NHS and Social Care: Winter Service Delivery

Lord Hunt of Kings Heath Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Barker (LD)]

My Lords, I thank the noble Baroness, Lady Wheeler, for the opportunity, as the noble Baroness, Lady Pitkeathley, just said, to return again to this subject. I will not make a long speech as I would like to leave as much time as possible for the debate that will follow. On behalf of my colleagues on these Benches, I wish the noble Baroness, Lady Jowell, all the very best and ask her colleagues to convey that to her.

The noble Baroness, Lady Pitkeathley, is right: we have been back to this ground so many times. In preparing for this debate, I thought back to many of the debates that we have had in the past. The origins of the problem we are looking at go back to the National Health Service and Community Care Act 1990. In that Act, for the very first time, welcome things happened: we began to break down procedures within the NHS and to cost and quantify them. But the problem was that we made them into individual units of activity, and to this day, within the NHS, the systems that join up those individual units are failing. They fail completely when they have to be matched up with the social care system, which is completely different.

Those problems were identified and partially addressed in 2003 with the Community Care (Delayed Discharges etc.) Act, when the then Minister, the noble Lord, Lord Hunt of Kings Heath, was sitting there trying to answer questions from very talented opposition spokespeople such as me. We asked him a question that he never could answer, which was why the then Government thought that the answer to the problems in the NHS was to fine social services departments. I never understood that. We still have, within the whole system of discharge, a system of penalties.

[Lord Hunt of Kings Heath (Lab)]

Perhaps I can answer the noble Baroness. Surely the point is that both local government and the NHS were being properly funded at that point. Therefore it was entirely appropriate to have a system to encourage local authorities to do the right thing.

[Baroness Barker]

The issue that I think the Government were trying to solve was one for which we have never had any evidence: that of local authorities trying to game the system. It is correct that the overall amount of funding has gone down, but we have not had evidence of people gaming the system.

We have never had a system, or even part of a system, that incentivises GPs and those in charge of social care to prepare for winter pressures, invest in programmes that will see older people through the increased incidence of illness that we know happens in winter, and avoid unnecessary admissions to A&E. What has changed in that time is that we now have better data and better information systems, but in many ways we are still failing to take all that and improve those systems. At the moment we still have ambulance services being rated on completely different systems across the country so we cannot generate data.

The Government have done some things that are very welcome. Everyone agrees that the primary care streaming system, into which they put £100 million, is a worthwhile initiative. Unfortunately, the initial evidence is that it is failing simply because it takes people from another part of the system—GPs—and locates them in hospital. What are the Government going to do to properly monitor that system in its entirety as part of an overall approach to winter pressures, to see whether it is worth more investment or whether it simply takes resources from other parts of the system?

On the question of beds, we have a national system of monitoring general and acute beds and ways of measuring the overall occupancy rate. We do not have a method of assessing the number of beds in relation to need. For example, we can open up a load more beds, as the NHS always does at times of crisis, but if there are no more staff to look after the people in those beds then we are not really addressing the need. We need to refine the measurement of this so that we have a metric along the lines of “nurses per bed per day”. That is the point at which things become really bad. I remember talking to a nurse about a patient—actually my mother—and being told that she was far too good to be in hospital and would be going home. She died two days later, which was not a surprise to any of us. I say that because it is not an uncommon experience for patients.

We have been through this time and again. The one thing that we have failed to do is incentivise GPs to work with community organisations from the summer onwards to predict the people in their area who are going to be most at risk and to put in place very low-level, simple and low-cost packages of care for them that can be there very quickly when they are discharged. The biggest cause of delayed discharge is not the absence of social care but the absence of community nurses and NHS staff available to work in the community to ensure that we do not send people home only to see them return unnecessarily into acute care.

--- Later in debate ---

[Lord Hunt of Kings Heath (Lab)]

My Lords, it is a great pleasure to respond to my noble friend’s debate. As my noble friend Lord Smith mentioned oral health in the north-west, I remind the House that I am president of the British Fluoridation Society, which of course is the answer, at a stroke, to the dreadful oral health issues among children in Greater Manchester and the north-west generally.

My noble friend Lady Wheeler made a persuasive speech about the pressures that the NHS is under and the relationship between that and front-line social care. The latest figures on performance graphically illustrate this: in 2017, 16.5% of patients spent more than four hours waiting for treatment compared to 5.6% in 2012. On delayed transfers of care, there were 1.97 million delayed days in the first 11 months of 2017 compared to 1.26 million in the equivalent 11 months of 2012. The 18-week referral-to-treatment target for consultant-led treatment has not been met since March 2016. The 62 days from referral to treatment target for cancer has been met for only one month since April 2014. The number of cancelled operations is going up, as are ambulance response times—the new target of seven minutes for life-threatening calls was not met in its first month of operation. Occupancy levels in hospitals have become a hugely difficult issue. On 2 January this year, 57 of 137 trusts had bed occupancy above 98%. That means not just pressure but almost certainly unsafe practices in those situations. The Secretary of State, who has made quite a lot of noise about safety, needs to take stock of his own responsibility for the fact that there are now some very critical situations in the NHS where undoubtedly patients are vulnerable.

If the Government were at least open about this, we could have a proper debate, but, as the noble Lord, Lord Kerslake, said in quoting Chris Ham—who knows a thing or two and goes back quite some way—it is the Government’s denial about the scale of the problems faced that makes it so difficult to debate with them and have any meaningful discussion about the way forward. I think all noble Lords agree with my noble friend Lady Pitkeathley that the NHS crisis is also a crisis of social care. The information we received from the Association of Directors of Adult Social Services, saying that 90% of councils are able to respond only to people with critical and substantial needs, is telling, because we know it means that we are storing up even more trouble for the future because we are not intervening at a stage where we could help people. The report that we saw from Age UK and the chair of the Malnutrition Task Force said that only 29,000 people now receive meals on wheels, down from 155,000 a decade ago. No wonder it is said that 1 million older people are starving in their own homes. That is the scale of the problem that we face.

The noble Baroness, Lady Wheeler, in talking about the experience of carers, really brought this home to us. As she said, emergency care and hospital admission and then discharge is a make or break time for carers and their families. People like her become carers for the first time when this happens. Despite all the guidelines and good practice, most discharges take place with very little notice, particularly when there is such pressure to free up beds to make way for patients who are waiting in A&E, on trolleys or, indeed, in the ambulance, waiting to be seen in A&E.

My noble friends Lady Pitkeathley and Lord Pendry talked about the impact of carers and the problems they face for their health. I hope the Minister will respond to this question: if we cannot produce a carers’ strategy, can we at least have an interim action plan? Let us not just hide behind a Green Paper, which, frankly, I do not think we will see for many a month, if at all. I suspect the problem is that the Treasury will not agree to any proposal that is not along the lines of that which Mrs May proposed during the last election, which caused such concern.

Capacity is a major issue. The pressure is increasing but NHS capacity is reducing. Could the Minister explain why that is happening? I should also like him to reflect on STPs. There was a time when all the answers to all the problems were to be in the sustainability and transformation plans, which then became programmes. We do not hear so much from Ministers about STPs now, but the health service is trundling on because no one has told it to stop work on them. We debated here a few months ago the west London STP, which is a remarkable document. Because financial balance by 2021 is the imperative, it is essentially taking a great deal of capacity out of west London and then saying that through heroic demand management, which we have never seen before, everything will be all right. Most STPs repeat this because, basically, they have been told by the regulators that they have to come up with a plan that meets financial balance. I do not think Ministers believe in them anymore, but they used to believe in them; they used to say that they were the answer to the problem—but everyone out there knows that they are pieces of fantasy, which will never be delivered. I pray in aid the National Audit Office report, which came out in January and said:

“Local transformation of care is being hampered by a lack of resources and ongoing pressure to make increasingly tighter finances balance each year”.


So they are reducing capacity, but not producing any investment to develop other services, which would then help to reduce demand on acute care. So there is no hope whatever of achieving anything that these STPs say they will do.

We then come briefly to the new role of the Secretary of State. Will the Minister explain what that new role is? He knows that his department has been responsible for social care for decades; he also knows that the Department of Health negotiates the adult social care vote, albeit that then goes through DCLG. So what is changing? Is the Department of Health now to have the money for social care and is that then to be ring-fenced as an allocation to local authorities? If not, has there been any change at all in the Secretary of State’s responsibilities? I think we ought to know.

I accept, and my noble friend Lord Smith and the noble Lord, Lord Kerslake, explained, that it is not simply a matter of having integrated health and social care budgets. First, you have to deal with the gap between free-at-the-point-of-use NHS spend and means-tested social care spend. Until you deal with that, integration is very hard to deliver at local level. Secondly, you cannot look at social care budgets without looking at the overall spend and discretion of local authorities. Adult social care is probably the biggest discretionary spend they have: if you start to intrude on what they can do, it is very difficult to see how local authorities have the flexibility at the moment to be able to manage the rest of the local authority responsibilities. This is not at all easy.

The noble Lord, Lord Macpherson, spoke very articulately about the pressures on government finance in general. He said we could do with better management and I agree: the system needs to be reformed. I also agree with my noble friend Lord Brooke about the way hospitals are run. The hypothecated tax, informed by the OBR and based on national insurance contributions, seems to be a runner. His point about retired people having to pay national insurance was very well made. I have just been re-reading, or glancing at, the book by the noble Lord, Lord Willetts, about intergenerational fairness. Reflecting on my noble friend Lord Desai’s willingness to increase taxes, which I agree with, it is very difficult to say to younger people, “We are going to increase your taxes to be spent largely on a service that provides for older people”, when you have the current benefits for older people. This is a controversial statement to make from this Dispatch Box, but inevitably this has to be confronted. I am hoping to join my noble friend in being sacked at this point.

I come back to the report by the noble Lord, Lord Patel. It is a very good report, published on 5 April 2017. “How long, O Lord, how long” before we get a response from the Government?