NHS: Nurses

Lord Lilley Excerpts

Tuesday 1st November 2022 Lords Chamber

[Lord Kamall (Con)]

My Lords—

[Lord Lilley (Con)]

My Lords—

[Lord Kamall (Con)]

I apologise to the noble Lord but it is some time since I have spoken in this part of the House. Given that it was Black History Month last month, does my noble friend the Minister agree that we owe a great deal of gratitude to immigrants from the Commonwealth who helped to save our public services after the war? Now that we have left the EU, can he also assure us that we will no longer give priority to mostly white Europeans over mostly non-white non-Europeans, and treat all equally when we want to recruit health and care staff from abroad?

--- Later in debate ---

[Lord Markham (Con)]

I am very aware of the Nuffield figures but that 40,000 includes people who have gone back into other parts of the nursing profession. The actual net number as cited by Nuffield is a 27,000 reduction, which is why we have had the growth. However, we should ensure that it is as attractive a profession as possible for people to work and progress in. That is very much what I would like to see.

[Lord Lilley (Con)]

My Lords, can my noble friend explain why we none the less turn away every year more than 20,000 applicants for nursing courses? Why does there appear to be a de facto limit on recruitment at universities for nursing, whereas they are allowed to take an unlimited number for media studies, PPE and other less worthy disciplines?

[Lord Markham (Con)]

I have been assured by officials that there is not a cap, so my only thought would be that, if people are turned down, it is perhaps because they may not have the necessary qualifications. I will check that and, if I am wrong, I will reassure the noble Lord, but my understanding is that there is no cap, and the more the merrier.

Nursing: Staffing

Lord Lilley Excerpts

Thursday 16th June 2022 Lords Chamber

[Lord Lilley (Con)]

My Lords, I congratulate the noble Baroness, Lady Tyler, on this debate and agree with a great deal of what she had to say by way of introduction. This report gives serious grounds for concern. Clearly, Covid has played a major part in the pressures that nurses feel, and they deserve our sympathy as well as our gratitude. I agree with many of the suggestions of a comparatively straightforward nature that she made, which might be able to alleviate some of these strains.

I will focus on an issue that the noble Baroness, Lady Tyler, raised: recruitment. She mentioned that we recruit more than half our additional nurses from abroad, and that the Royal College of Nursing said there was a problem as a result of Brexit. I looked at the Royal College of Nursing labour force survey, which shows that there is the same number of nurses from the EEA now as 10 years ago, so that has not been a problem—but we have recruited many more from other countries.

What I find particularly alarming is the recent news that more than 4,000 of those nurses we have recruited from other countries come from poor countries that themselves have a great shortage of nurses. That strikes me as immoral and wrong. I am not alone in saying that; people on both sides of the House have said it.

What puzzles me is why we do not go on to ask, “What is the alternative?” Surely the alternative is to train more of our own nurses. No one ever focuses on the fact that in the last year for which I could find figures in the Royal College of Nursing labour survey, we turned away 26,000 British applicants from nursing courses—a far higher proportion than are turned away from almost any other area of training or qualifications.

It used to be because we rationed the number of places by bursaries, which came from the NHS budget. I remember discussing with Jeremy Hunt why we had not increased that. He said he had reached the conclusion that his predecessors thought, “If I spend more money on bursaries and train more nurses, those nurses won’t be available until four or five years from now when I won’t be Health Secretary”. Of course, that was not the case with Jeremy Hunt and he was instrumental, along with George Osborne, in changing the rules so that thereafter nurses were trained out of student loans.

We thought that would end rationing, but it has not. I understand from those I speak to in the health service that there is de facto rationing because of the supernumerary rules and so on mentioned in the report. Training nurses is an encumbrance as far as the hospitals are concerned—they do not count as part of the workforce but subtract from it. I do not understand that. What I really do not understand is that those who clearly know far more about the NHS than I do never focus on it. They never use their great expertise and information to identify what is going wrong. Why are we rationing places in our universities and turning away people who want to be nurses and who we need as nurses, blighting their prospective careers and making them do something else instead? It is a scandal.

Of course, we know why. People say, “If you’re advocating British people being trained as nurses, that must mean you’re against immigration.” I am in favour of having the most highly qualified labour force we can and giving the maximum opportunities to people in this country who want to be nurses and do other worthwhile professions, rather than saying that we ought simply to make ourselves open to every form of immigration from the world.

I noticed one puzzling thing about this report. It contains a whole series of harrowing comments from nurses, and more than half of them come from nurses in Scotland. I could not see why. I claim Scottish ancestry and was brought up to believe that this made me racially superior, until I learnt that that was racism; now I just claim to be equal to everybody else. I have a natural love of Scotland, and I cannot believe that Scottish nurses are in any way different. I looked at all the answers, when they are broken down by whether they are in Scotland, England, Wales or Northern Ireland, and in almost every case the situation is more negative in Scotland, despite the fact that Scotland gets 25% more per head to spend on health than the rest of the United Kingdom. That makes me think that this is not simply a question of money; it is a question of morale, leadership and the whole ethos of the NHS.

Both in Scotland and in the rest of the United Kingdom, we ought to look at the sort of measures that the noble Baroness, Lady Tyler, has put forward to improve the lot and the work satisfaction of nurses, and at the same time see what we can do to recruit more British people into our universities to become nurses and stop us stealing nurses from poor countries that need those nurses much more than we do.

Health and Social Care Leadership Review

Lord Lilley Excerpts

Thursday 9th June 2022 Lords Chamber

[Lord Kamall (Con)]

The noble Baroness is absolutely right that there should be a duty of candour. Noble Lords will remember that during the Health and Care Bill debates there was the debate around the openness of HSIB process. Here we have a difficult balance. On one hand, if someone has acted inappropriately or caused damage, you would want them to be brought to justice but, on the other hand, we know that the NHS has a culture of cover-up when things go wrong. It is great that we praise the NHS when things go well but I have heard too many stories of when things go wrong and clinicians close ranks and cover up.

Sometimes, they gaslight. I was talking about this the other day to a young official in the department and she told me about her friend, a young Afro-Caribbean female, whose baby died during birth. When she complained, the papers suddenly, magically disappeared. How can that happen? We have to make sure that there is real justice, but we have to get the right balance. HSIB makes sure that there is a safe space so people can feel free to come forward, so that we learn from that. Sometimes there may not be justice for the individual, but we can make sure that we avoid a repeat of these incidents. The Ockenden report clearly showed the role that the culture of the organisation played. We must be careful: there should not always be a focus just on numbers; we do not want to train people within the wrong culture and do more damage. We have to tackle all these issues at the same time.

[Lord Lilley (Con)]

My Lords, I would congratulate the Secretary of State Sajid Javid on presenting this report if it called for fewer full-time equality, diversity and inclusion officers and devoting resources, intention and focus to patients. Sadly, on reading the report, it does not; quite the reverse. It is totally obsessed with EDI. EDI is mentioned three times as frequently as patients. There is no mention of waiting lists, whistleblowers, cover-ups or value for money, and only one reference to efficiency. There is nothing about the lessons of Staffordshire or the failures in the health service—nothing at all. It is about EDI only. Worst of all, it states that demonstrating a commitment to EDI is more important than just technical skills.

It is important that we eliminate discrimination from the health service, but when I am treated, it is the technical skills of the medical staff I am worried about, as it is when those whom I love are being treated. The report sets goals for increasing the representation of underrepresented groups, but no goals for improving outcomes for patients. Worst of all, it proposes using the everyday discrimination scale as an objective tool of management, yet it is entirely subjective and all the academic literature I have found suggests it is completely worthless. Will my noble friend commission another report that will deal with people’s real concerns about the NHS?

[Lord Kamall (Con)]

I thank my noble friend for the question. It is important that we recognise that not only do we have more doctors and nurses than ever before, but we need staff to be good leaders. That includes understanding diverse workforces and, as I said earlier, making sure that we have good leaders at the top. Why do we have a diverse workforce? In fact, that diversity is not represented right at the top, in the leadership. Sometimes, when you want to change an organisation—I am sorry, but I did an PhD in organisational change—there are a number of aspects and one of them is the culture and the leadership. Sometimes a new leadership comes in that can drive that change in the organisation. It is not just about structures but about making sure that we improve the standard of care we give to people. This issue came up in the report, because we have to have the right leadership and focus on patient care and on making sure that we have a proper integrated health and social care system for patients all the way through their lives.

Adult Social Care

Lord Lilley Excerpts

Thursday 2nd December 2021 Lords Chamber

[Lord Kamall (Con)]

The Government have been listening to the workforce and understand its pressures. We recognise that this is the vision, and that we need to look also at the short-term issues. We announced £162.5 million for the workforce recruitment retention fund, and the new Made with Care scheme to recruit social workers and to send a message that social work can be a rewarding career. We are talking to different bodies, including the Department for Education, about how we increase professionalisation. We have also increased the national living wage, meaning that many of the lowest-paid workers will be paid more. We are investing at least half a billion pounds in supporting the development and well-being of the social care workforce, including an investment in knowledge, skills, and well-being. We will work with partners to set the conditions for the professionalisation over a longer period. We cannot do this immediately; we want to consult the education sector and care and social care experts, to give recognition. That will be a precursor to making progress on pay.

[Lord Lilley (Con)]

Does my noble friend agree that the primary obligation of a Government is to provide decent care for those who cannot finance their own care, and that the lowest priority is to provide taxpayers’ funds to enable those who own valuable assets to pass them on to their offspring? If it is possible to enable people to insure against the risk of having to use the value of their home to pay for their own social care, possibly through a state-aided scheme, would that not be desirable? Is he not astonished that the Labour Party, normally the champion of public sector provision and the enemy of channelling public money to the rich, should advocate channelling money to the rich and not a state-funded insurance scheme?

Social Care: Family Carers

Lord Lilley Excerpts

Monday 13th September 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, I do acknowledge the pressures on unpaid carers and pay tribute to the incredible contribution they have made during these very difficult 18 months. We are continuing to work with local authorities, in collaboration with ADASS and MHCLG, to support local authorities in meeting their duties, particularly in the area of respite, which the noble Baroness rightly pointed out. We have also made contributions to Carers Trust, Carers UK and to “See, Hear, Respond” services to support unpaid carers. In the long term, our commitment is to social care reform and the financial proposition that we will bring forward in the White Paper.

[Lord Lilley (Con)]

My Lords, would my noble friend confirm that he just said there would be only £1.5 billion a year going to social care from the large increase in national insurance? Can he confirm that nearly half of that will be absorbed by the need to pay for the extension of free social care to those with valuable homes? That means that nothing will be left to help domestic carers.

NHS: Nursing Workforce

Lord Lilley Excerpts

Wednesday 8th September 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, there are 303,900 full- time nurses in the NHS trusts and CCGs, an increase of more than 8,900 from June 2020, so the impression that the noble Lord is giving is not, I am afraid, entirely supported by the numbers. In terms of recruitment, 2021 saw a third consecutive year of growth in the number of applicants to nursing and midwifery courses, which again is very good news. As for commitment on devolved Administrations, of course devolved does mean devolved, so I am not sure that I am in the position to make the commitment that he has sought.

[Lord Lilley (Con)]

Does my noble friend agree that, as well as retaining nurses, we need to train enough to end the scandalous reliance on poaching nurses from poor countries? The move from bursaries to loans was supposed to end the scandal of us turning away tens of thousands of applicants for British nursing courses in this country. Can he explain why last year we again turned away more than 20,000 young British people who wanted to train as nurses in this country?

[Lord Bethell (Con)]

My Lords, as my noble friend will know, the training grant of at least £5,000 per academic year per eligible student is in place, plus a further £3,000 of additional targeted funding—for example, for childcare costs and students studying special subjects. That is the kind of financial commitment that we have made to meet his concerns. On the specific point that he mentioned, I say that not everyone is suited for the nursing profession; it is a really tough job, and not everyone who wants to be a nurse can be a nurse. I am afraid that the applications that we get and the sifting that we do reflects that point.

Elderly Social Care (Insurance) Bill [HL]

Lord Lilley Excerpts

2nd reading
Friday 16th July 2021 Lords Chamber

Moved by

[Lord Lilley]

That the Bill be now read a second time.

[Lord Lilley (Con)]

My Lords, after 37 years in Parliament, I am grateful to have secured a place in the ballot entitling me to bring in a Private Member’s Bill. This Bill is about social care for the elderly, a subject that has preoccupied me for more than 25 years, since I was Secretary of State for Social Security.

I know from recent debates and committee reports of your Lordships’ House that noble Lords are seized of the crisis in social care provision in this country, which has been growing over decades. Local authority budgets have been squeezed to the bone, demand is rising, as we are living longer, and costs are rising, not least because the national minimum wage raises the pitiful earnings that many dedicated staff in the social care sector have had up to now. Many care homes were teetering on the brink even before the pandemic and are now in an even more precarious situation. Every winter, beds in the NHS are blocked as places cannot be found for patients in the social care sector.

Successive Governments have backed off from tackling the issue. That is because there is a live rail running alongside the basic issue, which has given an electric shock to those who have touched it. That live rail is the understandable and natural concern of home owners and their heirs that the potentially catastrophic cost of social care will consume the value of the home that they hoped to bequeath or inherit.

In 2010, Labour’s plan for a tax to finance social care was labelled a death tax. In 2017, Theresa May lost her majority when Labour retaliated by labelling her plan a dementia tax. In between, the Dilnot plan, legislated for by Cameron, was abandoned as too costly. All the solutions so far suggested have proved either unsaleable or unaffordable. At the last election, Labour promised to set a cap of £100,000 on the maximum cost that anyone would incur while in residential social care. Today, we read in the Daily Telegraph that the Government could, as early as next week, adopt that policy, hoping, no doubt, for bipartisan support. However, it is not Labour’s support that they need but that of home owners and the general public. The problem is that a £100,000 cap would be fine for the owner and the heirs of a £10 million mansion in Mayfair, even if they spent decades needing substantial care for dementia, but the owner of a modest, partly mortgaged home in Middlesbrough will see its value disappear entirely in two or three years. That is not a good proposal to go down well with red wall voters.

On the other hand, raising the value of assets shielded from means testing will still mean many home owners having to sell their homes to pay for longer periods in care. Both those options break the Prime Minister’s promise, repeated in his first speech as Prime Minister,

“to protect you or your parents or grandparents from the fear of having to sell your home to pay for the costs of care”.

Both are expensive. The only other option on the table would be to extend free social care to all, but that is the most expensive of all. Even if any of these options were affordable before the pandemic, they are certainly not now, when our debt is topping £2 trillion and we have an unprecedented deficit adding to it. Pre-empting billions of pounds desperately needed to bail out the existing care system in order to subsidise bequests from home owners to their middle-aged children would be a strange priority.

But there is a solution: insurance. Insurance against the risk of having to sell your home to pay for social care in old age was one of the first solutions to be considered by the Dilnot review, and again by the Economic Affairs Committee of this House. However, they and others rapidly abandoned the idea when the private insurance industry made it clear that it could not and would not provide policies to protect people from having to sell their homes. The inherent risk of needing social care is eminently insurable, and at reasonable cost, just as we ensure our homes against fire or burglary. However, there are two reasons why insurance companies will not touch it. Actuaries cannot measure the uncertainties about future government policy or about possible medical advances prolonging frail longevity. That makes this niche market wholly unattractive to private insurance companies. If they could overcome those problems, people cannot be persuaded to contribute to such policies during their working lives on top of paying for their pensions and paying off their mortgages.

There is an alternative to the private sector providing insurance, which has not even been considered, and that is for a state body to offer such insurance. Instead of people making contributions during their working lives, why not enable them to pay for such insurance after they retire by taking a charge on their homes? The state insurer would then be reimbursed when they die or sell their homes.

This Bill will set up a body owned and guaranteed by the state to offer such insurance policies. Everybody would be informed of the option by the DWP as they approach state pension age and for two years thereafter. To avoid adverse selection, people would have to take out the policy within a couple of years of the state pension age. The public insurer would publish a schedule of premiums, which would be larger for those with higher-value properties and smaller for those with smaller homes needing protection.

How much might those premiums be? The Dilnot commission on fairer funding calculated in 2011 that the average costs for such a premium would be comparatively modest—around £16,000 in today’s money. The arithmetic is simple: only one in four people ever needs to go into a residential or nursing home; the average length of stay is 30 months—two and a half years; and the cost of social care is around £25,000, plus £10,000 for the cost of accommodation and food and basic living costs—the so-called hotel costs, which are normally paid out of state pension benefits and other income not covered by insurance. One in four times two and a half times £25,000 comes out at a premium of around £16,000.

I spelled this out in a pamphlet called Solving the Social Care Dilemma? A Responsible Solution and suggested that the actual premium payable by any individual should be set at a percentage of the value of the person’s home—never their mortgage—at the time they take out the policy. People would be given the opportunity to take out a policy within a couple of years of reaching state pension age and would not have to pay any cash, since the premium would just be a charge on their home, and the premiums would be set at actuaries to meet the average costs.

Why has this proposal not been considered before? I suspect it is because those on the right find the very idea of setting up a state body to provide pensions—taking on a responsibility normally the duty of the private sector—anathema. Certainly, when I offered the proposal to a right-wing think tank, it turned it down with horror, expressing amazement that I, the author of the Government’s privatisation policy, should be the advocate of this. But of course, having thought long and hard about privatisation, I realised that some things are suitable for the private sector and some are not. We should be open-minded about this.

What will the likely take-up be? I do not know. The important thing, however, is that everyone has the option to protect themselves and their homes against the need to sell them and use up the entire proceeds to pay for care in old age. Some may decide that they are quite content to take the risk that they will be in the happy three-quarters of the population who never go into residential care or need social care. But if they take that risk, they will not be able to complain if it turns out that they need to sell their house to pay for some or all of their social care in old age.

I have brought this Bill forward to promote and provoke debate. I am sure that, like all Private Members’ Bills, it has flaws. I hope that Members may find and expose any flaws that it has; if they are remediable, I will address them. If they find fatal flaws, so much the better—we can put the idea to one side. On the other hand, if it garners some support, I hope that the Government will consider it before opting for proposals that, if we are to believe the Daily Telegraph, could land them in exactly the same sort of problems as other Governments who have touched this live rail in the past. I beg to move.

--- Later in debate ---

[Lord Lilley (Con)]

My Lords, I am grateful to all noble Lords who have contributed to this debate—those who disagree with the Bill, those who agree with it, and those who feel that it merits further debate. Two central criticisms were made. First, a number of noble Lords said that it does not address the main issue. With respect, that is precisely what it does. It says that the main issue is the underfunding of the existing social care system for those who do not have the means to pay for themselves, but we must not pre-empt the money needed to bring about proper funding of that by diverting much of it to subsidising those who wish to leave their homes to their heirs and beneficiaries. I hope people realise that resources are finite. If we spend money on those who can afford to contribute to their own care, we have less to spend on those who cannot.

Secondly, there were those who, as a matter of principle, believe in universal state provision. I respect that point of view, but they should recognise that no Labour Government since 1948 has introduced that, and that if it were possible to have done so before the pandemic, it is much less possible now that we have £2 trillion of debt and a massive deficit. They should also recognise that that is not what Labour offered at the last election; it offered the £100,000 cap on contributions. Setting a cap, which was also endorsed by the Liberal Party, brings me to my final point. They are saying that we should give the greatest benefit to those in Mayfair and the least to those in Middlesbrough. If that is their idea of fairness, priorities and a comprehensive solution, it is not mine. I beg to move.

Bill read a second time and committed to a Committee of the Whole House.

Social Care Reform

Lord Lilley Excerpts

Tuesday 29th June 2021 Lords Chamber

[Lord Bethell (Con)]

My Lords, I hear the noble Baroness loud and clear. Indeed, the needs and priorities of those with disability and the role of care for disability and the emphasis on care in the community are things that we hear loud and clear. I am not in a position to make any commitments on finances standing at the Dispatch Box at the moment, but the noble Baroness’s points are heard loud and clearly, and I would be glad to take them back to the department.

[Lord Lilley (Con)]

Does my noble friend agree that it would be better for the state to enable homeowners to insure against the potentially catastrophic risk of social care, rather than diverting billions of pounds desperately needed to pay for the care system for those unable to pay for themselves, instead using those funds to subsidise people, like most Members of your Lordships’ House, who want to pass on to our heirs homes worth hundreds of thousands or even millions of pounds? How would that be levelling up?

[Lord Bethell (Con)]

My Lords, the point made by my noble friend is entirely thoughtful and persuasive. Indeed, there may well be a role for insurance rather than any other mechanism, and it will be one of the options that those who define the policy will look at extremely carefully. The point that he makes about the desire of homeowners to pass on their homes to future generations is completely understandable and human, and one that will take into close consideration.

Social Care and the Role of Carers

Lord Lilley Excerpts

Thursday 24th June 2021 Lords Chamber

[Lord Lilley (Con)]

My Lords, the first duty of the state in social care is financing its provision to those who cannot pay for themselves. Yet local authority budgets have been cut to the bone, despite rising costs and increasing numbers.

This primary duty has been eclipsed politically by the natural fear of home owners and their heirs that potentially catastrophic costs of social care will consume the value of the parental home. Most proposals to deal with this involve setting a maximum amount anyone has to pay—say £80,000—after which the taxpayer would meet the costs. That gives the greatest benefit to those with the most valuable homes, particularly in the south. The owner of a modest or a partly mortgaged house who needs three years’ care would still lose nearly everything, while someone in a London home worth £1 million could bequeath more than £900,000 even if they spend more than 20 years in care. How is that fair, popular or levelling up? Moreover, extending free social care to some, let alone all, home owners would pre-empt public funds desperately needed to ease the pressure on councils’ social care budgets and on the many care homes that were barely viable even pre-Covid.

Yet there is a solution to the risk of catastrophic costs of elderly social care that does not pre-empt funds needed by the existing care system. It is insurance, which was one of the first solutions to be considered by Dilnot and others but was rapidly dropped because the insurance industry said that it would not provide policies to protect people from having to sell their homes. It could not do so because of uncertainties about future government policy and possible medical advances prolonging frail longevity. Moreover, working people will not pay for such policies on top of saving for their pensions and repaying their mortgages.

But an alternative to private insurance has been ignored: that the state offer such insurance. The alternative to asking people to contribute during their working lives is not taxing them but enabling them to pay for such insurance after they retire by taking a charge on their homes. The state insurer would then be reimbursed when they die or sell their homes. I have set out the details in the Civitas pamphlet Solving the Social Care Dilemma, and in a Private Member’s Bill coming before this House on 16 July, when I hope to see all noble Lords once again. Meanwhile, can my noble friend the Minister confirm that this option has been considered by his department, to which I sent it many months ago?

Health Protection (Coronavirus, Restrictions) (Steps and Other Provisions) (England) (Amendment) (No. 2) Regulations 2021

Lord Lilley Excerpts

Wednesday 16th June 2021 Lords Chamber

[Lord Lilley (Con)]

My Lords, as the Prime Minister and the Health Secretary have said repeatedly, we ultimately will have to learn to live with Covid. This means accepting that a tiny proportion of those who are immune, either because they are young and healthy or because they are have been vaccinated, will none the less succumb to Covid in future, which will continue to circulate as the flu and other viruses do.

We have already offered the vaccine to all those who are particularly susceptible through age and health condition. That accounts for 99% of potential deaths. Some 30 million of those people have had both jabs and are as safe as they ever will be; 12 million have had the first jab so are already partly protected. We are told that the only reason for extending the regulations is to give those people time to have the second jab. Surely it would be possible to say to those 12 million people, “If you want to achieve the maximum level of protection, you should, during the remaining 10 weeks, make sure that you behave very cautiously in who you mix with and obey more restrictions than the Government are imposing upon you.”

Of the remainder, a few have chosen not to be vaccinated. That is their right and their risk. They should not be able to hold the rest of us to ransom. The young and the fit face a tiny risk of fatality commensurate with other risks with which they also live and, I am told by officials, commensurate with the tiny risk of blood clots from the AstraZeneca jab. I can see no reason to extend the controls beyond 21 June. The only reason given was this business about allowing the people who have had one jab to have their second. Surely that should be left to their personal responsibility.

During the seminar this morning to which the noble Baroness, Lady Donaghy, referred, I was told that there is an additional reason: many of the 30 million people who have had two jabs could be infected asymptomatically and spread the virus. But who could they spread it to? The answer is: only people who are already vaccinated or are too young to be at serious risk. By definition, therefore, there is no reason for these regulations. I shall oppose them and possibly even vote against them via the fatal amendment.