of adult social care packages has fallen so dramatically that 90% of councils are now able to respond only to people with critical and substantial needs. At least 400,000 fewer people are getting publicly funded help. Age UK’s estimate is that there are now 1.2 million people with unmet needs for help with essential daily support, such as bathing, toileting, taking medicine, cooking, shopping and other everyday tasks.
All this makes it vital that the Government’s Green Paper this summer does not deal just with a cap in care costs or any disastrous proposal for a care cap floor, unless, of course, Jeremy Hunt throws in the towel and recognises that the Dilnot proposals that we all spent two years working on are actually the best chance we have for bringing fairness and some equity into the health and social care system in the near future. The Green Paper must also address how we can achieve the fundamental integration between health and social care that is needed to meet the scale of the current crisis and the rising demand and to provide the care and support that people should be getting.
The Government have tried very hard to make the change of Jeremy Hunt’s title to Secretary of State for Health and Social Care sound like a fresh and important sign of action and purpose. I must say that I am one of those who thought he was supposed to have that role anyway. However, if it means that the Green Paper will be health and social care-led—rather than led by the Cabinet Office—and that Jeremy Hunt will take leadership responsibility instead of, as is his frequent habit, blaming the health and social care crisis on everybody else, then that is at least a start. His recent recognition of the need for a 10-year strategy is also a step in the right direction.
Can the Minister confirm that the Green Paper is still scheduled for the summer? Can he be any more specific about its aims, scope and publication date? What work will be done alongside the Green Paper to produce a national integrated staff recruitment, training and development strategy for health and social care? Currently, Health Education England provides the NHS staff strategy and Skills for Care deals with social care staff. Is this not a key issue that needs to be addressed to ensure integrated working? Will the chronic low pay problems, particularly in social care, that are one of the root causes of staff shortages and low morale be tackled? How will health and social care budgets be joined up?
I am grateful that this debate has attracted so many experts among noble Lords, and I am very much looking forward to it. I close by paying tribute, on behalf of us all, to the extraordinary efforts and work of our NHS and social care staff, particularly over this Christmas and new year and this winter.
Baroness Wheeler
My Lords, I thank noble Lords for their thoughtful and wide-ranging contributions. I am not going to deal with them in detail because we want to move on to the next debate. I hope the Minister will write to noble Lords in response to the questions he has not been able to deal with and that he will draw the attention of the Secretary of State for Health and Social Care to everything that has been said today.
NHS: Winter Funding
Baroness Wheeler Excerpts(6 years, 3 months ago)
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Baroness Thornton
To ask Her Majesty’s Government, given the timing of the grant of additional funding to the National Health Service to prepare for winter at the end of November 2017, how they will assess the use and impact of that additional funding.
Baroness Wheeler (Lab)
My Lords, on behalf of my noble friend Lady Thornton, I beg leave to ask the Question standing in her name on the Order Paper.
The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)
My Lords, in the Autumn Budget, we allocated £337 million to be available immediately for trusts to use this winter. This package funded more hospital beds, community services, mental health services and urgent GP appointments to manage the expected surge in demand. After Easter, the NHS, as last year, will undertake a full review of this winter and identify any lessons for the future. We expect that that will include an assessment of the impact of this funding.
Baroness Wheeler
I thank the Minister for his response. He will have seen the BMA’s stark analysis of one week between Christmas and new year. In just those seven days, bed occupancy rose to 91.4%, 39 ambulances were diverted from A&Es that were too busy to cope, 731 beds were closed due to diarrhoea or vomiting, and by the end of the week, 3,400 escalation beds had to be opened because hospitals were full. Today’s figures and the warnings from NHS Providers tell the same sorry story. Does the Minister accept that announcing extra funding in November/December was far too late to prevent the worst period across the winter so far or the Government having to announce the bombshell of 550,000 cancelled operations? Can he also tell the House how the Prime Minister’s plan will now be revised to reflect these everyday realities and come up with the urgent action and funding that is needed to help the NHS cope with its worst winter crisis in two decades?
Lord O’Shaughnessy
I would hope that the noble Baroness would welcome the money that was set aside in the Budget. It is important to point out that in addition to that £337 million, half of which has gone to support plans that were already in place and being actioned before the Budget, there was a further £100 million to support A&E streaming, which is also a way of taking pressure off emergency services. That has had an impact, so I do not accept the accusation that the money came too late, and indeed there is still money in the pot as services come under pressure.
As regards the future, the noble Baroness will know that it was also announced in the most recent Budget that another £2.8 billion would be allocated to the NHS to help it get through the next few years. We know that the pressures are increasing because of the ageing population. The idea of that money is precisely to help the NHS get back on target on A&E waits as well as referral to treatment.
Social Care: Sleep-in Payments
Baroness Wheeler Excerpts(6 years, 4 months ago)
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Lord O’Shaughnessy
It is not our position that they will not be funded. That is one of the options being explored at the moment. A huge amount of work is going on with providers and all parts of government. In the end, however, the Care Act 2014 means that local authorities have a responsibility to take on the commissioning of and, ultimately, provision for providers, if they are looking at exiting the market, to make sure there is proper and comprehensive provision in the local area.
Baroness Wheeler (Lab)
My Lords, it is absolutely right that sleep-ins are defined as working time and therefore subject to payment of the national minimum wage. However, the Government’s November compliance scheme proposal not only failed to offer support for hard-pressed providers but also means that thousands of care workers, who are among the lowest paid in society, could be waiting until March 2019 to get paid what is owed to them. Does the Minister agree that these low-paid workers should not have to pay the price for the Government’s £6 billion cuts in social care or their failure to take action on addressing the social care funding crisis?
Lord O'Shaughnessy
I am grateful that the noble Baroness has raised the compliance scheme. For those providers that enter it, the scheme offers the opportunity to take 12 months for self-review and then report to HMRC, which will then allow a further three months for the providers to pay. That gives a 15-month leeway compared with the usual default enforcement period of 28 days. There is clearly a balance to be struck between the financial challenges posed to providers and the money that staff, rightly, need to take. I think that the compliance scheme provides that balance so that we can do it in a way that is sustainable.