Queen’s Speech

Baroness Greengross Excerpts

Tuesday 22nd October 2019 Lords Chamber

[Baroness Greengross (CB)]

My Lords, in my brief speaking time, I will focus on three important issues: first, the Government’s proposals to reform adult social care; secondly, the NHS long-term plan, prioritising prevention in an ageing world; and, thirdly, the Domestic Abuse Bill.

While I welcome the additional funding that the Government have announced for social care, what legislation can this House expect to scrutinise in this Session—or, perhaps I should say, the next Session of Parliament? Over the past 25 years, we have seen a lot of policy reports on how to reform adult social care but little substantive action. The problem has not gone away and will not do so until it is solved, which is why I hesitate to recommend another report to the Minister. She will no doubt be aware that, in July this year, the Intergenerational Fairness Forum, which I chair, published a cross-party report, Sustainable Funding for Social Care & Intergenerational Fairness. It put forward a range of recommendations seeking to build consensus through the prism of intergenerational fairness. In brief, the report recommended a Dilnot-style funding system built on a national pooling of risk, with a means-tested threshold for personal contributions and a cap on overall care costs. This would be partly paid for by a 1% social care insurance contribution for those aged over 40 until they retire and the replacement of higher-rate pension tax relief with a new, flat-rate relief below 40%, along with other tax and benefit changes to meet the existing, unmet demands for care. I hope that the Minister will consider these suggestions.

On the NHS long-term plan and prevention, I welcome the commitment to strengthen our NHS by addressing workforce shortages and improving service delivery, building on the set of recommendations published by the NHS last month. According to projections by the Nuffield Trust released this year, there is a current shortage of one in 12 NHS staff. Strengthening the NHS is especially important in the context of an ageing society, as recognised by the Government’s healthy ageing challenge. We know that there are currently 10 million people aged 65 and above living in the UK; that number is expected almost to double, to 19 million, by 2050. This means that we will see greater strain on health services still, and a growing number of limiting co-morbidities that require more costly and complicated secondary and tertiary care services. To ensure the future sustainability of our NHS, and to support people to lead longer, healthier and more productive lives, the prevention of ill health is crucial.

Therefore, I welcome the fact that,

“The Long Term Plan sets out how Government will improve the prevention, detection, treatment and recovery from major diseases, including cancer, heart attacks and strokes”.


However, the ambition should go further and be global, which is why the International Longevity Centre UK has launched an international programme of work, entitled “Prevention in an ageing world”. It is estimated that, in 2017 alone, 27.1 million years were lived with disability due to largely preventable diseases; that number is projected to increase by 17% in the next 25 years if we do not prioritise the prevention of ill health right across the life course. It was therefore welcome that the G20 leaders’ summit in Osaka this summer—and the G20 Health Ministers only last week—pledged to promote prevention across the life course. I hope that the Minister can help ensure that the UK positions itself as a world leader in the prevention of disease.

On the Domestic Abuse Bill, I am largely pleased that the legislation has now been carried over from the last Session, and I look forward to this House’s scrutiny of the Bill when it reaches us. However, I am concerned that the Government did not accept the recommendations of the Joint Committee, which considered the draft Bill, regarding the definitions of the “same household” criterion and “personally connected”. We may also wish to clarify further how abuse by carers is covered by the Bill, because domestic abuse is more than just abuse by a spouse. Depending on what amendments the other place makes to the Bill, I suggest to the Minister that we may wish to amend the Bill particularly in this respect.

Adult Social Care

Baroness Greengross Excerpts

Thursday 25th July 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

The right reverend Prelate has pointed out something very important: a significant portion of those accessing adult social services are actually those of working age and those with learning disabilities. It is very important that does not get lost in the debate. Anything that comes forward as part of the social care solution must address the concerns of that part of the community in a much more effective and joined-up way. Integration of social care and NHS budgets, and effective delivery, will be core to that delivery.

[Baroness Greengross (CB)]

My Lords, last week, with the Salvation Army the charity the International Longevity Centre UK, which I head, published a report on the funding gap in social care, in particular for older people living in rural areas. The report summarised it very well by saying that there is not just one crisis but lots of crises and that local leadership alone cannot overturn the inequalities. As co-chair of the All-Party Group on Adult Social Care, I hope that the Minister can assure me that Her Majesty’s refreshed Government will now prioritise this issue in the way I have suggested.

[Baroness Blackwood of North Oxford]

The noble Baroness phrased that very elegantly—I shall use the term “refreshed Government” myself. I will make the gentle point that the funding available for adult social care has increased by 8% in real terms from 2015-16 to 2019-20, which is a step in the right direction. However, there is a recognition that, to put it on a sustainable footing for the future, there needs to be a settlement in the upcoming spending review. That is recognised. On the point she made about rural areas, which is important, a lot of this hinges on workforce recruitment and retention, which can be more challenging in rural areas. That is why the Government have invested £3 million in the Every Day is Different national adult social care recruitment campaign, to encourage more people to apply to work in the social care sector and to raise its profile. This has had some success already, which is an encouraging picture. We need to work harder on that.

Antimicrobial Resistance

Baroness Greengross Excerpts

Thursday 2nd May 2019 Lords Chamber

[Baroness Greengross (CB)]

My Lords, first, I congratulate the noble Lord, Lord Lansley, on securing this very important debate. My interest in this issue is partly due to the work I do through the International Longevity Centre UK, which I established 20 years ago. It is one of 16 organisations across the world which looks at these sorts of issues. The ILC-UK, following the UN’s high-level meeting in 2016, held its Jack Watters memorial debate on the subject and produced a report on antimicrobial resistance in 2017. That report links to one of the ILC’s other key workstreams: the promotion of vaccines. I chaired a meeting on that vital issue in this House only last month.

This debate is very timely given that the Government published their new five-year plan in January of this year. There is now renewed vigour from the Government to tackle this issue. I hope that it will be tackled because, as noble Lords have said, this is a major, worldwide challenge and it needs to be taken very seriously. I cannot overemphasise that. The health of our whole population is at risk, but especially that of older people, who are more vulnerable to illness and disability than younger people. I was grateful to receive certain facts and figures from the British Society for Immunology, which points out:

“AMR could turn back the clock a century on medicine”.


It is of course alarming to read in the action plan that AMR might already cause 700,000 deaths every year worldwide and that this could rise to 10 million by 2050, which is partly why I welcome how seriously the Government are taking this issue. The UK has been a world leader, from David Cameron taking the issue so seriously back in 2013 to the review from the noble Lord, Lord O’Neill, in 2014 and the work of Dame Sally Davies, which we have mentioned, as well as useful scrutiny from both Houses of Parliament. Now at last we have the new action plan.

In my brief remarks I will focus on the action plan’s acknowledgement of the importance of vaccination’s preventative role and how we might better stimulate R&D into vaccines. While encouraging the development of new antibiotics is obviously sensible, as the noble Lord, Lord O’Neill, recommended, the ILC report agreed with his other recommendations to develop new vaccines and use existing ones more effectively as a way of reducing dependency on antibiotics.

The World Health Organization has calculated that, if coverage of existing vaccines was increased, millions of days of antibiotic use could be prevented. For example, if flu vaccination rates increased, antibiotic use would surely reduce as the incidence of flu fell, as well as from a decline in secondary infections caused by flu, such as ear or sinus infections. In the ILC’s Jack Watters debate, Professor David Salisbury argued that there was “no debate” about whether more should be done to increase the coverage of a wider range of vaccines across the life course. I very much agree with that. I note that the O’Neill review calculated that vaccine programmes save society 10 times their original cost.

The list of potential new vaccines that Professor Salisbury hoped to see developed in coming years ranged from Alzheimer’s to respiratory syncytial virus, as well as more obvious ones such as norovirus and TB. As the British Society for Immunology has pointed out, vaccines are the most preventative health tool in human history. Like me, it also wants to see significant investment in novel vaccine research, in particular into bacterial infections such as pneumonia and sepsis—I am a member of the All-Party Group on Sepsis.

This is why I hope the Minister can reassure me that the action plan will help to create the right environment to incentivise the science community on vaccine development, which historically has a poor commercial return on such investment. I was struck by what the Society for Immunology said in its briefing: that less than 5% of pharma venture capital investment over the past 10 years went into AMR. I hope that research on vaccine development is not held back by the focus on developing an AMR of “last resort”, the return of which is uncertain, and for recognition that a co-ordinated cross-government approach across all relevant sectors is urgently required if this is to be achieved.

Vaccine Hesitancy

Baroness Greengross Excerpts

Monday 1st April 2019 Lords Chamber

[Baroness Blackwood of North Oxford]

My noble friend is quite right that one of the things that was highlighted in the recent survey about public trust in vaccinations was that 93% of parents trust NHS staff and advice and that 93% of parents remain confident in the immunisation programme. So in order to cover that last percentage, we need to ensure that those parents have access to a GP programme. I therefore encourage parents to speak to their GP or a health professional about vaccinations and to look to credible sources, such as NHS Choices, for their information. I will certainly consider the point raised by my noble friend.

[Baroness Greengross (CB)]

My Lords, by coincidence, tomorrow here in this House I am hosting an event about vaccine policy, specifically about how we improve vaccine coverage in this country because, in spite of what the Minister said, there is room for improvement. Some of us are really quite worried about the decline in some communities and in some parts of the country. Does the Minister agree that much better use of social media is extremely important and necessary if we are to get the positive message about vaccine out there to counter the negative scare stories which do so much harm? Does she agree that more should be made of the intergenerational message? Older people—I refer not simply to Members of this House but to the older population—often have memories of the terrible impact of infectious diseases, whether we are taking about yellow fever, polio or measles. They can tell those who are still young all about them. Surely this will reinforce the importance of the vaccination programme.

[Baroness Blackwood of North Oxford]

The noble Baroness raises a very important point which is that while social media can be used to spread disinformation or misinformation, it can also be used in a positive way to spread the positive value of vaccinations. That is why we want to work with those who have doubts about vaccination to highlight the benefits of vaccinations, the protection that they bring from the very serious diseases which she highlighted and how safe they are. A wealth of information is available online through trusted NHS channels which will enable parents to make well-informed decisions about getting their children vaccinated. I encourage the noble Baroness to highlight in her event next week some of the channels which are available and which we will continue to push.

Domestic Abuse: General Practitioner Charges

Baroness Greengross Excerpts

Thursday 15th November 2018 Lords Chamber

[Lord O'Shaughnessy]

I can reassure the noble Baroness that we will celebrate that day. I think this Prime Minister has done more than any to clamp down on domestic violence and to support victims. That was shown in the £100 million that was set aside to support victims of domestic violence in a number of innovative ways. I can further reassure her that, as I understand it, the number of beds in refuges has increased over the past few years.

[Baroness Greengross (CB)]

My Lords, it was good to hear the recent government announcement that they would ask the Law Commission to consider whether offences against older victims should be recognised as hate crimes, and of course the charges in this respect are important. The Times has recently shown that crimes against the over-65s increased between 2013 and 2017 by 31%; and violent and sexual crimes against them increased by a similar amount. I agree with Action on Elder Abuse that the figures are symptomatic of a failure to recognise the signs of this kind of abuse. What action are the Government taking as the Law Commission considers hate crime as a potential offence? Can the Minister give an idea of the timescale in which he expects it to come to a conclusion on this matter?

[Lord O’Shaughnessy]

I join the noble Baroness in condemning this type of crime, and it is disturbing that violence against older victims has risen. That is precisely the reason the Government have asked the Law Commission to look at the issue and bring forward suggestions on how to give the authorities greater powers to clamp down on those who perpetrate such crimes.

Mental Capacity (Amendment) Bill [HL]

Baroness Greengross Excerpts

2nd reading (Hansard): House of Lords
Monday 16th July 2018 Lords Chamber

[Baroness Greengross (CB)]

My Lords, it has been a real privilege to hear the noble Baroness, Lady Barran, give her maiden speech. I enjoyed listening to her, and I think that we will all benefit enormously from her experience and her commitment to vulnerable people. I share that passion, so I hope we can do a lot of work together. She brings such a lot of important experience to this House. She has worked for many years to make a difference to the lives of a huge number of vulnerable people. I share her passion to eliminate domestic abuse and other forms of abuse and I hope that we can do some work together in future. I have worked in the field, particularly among abused older people, and the noble Baroness has done a lot of work among people of all ages. I have heard that she has four children and I have four children. I wonder whether there is a connection that brings our interests together because we know what bringing up a large family means. I wish her every success. I am sure that she will enjoy being in the House. I—like, I think, everybody listening to her today—look forward to working closely with her and gaining from her very valuable experience and commitment to people who are vulnerable and who need help and advice from her and from all of us.

I welcome the Bill, which has many positive features. It includes a lot more person-centred care planning, it attempts to reduce bureaucracy and it provides clarity around responsibilities for those closest to the delivery of day-to-day care. I acknowledge that there are omissions. Noble Lords who have spoken have pointed them out. We will concentrate on them as the Bill goes through our House.

Recognition that the system in its current form is overly technical and legalistic is long overdue. Indeed, in her letter to the All-Party Group on Dementia, which I co-chair, the Minister, Caroline Dinenage MP, remarked that the current system places too heavy a burden on people and their families and too often fails to achieve the positive outcomes that underpin the purpose of the process. I agree, and our committee will do all we can to help her make the Bill work and improve its outcomes, and I look forward to working with the Minister in your Lordships’ House to make that happen.

In 2013 our Select Committee on the Mental Capacity Act 2005 found that its provisions were inadequate and left those deprived of liberty without adequate protection. The committee felt that the provisions were poorly drafted, overly complex and bore no relation to the language and ethos of the Mental Capacity Act. The safeguards are not well understood and are poorly implemented. With this legislation, the appropriate delicate balance has to be struck between the protection and empowerment of individuals, who may lack the mental capacity to make their own decisions about their care and treatment, and the duty of care to staff, other patients and the public at large that the state has to protect them from the behaviour of people who may not be fully responsible for their actions.

I am not fully certain that in the Bill, despite the Government’s best efforts, we have got the balance entirely correct. Noble Lords will be aware that I am committed to promoting human rights for vulnerable people, so I welcome anything that seeks to drive up standards and accountability in the social care sector. I have been contacted by a social worker and co-ordinator from south Wales who is concerned that the new scheme, with its significant increase in legally prescribed duties for social workers, has not been fully discussed with leaders in the care provider sector. Indeed, he feels that many care home staff are scarcely aware of it and will be very concerned about these changes as they may not be well informed enough to make the crucial decisions that will be needed. He feels that the lessons of the patchy implementation of the Mental Capacity Act to date have not been properly studied and that it may be that all we do is simply transfer the burden, backlog and chaos from statutory bodies to unprepared care homes. Could the Minister reassure us that, in his view, there has been appropriate consultation within the care sector?

I also share the reservations expressed by the charity VoiceAbility about the lack of weight given by the Act to the wishes, feelings and views of the cared-for person or their family and carers, with concerns about how compliant with Article 5 of the European Convention on Human Rights the new scheme is. Under the Bill, the right to refuse a deprivation of liberty safeguard by a lasting power of attorney or a deputy has been removed, so we have concerns that the rights and safeguards for the cared-for person might be diminished by the Bill.

It is good news that £200 million a year will be saved by local authorities. However, we have to suppose that the increased role of NHS and independent sector providers will lead to increased costs elsewhere, while the new responsibilities being imposed on care homes, hospitals and CCGs will need some thought, resources and training. For example, the Royal College of Speech and Language Therapists argues that assessors often do not recognise or know how to support communication difficulties. One can envisage that this could be a real problem if English is not the first language of the patient or their family.

As a vice-chair of the Local Government Association, I share its assessment that the transition to the new framework and its future framework implementation should receive additional resources to reflect the additional costs that may be associated with the change. I also share the view of ADASS that a period of transition is likely to be needed to enable hearth and care staff to adapt to the new system. I hope that the Minister will be able to reassure us on these points, that an appropriate cost-benefit analysis of the changes will be in place and that the training and integration aspects have also been fully thought through and costed.

I have one or two other reservations. I do not think it unreasonable to ask the Minister to explain why, when the Bill so closely follows the recent proposals from the Law Commission, it differs from them in several significant respects. For example, the regime applies only to those who are 18 and over although the Law Commission argued that LPSs should apply to 16 and 17 year-olds because it feels that the current regime is inadequate and is failing to protect the rights of some young people. The Government said they accepted this recommendation in principle but would,

“need to consider in more detail this recommendation’s practical application and implementation”.

Turning to older people, I welcome the inclusion of a new special procedure for care homes within the scheme, which gives them greater responsibility for arranging the assessments of people who may lack capacity from dementia. As much as I welcome this change, I share Age UK’s concern that provision must be made to ensure that care home managers have the training and resources to be able to clear the significant backlog of assessments under the Bill’s provisions.

In my view, the Bill should set out a specific route for authorisations within a person’s home. Can the Minister assist the House by explaining how he sees at-home assessments working? I note that the new system retains the distinction that, where an individual who could be detained under the Mental Health Act objects to being detained, they cannot be made subject to an authorisation under new Schedule AA1. I also share the concern of the Alzheimer’s Society that the current interface between the Mental Health Act and the DoLS process for authorising deprivation of liberty within the Mental Capacity Act is a key issue for people living with dementia.

Lastly, the Bill makes provision for the introduction of approved mental capacity professionals, who must carry out the pre-authorisation review and determine whether the authorisation conditions are met. This role replaces the best interest assessors’ role under the Mental Capacity Act. However, the Bill and the Explanatory Notes do not detail which professionals could act in this new role and how they interact with other clinicians. I know that the General Medical Council sees potential for conflict between its regulatory standards and the proposed legal requirements. It has called for more clarity about doctors’ roles and responsibilities in such a challenging area. Perhaps the Minister could explain a little more about how and when the Government plan to firm up the status and context of this important role.

In closing, we must find a way to define deprivation of liberty more clearly. The JCHR’s view is that this is needed to clarify the application of the Supreme Court’s acid test, which sets out questions that must be considered when determining whether an adult who has been assessed as lacking the capacity to consent is being deprived of their liberty. Without a clear definition, there is a risk that the Bill will be unworkable, particularly in domestic settings. The development of the LPS must also be considered in the wider context of other issues within the health and social care system, such as the upcoming Green Paper on care and support reform and the independent review of the Mental Health Act.

The Government need to act speedily to ensure that the rights of this group of very vulnerable people are clarified and that their needs are met quickly. They are not in a position to wait any longer.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Greengross Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Greengross (CB)]

My Lords, I welcome the Government’s commitment in their response to the committee’s valuable report to making sure that the NHS meets the needs of everyone, no matter who they are or where they live. I shall look mainly at the needs of older people, but also at the fact that intergenerational fairness is becoming more important and we must consider that.

I share the view of the British Geriatric Society. It is not as confident that the Government’s response represents a genuinely strategic approach to ensuring sustainability. I am concerned that the range of positive initiatives either under way or being planned are less joined up and integrated than they could be. I endorse the British Geriatric Society’s call for a new strategy for people living with frailty, dementia, complex needs and multiple long-term conditions, ensuring access to comprehensive assessment, personalised care plans for treatment and long-term follow-up for all older people with frailty, dementia and complex multiple long-term conditions.

Sadly, disability-free life expectancy is rising more slowly than life expectancy itself. Most people aged 75 and over have one or more health conditions and one in four people aged 85 and over is frail. Significant changes are needed in the workforce, flexibility in the place of care, and a more strategic and integrated approach for people living with those conditions. If we do not do that, the long-term sustainability of the NHS will not be achieved.

I agree with Care England that a well-funded, sustainable social care system underpins a sustainable NHS. Delayed discharges are a good example of this. Older people are unable to be safely discharged because adequate social care plans are not in place. This is even more important than it used to be and it must be properly addressed.

I am indebted to Age UK’s report Why Call it Care, When Nobody Cares?, which looks at some key questions which remain to be resolved. For example, when the Green Paper is published, how will it ensure that older people in care are consulted, especially about their unmet care needs? In the interim, will the Government consider additional funding to support the system until the outcomes of the Green Paper can be implemented?

We know about the ignorance of the whole system. Many people are shocked by the cost of social care. There are huge misconceptions about how it is funded and how to access support and deal with the complexity of the system. Earlier this week, Sir Andrew Dilnot spoke at a parliamentary forum that I chair on intergenerational fairness. He reminded us that the increasing number of older people is not at all a surprise. Of the £150 billion spent on older people per year, only £7 billion is on social care. His proposed care cost cap, which would have ensured that people did not face catastrophic care costs, would have cost £2 billion, the same as the cost of the winter fuel allowance. It needs to be reconsidered.

We know that the main difficulty facing this and previous Governments is how to pay for all these things. On fairness grounds, the cost must be spread across all age cohorts, but especially this must now include older people themselves. It could be through an increase in national insurance, whereby older people would no longer be exempt from national insurance payments if they worked beyond retirement age. This would be fair: everybody in paid employment pays national insurance and you do not pay it if you are not in employment.

We know that self-funders of social care are subsidising people who are funded by local authorities. This is a hidden tax which is unfair. The extra funding that the Government have made available to adult social care to date is welcome, but the LGA, of which I am a vice-president, tells me that adult social care faces a funding gap of £2.2 billion by 2020. This must be addressed as an urgent priority. It should ensure that local partnerships with the NHS recognise the vital contribution of adult social care, public health and other key council functions, as well as suitable housing, to achieving improved health outcomes and sustainable services.

Good local public services are the bedrock of good mental and physical health, well-being and resilience. Despite the potential benefits of public health services, we know that local authorities face a £331 million reduction to their public health budget, on top of a £200 million reduction announced in 2015. Almost every service provided by councils has an impact on public health. Reducing health inequalities makes sense at a pragmatic as well as at a moral level, because it can prevent people becoming and remaining ill and reduce the associated costs to local government, the NHS and the rest of government.

Recent research modelling from the International Longevity Centre-UK, of which I am chief executive, explained that, between 2000 and 2015 across the OECD, even after controlling for other factors, health spending positively correlated with life expectancy. Therefore it is safe to assume that the increases in life expectancy seen in the UK in the past 40 years are similarly due to increased health spending. Indeed, between 1971 and 2012, average health spending per person increased by 3.7%, while GDP per person increased by just under 2%. Health spending is also increasing in terms of the total proportion of public spending, increasing its share of overall government expenditure by more than six percentage points over the same period

Last year, the ILC-UK published Towards Affordable Healthcare: Why Effective Innovation is Key, a report that concluded that while the UK is well placed to innovate to improve health outcomes and reduce costs, we are often not doing enough with the tools at our disposal. As it is impossible to control the rate of growth in the economy, or the rate of population ageing, policymakers must concentrate on the residual costs that can be accounted for by policies and institutions, relative prices and technological change.

The ILC-UK report identified that targeted investment to implement and upscale seven systems already in operation in the UK or abroad could save the NHS £18.5 billion between 2015 and 2030. But funding mechanisms within the health system can often discourage targeted investment in innovations and there continues to be a slow uptake in the UK of new drugs and treatment. Speaking of costs, the Select Committee report raised a fundamental question: is it not time to stop increasing spending ad infinitum?

We must also learn from other systems and take them on. No social insurance system is wanted here, but we can learn from such systems because, through them, people know the value of what they get and what they pay for. We can borrow from those systems and learn.

I mentioned those who work paying national insurance, and everyone who puts in an annual tax return of earnings should declare all benefits, including free travel locally, TV benefits, fuel benefits and so on. Perhaps if we pushed that up a notch it would be fair; it would not bring in a lot of money, but it would be brilliant PR for the Government who introduced it and would contribute to free services for all.

Our health system is one of our most-valued services. Let us protect it at all costs and do something about the uncrossable divide between health and social care. These are services for everyone in times of need. Let us value them accordingly.

Antimicrobial Resistance

Baroness Greengross Excerpts

Thursday 8th March 2018 Grand Committee

Asked by

[Baroness Greengross]

To ask Her Majesty’s Government what assessment they have made of the risks of antimicrobial resistance.

[Baroness Greengross (CB)]

My Lords, I declare an interest as the CEO of the International Longevity Centre-UK, which has done quite a lot of work on the issues that we are discussing. Antimicrobial resistance poses an unprecedented threat to human health. As bacteria become resistant to antibiotics, even minor infections have the potential to become serious and indeed fatal. The rise of drug-resistant infections is estimated to account for around 700,000 deaths per year worldwide, with 50,000 of those deaths occurring within Europe and the United States.

I am sure that noble Lords will be familiar with the review of the noble Lord, Lord O’Neill, on antimicrobial resistance, published in 2016, which projected that by 2050 global mortalities due to this could reach 10 million a year and cost the global economy £66 trillion in lost productivity. The Chief Medical Officer, Dame Sally Davies, has also shared her concerns that the recent era of material mortality improvement will give way to many years of material mortality worsening if drug-resistant infections continue to develop at current rates. Willis Towers Watson’s head of mortality and longevity has calculated that a “plausible” worst-case scenario for the development of antimicrobial resistance will,

“largely zeroise or even negate”,

the longevity improvements made since the mid-20th century.

Fortunately, there have been some developments in the global effort to reduce the spread of AMR. The Access to Medicine Foundation’s 2018 Antimicrobial Resistance Benchmark report found that nine life sciences companies are active in antimicrobial resistance surveillance programmes covering 147 countries between them. There are also currently 28 antibiotics for high-priority pathogens in late-stage development. However, in other areas there is cause for concern as progress seems to have stalled.

A freedom of information request issued to Public Health England in 2017 found that prescriptions of colistin, the last line of defence in antibiotic treatment, rose by 40% between 2014 and 2015, from 346,000 doses to 485,000. Antimicrobial resistance was common in the more than 1 million urinary tract infections caused by bacteria identified in NHS laboratories in 2016. Some progress was observed in reducing rates of prescribing in secondary care in 2015, but there has not been a sustained reduction in total antibiotic prescribing in this care setting. While antibiotic prescribing reduced by 5% overall between 2012 and 2016, when measured as defined daily doses per 1,000 inhabitants per day, significant regional variation in antibiotic use continues to occur.

Unfortunately, there is also significant regional variation in the uptake of a crucial means of preventing the spread of antimicrobial resistance—I am talking about vaccination. The review by the noble Lord, Lord O’Neill, noted that vaccine programmes can reduce antibiotic consumption by preventing secondary infections and that, in addition, they often save society more than 10 times their original cost by protecting against vaccine-preventable diseases.

A study conducted jointly by the Department of Health and Social Care, the Norwegian Institute of Public Health and the South African directorate of health estimated that universal coverage with pneumococcal conjugate vaccine could avert up to 11.4 million days of antibiotic therapy annually worldwide in children younger than five years of age. A separate study published in the Journal of Clinical Infectious Diseases and Practice found that the introduction of a universal influenza immunisation programme for everyone aged six months and over in Ontario in the year 2000 resulted in a 64% decrease in influenza-associated respiratory disease antibiotic prescriptions relative to other regions.

However, despite the demonstrable impact of vaccination on antibiotic prescription, there is significant regional variation in immunisation uptake rates. Uptake targets set by the Department of Health and Social Care are sadly being missed. Between September and December 2017 flu vaccine uptake among GP patients aged 65 and over varied from a high of 74% in Greater Manchester to only 64.9% in London. Between September 2016 and August 2017 shingles vaccine coverage in the routine cohort—those aged 70—declined 13.5% since the start of the programme to 48.3%. I can speak personally about that vaccine. With shingles about to descend into my eye, it was so quick in getting rid of it. It was extraordinary and I am very wedded to this.

The coverage rate for the infant pneumococcal vaccination programme is now sadly below the 95% national target adopted by the Department of Health and Social Care. Given that the coverage level in the UK is already falling, it is worrying that the Government might deprioritise pneumococcal immunisation following a recent proposal to remove a dose of the vaccine from the infant pneumococcal immunisation programme. This advice has recently been consulted on, so it is to be hoped that in the interests of public health, the Government will consider the views of stakeholders closely, including the potential impact of a reduced schedule on antimicrobial resistance before making any policy decisions. The Government could also consider how they can ensure that the NHS benefits from future vaccines targeted at preventing hospital-acquired infections such as MRSA and C. difficile, which are of particular relevance to AMR. The Government should consider how tackling AMR can be incorporated into decision-making processes about the introduction of vaccination programmes.

Finally, given that the Civil Contingencies Secretariat 2017 national risk register categorises antimicrobial resistance and climate change as long-term trends that pose severe risks to the UK, I would urge that each of us should approach the problem of antimicrobial resistance with the same urgency and vigour as the threat posed by climate change.

Older Persons: Human Rights and Care

Baroness Greengross Excerpts

Thursday 16th November 2017 Lords Chamber

[Baroness Greengross (CB)]

My Lords, I congratulate first the noble Lord, Lord Foulkes. We shared for many years a mutual interest in promoting the rights of older adults and many other interests, including the legal systems of our two countries regarding children and young people. As outlined in the excellent report he has introduced, the emphasis—which I share—on intergenerational work is so important, because intergenerational relationships promote the best sort of life for both old and young.

The human rights of older people are only part of universal human rights. Older people must always be treated as adults. Their rights cover not only employment—as in the US—but, in this country, the provision of care, goods and services. When services are worse, or of a lower standard than those provided to younger adults, this is an infringement of those rights and a serious form of age discrimination. When I was a commissioner on the Equality and Human Rights Commission, I headed up an inquiry into domiciliary care in this country. We found that only 50% was of an acceptable level: therefore, 50% was not, and things have certainly not improved since we did that piece of work.

Turning to social care more broadly, we know that local authorities spend £8.8 billion a year on care for the over-65s in England, and that a further £10 billion is spent on formal care services by self-funding individuals and informal carers. If local authorities, self-funding and informal care are included, the total cost of social care is similar to the annual amount that the UK spends on the NHS. The consequences of long-term underfunding are an even more fragile provider market, growing and undermet needs, further strain on informal care, less investment in prevention, continued pressure on an already overstretched care workforce and a decreased ability of social care to help to mitigate the demand pressures on the NHS. We know that this is having a huge impact on many people supported by adult social care and support services.

The extra money for social care announced in the spring Budget was a step in the right direction, but it is only one-off funding that decreases each year and stops at the end of 2019-20; it is not a long-term solution. A report by the London School of Economics found that 1 million older people reported poor or inconsistent standards of dignity and respect when in hospital, and even not getting enough help to eat. The last CQC report found that levels of inadequate care had risen, with 25% of services not considered good enough. Stories of abuse and neglect within both residential and nursing homes are still far too common, and Health and Social Care Information Centre figures show that the majority of all safeguarding concerns relate to people of 65 and over. Inequalities in life expectancy are also very serious and have been rising, particularly for women.

So there is a huge amount that needs to be done. Supporting longer, healthier lives must be a critical priority for the Government and employers, as well as for people who experience social care. Only through such an effort will we be able to succeed in a number of key policy areas such as raising the state pension age and securing a sustainable health and care system. Human rights are universal; they do not lessen with age. If we forget that, we of all ages are equally lessened.

Care: Older People

Baroness Greengross Excerpts

Thursday 7th September 2017 Grand Committee

[Baroness Greengross (CB)]

My Lords, I thank the noble Lord, Lord Lipsey, very much because this is a very important issue. I think I have been involved in it for longer than anybody else. I have tried to get the issues around social care, care homes and how to pay for care right. This is a persistent, complex and very difficult subject, and we have to do something about it. If we started again, I think we would have a unified system but, let us face it, the majority of people who have to go into care homes are very old and have some form of cognitive dysfunction or dementia. They are shuffled between healthcare and social care. We are once again talking about how these people are going to be funded. It is very important that eventually we get this right. All these terribly frail people cannot go on waiting year after year while David and I meet regularly at events. Those events are not perhaps as important as being here, but they are occasions where people try to deal with this subject.

It is very hard to know what the prevalence of deferred payment agreements is because the data collection is now mandatory but the 2015-16 data collection was voluntary. Data collected by Care England, Age UK and NHS Digital found that out of 55 local authorities in England, just 1,300 DPAs were written in 2015-16, the first financial year in which the mandatory scheme was in force.

If we assume that this sample is representative of the 152 local authorities offering adult social services in this country, these data suggest that only 3,600 DPAs were issued in 2015-16. That is less than a third of the Government’s original estimate and lower than the figure in 2012. Meanwhile, Reform suggests that a higher figure of about 6,000 DPAs were issued in 2015-16 compared with the Government’s projection of 12,300. But whatever figure we use, the uptake and availability of deferred payment agreements has been very much lower than expected.

Reform concluded that tighter than expected eligibility is the principal reason why the Government overstated the number of people who would take up a DPA. These outcomes are despite councils having a statutory duty to offer DPAs under the Care Act. However, there is no government target for the number of DPAs issued by local authorities. To redress this imbalance, Reform argues for the DPA means-test threshold to be increased from £23,250 to £100,000, which would raise the percentage of self-funders who are eligible for support from 45% to 62.6%. One major challenge, however, is the lack of public awareness. Different councils develop different approaches and the pause in the Care Act is also something to be contended with.

All this has led to a huge amount of confusion. First, people do not understand the difference—they never have—between healthcare and social care. I have spent years saying that somebody who has a terminal disease, such as one of 100 different types of dementia, needs only social care, according to the rules, whereas somebody with a chronic illness such as back pain is given health service care. It is all very odd, really.

There is huge confusion in people’s minds, particularly about deferred payments. Neither is it transparent to the people who provide care or to people admitted to homes under a DPA, who would otherwise have been self-funders paying the home directly. DPAs also work by placing some people under a council contract, at council fee rates, and the home does not know their true status, which might mean that they have enough money to pay for it. So, as much as I deplore the fact that we have different criteria for healthcare and social care—as we always have had—it works both ways. Some people who really have enough money are not paying, because we know that councils pay very much less, which is one reason why so many care homes are going out of business.

So the use of DPAs is not transparent to the provider and, as an example of the rather covert nature of this landscape in which DPAs operate, the Department of Health recently completed an internal review of them in order to inform policy making, but it has chosen not to make the findings public. Perhaps the Minister can say why. It would be useful to know. There has not been a detailed analysis of the deferred payments scheme since 2013, when an impact assessment was published alongside the Care Act. At the time, the analysis suggested a highly patchy take-up of the scheme. There was a lot of regional variation, ranging from 1% to 40%. A new analysis to see how much take-up has changed is very much overdue, in my humble opinion.

Expectations from citizens, however, have risen. We know that they experience social care and healthcare as a continuum. The current financial challenges make the delivery of such expectations completely untenable. Taxpayers really are not getting value for money, so I endorse Care England’s view that, for DPAs to become a constructive part of a secure funding environment, a long-term vision with strong central leadership is required to take duplication and unnecessary administrative burdens out of the system. At the national level, much more clarity is needed about the partnership between the state and the individual in terms of funding. Locally, commissioners and providers need to agree the suitability of an individual’s care package, rather than this being seen as part of an arbitrary standard price.

DPAs are only part of the solution to funding social care fees, and the promised consultation on funding is a key opportunity to think about what sort of society we want to live in. Therefore, key questions on this issue are: when will the consultation be published and what form will it take, and in the meantime what short-term provision will the Government be recommending to tackle the current levels of unmet need? I hope that the noble Lord will be able to answer at least some of those points.