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

Baroness Jolly Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Jolly (LD)]

My Lords, I join all Members in the House today in congratulating the noble Lord, Lord Patel, and his committee on an excellent report, which came with a list of three dozen recommendations. I also share the anxiety expressed by some Members of the House about the quality of the government response. To wind up this debate is difficult because it has been so rich. People have brought to it their personal experiences as clinicians, as experts and even as patients. That has made the debate very broad so I shall try to narrow my remarks to just a few areas.

When the NHS was formed, in 1948, no one could foresee a world in which people were living longer and much care was taking place outside of hospitals. To tackle the demands facing our health and social care sectors today we need still to innovate and change and to develop a patient-centred model of care. In recent years, the NHS has halved the number of hospital beds, and it is estimated that with more efficient care half of patients currently in hospital could be treated at home or within their community.

Much has been said about joint working and integrated care, and here technology can really help. I think the noble Baroness, Lady Redfern, was the first person to mention data. Having common datasets by which NHS computers can talk to social care computers was seen as part of the solution to this very problem of integration when I first became involved in the NHS, 20 years ago. As an aside, my noble friend Lord Rennard might wonder why the NHS uses a fax machine to talk to itself but apparently security is the issue: it is the most secure way of communicating between NHS establishments and regular telecoms are not up to the task. We need systems that work together to smooth the transition from primary care to hospital to social care services, and reduce cross-referrals and delays—the bumpy departures and landings to which the noble Lord, Lord Carter of Coles, referred. I hope the Minister will be able to give us some indication in his summing up of where we are with this particular piece of the integration jigsaw and other ground-breaking digital innovations.

To do all this, we need money. To have care that is oriented towards the future, we must have a properly funded and integrated framework for health and social care. This is to be seen not as government expenditure but as investment. There will be payback: in increased efficiency, better care and improved patient satisfaction. Both health and social care have suffered from ebbs and flows of funding depending on the direction of the political wind, and we must endeavour to change that. In the social care sector alone, real budgets have fallen by nearly a quarter and brought the sector to near collapse, while in the NHS hospitals are overstretched and underprepared to combat the annual winter crisis, which seems to be all year round. The noble Baroness, Lady Watkins of Tavistock, reminded us that social care involves not just old people. It includes people with a disability, whether it is a learning disability or a physical disability, and, as she mentioned, children. Both systems are in need of rescue and reform in order to serve future generations. Without proper funding levels, we cannot expect to effectively implement cost savings that would arise from the integration of care services, and we run the risk of seeing money targeted for innovation and changes to our services go towards merely keeping our NHS afloat.

At the local government level, council taxes are at the highest levels that could realistically be sustained, and the opportunity to add a discretionary amount for social care is now widely acknowledged as a flawed policy. The challenge at local government level is commissioning. A move to outcomes-based commissioning is slow to be embedded but would bring transformational change to service delivery. An example of that came in the debate today from the noble Lord, Lord Colwyn, who is a dentist. I did not expect such an example to come from the area of dentistry, but he made the point perfectly that if you commission for outcomes, you will get a better service.

Sustainability and transformation plans should prepare our system for the future and should be given the financial investment needed to see services change with the times and produce quality results for patients.

We on these Benches believe that proper NHS funding can be accomplished through bringing our health expenditure in line with other nations and by providing a ring-fenced integrated budget for health and social care that would be kept separate and defined for a 10-year period. This would allow the NHS, care providers and local communities to prepare for long-term needs, together with a plan that they can implement. It would remove short-term thinking on health and social care budgets and create a sector that is looking forward to the future instead of being occupied with daily crises.

The noble Lords, Lord Kakkar, Lord Willis, and Lord Carter, and the noble Baroness, Lady Finlay, and many others, mentioned the acute workforce shortage, which must be the single greatest threat to our health sector. To begin solving this we need to train new workers while protecting the immigration status of foreign-trained staff already here. As we come up to 70 years, we must also acknowledge our debt to the Windrush generation—the people who came from across the Commonwealth to help us set up the NHS to become what it is now.

In order to have a functional health and care service we must continue to support health and care workers, who will be absolutely critical to the way we work in any future model of care. I welcome the Government’s shift on nursing pay, but in the current climate perhaps the Chancellor might consider a further uplift.

Health and care workers feel the pressure of caring for an ageing population and have remained committed to giving their services, even in the face of long hours and stagnant wages. In the long run, however, this will not be sustainable. The health and social care workforce is facing a tremendous gap in the number of workers, which we urgently need to address.

The noble Lord, Lord Willis, mentioned nursing associates. Before this debate I was speaking to members of a delegation from Kent. They were anxious about the nursing crisis in Kent. They mentioned nursing apprenticeships and asked me whether I was aware that there were no nursing apprenticeships at all in Kent. I confessed that I was not aware of that. Can the Minister give some indication of the uptake of nursing apprenticeships, and of the number of nursing associates, in England?

It is time to consider care work as a profession, which may well include regulation. For the most part, care workers work on the basic minimum wage. They often train in their own time and at their own expense and work unsocial hours with a difficult client group. They can always go to the supermarket and work for the same number of hours with less hassle—but they do not. They have a commitment and a love of the job and, as a society, we take advantage of that. So I hope that the Green Paper, in addressing the cost of care, will look at a model where their commitment and professionalism are recognised. We can then work to attract new care workers through providing regular performance-related pay rises and flexible working conditions to those who need them. Will the Minister tell the House how his department is involving partners in the preparation of this Green Paper and who represents the voice of the care workers? I would be grateful if he told me it is not care providers.

The picture with doctors is not hugely better than that for nurses. Yesterday, many of us received information from the Royal College of Paediatricians expressing alarm at the number of doctors on duty at any time. Nearly three-quarters of all medical specialties had unfilled training posts in 2016, with the number of applications to our British medical schools decreasing for the third year in a row, and by more than 13% since 2013. Fewer trainees are moving directly into speciality training, instead choosing to take a career break. Will the Minister give an indication of the attrition rate at this stage? What remedies are being considered to keep these hugely expensive to train professionals in the UK at the early stage of their careers?

This has been an excellent debate on an excellent report. I hope that as a House we will continue—I am sure we shall—through questions and debates to understand the Government’s thinking and to influence their direction in this area.