Care Services: Elderly People

Lord Turnberg Excerpts

Wednesday 6th March 2013 Grand Committee

Asked By

[Lord Turnberg]

To ask Her Majesty’s Government what steps they are taking to improve care in the community for elderly patients.

[Lord Turnberg]

My Lords, I am grateful for the opportunity to open this debate, even though I suspect that many noble Lords might share a faint sense of déjà vu about this topic. However, the fact that care in the community keeps reappearing on our agenda suggests that, despite numerous impressive reports and repeated debates in this House, we are not yet anywhere near solving the problems.

I suspect that few here will admit to any ignorance of the facts, so I hope noble Lords will forgive me if I start by reiterating the nature of the difficulties we face. It may save others having to repeat them. First, the country has entered a prolonged period of severe economic constraint, so there is little new money available centrally. Secondly, we have no control over the demand for social care that is growing at a remarkable rate.

The population is ageing as life expectancy goes up in an inexorable straight line. The current 3 million people over the age of 65 will rise to almost 5 million in the next 20 years, while the number of over 85 year- olds will double from 1.3 million to 2.6 million. We would celebrate this extension of life were it not for the fact that the number with multiple chronic diseases will also increase by about a third, while the number of those with dementia is set to double from the current estimate of 800,000. If that is not enough to frighten you, there is the statistic that one in three people over the age of 85 will develop dementia. That is what I am told. Many of these people end up in an acute hospital, the place least suited to their needs, and the number lingering there unnecessarily is huge. Of the over 85 year-olds admitted, some 140,000 stay for more than 30 days, and the numbers are rising. A diagnosis of dementia is the primary reason for admission in some 55,000 patients a year, in the majority of whom the diagnosis had not been made before admission. Where, I wonder, were the GPs?

These patients are admitted, but too often there is nowhere else for them to go. Social services departments are sorely underfunded and about four-fifths of local authorities are now said to be restricting social care to those with needs graded as substantial or critical. There is a black hole of some £16.5 billion looming in social care funding over the next few years. The gap between the money needed to meet demands and that available is growing year by year. Here we have the nub of the problem—increasing demand from an ageing population acquiring multiple long-term illnesses and a veritable epidemic of dementia, together with social services departments stretched way beyond their capacity now and with a future in which they will be unable to deliver even the basics of care, and all against a background of severe constraints on the money available from government.

We cannot simply go on as we are and try to patch up the current system of an NHS designed for acute hospital care, essential though that may be, while the desperate need is for prevention and the long-term care of the elderly. We must start now to develop a long-term plan to meet these problems. My first question to the noble Earl is: is there any sign that the Government are thinking along the lines of long-term future planning?

At the end of the day, we must ask ourselves where the money is to come from. Of course, some measures could be taken that would help a little. The poor co-ordination between care workers in hospital and in the community has been resolved in a number of well recognised places around the country and more should be done to spread that good practice. Of course, there may be efficiency gains to be made somewhere in the system. Then there is the recent government initiative in the wake of the Dilnot report to help the elderly pay for their care. Will that ease the financial burden on local authorities? I fear not, because although it offers some help to the elderly themselves, it seems more likely to add to the problems of local authorities than to help them.

Then there are the usual calls for funds to be transferred from the supposedly cash-rich NHS to social services. I am very supportive of proposals that NHS and social service budgets should be pooled to fund care for the elderly. That makes a lot of sense and I was happy to see something along those lines in Andy Burnham’s recent speech about a future Labour health policy. We need to think, too, not only about merging budgets but also medical and nursing staff so that they can work across the boundaries between hospital and community. We also need to look critically at how we can incentivise and support GPs who are really the key players in the community. It is far from clear whether they are prepared in the CCGs for commissioning long-term care. Will the noble Earl tell us whether any attention is being focused on the role of GPs there?

What about closing hospitals or beds and transferring the savings? Data showing that up to a third of acute hospital beds are occupied by patients who should not be in hospital at all provide ammunition for those who see considerable savings from cutting bed numbers. That is not easy. If we try to go along that route, we have to look at where the costs of acute hospitals really lie. They lie largely in the staff and relatively less in the number of beds. The workload for the medical and nursing staff of acute hospitals is not determined by the number of beds, or even by the number of long-stay patients, but by the rising tide of acute emergency admissions. It is hard to escape the conclusion that we are not well off in NHS hospital services. Hardly a day goes by when we do not hear of failings in the care of the acutely ill.

If wards or even whole hospitals were to close, that acute workload would not diminish. Indeed, the more rapid throughput of patients through a smaller number of hospital beds would increase the intensity of the work. I am not saying that there would not be any savings made on, for example, heating and lighting bills and perhaps on administration, but the savings to be made, especially on doctors and nurses, would be rather less than one might hope. That may account for the intriguing piece of research evidence from Julien Forder, who published a paper in the Journal of Health Economics in 2009 in which he showed that for every pound spent on community services it was possible to save only a third of a pound on hospital services. Caring for someone in the community is not a cheap option.

Meanwhile the NHS itself is under remarkable cost-saving pressures as it seeks to answer the Nicholson challenge. Hospitals are barely coping in many instances, and the prospect of diverting even more funds is likely to be impossible to bear. I am not suggesting that rationalisation of services into a smaller number of specialised centres is not a good thing—it clearly is—but closing acute hospitals to save money simply to transfer it into the community does not bear too close examination. In any case, there are the calculations suggesting that there will be a shortfall in NHS funding of some £30 billion per annum by 2020 on current trends, so the question remains: where will the funds for social services come from? It is difficult to see much coming from simply integrating NHS and social service budgets, desirable though that may be. Simply pooling two inadequate sources of money does not sound like an answer to me. We have to face the idea that the Government of the day, whoever they are, will have to give a higher priority to care in the community than they have currently been able to do. It is a political decision, and we must think more broadly than simply within the box of the Department of Health.

Are there are any discussions going on between government departments— housing, transport and so on—on plans for future care in the community? How much priority are Governments as a whole willing to give to this compared, for example, with a high-speed train or nuclear submarine, desirable though some may think they are? Do they have a higher priority? These are decisions that only a Government have to face. I do not envy them for that, but in a democracy such as ours I do not believe it is entirely wishful thinking to feel that a clear majority of the population would strongly favour a diversion of resources to areas that they think are of high priority, and I can think of few higher priorities than the way we care for our elderly.