Queen’s Speech

Lord Turnberg Excerpts

Tuesday 14th May 2013 Lords Chamber

[Lord Turnberg]

My Lords, the Care Bill represents an important recognition by Government of the need to tackle one of the major problems facing society: how we cope with the growing number of elderly dependent people. The fact is that we are all living longer, and although we are also remaining healthy and active for longer—here I must disagree slightly with my noble friend Lady Hollis; we are extending healthy life for longer, at least for women—we are leaving behind a long tail of unfortunate elderly people who are increasingly disabled with multiple chronic illnesses, many living in poverty, lonely and neglected. It is this growing group that is too frequently admitted to hospital as an emergency when they are tipped over by an acute exacerbation. They stay in hospital for far too long when they would be much safer and certainly better off at home. This is the picture that is painted so clearly in a recent Age Concern publication.

The Bill goes some way to providing help for pensioners themselves in the cap it will put on how much they have to pay for their long-term care. We can argue about how high or low the cap should be, but it is important to recognise that an extra financial burden will be placed on local authorities. Once an individual’s cap is reached it will be up to the local authority to pick up the bill for their care. Yet the local authorities are already under severe constraints and are complaining bitterly about being unable to fund even basic levels of care. The projected shortfalls in the face of increasing demand over the next few years are positively frightening, and I shall return to funding issues in a moment.

The Bill also takes up the challenge of the Francis report and proposes a number of measures to try to reduce the scandal of abuse and neglect. However, in focusing on systems for the detection of bad practice and more punishment of those who offend, the Bill seems to be missing the need to prevent bad practice in the first place. I believe that it would be much more effective in preventing bad behaviour to have someone on the ground at ward level who has responsibility and sufficient clout to ensure that high standards of care are maintained. As I have said in previous debates, that person has to be the sister or charge nurse in charge—really in charge—in a career grade post, not rushing off up the nursing career ladder in a year or so. Here I would echo very much what the noble Lord, Lord MacKenzie of Culkein, said. She or he should be rewarded and given a salary similar to that of a consultant, in recognition of the level of responsibility that she or he carries. These preventive measures are likely to be more effective than simply looking for abuse once it has happened.

One really big problem is how to prevent elderly patients being admitted in the first place, where we have been failing miserably. The Bill talks of the responsibility of local authorities to promote well-being and to prevent the need for care and support but it cannot say how they might do this or where they might find the money. There are many constructive things we could do now, without waiting for government action. It is worth examining what makes so many patients end up in accident and emergency departments. Many turn up with “dizzy do’s” and falls, and yet we could prevent most of those. Poor lighting at home and the absence of handrails or chair-lifts could all be discovered by regular home visits and corrected in a timely way, which may prevent many a fall. We can reduce the incidence of fractures, particularly hip fractures, which have such a big impact on the need for admission, by reducing the prevalence of osteoporosis through screening for it, treatment with calcium and vitamin D, and regular exercise, all at trivial cost compared with hospital admission. Then there are the “blackouts” that are so common. Screening the vulnerable elderly for predisposing causes—cardiac rhythm disorders such as atrial fibrillation, transient ischaemic attacks, epilepsy—and checking for hypertension and diabetes could prevent even more admissions. Far too often, it seems that patients with a diagnosis of dementia turn up in casualty. It is surprising but true that this may be the first time that a diagnosis of dementia is made, despite it being hardly likely that their dementia has suddenly appeared overnight.

All these rather obvious, and you might think straightforward, measures should be taken in primary care with the help of social services. Unfortunately, the regular screening of the vulnerable members of a practice is far from routine. I hope that the noble Earl, who is not here at the moment, will say in summing up whether it is possible to press those in primary care to include such screening. Focusing social and mental health services around GPs will bear dividends, but we need to take more action at that level than we have managed so far. It is particularly needed in poor inner cities, where it is least likely to be available. I was, incidentally, encouraged to hear that the Secretary of State was asking for ideas along those lines. There they are.

That still leaves us with what to do about patients lingering too long in hospital when they should be at home. Here again we have lots of ideas about what to do but seem quite unable to put them into practice in more than a few places, patchily, around the country. Why do all hospitals not appoint an officer whose sole responsibility is to plan for a patient’s discharge from the moment they enter the hospital? Better co-ordination between hospital and social services now occurs in a number of well rehearsed places but we have failed in trying to scale this up. The idea of pooled budgets between the NHS and local authorities is a good one, since it promotes better integration of functions, even though pooling two rather inadequate sources of funds will not provide much of the extra money that is needed.

All these measures can help, but the overriding problem will remain one of trying to provide more care in the community with too little money. Some believe that we should close NHS hospitals and beds to provide the money. Although there may be good service and quality reasons to focus expertise in fewer places—I am all in favour of that—it is a vain and somewhat naive hope that simply closing beds will save much money. To be clear, I am talking here of the 30% of beds occupied by elderly patients who should be at home. Close those, and Bob’s your uncle. However, hospital costs are not simply dependent on bed numbers. They lie much more in the high level of acute care, which is so labour-intensive. It is the high-cost medical and nursing care that severely ill patients need for their investigation and treatment that consumes so much resource. Those services are now so stretched but are hardly used at all for long-stay patients sitting in beds waiting to go home. Closing those beds will save very little, since the hospitals will still be stretched by their acute, high-intensity work. Certainly, discharging patients home quickly is a worthwhile endeavour for the patients but I do not believe that we should be looking for much in the way of savings there.

So where is the money to come from? In his excellent report, the noble Lord, Lord Filkin, pointed quite rightly to the need for the whole Government to respond. We need a combined effort across the whole of government, including housing, transport and work and pensions, and the Treasury and the Cabinet need to consider their overall priorities. Ultimately it is the priority that government as a whole gives to care of the elderly compared with the many other pressures it is under that will count.

Welfare Reform Bill

Lord Turnberg Excerpts

Wednesday 25th January 2012 Lords Chamber

For these people, a key benefit of this approach would be that a person with mental health problems would be diagnosed and treated by the same professional. The diagnosis should be compulsory but, as with all healthcare, the treatment should reflect patient choice. I urge the Minister to go further and give this idea serious consideration and, I hope, produce an appropriate response. The statistics speak for themselves, but I will leave noble Lords with one that is quite worrying: mental health conditions are incredibly costly to the economy and are now the most common reason for claiming health-related benefits, with 86 per cent remaining on benefits for more than three months compared with 76 per cent of other claimants. Those figures come from the Department of Health and the Department for Work and Pensions report Working our Way to Better Mental Health: A Framework for Action. Recent estimates put the cost of mental ill health at £30 billion to £40 billion attributed to lost productivity and NHS costs. I beg to move.

[Lord Turnberg]

My Lords, in the absence of the noble Lord, Lord Layard, I would like to intervene briefly on his behalf. He spoke eloquently in Committee on this matter, and he is now busy saving the world in the economic forum in Davos, much to our dismay. I do not know exactly, but I have no doubt that he would want to point out that people with mental illness form a very high proportion of those who are out of work and seeking employment. They must be among the most difficult to place in work and among those we must strive harder to help. I recognise that the Government have put in place a system that aims to help with prime providers and so on but, as we have heard, this is of only modest benefit. It would be made so much more effective if, at the same time as being assessed for work and support allowance, claimants could be assessed medically for their mental illness and given the relevant treatment. A person whose mental illness is treated must be much more likely to get into work and to stay there. As the noble Lord, Lord Layard, pointed out in Committee, it makes no economic sense for the country, let alone for the people themselves, to leave them out of work because they are not gaining access to the relevant diagnosis and treatment that could make them fit for work. This is a marvellous opportunity when they are being assessed for work for them to be given the opportunity to get the treatment that would make them fit for it. I hope the Minister will look at this amendment as a valuable adjunct to the Bill and will accept it.

[Baroness Thomas of Winchester]

My Lords, I have a great deal of sympathy with this very practical amendment to a very real problem.

We heard a lot on Monday about taxpayers’ money, and particularly about how unfair it is for people on out-of-work benefits to be receiving more from the state for doing nothing than many of those who are in work, paying their taxes. However, we seem strangely passive about the problem of thousands of ESA claimants who are signed off work because of mental health disorders, thus costing the state millions of pounds, and who, as we have heard, are not required or even encouraged to seek treatment.

My noble friend the Minister sent us all a very interesting booklet entitled Models of Sickness and Disability Applied to Common Health Problems, written two years ago by Gordon Waddell and Mansel Aylward, a lot of which I have now read, he will be pleased to hear. We know that mental health problems now account for more than 40 per cent of long-term sickness absence, incapacity for work and ill-health retirement. We learn from the booklet that if current trends continue, within a few years they will be the majority; that the problem is mild to moderate conditions such as anxiety-related disorders, depressive disorders and stress; and, as we have just heard, that the cost of mental illness in the UK is estimated to be as high as £40 billion to £48 billion per annum, the greater part of which is due to sickness absence and long-term incapacity. Finally, we learn that about one-third of the working-age population have mental symptoms such as sleep problems or worries; one-sixth would meet the diagnostic criteria for a mental illness such as depression; but only about 6 per cent of the working-age population actually seek healthcare.

No wonder those who have made more of a study of these statistics than I have have tabled this amendment. However, the jury still seems to be out, according to page 39 of the booklet, on exactly which treatments improve work outcomes, although there is strong evidence that various medical and psychological treatments for anxiety and depression can improve symptoms, clinical outcomes and quality of life. Waddell and Aylward conclude that there is an urgent need to improve vocational rehabilitation interventions for common mental health problems, and that promising approaches include healthcare that incorporates a focus on returning to work, workplaces that are accommodating and non-discriminating, and early intervention to support workers to stay in work and so prevent long-term incapacity.

We now also have the report Health at Work: An Independent Review of Sickness Absence, by Dame Carol Black and David Frost, published in November last year. They mainly focus on those in work who might well be off sick without the right interventions, and make the point that people with health conditions too often do not receive appropriate early support to remain in work, especially those with common mental health conditions.

I am sure that the noble Lord, Lord Adebowale, will not divide on this amendment at this hour but perhaps he will instead seek a meeting with the Minister to discuss how to take forward this important matter, perhaps together with Dame Carol Black and Professor Waddell. I can quite understand why it is tempting to put something prescriptive into the Bill, but I do not believe this would be the right way forward.