Health and Social Care

Andrew Murrison Excerpts

Monday 27th February 2017 Commons Chamber

[Dr Wollaston]

I thank the hon. Gentleman for making that point, although I think we should use the term “delayed discharges” rather than “bed-blocking”, because the latter can make older people who are in that position feel as if somehow they might be to blame. Nevertheless, I take his point.

The estimates memorandum seeks a transfer from the capital departmental expenditure limit of £1.2 billion to prop up revenue. It also seeks a £23 million transfer from Her Majesty’s Treasury reserve, a £58.5 million transfer from other Government Departments, and a £6 million transfer to capital from other Departments. Again, we see an unsustainable position, as pointed out by the Comptroller and Auditor General.

[Dr Andrew Murrison (South West Wiltshire) (Con)]

I am following closely my hon. Friend’s remarks, which are, as ever, wise. Does she share my concern that if we are to transfer money from capital to revenue, the sustainability and transformation plans, most of which imply a certain level of capital investment in order to save revenue in the long term, will not be possible?

[Dr Wollaston]

I absolutely agree with my hon. Friend and will discuss that later.

The point about the raids on capital budgets over the years—this is the third year in which we have seen transfers from capital to revenue budgets—is that we are talking about the money required to keep facilities up-to-date, and for essential repairs and the roll-out of new technologies. Putting off such repairs and investments means they cost more down the line, so it is a false economy. It is simply an unsustainable ongoing mechanism. The Department of Health has indicated that it would like to see an end to the practice by 2020, but both the Public Accounts Committee and the Health Committee have called for it to be stopped immediately because we feel it is, as I say, a false economy. As my hon. Friend the Member for South West Wiltshire (Dr Murrison) pointed out, it is about raids not only on capital budgets, but on the sustainability and transformation fund. It is increasingly becoming all about propping up the sustainability part rather than putting in place the essential transformation.

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[Anne Marie Morris]

I thank my hon. Friend for that helpful example. She is absolutely right.

If we look at the whole measurement system—this was acknowledged in one of our Public Accounts Committee sessions by the Department of Health—we see that there is limited measurement, and that there probably should be more. When I challenged the individual concerned on whether the Government would be looking at that, he stood from one foot to the other and could not give us much of an answer. These estimates have to be based on proper measurement of need, on what is operationally put into practice, and on the outcome for patients, but that simply is not the case.

We need to look at the differences between the NHS and social care as regards how the money is allocated. In the NHS, we have some ring-fencing, while in social care we do not, but because the two are inextricably linked, unless we look at the way in which each of those pots is managed, never mind how much is in them, we give rise to problems for the future. Social care is not ring-fenced. I am sure we are all grateful for the additional moneys that have been provided, but frankly they do not go far enough. The first chunk of money might cover the living wage, and the ability of local authorities to increase the precept by 3% is welcome, but as the Chair of the Public Accounts Committee said, that is taxpayers’ money.

[Dr Murrison]

My hon. Friend is making a very good speech. Does she share my concern about the 3% precept, as shifting the cost of health and social care away from general taxation on to a property-based tax has obvious problems—not least, that it will disadvantage communities that are less well off?

[Anne Marie Morris]

My hon. Friend makes a fair point. I have one of those constituencies where communities are not very well off. Many of the facilities that are there to provide social care are failing because we do not have the more affluent individuals who can ensure that some of our care homes, particularly nursing care homes, are alive and well. I am now down to just three for a very large constituency, and that is completely inadequate.

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[Mr Clive Betts (Sheffield South East) (Lab)]

The Communities and Local Government Committee is currently undertaking an inquiry into the funding of social care. We have not produced our reports yet, so anything I say should be taken not as the Committee’s considered view but as some of my own reflections on the evidence we have heard so far. I hope it will not be too long before we can provide a report for Members to look at on the immediate issues of social care, and then, in due course, we will go on to look at the longer-term issues as well. We have taken evidence from a variety of different organisations, including councils, care providers, directors of social care, the Nuffield Trust, and the King’s Fund. Carers and care providers, as individuals, have related their personal experiences to the Committee.

As a constituency MP, it is not terribly surprising to have heard what I have heard today. Unfortunately, as an MP, like everyone else here, I am sure, I see only the tip of the iceberg of problems. Cases about the nature, and number, of social care failings have undoubtedly been increasing in my surgery, my postbag and my emails in the past two or three years. Some of the cases are quite horrific. A council that has to cut its budget on social care does so by going out to the private sector, or agencies, and substituting their services for the service that the council used to provide through directly employed staff. The way in which those services are delivered—often the simple failure of people to turn up and provide the care when it is promised—causes real and increasing problems that I am certainly seeing as a constituency MP.

This is not surprising. The Chair of the Health Committee referred to the fact that we have had a 7% cut in real terms in spending on social care since 2010. Local authorities’ grants from central Government have been reduced by 37%. Councils have tried to prioritise social care—the evidence for that is absolutely clear—but they have not been able to protect it completely from the cuts. That is the reality. On top of that, not only has the money been going down but the number of elderly people requiring care is going up. We heard evidence that although the Care Act was great legislation in principle, all was not delivered in practice. The extra measures are welcome in trying to reward staff properly for the excellent work that many of them do in social care, but the increase in the minimum wage places additional costs on the system.

Amyas Morse, who wrote a very good article and made a good speech the other day about the relationship between health and social care, said that for a long time local authorities had been very successful in doing more for less, but have now got to the point of doing less for less, which is impacting on the people who received the services.

We should not blame local councils for failing to provide a certain standard of service. Simon Stevens told the Communities and Local Government Committee that even if every council did as well as the best, there would still be problems in the system. I challenged the Under-Secretary of State for Health, the hon. Member for Warrington South (David Mowat), to say whether there was a crisis in social care. He did not want to use the word “crisis”, but he did say that the system was “under stress”. Although we cannot agree about the word “crisis”, I think we can at least agree that the stress is obvious for all to see. An estimated 1.2 million people do not receive the care they need. That figure is 40% higher than it was in 2010.

We took evidence from people who were not getting the same amount of care as they had received in the past and others whose needs were increasing but whose care was not. We talked to care providers who were handing contracts back or pulling out of the service altogether, and to local authorities that are sacking care providers because the contracts were not being delivered properly. We also heard that people who pay for their care in care homes are subsidising local authorities because they cannot afford to keep increasing their fees. There is a cross-subsidy in the system, which does not seem fair to many people. At the same time, the turnover rate for care staff is 27%, so they do not have long-term experience and are not being trained regularly over time to deliver care. Those are all problems that we learned about from the compelling evidence that our inquiry received. The Committee will reflect on its conclusion, and I am sure that eventually we will, as always, come to an unanimous view in our report.

In the short term, of course the Government have done things, including the introduction of the council tax precept. I welcome the fact that, by and large, local authorities have taken that up, because the situation is so serious. There are problems, of course, with the fact that the council tax precept raises much more money for some local authorities than for others, and the better care fund, which is meant to stabilise the situation and help authorities that raise less, is back-end loaded. The new homes bonus cut and the additional grant are welcome for social care, but that causes real problems for some small district councils that are not social care providers and suddenly find that their budget position is fundamentally altered.

In his article, Amyas Morse described how the Government simply were not thinking through what would happen in the long term. They moved money—it is often a lack of money—around between social care and health without giving any real thought to the end result. Government officials, and sometimes Ministers, took decisions without any real understanding of what happened to the money at the end of the line, when local authorities faced with very difficult choices had to make decisions about the cuts that were being passed on to them. Those are just some of the issues on which we will reflect in our report.

Clearly, the link between health and social care is very important. We ought to join them up better and it will be interesting to see what comes out of the Manchester example, given that both services have been devolved. There is a clear link between the two, and not just with regard to delayed discharging; there is now virtually no money in the system for preventive social care. The only social care funding available is that for people with the highest need. If people do not get it in the early stages, that means that they are more likely to end up in hospital and cost the whole system much more. That is another thing that we learned.

I was pleased to sign, along with the Chairs of the Health Committee and of the Public Accounts Committee, the letter to the Prime Minister saying that we need longer-term arrangements. It is right, however, that the Government should respond to the here and now, because that is important. To put it bluntly, if we do not deal with the here and now, some people will not be around to see the long-term arrangements being put in place.

When the Communities and Local Government Committee went to Germany, we learned that it solved this problem 20 years ago. Those involved sat down on a cross-party basis and agreed a long-term solution. It might not be the right solution for this country—it is based on social insurance, because that is what the German health system, as well as its pensions system, is based on—but that is what they decided to do. It is interesting that it has stood the test of time for 20 years. They have recently decided, with cross-party agreement, to increase social insurance and there has been virtually no public opposition, because the system is seen to be reasonable and fair. The German system is not purely funded by the taxpayer—there are private contributions as well—but it is an example. For heaven’s sake, let us sit down on a cross-party basis, as the Chair of the Health Committee has said, and work out a solution that stands the test of time, whichever Government comes to power in the future.

[Dr Murrison]

There is much in the hon. Gentleman’s speech with which I agree. Does he agree that the fundamental issue is that countries such as Germany, France and Holland, to which people here would reasonably compare this country, spend a great deal more money through either the Bismarckian system that he describes or others—this country’s system is based on Beveridge—and that somehow or another we are going to have to close that gap, as it is highly likely that the difference in mortality, morbidity and outcomes generally in this country compared with those aforementioned countries is causally related to the amount of money that we put into healthcare?

[Mr Betts]

We heard quite a lot of evidence that, as a percentage of our national income, we do not spend as much as several others on health and social care combined. The Communities and Local Government Committee will reflect on that. Of course, it is not simply a question of asking for more public funding; I would not come to that conclusion, although I might personally believe it. There is, however, an issue with where we get the private funding from, because nobody has argued to us so far that the whole of social care can be publicly funded. There will be private contributions, so how do we raise that private money? Should it come from individuals who simply need care at that point in time, or should we ask people to pay more into an insurance system? How do we put in more money from the public sector? Indeed, can we rely on local authority funding alone, particularly if it comes largely from business rates, which will not grow at the same rate as the number of people who want social care?

[Kevin Hollinrake (Thirsk and Malton) (Con)]

rose—

[Dr Murrison]

rose—

[Mr Betts]

I give way to my Select Committee colleague, the hon. Member for Thirsk and Malton (Kevin Hollinrake).

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[Andrew Selous (South West Bedfordshire) (Con)]

It is a pleasure to follow the Chair of the Communities and Local Government Committee, the hon. Member for Sheffield South East (Mr Betts).

Notwithstanding the issues that have already been brought to the House’s attention, it is worth putting on the record the increase in the money—the extra £10 billion by 2020—that the Government are committing, with the 11,400 more doctors and 11,200 more nurses in the system, as well as the near eradication of mixed-sex wards and the huge reduction in hospital infections. I also note that health spending in England is nearly 1% higher than the OECD average.

[Dr Murrison]

I am sorry to intervene on my hon. Friend so early in his speech. Does he agree with me that the OECD average is probably a specious comparator? It covers countries—such as Mexico and Turkey, and former eastern bloc countries—whose health economies, laudable though they may be, are not ones with which most people in this country would wish ours to be compared.

[Andrew Selous]

My hon. Friend makes a fair point. I will outline some areas in which I think more spending is necessary.

I want to start by focusing on an individual case—it is not from my constituency—which highlights many of the issues that have been raised so far. It concerns a 98-year-old lady who was admitted to a hospital in one of our major cities on 22 January. Unfortunately, she died in that hospital on 31 January. It was made clear to the hospital on 25 January that the nursing home she had come from—she had been in its residential part—had nursing facilities, and it would have been able to take her back and deal with the deterioration in her health. Despite that, no action was taken to remove her back to the nursing home, which resulted in an extra six days’ stay in hospital.

The relatives who drew this true case to my attention asked me to raise two points. First, they thought it was not really good enough that the hospital concerned did not have a good knowledge of the fact that in addition to the residential facilities, the nursing home had facilities that would have been able to care for the elderly lady and thus free up a hospital bed. Secondly, they were disappointed that because her period in hospital spanned a weekend, they were told by several of the nursing staff that no doctor was available to make a decision about moving her back to the nursing floor of the home she had come from and where she had always wanted to end her days. That story illustrates some of the issues—I know Health Ministers are aware of them—of making sure that there is knowledge of what residential and nursing facilities are available in the community for elderly or frail people who go into hospital, and of making sure that there is weekend cover so that appropriate decisions can be taken and beds are not unnecessarily taken up in hospitals.

A couple of weeks ago, I sat down with a number of social care providers covering both residential and domiciliary care in Bedfordshire, and I asked them what they thought they needed to attract enough people into care provision. As the Chair of the Select Committee has just told us, there is a 27% turnover rate, and I learned that the providers cannot always attract people of the calibre they would like. For domiciliary care, I was told very clearly that the ability to offer a salary—perhaps of £16,000 to £18,000 a year—rather than paying people on an hourly basis when they provide care, would go a very long way to attracting the right sort of people into this profession.

That domiciliary care provider, which is one of the better ones in my area, pays 30p a mile for travel costs. All of us, as Members of Parliament, get paid 45p a mile when we travel in our constituencies. Frankly, I find it an affront that there is a division between rates for travel within the public sector. Social care staff do an incredibly important job and, frankly, it is not right that they are lucky to be offered 30p a mile, when Members of Parliament get 45p a mile. I am not just asking local authorities to put up what they pay to such a level straightaway. We must be realistic, and I fully recognise that that would come with a price tag that would have to be provided through taxation. However, having a salary of £16,000 to £18,000 a year, rather than hourly rates of pay that do not include travel time, and having travel properly paid for—it is currently paid for at a very miserly rate compared with what other people in the public sector get—would go a long way.

One of the issues that has not been highlighted so far in the estimates is the revaluation of the NHS litigation costs. There has been an increase of some £8 billion, which is a fairly large figure. It is worth focusing on that because litigation costs mean a couple of things. First, they mean that patients have not got the right quality of care first time around, and secondly, they mean that money is going out the door of the NHS, often to lawyers, that could be better used doing the job correctly the first time.

In that regard, I make no apologies for again drawing the House’s attention to the Getting it Right First Time initiative, which seeks to embed quality in clinical care across the NHS. I often find that we do not focus sufficiently on that in this House. Variability in the rates of infection and of the revision surgery that is required are significant across the NHS. If we could raise the quality of clinical care to the level of the best across the NHS, we could get the amount for litigation down substantially.

I was pleased to join a meeting that the Chair of the Public Accounts Committee, the hon. Member for Hackney South and Shoreditch (Meg Hillier), held a couple of weeks ago on the “Manifesto for a healthy and health-creating society”. It was led by Lord Crisp, the former permanent secretary of the Department of Health, with colleagues in the House of Lords and others. Although that may seem a long-term approach to the acute problems we face today—the Chair of the Communities and Local Government Committee is right to say that we need action now to get the preventive issues right, because not everyone will be around in the longer term—it is incredibly important, none the less, that we take a lot of the ideas in the report seriously to try to reduce the strains on the NHS and to create a healthier population in the years to come.

There are already some very good examples of such ideas. The St Paul’s Way transformation project in Poplar in the east end is doing sterling work. The Well North initiative, which is supported by Public Health England, is focusing on 10 cities in the north of England that have poor health outcomes and bad levels of health inequality. It is all about creating what it calls vibrant and well-connected communities to deal with issues such as debt, jobs, training, missed educational opportunities, poor housing and loneliness. Our late lamented colleague Jo Cox focused on the issue of loneliness, and many of us in the House are determined to carry on her work in that important area. Such long-term preventive work to increase the resilience and health of society is absolutely fundamental to all the issues we are talking about tonight.

On the sustainability and transformation plans, I have spent time with both GPs and hospital staff during the past couple of weeks, and I observed that clinicians in hospitals often point to the work that they thought should have been done but had not been done by GPs, while GPs pointed out that they do quite a lot of work that in the past they would have expected hospitals to undertake. As we move forward with the sustainability and transformation plans, there would be some merit in making sure that those in time turn into accountable care organisations, so that we get a proper join-up between the different parts of the system and such finger pointing between different parts of the health system becomes a thing of the past.

Finally and briefly on the issue of beds, I totally understand the Government’s correct focus on shifting more care to the community, but we have 8,000 fewer beds than we had five years ago, while the occupancy rate has increased from 84% to 87%. At times, operating theatres stand idle because of delayed discharges for care. I should like Ministers to reflect on that.