NHS: Winter Staffing Levels
Lord O'Shaughnessy Excerpts(6 years, 6 months ago)
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Lord Clark of Windermere
To ask Her Majesty’s Government what plans they have to increase staffing levels in the National Health Service to meet anticipated demand during the forthcoming winter period.
The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)
My Lords, providing appropriate staffing over winter is essential. NHS England and NHS Improvement have worked together to make sure that every major consultant-led emergency department has a robust plan to meet demand. This includes necessary staffing levels. In addition, the department has provided £100 million to relieve pressure on urgent and emergency care specifically to allow primary care streaming and improve patient flow in A&E departments.
Lord Clark of Windermere (Lab)
I thank the Minister for his reply. Those are soothing words, but I am afraid not really matched by the reality on the ground. It is clear that we face a dire prospect this winter on account of the Government’s poor labour planning over the years they have been in power. We know that we are 40,000 nurses short, GP numbers are tumbling and adult social care staff numbers have fallen from 70,000 to 48,000 in four years. Last year, 45% of the consultant posts advertised were not able to be filled. We really are in a very difficult position.
I ask the Minister a very specific question: is it true that the Government have given the go-ahead for vulnerable patients who are not fit to be discharged to their home to be discharged to third parties? They will be allocated to homes where the hosts have no medical expertise and for which they will get paid £1,000 a month.
Lord Clark of Windermere
This is my final question. Will the Government not listen to medical opinion and drop this preposterous scheme?
Lord O’Shaughnessy
The noble Lord knows that winter is always a more difficult time for the NHS. I hope he also knows that there are 11,000 more nurses on wards than there were in 2010. Indeed, I was looking at the data on doctors. There has been a 30% uplift in emergency doctors in that time as well. So there are more staff in the NHS—but, of course, there is much more need for winter preparedness. The NHS feels that it is better prepared than ever for winter.
On the issue that the noble Lord refers to—I assume he is talking about the story in the press today—that is, I stress, a local pilot that is being explored. I do not think it is even under way. It is being proposed by a local doctor—indeed, an emergency registrar. For it to go ahead, it is clear that any such pilot would have to abide by the very strict rules that exist on safety, safeguarding quality and so on for any care setting. The head of Age UK said that any new innovation—I think we want to encourage innovation—needs to pass the mum or grandma test. I think that is a very reasonable test to apply to something such as this.
Lord Ribeiro (Con)
My Lords, the only way in which to increase staffing levels in anticipation of the flu epidemic is through agency staff, which is going to cost a huge amount of money. Surely, the better thing to do would be to ensure that all health staff are vaccinated so they are at least healthy when the epidemic hits us—if it does.
Lord O’Shaughnessy
My noble friend talks with great authority on this issue and he is quite right. The NHS is offering all front-line health staff free vaccinations. NHS England has confirmed that it will also be paying for care workers in social care settings to get free jabs. Furthermore, we are now, for the first time, inoculating in school children aged between two and eight, who are sometimes known as “superspreaders”. This is to ensure that, if such an epidemic were to happen, we would be as well prepared as ever.
Baroness Watkins of Tavistock (CB)
My Lords, will the Minister join me in acknowledging the stance being taken by the NMC in seriously considering changes to the English language test to make it more relevant to nursing practice, while maintaining patient safety? This has the potential to increase significantly the recruitment of overseas nurses in the UK. I also seek assurance that the Government will not cut investment in district nurse training.
Lord O’Shaughnessy
I am grateful to the noble Baroness for raising this. We have discussed a number of times the impact of the test on recruitment from countries other than the UK. It is entirely sensible for the NMC to look at this. On nurse training, I hope she will have been reassured by the announcement from my right honourable friend the Secretary of State for Health at the Conservative Party conference that we will deliver a 25% increase in nurse training places from 2018-19 onwards.
Lord Rennard (LD)
My Lords, is not part of the problem for the NHS, and for hospitals in particular, during the winter that so many people have difficulty in accessing their GP? The number of GPs has fallen by 3% over the last two years. Is it not, therefore, counterproductive that the Government have been cutting funding for community pharmacies when many more people should be seeing their pharmacist and not seeking to see their GP or even turning up at A&E units?
Lord O’Shaughnessy
We recently debated community pharmacies. Reforms have ensured that most people—more than 80%—are within a 20-minute walk of a community pharmacy. As a consequence of these reforms, there has been no decrease in the number of community pharmacies in England.
Lord Hunt of Kings Heath (Lab)
My Lords, the case raised by my noble friend relating to Essex goes to the heart of the problem of discharging patients from NHS hospitals because of the lack of support in the community from social care and the reduction in nursing home places during the last four years. Is the Minister as surprised as I am that, despite this, up and down the country the NHS, through its sustainability and transformation plans, is putting forward proposals to cut out community hospitals and community hospital beds? Will Ministers issue an instruction to the NHS so that this will not be allowed to happen?
Lord O’Shaughnessy
We have discussed the issue of nursing home beds. We also know that there has been an increase in the provision of domiciliary care packages which reflects people’s changing care needs. Figures published yesterday show that social care spending has risen by £500 million during 2016-17. I am sure this will be warmly welcomed across the House. On community beds, noble Lords should know that, in addition to the usual four tests for reconfigurations, last year Simon Stevens, the head of NHS England, said that there is now a fifth test—the bed test. There must be robust evidence that any proposed reduction in beds is because of a reduction in demand and not the other way round.
National Health Service (Pharmaceutical and Local Pharmaceutical Services) (Amendment) Regulations 2017
Lord O'Shaughnessy Excerpts(6 years, 6 months ago)
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Lord Shipley (LD)
My Lords, I should like to ask the Minister to clarify four issues. First, does he agree that community pharmacies are for many people the most accessible healthcare location, particularly where there are no GP surgeries locally; that community pharmacies in those situations can take pressure off GPs, and that in fact overall community pharmacies can take pressure off accident and emergency? Both GPs and A&E are experiencing rising demand.
Secondly, I am not clear whether the Government have responded to the Murray review and whether they plan to be clear what they think about that review, which was published in December last year. What policies do they have for community pharmacies as a consequence of that review?
Thirdly, we have heard about rural areas. I agree entirely with what has been said, but I shall talk in addition about deprived urban neighbourhoods where few people have cars. Has the department done an impact assessment on deprived communities’ access to health and care services, because I think it is material to this debate, particularly in the context of my fourth question? Do the Government accept that many pharmacies have cash flow problems? Many do, and I understand that it will be much worse from next month. What exactly is the Government’s grand plan? I cannot see one at the moment.
The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, I begin by thanking all noble Lords who have spoken in this interesting debate. Obviously, the Government disagree with the premise of the Motion of the noble Lord, Lord Hunt, but I am grateful for the opportunity that it has given us all to discuss this critical sector. I join the noble Lord in paying tribute to Bill Darling. I did not have the opportunity to know Mr Darling but, having researched his career, I can see that he was a man with a deep commitment to serving his community and the public, and showed true leadership throughout his life, so I pay tribute to him on behalf of the Government and send our condolences to his family and friends.
Perhaps no noble Lord has done more than the noble Baroness, Lady Jolly—I welcome her to her position on the Liberal Democrat Front Bench—to list the benefits and impact of the community pharmacy. It has a vital role to play in the nation’s health. More than that, pharmacies are, as my noble friend Lady Redfern pointed out, both a health asset and a social asset. They play more than just a straightforward health role. There are about 1.6 million visits to community pharmacies a day, and more than 11,500 community pharmacies are in operation, which is 20% more than in 2004-05.
As several noble Lords have pointed out, not least the noble Lord, Lord Shipley, they are increasingly important as healthcare moves into the community, and they certainly have a role to play, particularly in primary care, probably less so in A&E or urgent care. I reassure all noble Lords that the work of community pharmacies is deeply valued by the Government.
The regulations specify a detailed market entry and exit regime and terms of service for making arrangements for NHS pharmaceutical services in England. Their aim is to ensure that there is a proportionate regulatory framework which encourages the delivery of NHS pharmaceutical services that meet local needs, without excessive provision in areas already meeting demand. The regulations have been continually reviewed and updated since their inception, and the Government are committed to conducting a full post-implementation review. The regulations amend the deadline for that review, which was originally 31 August 2017.
As has been discussed, the delay is due to two reasons. First, the judicial review by the negotiating partner, the Pharmaceutical Services Negotiating Committee, was brought into the decisions made by the Secretary of State. We did not feel that it was appropriate to begin a judicial review, as the noble Lord, Lord Hunt, correctly said. Secondly, of course, we had a general election, and therefore a purdah period, followed by the summer holidays. That had some impact on the ability to conduct proper stakeholder engagement before the deadline. Therefore, the deadline was extended to 31 March 2018, to allow proper and wide-ranging engagement of stakeholders, so that we can fully consider whether the regulations are delivering their intended outcomes. A further stakeholder meeting is scheduled for later this month to present the emerging findings to these stakeholders and to shape the final report to be published early next year. I apologise if I have laboured the point about why the delay happened, but I thought it would be useful, given that it is the topic of the debate.
Medical Examiners and Death Certification
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Lord Low of Dalston
To ask Her Majesty's Government when they expect to report the outcome of the consultation on the introduction of medical examiners and reforms to death certification launched in March 2016; and whether they still intend to introduce those reforms in 2018.
The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, since the election the Secretary of State for Health has reaffirmed his commitment to introduce medical examiners to provide a system of effective medical scrutiny applicable to all deaths that do not require a coroner’s investigation. The Government’s response to the consultation will be published shortly and the system will be introduced no later than April 2019. Pilot sites are already offering the bereaved an opportunity to raise concerns while improving patient safety through mortality data.
Lord Low of Dalston (CB)
My Lords, I thank the Minister for that reply. While welcoming the Government’s commitment to introduce the medical examiners scheme by April 2019, the president of the Royal College of Pathologists said in March that,
“it is vital to ensure that implementation is properly planned. There is still much work to be done in adapting the current system and recruiting and training medical examiners and officers”.
Given all the delay to which the introduction of the scheme has been subject already, are the Government satisfied that it will be ready in time?
Lord O'Shaughnessy
The noble Lord is quite right to highlight this point. There have been calls for medical examiners since the Shipman inquiry; those were also endorsed following the inquiry into Mid-Staffordshire. Our intention is to ensure that, with planning time, the system can be introduced by April 2019, which is why the consultation and the regulations needed to underpin the planning for the system will be produced in short order.
Lord Hunt of Kings Heath (Lab)
My Lords, I chaired a foundation trust where we trialled the medical examiner role. I commend to the House the value of having a senior consultant able to talk to relatives about concerns, drawing the attention of fellow clinicians to issues relating to practice but, above all, safeguarding the public against tragic and appalling actions such as those taken by Harold Shipman. Does the Minister expect every part of the NHS to be covered by medical examiners by April 2019, or is that the start of the rollout? I hope that it can be extended throughout the NHS by that date.
Lord O'Shaughnessy
The noble Lord is quite right to highlight the pilots; indeed, early adopters have followed in their wake and have provided a much better service. The intention from April 2019 is for the service to cover the entire country, but it is most likely to start in secondary care and then move out into primary and community care.
Baroness Jolly (LD)
Changes to death certification are welcome and will impact on bereaved families. How were the general public involved in the consultation?
Lord O'Shaughnessy
I think I missed the critical word in the noble Baroness’s question. Did she ask whether the public were involved?
Lord O'Shaughnessy
There was full consultation on the proposals. We have been considering that and will respond to it.
Lord West of Spithead (Lab)
In 2009, a certain amount of work was done on how we would handle mass deaths should they occur because of some crisis or emergency. Does any of the current work affect that? Does that work still stand, so that we can handle such events properly?
Lord O'Shaughnessy
I think that the difference here is between handling mass deaths, which would obviously be an emergency situation—so we are talking about contingency and resilience planning—and looking at all deaths. About half a million people die each year. At the moment, only those who go through coroners receive that additional level of investigation, except in those pilot sites and early adopter areas that I mentioned. The new arrangements are about making sure that there is a system of verifying deaths from normal causes.
Baroness Hayman (CB)
My Lords, when considering these issues will the Minister look at the proposal made by bereaved parents and raised by the chief coroner in his report in 2016 that there should be coroners’ investigations of cases of stillbirth, so that the causes of stillbirths could be better understood and such tragedies could be averted in the future?
Lord O'Shaughnessy
The noble Baroness is quite right to highlight this point. Medical examiners are not involved in stillbirths, because the cause of death is before the point of birth. However, there is clearly a need for the involvement of coroners. I will look into the detail of that. I can tell the noble Baroness that the Government are taking the issue of stillbirths seriously. A new perinatal mortality review tool is looking at that and it is integrated into the learning from deaths scheme now going on in the NHS.
Lord Clark of Windermere (Lab)
My Lords, this is a very welcome initiative, but in view of the incredible shortage of medical staff in the NHS, is the Minister confident that there are sufficient staff to cover it? Are the Government looking at other ways of making staff available—for example, people may be brought back from retirement—to handle it in the initial years?
Lord O'Shaughnessy
That is a very good question because we are talking about a greater workload. The pilots and the early adopters have demonstrated that it is possible to do this with existing staff loads. As it is rolled out across the country, there may be a need for additional staff. I reassure the noble Lord, and indeed others including bereaved families, that any staff who are used will be registered practitioners and would be regulated by the GMC.
Hospitals: West London
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The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, I congratulate the noble Lord, Lord Dubs, on securing this debate and thank him and all noble Lords for their contributions. As ever, I will try to address as many of the points made this evening as possible.
In responding to this debate as a Minister in the Department of Health, I should declare an interest as a resident of west London for the past 11 years. I have counted up the number of hospitals in the STP area that my family have used—often too often. That figure incorporates pretty much all of them one way or another for various services. Therefore, I know from personal experience as a resident, patient, husband and father what we are talking about, and the very strong emotions that can be evoked by the discussions we are having about the future of Charing Cross and other hospitals. I also confirm to the noble Lord, Lord Dubs, that this has been an issue on the doorstep during local and national elections. However, some of the accusations I have heard about what will happen have been wrong, very misguided and, frankly, scaremongering. I see posters up all the time, as I am sure does the noble Lord, saying that hospitals are going to close. Indeed, he talked about hospital closures when, as he well knows if he has looked at the plans, we are not talking about closing hospitals and the sustainability and transformation plans are not talking about closing hospitals.
Noble Lords will know that west London—I think pretty much everyone who has spoken is a resident of west London—is a large area with many clinical commissioning groups, local authorities and providers split across two transformation plans in north-west London and south-west London. The north-west London plan covers about 2 million people. As that is the one that the noble Lord and other noble Lords have highlighted, that is where I shall focus my attention. The area covers a broad range of population and some of the country’s leading hospitals, including world-famous trusts such as Imperial, the Royal Brompton and the Royal Marsden, and cherished district general hospitals such as Ealing and Charing Cross. I note that this year the funding for the North West London Sustainability and Transformation Plan area is £3.7 billion, and that between 2015-16 and 2020-21, funding is expected to rise on current plans by £602.5 million—a cash increase of 17%. I think that answers the question asked by the noble Lord, Lord Warner, about funding. We also know that it is an area with a growing population with changing needs, driven by a relatively high turnover of people, with large-scale, inward migration from the UK and other countries. The changing needs of this population must of course shape the local NHS’s plans for the future.
Many times in this House we have discussed how the healthcare needs of patients in our country are changing. On average, we are becoming older and frailer, but also more mobile and more networked together by technology. Added to this, the science and practice of health is changing. We understand that some services are better centralised into highly specialised facilities—the noble Lord, Lord Warner, talked about stroke care and my noble friend Lord Suri talked about neurology, which are two good examples—while other treatment, such as rehabilitation, is better delivered in the community.
Therefore, because of demographic and professional developments, service change is inevitable. But it is of course always an issue that raises concerns, so it is vital that any proposed changes are looked at with great care. The noble Lord, Lord Warner, talked about it as being like the Somme mud; in slightly more uplifting terms, my noble friend Lord Lawson once said that the NHS is the closest the English get to a religion—and I think hospitals are our churches. That describes how people feel about them. It is therefore incredibly important that I stress that any potential service changes affecting west London hospitals must be driven by local health organisations and, while I am sure local people will follow this debate with interest, the opportunity to shape their future health services is driven by engaging with their own clinical commissioning groups and the STP.
The Government are clear that any health service changes proposed are subject to an agreed set of procedures. Proposed changes stand and fall on their ability to show clear evidence that they will deliver better outcomes for patients, and they must meet the four tests for service change. First, they should have support from GP commissioners; secondly, they should be based on clinical evidence; thirdly, they should demonstrate public and patient engagement; and fourthly, they should consider patient choice.
In addition, in April this year NHS England introduced a new test on the future use of beds, which requires commissioners to assure NHS England that any proposed reduction is sustainable over the longer term and that key risks, such as staff levels, have been addressed. This is precisely the point that the noble Lord, Lord Hunt, made about preserving beds, and he will also know that the number of acute beds has been falling over many years under many different Governments. Indeed, the number has stabilised in the last couple of years, which speaks to the point he raised from the King’s Fund research.
Where local discussions fail to provide resolution, proposed changes may be challenged on a number of grounds—for example, if there has not been proper local consultation or where the local oversight and scrutiny committee concludes that the changes are not in the best interests of the health service. The Independent Reconfiguration Panel exists to arbitrate and provide independent and authoritative advice to the Secretary of State in such instances. That is therefore the policy background against which any plan must be judged.
The North West London Sustainability and Transformation Plan was published in November 2016, and a core component is a programme called Shaping a Healthier Future, plans of which were first published in 2012. The public consultation in 2012 set out plans for a more integrated approach to care, whereby specialist services would be consolidated on fewer sites to improve quality and efficiency, and routine and chronic care would be expanded to improve access, particularly in the community. It was proposed that the Charing Cross Hospital would become a growing hub for integrated care within this network of services.
Following feedback from the public consultation, the proposals were refined to retain the integrated care approach and, in addition, for the Charing Cross site to house a wider range of services than initially proposed. Following examinations by both the IRP and the Secretary of State, the plans changed further. Since then, as noble Lords may be aware, NHS England invested a further £8 million in the Charing Cross Hospital site last year. This funding enabled refurbishment of urgent and emergency care wards, theatres, outpatient clinics and lifts, as well as the creation of a patient service centre and the main new facility for North West London Pathology.
There is widespread recognition that in north-west London and other areas of the country we need to ensure there are strong primary and community services to keep people well, effective urgent care services to deal with more intensive need, and world-class services to treat the most severe and urgent emergencies. That is why I welcome the sustainability and transformation plan commitment that there will be no reduction in A&E or acute capacity at Charing Cross Hospital unless and until a reduction in acute demand can be achieved—and, as the noble Lords, Lord Warner and Lord Hunt, pointed out, it cannot happen before 2021. Furthermore, despite the accusations of local campaigners, there are no plans to close Charing Cross Hospital, and none of the land on the hospital site has been designated as surplus land for redevelopment.
I turn to some of the points raised in the debate. There is of course with any difficult decision such as this the question of whether there is support from the clinical community. Members of the clinical community were clear from the beginning in 2013 that they,
“remain absolutely confident that delivering the Shaping a Healthier Future recommendations in full will save many lives each year and significantly improve patients’ care and experience of the NHS”.
The noble Lord, Lord Dubs, pointed out that two councils had not signed up to any plan that involved a hospital being closed. I will say two things in response. First, there is no suggestion that any hospital will be closed. Secondly, I suggest that one reason those councils are not engaging is that they won elections on the basis of suggesting that hospitals would be closed and it is not in their political interest to endorse a plan which makes clear that that is not going to happen.
My noble friend Lord Suri was absolutely right about the need for a bipartisan approach and to avoid mud-slinging at local political level. He made a particular suggestion about the potential use of Wormwood Scrubs. It is not one that I personally endorse, but the point is that any suggestion for reconfiguration must emanate from local health organisations and then go through the service-change tests that I outlined.
The noble Lord, Lord Warner, made a very valid point about co-ordination across London. This is something that we are looking at in particular at the moment. I hope that we will be able to say more about it in due course. Clearly, the interaction between services across the five STP areas is incredibly important; people are clearly moving across boundaries for the healthcare that they need and it is important that there is a degree of local co-ordination.
Of course, there is always with our health service a need for more funding. I know that many noble Lords feel that the Government are not giving the funding they should. With the STPs, I have to disagree; the Budget provided £325 million as a first capital instalment towards transformation and we are absolutely supporting the process—which of course was begun and is being led by NHS England—to transform our health service into an integrated process. One way in which that can be delivered, as my right honourable friend the Secretary of State set out in a speech to the Royal College of General Practitioners, is to have more GPs in training so that there can be more community-based care.
The noble Lord, Lord Hunt, called the STPs a “fantasy”. I know that his right honourable friend the shadow Secretary of State for Health said in his party conference speech that he did not support the STPs but did want integrated care. That is a very easy thing to say, but the challenge is how it will be delivered if STPs are not going to get the backing of the Opposition.
In conclusion, I hope that I have been able to reassure noble Lords and local residents on two fronts. First, there are strict rules that govern the reorganisation of NHS services and that put patient outcomes first. Secondly, Charing Cross hospital has a critical role to play in the sustainability and transformation plan for north-west London and will continue to operate A&E and acute services while the demand for them exists.
The Government remain committed to supporting the local NHS to make complex and sometimes challenging decisions about the future configuration of the services on which we all depend. As those discussions take place locally, it is incumbent on all of us to deal with the facts about what is and is not in prospect, and to avoid playing political games with people’s healthcare.
I will close by congratulating all noble Lords on their incisive and, as ever, forthright contributions to the debate, informed by their role both as legislators and local residents—and once again thank the noble Lord, Lord Dubs, for securing it.
Care Homes: Hospital Discharges
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Lord Hunt of Kings Heath (Lab)
My Lords, on behalf of my noble friend Lord Dubs, and with his permission, I beg leave to ask the Question standing in his name on the Order Paper.
The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)
My Lords, information is collected on the number of bed days occupied by patients waiting to be discharged from hospital. The latest available information estimates that on an average day in August this year, 1,574 beds were occupied by patients waiting to be discharged to nursing or residential care homes.
Lord Hunt of Kings Heath
My Lords, that is a big number. I understand that over the last financial year, about 2.3 million days were essentially lost because of transfer delays. We know the number of nursing home places has been reduced by 4,000 over the last two years; we know social services are under pressure; we know the health service is not using housing services sufficiently. Why does the health service seem determined, in its STP plans for each area, to rush into yet further plans to cut acute capacity when hospitals are under so much pressure at the moment?
Lord O'Shaughnessy
I am glad the noble Lord mentioned the number within a year. He will be interested to know, as other noble Lords will, that the number of delayed transfers of care went down year on year between August 2016 and August 2017. That is good news. That reduction has been caused by greater funding in that period and a greater focus on accountability, particularly for local authorities and trusts together. In terms of acute capacity, the number of beds has been relatively stable recently and NHS England has introduced a new test for any reconfigurations that adds a fifth category, looking at the number of beds available in any given area.
Lord Laming (CB)
Does the Minister agree that the position is likely to get more difficult as more care homes are saying that they cannot function on the level of fees being offered by local authorities? They are therefore withdrawing beds that are supported by public funds from this facility. Will the Minister look into that?
Lord O'Shaughnessy
I know of the issue that the noble Lord raises about withdrawing beds. As we discussed last week, there has been a small reduction in the number of nursing and residential care home beds. However, there has also been an increase in the number of domiciliary care packages. The noble Lord may also be interested to know that we are creating 6,000 new supported homes through the Care and Support Specialised Housing Fund. It is a changing market. I understand the funding pressures on local authorities, which is why we are putting in more funding.
Lord Naseby (Con)
In the broader context, would it not help my noble friend if we looked at the role and number of district nurses who, in the past, kept people out of hospital and ensured that GPs were relieved of some of their work?
Lord O'Shaughnessy
The noble Lord is right to highlight the issue of community nurses, where in particular there has been a reduction in numbers even though the total pool of nurses has increased in recent years. He will hopefully have noticed an announcement at the Conservative Party conference from my right honourable friend the Secretary of State about more nurse training places—25% more—to address the kind of issues he is talking about.
Baroness Pitkeathley (Lab)
My Lords, with the pressure on hospitals to discharge people and the lack of nursing and residential care beds, does the Minister agree that undue and unfair pressure is sometimes put on families and carers to accept discharge in an unsuitable situation? Last week, I spoke to an 87 year-old carer, herself frail and with severe angina, who was induced—I use the word advisedly—to accept discharge of her 91 year-old husband, still immobile after a fall, with a promise of visits from a community nurse twice daily. Of course, those visits have not yet materialised.
Lord O'Shaughnessy
I am sorry to hear about that particular issue. I obviously have not seen the details; perhaps the noble Lady might write to me about it. Clearly, nobody should be induced or otherwise forced to accept the care of somebody for whom they are not capable of caring. Looking at our growing and aging population, I think we all accept that the number of operations and admissions going through the NHS is increasing. We need much more capacity in the system, whether in nursing and residential homes or, increasingly, in domiciliary care.
The Lord Bishop of Norwich
My Lords, since the difficulties of hospital patients awaiting discharge to care homes is but one of a number of bottlenecks in the present system, does that not suggest that we need a fully integrated national health and social care service and that, until we achieve such integration, these problems are bound to recur—as the National Audit Office report in February this year so clearly and vividly illustrated?
Lord O'Shaughnessy
The point about integration is critical. The CQC’s report from last week, which we were discussing, is all about collaboration and integration. Someone in their 80s who is experiencing care does not distinguish between different bits of it as we do bureaucratically. They want to know that there is seamless care. That is what the sustainability and transformation process is attempting to do.
Baroness Brinton (LD)
My Lords, I am grateful for the right reverend Prelate’s comment about the National Audit Office’s report from February, which makes it clear that 43% of the multidisciplinary team meetings in acute hospitals began immediately, which is to be encouraged, but only 20% of local authorities were invited to those early meetings. What are the Government doing to ensure that the advice from NHS Improvement about getting that earliest intervention will actually happen?
Lord O'Shaughnessy
The noble Baroness raises an excellent point. She may know that the better care fund—the route by which the additional money goes into social care—reviews and holds accountable local authorities and the NHS for interacting with one another to deal with delayed transfers of care. There is something called the high-impact change model, which is designed precisely to bring people together to ensure that the number of delayed transfers in care are reduced. That is compulsory as part of the funding provided.
Lord Elton (Con)
My Lords, the essential issue is pressure on hospital beds. Will my noble friend tell us what the effect is of the work of charitable—I am sorry, the name has gone, but which charitable institutions take people in their last days?
Lord Elton
Thank you very much—retirement draws closer. What effect do charitable hospices have on the pressure on hospital beds? To what extent could a nationally efficient National Health Service palliative care service continue that effort?
Lord O'Shaughnessy
I hope that my noble friend’s retirement is still a long way off. I do not have specific numbers on the impact of hospices, but various changes are going on in the funding of palliative care to make sure there is much more consistency across the country for what is available. I hope that will be one of the ways we can ease the pressure.
Health and Social Care
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Lord Hunt of Kings Heath
To ask Her Majesty's Government what is their response to the conclusion of the Care Quality Commission in its annual state of care report that 1.2 million adults are not getting the care they need as the health and social care system is “straining at the seams”.
The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, the Government are committed to improving the quality and availability of adult social care in England. The Care Act 2014 introduced, for the first time, a national eligibility threshold for care, and the Government are increasing funding for social care by £2 billion over the next three years to meet growing demand.
Lord Hunt of Kings Heath (Lab)
My Lords, two days ago, in answering a Question on this report, the Minister spoke of a 20-year search for consensus on the funding of long-term care. We had consensus about the Dilnot proposals, which capped the amount a person would have to contribute to their own care. The Opposition co-operated with the Government in getting the 2014 Act through Parliament and the Government announced the cap at £72,000, but then they postponed its introduction and in the election they effectively abandoned it. No explanation has ever been given to Parliament about why the Dilnot proposals have been abandoned.
Lord O'Shaughnessy
There has been a 20-year search for a solution to this problem. It was not me who said that; it was the chief inspector of hospitals, who said:
“I think the one thing I regret is that 15 or 20 years ago when we could see the change in the population the NHS did not change its model of care”.
This is something we have all grappled with, but we have not yet come up with the solution that we need. That is why, through this consultation, we will be looking not just at finance but at quality of care, variation and sustainable staffing to rebuild the consensus that we need to move forward.
Baroness Finlay of Llandaff (CB)
Given that the report has pointed out that staff resilience is not inexhaustible and that services are at breaking point, do the Government recognise the enormous contribution of voluntary sector providers, particularly—I declare my interest in the area—in palliative and end-of-life care and hospice services, which are maintaining patients in the community and taking a great deal of pressure off statutory services? Are the Government giving any consideration to a national funding formula, such as I propose in my Access to Palliative Care Bill, which has had its First Reading?
Lord O'Shaughnessy
I join the noble Baroness in paying tribute to voluntary sector providers and volunteers, whether family members or others, who support care throughout the NHS and social care. There need to be more paid staff to meet the needs of our growing and ageing population, which is why the Secretary of State announced a 25% increase in the number of training places and more nursing associates. That is being put in place to make sure that the system, which is described in the report as stretched, has the capacity it needs to meet patients’ needs.
Baroness Brinton
My Lords, the CQC report has shown that over the past two years there has been a reduction in beds in nursing and care homes, while the Lancet published the results of a research project in the summer showing that we will need an extra 9,000 beds per annum by 2025—that is more than 70,000 beds. What are the Government proposing to do to make it easier for more homes to be set up and run and to fund the beds we clearly need urgently, not just in 2025 but from now on?
Lord O'Shaughnessy
The noble Baroness will know that there has been a small reduction in the total number of residential nursing home beds, although it is a fairly flat picture over a long period of time. We have also seen an increase in the amount of domiciliary care. One of the things we need to get to the bottom of, and this is what the consultation will look at, is the imbalances that exist between the funding regimes for residential and domiciliary care. We have to get to the bottom of it, because it creates an imbalance on the provider side as well, so that we can have proper funding for the kind of care that people need regardless of whether it is in a residential nursing setting or at home.
Lord Davies of Stamford
Could I perhaps try again? I would like to give the Minister a chance to answer the very important question from the Lord, Lord Hunt, which he completely ignored. Why did the Government drop Dilnot?
Lord O'Shaughnessy
The Government have not dropped Dilnot. We will be consulting on both the cap and the floor in the proposals that come forward on social care funding, which build on the Dilnot proposals.
Lord Forsyth of Drumlean (Con)
Does my noble friend recognise that the importance of the cap on people’s contributions was that it made it an insurable element, and therefore it could be incorporated in people’s long-term pension and other plans? Will the Government please revisit the idea of abandoning the cap, which was a central part of Dilnot?
Lord O'Shaughnessy
I reassure my noble friend that he is quite right to point out the benefits that attend to a cap. The intention is to consult on both the floor and the cap.
Lord Warner (CB)
My Lords, I declare my interest as a member of the Dilnot commission but I will not actually go down that territory. Are the Minister and his department aware that over the last three or four years there has been a considerable surge out of publicly funded social care by all providers, particularly nursing homes? What risk assessment has his department made of the implications of that, particularly for the NHS?
Lord O'Shaughnessy
The CQC report, which I am sure the noble Lord has looked at, talks about agencies and indeed nursing home providers deregistering. It also talks about the ones that are registering. There is a fairly consistent turnover in the number of those, so it is about balance. There is a similar number of providers within the market—again, with slightly fewer residential nursing and slightly more domiciliary to reflect the kind of balances of care that we have discussed.
Lord Clark of Windermere (Lab)
My Lords, as the figures today show that the number of registered nurses in Britain is actually falling, and bearing in mind that the existence of care beds depends upon nurses, will the Minister answer the Question that I asked earlier this week and give us a progress report on the number of students who entered nursing courses at universities this September, so that we can make a judgment on the current position?
Lord O'Shaughnessy
I think the noble Lord is referring to the King’s Fund report on nursing. It is important to stress that there are still greater numbers of nurses overall compared to 2010; indeed, over 11,000 more on wards. There are some particular shortages in mental health and community nursing, which have been alluded to before. In terms of the nursing numbers, he will know, because we have discussed this before, that there is a ratio of about 2:1 in the numbers of applications for nursing places. I do not have a more recent update than that. My expectation therefore is that that was the position going into September. I shall certainly write to him with the details. I emphasise that this increase in the number of training places, with funded clinical placements, is designed to address the issue that we have about the need for more nurses as we have a growing and ageing population.
National Health Service
Lord O'Shaughnessy Excerpts(6 years, 7 months ago)
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Baroness Walmsley
To ask Her Majesty's Government what assessment they have made of remarks by the Chief Inspector of Hospitals that the NHS is not fit for the 21st century.
The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, the Government agree with Professor Baker’s statement that,
“we need a model of care that is fit for the 21st century and the population as it is now”.
That is why we are backing the NHS’s own plans for transformation with an extra £8 billion a year in real terms by 2020-21 and an extra £2 billion over the next three years for social care.
Baroness Walmsley (LD)
I thank the Minister for his reply. Does he also agree with Professor Ted Baker’s statement:
“The model of care we have got is still the model we had in the 1960s”,
and that this “needs to change”? Can the Minister say how many of the new models of care are up and running and how many of the sustainability and transformation plans are in special measures? On World Mental Health Day, will he look into how many clinical commissioning groups are failing to commission good and timely mental health care, especially for young people?
Lord O'Shaughnessy
The noble Baroness asked a few questions that I will try to deal with. First, on new models of care and STPs: STPs are now being ranked in order to see their fitness for moving forward. The Chancellor announced in the Budget that we will invest £325 million initially, with more funding in the future to support the transformation that we all want to see. The noble Baroness is right to point out that our care model is still based around hospitals and curing infectious diseases, rather than dealing with chronic illnesses and comorbidities. That needs to change.
I echo, as the noble Baroness would, the Care Quality Commission’s report, which talked about staff dedication—nowhere is that more true than in mental health, where staff often deal with very difficult circumstances. It is important to talk about that on World Mental Health Day. She may be interested to know that the Cabinet was briefed today by mental health experts about training programmes going into schools, and so on. There is a lot of work going on, but these are the NHS’s own plans for change, which this Government are backing.
Lord Kakkar (CB)
I speak as Professor of Surgery at UCL and chairman of UCL Partners. It is widely accepted that innovation is essential to ensure NHS sustainability. Are Her Majesty’s Government satisfied that there is sufficient emphasis on and support for NHS England in driving types of innovation, such as therapeutic innovation—both in models of care and working practices—that will achieve long-term sustainability?
Lord O'Shaughnessy
The noble Lord makes an excellent point. It is true to say that in this country we are very good at creativity and innovation but not always very good at spreading it round. In a way, that is one of the biggest challenges the NHS faces. I would merely highlight a couple of areas where the NHS is working well. The first is the test beds programme, which is working with industry, taking new innovations and spreading them round. Secondly, we have committed to publishing our response to the accelerated access review by the end of the month on how to make sure the most transformative drugs, devices and therapies are taken up throughout the system.
Lord Hunt of Kings Heath (Lab)
My Lords, can I ask the Minister about the sustainability and transformation programmes? Has he seen the report issued by the King’s Fund last week that said we have fewer acute beds in this country than almost any comparable country? It also pointed out that the plan of many STPs is to reduce acute care numbers even further. I fully accept that we could use our beds and discharge patients more effectively, but the King’s Fund warns that STP plans to further cut acute beds are unsustainable. Will the Government consider that?
Lord O'Shaughnessy
Simon Stevens, the head of the NHS, made an important point several months ago about reconfigurations. Any reconfiguration has to meet four criteria: clinical need, popular support and so on. He added a fifth, which was about taking out beds. Those STPs are judged on their ability to meet the changing needs of their population. If there are proposals to take out beds which mean that those needs will not be met, such reconfigurations will not be accepted.
Lord McColl of Dulwich (Con)
Does the Minister agree that the major problem in the NHS today is the enormous increase in demand? It is not old people getting older; it is not young people being couch potatoes, because inactivity does not cause obesity. The obesity epidemic is what is wrecking the NHS.
Lord O'Shaughnessy
The NHS is seeing more people than ever—I think that some 1,500 more people a day are being seen in A&E. A lot more people are going through the service. The truth is that there are a number of factors: there are factors around lifestyle and around ageing. The point is that we have to change. At the heart of this Question is the comment made by the chief inspector about our not having new models of care. We need to change the way in which we provide care. That means integrated care, with much more of it based in the community. That means us all taking difficult political decisions about how care is configured so that it meets changing needs related to obesity and ageing.
Lord Clark of Windermere (Lab)
My Lords, a major problem facing the NHS is the drastic shortage of nurses. As the Government have changed the funding of nurse training at universities and as those universities now have their students in place, can the Minister give us any figures on the number of nurses in training in this current year?
Lord O'Shaughnessy
I know that the noble Lord has been concerned about this issue. I hope that he heard my right honourable friend the Secretary of State announce last week not only an increase in the number of nursing associate places, where qualification is through an apprenticeship route, but a 25% increase in the number of degree training places and funding for the clinical placements that they involve.
Lord Patel (CB)
Can the Minister say whether he found helpful the House of Lords Select Committee report on the long-term sustainability of the NHS and social care?
Lord O'Shaughnessy
The noble Lord knows that I found it extremely helpful. It has pride of place on the coffee table in my office, and we will of course respond to it in due course.
Adult Social Care in England
Lord O'Shaughnessy Excerpts(6 years, 7 months ago)
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Baroness Bakewell (Lab)
My Lords, I beg leave to ask a Question of which I have given private notice.
The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, the Government are committed to improving the quality and availability of adult social care in England. That is why we passed the Care Act in 2014 to provide for the first time a national eligibility threshold for care. It is why we are investing £2 billion more in social care provision over the next three years and have plans to reform how care is funded for the long term.
Baroness Bakewell
My Lords, the situation in social care is deteriorating and the Government’s strategy to handle the challenge is inadequate. The situation is getting worse because of the fundamental change in the demographic of this country. Some 15,000 people are now 100 years old, and the size of that cohort is increasing. Surgeries are closing, hospitals are inadequate, and 1.2 million people are unpaid carers and themselves over the age of 65. This calls for a radical, fundamental response, rather than the usual Green Paper and sums of money. That is not enough. This country faces a crisis of demographic change.
Lord O'Shaughnessy
I agree in part with what the noble Baroness said in the sense that demographic change represents a big challenge. She mentioned the over-100s. The population of over-85s will double between now and 2037. As the CQC report makes clear, many of those people will have difficulty with the basic behaviours and actions they need to be able to live independently. That is the big challenge that we face. The report provides a very honest exposure of strengths and weaknesses in the current system. The strengths are there, though the noble Baroness perhaps did not give them as much credit as they deserve. The report says:
“Overall, the quality of care remains relatively stable, with the majority of all care rated as good and improvements in some services”.
Indeed, only 1% of services are rated inadequate. Clearly we want that percentage to be zero but it is better than in other sectors. I do not disagree with the noble Baroness about the demographic challenges we face. As I said in my first Answer, we are trying to put more funding in, to recruit more staff and raise quality now that we have this national threshold. We hope to decrease variation and then look for a long-term solution that will solve this problem that we have all been wandering around for the last 20 years.
Baroness Verma (Con)
My Lords, as a care provider for the last 17 years I say humbly to my noble friend that we need to pay care staff a proper wage so that they can actually have a life that is not just about existing. I am told constantly that local councils are being given extra funding. It is not trickling down to the providers and there needs to be a really serious look at the level of funding and at what we are entitled to pay care staff, because with Brexit around the corner we are going to need ever more of our own homegrown talent to provide those places.
Lord O’Shaughnessy
The noble Baroness speaks from experience here. On the point about paying care staff, one of the greatest beneficiaries from the new national living wage are and will be care staff. That will increase over time and is one of the reasons why increased funding needs to go into the system. She also talks about the interface with local authorities. She will know that it is a very fluid market, with providers registering and deregistering all the time. We are trying to make sure that there is a proper review of the quality of the interface between local authorities and the National Health Service. Some do it very well, with very few delayed transfers, while others have huge problems. We get people in beds who should be in a care setting, either in a nursing home, in community care or at home. Those reviews are taking place and should highlight some practice that is not good enough. The challenge will be to work with those councils to make sure they do something about it.
Lord Warner (CB)
My Lords, is the Minister aware that the CQC has drawn attention to the loss of 4,000 nursing home beds in the last year? Does he accept that this is a loss that the NHS could do without? What action are the Government taking to increase the number of nursing home beds in this country?
Lord O’Shaughnessy
The noble Lord is quite right that the CQC report highlights that. It also highlights a broadly stable residential care home situation. What is changing the nature of care provision is the increase in the amount of domiciliary and community-based care that is being provided; we are seeing a shift there. The CQC report also shows big discrepancies across the country in terms of the proportion of beds per head of population. That is one thing we are trying to address, to make sure there is much more evenness of care.
Baroness Walmsley (LD)
My Lords, the CQC report emphasised the need to co-ordinate care by stating that in future it will report not only on the quality of care in individual providers but on the quality of co-ordination between services. It quotes examples of services working together using technology and innovation to share data and improve care. How do the Government plan to encourage this approach? Will they look at funding models to make sure that they encourage co-ordination rather than deter people from co-ordinating?
Lord O’Shaughnessy
The noble Baroness makes an excellent point. We will certainly look at those funding models. Co-ordination, as we have been saying, is the way forward, because if you are a user of care in your eighties, you may be visiting a GP, you may be based in a nursing home, and to you, it ought to be one system and you ought to be travelling through it smoothly. Of course, we know that that is not the case at the moment, and the noble Baroness is quite right to highlight that there are great gains to be made, whether from having pharmacists in nursing homes or from having GPs coming to visit. Her point about technology and data is a good one. We still have an argument to win in reassuring people that their data are safe within the NHS so that they can be confident that they are used wisely for their direct care. That is the policy area I am now responsible for, since the election, so I am focused on providing that reassurance so that we can unlock the kind of innovation she is talking about.
Baroness Pitkeathley (Lab)
My Lords, is the Minister able to give us any idea about when we may see the Green Paper for which some of us feel we have been waiting 40 years? Will it contain any revisiting of the Government’s response to the so-called Dilnot proposals about a cap on social care costs, about which there was so much confusion in the general election?
Lord O'Shaughnessy
I am sorry to disappoint the noble Baroness but I am not able to give her any more details on the timing of the consultation.
Lord Bichard (CB)
Will the Minister reassure the House that the long-delayed Green Paper will address not just resources but some of the other points that have already been raised, and maybe one or two others? For example, how do we recruit, retain and motivate a high-quality workforce? How do we provide urgent support for many small providers, which are struggling to survive, let alone improve the quality of the service? How do we make use of the digital potential that exists, which is currently not being realised? How do we get a real integration of health and social care services around the client? Will he reassure the House that these issues will be addressed explicitly?
Lord O'Shaughnessy
The consultation is looking primarily at the funding situation but in doing so it will have to consider the shape of the market and making sure that the whole system is put on a sustainable basis for the future, which obviously will involve looking at some of the issues the noble Lord has highlighted.
Baroness Manzoor (Con)
My Lords, first, I congratulate the Government on making £2 billion available to social care. That is very welcome, but there is great variation in social care across the country which needs to be tackled, as well as the need to focus and co-ordinate services between acute and social care. Can my noble friend the Minister say exactly how NHS England will be helped to ensure that this is tackled quite urgently?
Lord O'Shaughnessy
The noble Baroness is quite right. In social care and the delayed transfers of care from hospitals, there is a huge amount of variation across the country. The additional money that was announced in the Budget comes with a variety of conditions, which has not been the case previously. One of these is to reduce the amount of variation in the quality of services available from local authority to local authority. For the first time, a set of reviews is taking place of local authorities—some of which will be facing challenges, others will not yet be—to make sure that that interface between the NHS and social care, which is one of the big problems where the system falls down, is looked at; that people are moving forward smoothly; that money is crossing those silos; and that the kind of service being provided is joined up and is actually providing for the needs of the people affected.
Health: Sepsis
Lord O'Shaughnessy Excerpts(6 years, 8 months ago)
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Lord Grade of Yarmouth
To ask Her Majesty’s Government what new efforts they will be making in the coming year to improve public awareness, and clinical management, of sepsis.
The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)
My Lords, yesterday was World Sepsis Day, a timely reminder that patients rightly expect the NHS to recognise and treat this devastating condition. To continue making progress in tackling sepsis, NHS England yesterday published its Second Sepsis Action Plan. At the same time, NICE published a new quality standard for sepsis, building on the guidance it published in July 2016.
Lord Grade of Yarmouth (Con)
I thank my noble friend for that constructive response. The House may or may not know that sepsis kills 44,000 in the UK every year. It can develop from a simple scratch on the skin, but it is easily cured with antibiotics. The problem is ignorance of the symptoms on the part of both patients and clinicians. Will the department undertake to explore, with the UK Sepsis Trust, an urgent and impactful awareness campaign that will save both lives and money?
Lord O’Shaughnessy
I am grateful to my noble friend for raising this important issue and I should like to pay tribute both to the UK Sepsis Trust and to the campaigner, the parent Melissa Mead. I do not know if noble Lords saw the moving “Panorama” programme broadcast earlier this week about the work that she has done to raise awareness of this issue. She is truly inspiring given that she lost her child.
A major campaign was launched at the end of last year to raise public awareness. It was fronted by the Secretary of State, and, indeed, Public Health England is building messages about sepsis into its Start4Life campaign. I believe that the particular proposal is that there should be a campaign of advertising on the sides of ambulances. The Secretary of State is sympathetic to the idea and is raising the issue with the chief executives of ambulance trusts to see whether this is something that we can take forward.
Baroness Ludford (LD)
My Lords, I am grateful to the noble Lord, Lord Grade, for raising this extremely important topic, which coincides appropriately with World Sepsis Day this week. My husband is a fortunate survivor of sepsis, albeit at the cost of an amputated leg. He is not one of the 44,000 annual fatalities only because of the speed and skill of the medical professionals at the Whittington Health NHS Trust. I should declare an interest in that he is the chairman of the trust, which I believe has the best record on treating sepsis in London. Clinical awareness is rising in the NHS but it is patchy, so more must be done. Public awareness is very low, and I am grateful to the Minister for announcing those plans. However, they must be reinforced so that friends and family and members of the public know how to spot the possible symptoms.
Lord O’Shaughnessy
I am sorry to hear that sepsis has affected the noble Baroness’s husband in that way and I am glad to learn that he is not one of the more than 40,000 people who die from the condition every year. Public awareness is critical and, as I say, we are looking at new ideas for how to get the message across using a range of routes. The point about clinical awareness is also very important. Until a couple of years ago, there was no widespread clinical awareness of the symptoms of sepsis and how to assess and then treat people, but we have seen quite a big improvement. I can give one example. For those presenting with symptoms in emergency departments, previously only around half were assessed for sepsis; the figure is now up to nearly 90%. I see that as good progress, but clearly there is much more to do.
Lord Turnberg (Lab)
My Lords, one of the major difficulties with sepsis is the fact that it is so speedy. It can kill within a few hours. Awareness of this speed is vital—for the public and for practitioners.
Lord O'Shaughnessy
That is absolutely right but I draw the attention of the noble Lord to a couple of things. First, in the NICE quality standard published yesterday there are some very clear statements about the speed with which people suspected of these symptoms should be treated. Those are quite robust in terms of getting intravenous antibiotics to people within an hour, being reassessed by a senior clinician if they then fail to improve within an hour and so on. That is very clear and there is implementation guidance going through. Another thing announced yesterday is quite important. It is a slightly odd phrase but “safety netting” is where someone has been assessed on whether they have sepsis, does not have it but is sent away with materials that show what the symptoms might be and how to report back if their condition deteriorates.
Baroness Masham of Ilton (CB)
My Lords, as has been said, sepsis can be a big killer if the correct antibiotics are not given. Should it not be conditional to report sepsis so that more research can be done? Should there not be a very quick test for it?
Lord O'Shaughnessy
The noble Baroness is quite right. Trusts are now incentivised to report incidences of sepsis and their performance against these quality standards. That is happening. Unfortunately there is still variation within the system. That is why the documents that came out yesterday are so important. For the first time, we have an operational definition of adult sepsis. Clearly, that is critical to making sure that it is spotted in time.
Lord Hunt of Kings Heath (Lab)
My Lords, the action plan is very welcome. It seems apparent that when patients come through, particularly from A&E, they are not recognised as having sepsis. Clearly, there is an issue about health service staff not recognising the symptoms or understanding the scale of the problem with sepsis. The Minister will be aware of a 2015 report by the national confidential inquiry which criticised the way coding is designed so that, in fact, sepsis does not appear as the prime responsibility for a death. The Government have been asked to look at coding. If it is not in the action plan, will the Minister look at this?
Lord O'Shaughnessy
That is absolutely right: there was an issue with coding. The noble Lord will be pleased to hear that from April this year NHS Digital published new guidance on coding for sepsis to deliver exactly the kind of improved reporting he wants.
Baroness Pitkeathley (Lab)
My Lords, as a survivor of total-body sepsis, I very much endorse what my noble friend Lord Turnberg said about the speed and danger of this illness. What was so difficult for both my family and the professionals who treated me to understand was that it could lead to a total failure of all the body’s organs—as it did in my case—within, literally, hours. The urgency of this must be emphasised in any public awareness campaign.
Lord O'Shaughnessy
I am very sorry to hear that the noble Baroness suffered that but am obviously delighted that she is still here. Just to re-emphasise the point about speed, I encourage noble Lords to look at the quality standard because it is very stringent about the speed at which treatment must be administered. Of course, the critical thing is making sure that there is proper triage and assessment ahead of that. That is where we still need to make some progress.
Care: Older People
Lord O'Shaughnessy Excerpts(6 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Lord O’Shaughnessy) (Con)
I thank the noble Lord, Lord Lipsey, for bringing forward this debate. I know that he has been a tenacious proponent of deferred payments and of reform of the care system. I pay credit to him for that—it is very rare that we have a debate where I can thank everyone individually, so I also thank the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. Unfortunately, I did not have the opportunity to know Lord Joffe, but I know how much the House has mourned his passing and have noted the contribution he made. I want to acknowledge that as we talk about this issue.
We have had a bit of a trip down memory lane today, although others might call it Groundhog Day. We seem to be going over this issue repeatedly without properly resolving it. Of course it is not easy; the ageing population is probably the greatest social challenge, at least the greatest domestic social challenge, that we face. It is not one that we have grappled well with in the past, and that is true of Governments of all hues. That is for a number of reasons, including obviously the money and the changing nature of society, particularly working patterns. What has been highlighted by all noble Lords is the interplay between the taxpayer funded, free at the point of use National Health Service and a social care system that works on a different basis. It means that any attempt, whether it is a Labour-proposed national health and care service or through integration at STP level, is made very hard, particularly as things move. So I do not underplay the importance of this issue, and, of course, as we think about the narrower issue of DPAs, it has to be set in a context of what is happening elsewhere.
In the short run, more money is going into local authorities to try to provide the social care that is required. It is particularly focused on delayed transfers of care. That has some interplay with this issue precisely because of the concerns about moving from one part of the health system into another, something mentioned by the noble Baroness, Lady Greengross, and the noble Lord, Lord Hunt. It is about the difference between continuing healthcare and social care and the quite radical consequences of the different funding situations for families that are necessarily trying to navigate through it at a time of stress. It is a challenge, but we are trying to address it through this additional funding.
In the long run, as noble Lords have pointed out, the intention is to bring forward proposals on social care reform for consultation. The objective in the consultation—I am glad the noble Lord mentioned the Care Act—is to achieve the widest possible consensus. It should not be a completely open-ended “what shall we do” process, but it should try to put forward some proposals that, inevitably in the process of consultation, will change but will try to achieve some kind of consensus. The noble Lord, Lord Hunt, specifically asked about Dilnot. There was a lot of agreement around Dilnot, but I still come across people who think that Dilnot was the worst thing that could ever have happened. There is a more nuanced picture. If anything, that just underlines the importance of taking care as we try to build a consensus.
Moving forward to the specific issue of the debate, which is deferred payment agreements, as has been outlined, they are a means by which individuals can access equity in their home to pay for care without having to sell it, meaning that they do not have to sell their home in their lifetimes. As the noble Lord, Lord Lipsey, pointed out, DPAs have been in existence for a number of years and the issue was addressed in the Care Act precisely to attempt to create a more thoroughgoing national system to replace what had obviously been quite a patchy one. Even though some elements of the Care Act have not been taken forward, in particular the social care reform agenda, as has been pointed out, the Government took the decision to move ahead with the implementation of DPAs in order to fulfil the pledge of the previous Prime Minister—to whom both he and my noble friend Lady Sugg owe their position in this House—that people should not have to sell their homes in order to go into care during their lifetime.
In terms of the actual performance of the scheme, we had a year of voluntary data collecting for 2015-16, although it is now compulsory. A helpful note tells me that the next iteration of the data is 2016-17, and NHS Digital should be publishing them towards the end of October. We will then have a really thorough look at what is happening. The previous year showed that about one-third of local authorities responded, so it was only a partial picture. Nevertheless, it was disappointing that fewer DPAs were agreed than had been anticipated. Indeed, the noble Lord, Lord Lipsey, pointed this out as likely to be the case in the debate on the regulations. I will come to what we can do about it, but these are of course a means to an end in themselves. This is why I am not convinced that having a target is appropriate because it is about enabling a choice and adding to the choices that are available for people by providing a means of deferring payment until after death. There are many reasons why people may not choose a DPA, and of course the private market is evolving all the time. But we need to understand why there were fewer DPAs than anticipated and to ensure that those who are eligible for them can access one. If there are local authorities where not one has been signed, that suggests that something is going wrong at the local level in terms of communication between the local authority, individuals and the social care sector. So we need to know why that happens.
Lord Hunt of Kings Heath
In the noble Lord’s very helpful response, he referred to the private market. He mentioned that not everyone thought Dilnot was the right answer, because one of Dilnot’s aims was, by capping costs, for the insurance market to come in when they have been reluctant to. I wondered whether part of the consultation would seek to answer the conundrum of what could make the insurance market come into this area more enthusiastically. Clearly, that would be one way that we could solve some of the problems.
Lord O’Shaughnessy
The noble Lord makes a good point. I do not know if that will be laid out explicitly. We have talked a little about the manifesto and how it was a movable feast over the course of a weekend. We ended up with a floor and a cap. At the point at which you have a cap, in theory, you have an insurable product. It depends whether it is insured by the private market or the state, but that was clearly at the core of the Dilnot design. There was lots of disagreement about how you could take forward that principle, but I think it useful so that, in keeping with the nature of the market, you have a mixed economy of funding.
We have been talking to local authorities to understand why people may not be accessing DPAs. There are a number of barriers, such as lack of awareness, interest charges and administrative fees. We are considering what actions can be taken locally and nationally to raise awareness and understanding of the scheme. One example of that is that is the wide variation in administrative fees charged by local authorities. Clearly, it is important that those fees are not set at a prohibitive rate, nor that local authorities are or seem to be profiting from the fees. They are meant to be covering costs. However, I think interest rates provide quite a positive picture, because the interest rate is around a third of that offered by the standard equity release scheme on the market. With wider awareness, that would prove more attractive than it has done.
Regarding the eligibility criteria, £100,000 is a magic fee in this social care debate—even more so after the election. That was the point that the noble Baroness, Lady Greengross, made about the reform proposal and widening eligibility. There are two points I would like to make on this. First, the Government’s aim in establishing the scheme was particularly to ensure that people did not have to sell their homes, rather than run down other capital. I know that that is more limited than noble Lords might like, but that was nevertheless the aim of the scheme.
The second point is that, in expanding the criteria, a local authority should in theory be able to recoup its costs, but there may be some costs in taking on a wider group of qualifying people. There is always a balance to be struck, particularly in cash flow terms, between helping a group who are by definition better-off people, and fairness to local taxpayers. That is one issue that needs to be considered.
The noble Baroness, Lady Greengross, asked in particular about the deep dive that happened. She will be disappointed to hear that departmental protocol is that these are for internal use only, so I am afraid I am not in a position to share that information with her. It sounds like she has the detail on what happened anyway, so I am not sure that that would necessarily reveal anything that she does not know.
To conclude, it remains a departmental priority to make the scheme accessible to all those who are eligible and would benefit from it. We will continue to monitor the scheme and, once the data are published, may look at some of the ideas suggested by noble Lords on how to give this scheme more momentum. Clearly, the intention of it is not to be de minimis, but to reach the original target and more people beyond that. We are open to ideas on how that can be achieved.
Finally, any DPA scheme must in the long run fit into the wider context of social care funding and provision. That point has been well made in this debate. As the proposals come out for consultation, considering the interplay of DPAs and the overall funding environment will be critical in whether reforms are successful. I conclude by thanking the noble Lord, Lord Lipsey, again for tabling this debate and other noble Lords for their contributions. I look forward to working with them on getting consensus on real reform in the sector.