Health and Care Services

Baroness Keeley Excerpts

Wednesday 3rd July 2013 Commons Chamber

[Barbara Keeley (Worsley and Eccles South) (Lab)]

I thank the Chair of the Select Committee, the right hon. Member for Charnwood (Mr Dorrell), for the way he opened the debate.

The context of our debate on public expenditure for health and care is, as we have heard, not just the substantial upward cost pressure on the NHS, but substantial cuts to the budgets of local councils, which are affecting their social care budgets. Adult social care directors tell us that £2.7 billion has been cut from care budgets since 2011, representing a significant 20% of those budgets. That level of cuts now means actual service reductions, as well as increased charges for service users—a fact brought home to me week in, week out by the cases I am now seeing in my constituency. My local authority of Salford had maintained eligibility criteria of “moderate” until this year and has been pushed by cuts into changing it to “substantial”. That is very sad.

Often what are described as efficiency savings in social care budget cuts are actually cuts to the fees paid to care providers. Some 45% of the adult social care directors polled by the Association of Directors of Adult Social Services said that they did not increase fees to care homes to cover inflation this year, while nearly half said that providers in their areas were now facing financial difficulties as a result of savings made in fees paid to councils. In many cases, this has led to the poor care that we have had described in so many reports, and to which the right hon. Member for Charnwood has just referred. We hear of care tasks timed down to the minute, and paid care workers earning less than the minimum wage because they are not paid for travel time or costs.

The social care directors also warned that worse cuts are still to come, given that further cuts to local council budgets are still planned. Sandie Keene, the president of ADASS, warned Ministers that further cuts could have seriously adverse consequences for families. She said:

“it is absolutely clear that all the ingenuity and skill that we have brought to cushioning vulnerable people as far as possible from the effects of the economic circumstances cannot be stretched any further, and that some of the people we have responsibilities for may be affected by serious reductions in service—with more in the pipeline over the next two years.”

Not surprisingly, the Local Government Association has warned the Government that they need to ensure protection for adult social care in future. Zoe Patrick, chair of the LGA’s community wellbeing board—so perhaps the most senior wellbeing board in the country—has said:

“We need an urgent injection of money to meet rising demand in the short term and radical reform of the way adult social care is paid for and delivered in future, or things will get much worse.”

Both the LGA and the Society of Local Authority Chief Executives have warned that the planned cuts will get in the way of implementing the Dilnot proposals and the measures in the Care Bill. They also say that the Government’s impact assessment for the Bill significantly underestimated the likely cost to councils of the new duties under the Bill—an issue that came up repeatedly on the Joint Committee considering the draft Bill. I hope that as the Care Bill makes it way through Parliament—and certainly by the time it reaches the Commons—issues to do with the cost on local authorities will be dealt with.

Some £1 billion of funds from NHS budgets was earmarked for transfer to councils responsible for adult social services in the 2010 comprehensive spending review. However, three years into a four-year process, much of the funding continues to be spent in a short-term way—there was much focus in our report on that fact—and not on the systemic transformation that social care needs if it is to ensure sustainable services in future. Let me give an example. Of the £648 million transferred in 2011-12, 18% was used just to maintain eligibility criteria, with £284 million spent on offsetting pressures and cuts to services and another £149 million allocated to working budgets. As we have heard, that is not the sort of systemic transformation that the Health Committee would like to start seeing.

Of course, this firefighting is not surprising given the cuts to local council budgets, which I have touched on, but it is not sustainable if our aim overall is the transformation necessary to achieve the integration of health and care services. We have seen a downward spiral in social care funding. It is clear that more must be done to move from using scarce resources when they are allocated as a sticking plaster to cover the costs. They should instead be used to build more joined-up services. With another £2 billion a year moving from the health budget to social care from 2015, it is extremely important that we start to get this right. I fully support the call made in the Committee’s report for a ring fence to protect social care funding. That is important.

As for health spending, the Department of Health says that it managed to save £5.8 billion in 2011-12, but evidence provided to our Committee by the National Audit Office shows that much of that was made through one-off savings, such as pay restraint and other staff cost savings, reducing payments to NHS providers and some savings that were truly one-off, such as land sales, which cannot be repeated. Those savings are not sustainable and cannot continue in the long term. There is an argument, which we keep coming back to, that a lead needs to be taken as soon as possible to transform how services are delivered.

I welcome the suggestion of a pooled budget for health and social care services to help older and disabled people. I see that as a move in the right direction. Indeed, the shadow Health Secretary, my right hon. Friend the Member for Leigh (Andy Burnham), has repeatedly made the point that integration is the future direction of health and social care. Mike Farrar, the chief executive of the NHS Confederation—I guess this was the expression of an NHS view—said of pooled budgets:

“This allocation should help address the need to join up services and provide the right care for people, allowing them to stay in their own homes. But NHS organisations will want to have strong assurances that the money going to social care does the job it is meant to do.

Rather than see local health and social care budgets as separate, we need to support integrated care by bringing together providers and commissioners to look at how we can spend our money to the best effect.”

That must be what we start to see.

Creating joint budgets has the potential to facilitate a move towards more joined-up working, but as the right hon. Member for Charnwood outlined, there need to be safeguards. In fact, we need to be clear that the money intended for social care should definitely be spent on it. Labour’s whole-person care approach is a vision for a truly integrated service—not just battling disease and infirmity, but aspiring to give people a complete state of well-being across all the services, physical, mental and social. Shared budgets are one small step towards that, but we want to see a people-centred service, strengthening and extending the NHS in this century, not whittling it away.

Let me turn to the long-term funding of social care to avoid catastrophic costs falling on certain groups of people, particularly those with long-term conditions or dementia. Support will be given in such a way that people must meet thresholds and a spending cap. First, people must meet eligibility criteria, which, we know now, the Government plan to set at the “substantial” level. Secondly, they must fall below a means-tested threshold. I understand that the upper level is to be set at £100,000, but the lower level is still set at £14,250, with an assumption that assets between those thresholds attract interest, which affects the calculation of social care funding.

After all that there is the cap, set at the—in my view—high level of £72,000, plus accommodation costs of £12,000 a year. I feel that the £72,000 that individuals must contribute to their care before they exceed the cap is not as it seems. That is how the figure is expressed, but the metering will take account only of the costs that the council would pay for care. Many thousands of families are already paying a top-up for care. Cuts to council budgets, which I touched on earlier, will continue to depress the rate at which they pay towards providers, yet that is the rate that would be taken into account in the calculation of the metering.

My hon. Friend the Member for Leicester West (Liz Kendall) has analysed the plans and said that

“families will face losing even more of their homes than they do now”.

Since she pointed that out, we have learned that in 2016, with accommodation costs of £12,000 a year and councils at that point paying about £500 a week, it would take about five years to reach the care cap. Even at that point, we now know that care needs would have to be at the “substantial” level. Families using nursing homes charging more than the local authority rate will therefore have to pay the extra cost, as they do now.

I have had constituents paying £40,000, plus interest, for care costs, which were taken out of the value of their home, which was eventually sold for only £60,000. There are people in my local authority area who have homes valued at only the £50,000, £60,000 or £70,000 mark who surely will look at the cap set by the Government and think that it would help them. It is unfair not to tell people that what they think is a cap set at £72,000 will, for many of them, turn out to be much higher.

The Health Committee has committed to look at the implications of the Government setting the cap at a level higher than that recommended by the Dilnot commission. I hope that the review shows that this is not a policy to brag about straightforwardly, as the Prime Minister did today. I understand that the number of people likely to be helped by a cap set at that level is around 110,000. I am sure that many people would be surprised by that low figure. However, I am pleased that the direction of travel for Government policy is towards what the Health Committee has repeatedly set out in its reports on social care and the whole-person approach set out by my right hon. Friend the Member for Leigh. Pooled or joint budgets are a small step on the way. I hope that Government policy will start to move further towards addressing some of the other vital issues in social care that I have outlined. Unless we solve those issues in social care, we cannot move forward on the whole picture.

--- Later in debate ---

[Andrew Gwynne (Denton and Reddish) (Lab)]

May I begin by thanking the Health Committee and its Chairman for the report and the clarity with which he presented its findings, and Members from all parties for the thoughtful way in which they have debated the issues today? The right hon. Member for Charnwood (Mr Dorrell) is known for his diligence and attention to detail, and his speech clearly illustrated those instincts.

Before I address the points raised by the report, let me put on record our gratitude to the many thousands who work in our health service. As we approach the 65th anniversary of the NHS, we should take a moment to pay tribute to those staff who are doing a tremendous job, often in difficult and challenging circumstances.

With the indulgence of the House, I would also like to place firmly on the record my support for and appreciation of the dedicated doctors, consultants, nurses, carers and support staff in Tameside general hospital, many of whom will be feeling battered and bruised today. Tameside general hospital serves most of my constituency and today’s media reports highlight some of its failings. Deep-seated issues need to be grappled with urgently, but we should also recognise and listen to the many decent, good and hard-working staff who work there, because they often have many of the solutions and have not been listened to in the past.

I also apologise for leaving the Chamber briefly during the speech of my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley). There was no discourtesy intended to either her or the House: I was dealing with the BBC’s breaking news that both the chief executive and the medical director of Tameside general hospital have resigned, which I support. Sadly, it has come three years too late—I called for it to happen three years ago—but, nevertheless, it is a step in the right direction to ensure that Tameside general hospital has a safe and secure future.

[Barbara Keeley]

We heard from the hon. Member for Southport (John Pugh) about the value of executive leadership. Our conurbation of Greater Manchester has one of the best and safest hospitals in the country. The Salford Royal hospital is the seventh safest in the country and has an excellent chief executive. Today the leadership of Tameside hospital has changed and I hope that the people of Tameside will end up with an excellently led hospital. I agree with the hon. Member for Southport. My example shows the difference between a hospital that is well led and one that is not.

[Andrew Gwynne]

I agree with my hon. Friend. Had she been listening to BBC Radio Manchester this morning, she would have heard me making precisely that point. The situation at Tameside is incredibly frustrating for me and my hon. Friends the Members for Stalybridge and Hyde (Jonathan Reynolds) and for Ashton-under-Lyne (David Heyes). Whenever we meet the chief executive and chair of Tameside hospital—we do so frequently—they always give us excuses as to why Tameside is different from the rest of Greater Manchester because of the industrial legacy and poor health outcomes in the borough, but one could make exactly the same arguments for Salford: there is no reason why one part of Greater Manchester should have an excellent hospital while another has one with long-term problems.

Following that slight indulgence, I want to turn to the report and focus on four key areas. First, the right hon. Member for Charnwood made some pertinent points about the Nicholson challenge. To be fair, in previous reports the Health Committee has taken the consistent view that the Nicholson challenge can be achieved only by making fundamental changes to the way in which care is delivered. It makes that argument in this report too. It states:

“Too often…the measures used to respond to the Nicholson Challenge represent short-term fixes rather than long-term service transformation.”

The Select Committee is right about that.

If we are to sustain the breadth and quality of health and care services, we need a fully integrated approach to commissioning—something that the right hon. Member for Charnwood and others have spoken about powerfully. The Opposition agree with that. I hope that the right hon. Gentleman will agree that we have put forward bold proposals for a genuinely integrated NHS and social care system that brings physical health, mental health and social care into a single service to meet all our care needs.

We know that that approach works. In Torbay, integrated health and care teams have virtually eliminated delayed discharges. Partnerships for older people have helped older people to stay living independently in their own homes and have delayed the need for hospital care—something that my hon. Friend the Member for Birmingham, Selly Oak (Steve McCabe) rightly referred to. Where physical and mental health professionals have worked closely together, they have shown that a real difference can be made.

An integrated, whole-person approach is the best way to deliver better health and care in an era when money remains tight. As the Committee’s report notes,

“the care system should treat people not conditions.”

The right hon. Member for Charnwood was right to point out that developing the role of health and wellbeing boards is the best way to plan such integrated care. He reaffirmed that he is “happy to endorse” the Burnham plan. We were happy to hear that. He is right that there is an issue with single commissioning budgets without checks on local government. As somebody who has a background in local government, I think that he is right about the need to extend the ring fence to social care spending. Unless those budgets are protected, there will be a temptation to siphon off the money that is needed to provide the integration that we all want to see.