Health and Social Care

Baroness Keeley Excerpts

Monday 27th February 2017 Commons Chamber

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

I thank the Chairs, members and staff of both the Health Committee and the Public Accounts Committee for their work on the reports under discussion. I also thank the two Chairs for their excellent opening speeches.

The Health Committee noted a tight financial situation for health and the fact that deficits were growing and widespread. The King’s Fund and the Nuffield Trust reported in November 2016 that there was a net deficit of £2.5 billion for NHS trusts in 2015-16. Furthermore, they said that the 1.3% funding increase for the NHS in 2017-18 would largely be absorbed by deficits. We have heard many useful contributions on the issues with trust deficits. NHS funding increases will be 0% in 2018-19 and 0.3% in 2019-20. Those are seen as “inadequate” and not enough

“to maintain standards of care, meet rising demand from patients and deliver the transformation in services outlined in the NHS five year forward view.”

I take the point made by the hon. Member for Central Ayrshire (Dr Whitford) that we are now halfway through the five year forward view, so in fact we have only a two and a half year forward view. If the opinion is now that the view is inadequate, we have got some issues.

On social care, the Health Committee has said that increasing numbers of people with genuine social care needs are no longer receiving the care they need because of a lack of resource, and we have had very many contributions about that. The Chair of the Health Committee, the hon. Member for Totnes (Dr Wollaston), talked about increases in demand for social care. The King’s Fund and the Nuffield Trust have said that six years of “unprecedented” budget reductions have led to a 26% fall in the number of people aged over 65 accessing publicly funded social care, which is

“imposing significant human and financial costs on older people, their families and carers and”—

as we know—

“exacerbating pressures on the NHS.”

They also estimate that the publicly funded social care system faces the prospect of a £1.9 billion funding gap next year, and one of at least £2.3 billion by 2020.

As we have heard in this debate—it has rightly focused on this—the cuts mean that 400,000 fewer older people now receive publicly funded care packages than in 2010. An Age UK report shows that nearly 1.2 million people do not now receive the care and support they need with essential daily living activities. It is worth breaking that down further: nearly 700,000 older people do not receive enough help for their daily care needs; and 500,000 people receive no help, not even from family and friends. Taking into account tasks such as shopping and taking medication—the hon. Member for Lewes (Maria Caulfield) mentioned the important factor that older people need to be reminded to take their medication—Age UK says that 1.5 million people are not getting the help they need day to day.

It is shocking that nearly one in eight of the entire older population now lives with some level of unmet need. Of course the impact on the NHS of the crisis in social care funding is important—I will come on to delayed discharges—but the real impact, which we must never forget, is on all those older and vulnerable people living without care. Cuts to social care budgets also hit the 6.5 million unpaid family carers and the 1.4 million people in the care workforce who provide care. The impacts on those groups are often overlooked. The hon. Member for South West Bedfordshire (Andrew Selous) talked about the terms and conditions for the care workforce, and he was right to raise that point, but cuts hit those 1.4 million people as well. There have been dreadful cuts in terms and conditions; providing care is an important job and that should not happen.

The Government responses to the social care funding issues in the Select Committee reports are inadequate. The responses talk about the social care precept and the additional funding in the better care fund, but most of that funding is proving to be a problem because it is back-loaded to 2019-20. The King’s Fund has described using the social care precept as an

“inadequate response that just passes the problem to local government”.

That is a key factor. There is also the question of whether the precept is adequate or otherwise. The precept raised £382 million in 2016-17, and it will raise £543 million in 2017-18. In both cases, that is less than the cost of the national living wage to be paid by care providers.

Sadly, this Government’s inadequate funding of social care was made worse by measures in the local government finance settlement. Having passed the problem of extra funding for social care on to the council tax payer, Ministers went on to make the problem worse by announcing the creation of the £240 million adult social care grant, with funding recycled from the new homes bonus. One third of councils providing social care will be worse off next year as a result of this inept settlement. My own local authority, Salford, will have £2.3 million less in its budgets for social care, and Tower Hamlets Council is set to lose £3.3 million. Where does the Minister think we, with such notice, can find £2.3 million in one local authority budget? Sadly, the answer will be rationing, which is not where we should be.

The Public Accounts Committee has published a report on discharging older people from acute hospitals, but the situation has got worse since the Committee’s report was published. In 2016, a record number of hospital bed days was lost as a result of problems with social care. The number of days lost has increased by over 400,000 in the past year. Over a third of those days were lost as a result of social care problems, and we must take into account the fact that the proportion attributable to social care problems has been increasing. Given the funding cuts, we should not of course by surprised by that. My hon. Friend the Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, said:

“Delayed discharge is damaging the health of patients and that of the public purse.”

Unnecessarily long stays in hospital can affect patient morale and mobility, as well as increase their risk of catching hospital-acquired infections. In 2014, Professor John Young said of the mobility effects of long hospital stays:

“A wait of…seven days is associated with a 10 per cent decline in muscle strength”,

which is clearly not desirable.

The funding crisis in social care is a theme in many of the reports we are debating. The Public Accounts Committee report on personal care budgets expresses concerns that

“funding cuts and wage pressures will make it hard”

for local authorities

“to fulfil their Care Act obligations”.

That is serious. The legislation was passed only in 2014, but councils now find it hard to fulfil their obligations. On underfunding, the Local Government Association said in its recent Budget submission:

“Without bolder action the Government will need to re-evaluate its offer to residents and consider whether the set of legal rights and responsibilities contained within the Care Act are appropriate and achievable.”

The Chair of the Communities and Local Government Committee mentioned that.

The Public Accounts Committee report on improving access to mental health services described the ambition to improve services as “laudable”, but, given the current pressures on the NHS budget, it said that it is

“sceptical about whether this is affordable, or achievable”.

The Committee rightly said that achieving parity of esteem between mental and physical health is a task

“for the whole of government”.

I trust that that includes the hon. Member for Mid Norfolk (George Freeman), who heads the No. 10 policy unit, and who said that disability benefits should go to “really disabled people” rather than those

“taking pills at home, who suffer from anxiety”.

I should say that that has been mentioned already today, and that I have informed the hon. Gentleman of my intention to mention it this evening. Comments such as those reinforce stigma about mental health rather than reduce it. They are profoundly disappointing coming from someone who was until recently a Health Minister. They show just how far hon. Members and the Government have to go on parity of esteem.

Underfunding of mental health services by commissioners has dominated many debates in the House. The Government have failed to deal with the problem that funds intended for mental health services have been used by the NHS for other priorities. In their response to the Committee’s report, the Government say they accept all the recommendations and have implemented them, but I question that. The Government response says that the mental health five year forward view dashboard published in October 2016 monitors key performance and outcomes data. In December, the Royal College of Psychiatrists released compiled figures on spending by CCGs on child and adolescent mental health services, which are vital and which we often discuss in debates in the House.

A number of hon. Members have mentioned the scale of variation that came out of the Royal College of Psychiatrists figures, because the range was from £2 per child per annum to £135 per child per annum, which is a disturbing variation. They have been told only that the CCGs were reporting the data on their spending differently. I say to the Minister that it hardly helps transparency for CCGs to report on their mental health spending differently.

I wrote to the Under-Secretary of State for Health, the hon. Member for Oxford West and Abingdon (Nicola Blackwood). From her response, I understand that further guidance has been issued to CCGs. I would be grateful if, in the Minister’s response, he told the House whether we can expect that the actual spend and planned spend on mental health services reported will be accurate and comparable. Hon. Members have mentioned in the debate their local CCGs decreasing spending on mental health. We hear that that is not the Government’s intention, but we cannot track what is happening if CCGs do not report accurately. We know that one in four young people who need mental health services are being turned away. The Government should therefore do all they can to ensure that young people can get that access. Extra funding prioritising mental health should be spent as intended and not spent on other NHS priorities.

In its report on NHS specialised services, the Public Accounts Committee said:

“Accountability, to both patients and taxpayers, is undermined by the lack of transparency over NHS England’s decision-making”.

The Committee recommended that NHS England should

“improve the transparency of its decision-making”.

I note that 30 charities from the Specialised Healthcare Alliance wrote to the Prime Minister recently to raise the issue of NHS England restricting and rationing treatment because of underfunding, especially for patients with rare and complex conditions. The charities say that this has taken place without sufficient public scrutiny. Lack of transparency in decision making is a serious issue and I ask the Minister to address it in his response.

There are many issues raised in the Committee reports relating to funding for the NHS and social care. Media reports say that the Chancellor is considering a short-term, ring-fenced cash injection for social care worth hundreds of millions of pounds for councils, but I hope the Minister will convey to the Chancellor that adult social services directors say they need an immediate injection of £1 billion for social care to prevent the weakening and collapse of some parts of the sector. As I have said, the funding gap in social care will be between £1.9 billion to £2.3 billion by 2020. I hope the Government are not going to try a quick fix in the Budget that is too little. The hundreds of thousands of vulnerable people who need social care certainly deserve better.

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

The hon. Member for Central Ayrshire (Dr Whitford), who speaks for the Scottish National party, described this as a great debate. I agree that it has been a very good debate. Members on both sides of the House have spoken with a great deal of passion and, in general, with a great deal of knowledge. A number of clinicians, as well as three Select Committee Chairs, have spoken. I join the shadow Minister in thanking the Select Committees for the reports we are discussing today. An awful lot of comments have been made by Members and I will do my best to respond to the majority of them.

The Government accept that these are challenging times for both the NHS and social care. My hon. Friend the Member for Totnes (Dr Wollaston), the Health Committee Chair, talked about this at length. The demographics—both the number of people and their age—are uncompromising. I was at a Health Check conference recently and one of the speakers described the process we have been through. We have been very successful at elongating quantity of life. Until now, however, quality of life has not kept up. Increasingly, older people are living with multiple long-term conditions. Having one long-term condition is becoming unusual, whether it is diabetes, chronic obstructive pulmonary disease or heart disease. This is a fact we all have to face. One reason why we are so keen for the STPs to address this issue is that 70% of total expenditure on the NHS is spent on long-term conditions. Frankly, if we were starting with a blank piece of paper, we would not start with the NHS we have now. Instead, it would be organised around those long-term conditions, meaning more work in the community and all that goes with that. I will come on to talk about the STP process and how we are trying to achieve that.

We know, therefore, that there is an issue with demography. I think it was a Public Accounts Committee report that said that, in 1948, 50% of people lived to be over the age of 65. In 2017, only 14% die before they are 65. That is a massive demographic change and we all need to step up to the mark to meet it. We will try to do that. Drugs and treatment are becoming more expensive. They can do a lot more, but we have all heard the discussions around the cancer drugs fund. The third driver is that patients’ expectations are, rightly, higher than they were decades ago.

The Government response in the spending review was a front-loaded £10 billion injection into the NHS budget, representing an 8% or 9% increase, depending on how it is counted. I agree with the hon. Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, that we should not bicker about these amounts. We can argue about whether it is enough, but the facts are that this is a real increase over the course of this Parliament. There is a discussion to be had on whether that real increase is enough—I accept that. What I do not accept is what we have heard about cuts from some of those on the Opposition Benches. There is a valid discussion to be had about whether an 8% or 9% real-terms increase is enough—I gently remind the Opposition that at the last election they said they would not be in a position to fund more than that—but it is not right to talk about it in the context of cuts, as some Opposition Members have done.

[Barbara Keeley]

We get into this repeatedly. The Opposition have no plans to cut £5 billion from social care or to cut the budgets of local councils. That is the difference between us and the Government. Given that we have talked mainly about social care and cuts to social care, the Minister ought to take that into account.

[David Mowat]

I will come on to social care. We have covered the NHS, which this Parliament will get a real-terms increase of 8% or 9%. Let us accept that and move on. On social care, a 5% or 6% real-terms increase has already been made available—that is not the Budget; I do not know what is in the Budget. Again, we can argue about whether that is enough, given the demographics, but we cannot argue whether it is true.

I want to spend a little time on the international comparisons, about which we heard some discussion earlier. According to the OECD, in 2014 this country spent 9.9% of its GDP on health. The OECD average is 9%, so that is 1% more, but it is true that the OECD average includes countries such as Mexico with which we would not necessarily wish to compare ourselves. The average for the EU15, which by and large does not include the newer states in the east, is 9.8%. So in 2014 we spent more than the EU average. It is true that we spend less than some of our comparator countries—we spend less than France and Germany—but it is completely wrong to say that there is a massive gap between us and the EU.

--- Later in debate ---

[David Mowat]

There are assumptions in that—to do with our GDP growth, their GDP growth and everything else—so it is a difficult question to answer. I would just refer again to the latest OECD figures, for 2014. Those figures are accurate. There is a valid debate to be had about whether they are enough, given the demographics and all the rest of it—that is fair—but it is not fair to imply that there is a massive disparity between us and our EU neighbours.

[Barbara Keeley]

rose—

[David Mowat]

I have given way to the hon. Lady once already, and I need to make some progress.

--- Later in debate ---

[David Mowat]

He is right about that. NHS England is evaluating the STPs at the moment and during March and April, and it will decide which STPs are high priority, which will be invested in and which will be taken forward at speed. We heard the phrase “accountable care organisations” used earlier, and it is the Government’s intention to ensure that those high-performing STPs that we proceed with—it will not be all of them; frankly, the standards are variable and locally driven—will in time become accountable care organisations.

The shadow Minister asked me to talk about social care, and I will do so. During the present Parliament, accessible funding for social care has risen by 6% in real terms; it fell during the last Parliament. Last year 42% of councils increased their social care budgets in real terms, and in December £900 million was provided in new homes bonus payments.

[Barbara Keeley]

Will the Minister give way?

[David Mowat]

No, I will not.

[Barbara Keeley]

rose—

[Mr Speaker]

Order. The Minister is not giving way at the moment.