Primary and Community Care: Improving Patient Outcomes

Baroness Pitkeathley Excerpts

Thursday 8th September 2022 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I am grateful to the noble Lord, Lord Patel, for leading this debate and, beyond that, for the leadership that he provides to this House on all matters health related. Although he used the words community care to refer to community care health services, I know that he will forgive me if I slip over into the other bits of community care, which are so vital when we consider healthcare and which work in collaboration with primary care.

Patients and carers must be the focus of this debate, because improving outcomes for them is what primary and community care services are all about. But I must put in a word of warning here on behalf of those patients and carers: if you ask a typical patient or carer to define primary or community care, they would struggle, as the noble Viscount so ably and vitally reminded us. I must say it is a pleasure to see him with us, not at all past his sell-by date. A typical patient simply does not know the difference and why should they? They refer to “my doctor”, “the hospital” or “the carers who come in to see my mother”. They do not know about different streams, different types of training or regulation; they are puzzled only by why test results take so long to reach their GP, why some care is free and other care has to be paid for.

I have lost track of how many friends and neighbours I have advised should be in receipt of NHS continuing care funding for their elderly parent, when they have immediately been advised to seek a place in a private and very expensive nursing home, without any reference to possible alternatives. What puzzles patients and carers most of all is the lack of communication and integration between services. “Why on earth do they not talk to each other?” they say. “Why do I have to tell my story all over again to every new person I see? Why did my GP not know that I was being discharged from hospital?” Every time I speak to a patient or carer, I find myself at a loss to explain why these things happen.

It is not as though they are new problems or that we do not know how to solve them. We know about integration, shared budgets, joint training initiatives, more realistic funding and better workforce support. We had great hopes when the integration White Paper was published earlier this year: it promised shared planning and delivery for health and social care and making access easier. But there was little to explain how a joined-up system would be managed, be accountable to the public and balance what is delivered locally with national standards and entitlements. That is another cause of bewilderment among patients: “Why does my sister in Devon or Doncaster get something that I have been told I can’t have where I live?”

I must turn to the disaster area of social care, because you cannot focus on any problems in the NHS without fixing social care. I was amazed, as many of your Lordships would have been, to hear the outgoing Prime Minister claim, on Tuesday, that he had fixed it. You could have fooled me or anyone else who works in the system. Why are ambulances in short supply and taking longer to reach those in need? It is obvious: they are queuing at hospitals because there are no beds to move people into from A&E. One in seven hospital beds is now occupied by a patient who is fit to be discharged but cannot be, because there is nowhere for them to go, because of chronic underfunding in the system. With such long-term shortages in the workforce, even those who have a care home place may be neglected, while unpaid carers carry even more burdens, as I have reminded your Lordships on all too many occasions.

I was grateful that the Minister was able to secure a concession for carers in the recent Health and Care Act, enabling them to be consulted at the point of discharge. However, all too often, local services to support them are sparse or non-existent. The charitable sector, which is often the main source of support, is also under severe pressure.

One reason is Brexit—so many former employees were from the European Union—while another is poor wages and another is lack of respect for the social care professions, which are always seen as the poor relation when compared with health services. The Minister referred to that in his Answer to a Question earlier.

The new Prime Minister said that she will stop the health and social care levy, which was meant to fund, first, backlogs in the NHS and, secondly, social care. Will she now give all that money to social care? If so, how much will it be and how many constraints will be placed on how it is used?

The lack of attention to and funding of preventive services is a constant problem, as the noble Lord, Lord Bethell, reminded us. Small amounts of money spent early in a patient journey can head off many problems, but too often we wait for a crisis, which requires far more resources and has poorer outcomes anyway. GPs can be vital in identifying such early-intervention opportunities, but are often denied the opportunity to do so. We must remember too that the cost of living crisis will only make problems of access worse and there will be more demand because of cold homes and inadequate diets.

Many have mentioned problems with primary care and the supply of GPs. The reason there are so many patients who walk into A&E is often the difficulty they experience getting a GP appointment. I know this is a major problem in many areas, but I must put in a word for some GP practices, such as my own, which provide services way beyond those we expect and attempt to support their communities with services and initiatives for the homeless, the lonely and those with mental health problems.

I turn to the reforms needed. We need more progress on integration, taking note of some of the local initiatives, which are fine examples, and not being constrained by the “not invented here” syndrome, which is a problem for many people who work in the health service. We must also face up to the workforce crisis. The Public Services Committee, on which I serve, has been mentioned, and it showed that no recruitment targets are being met. It was a great pity that the Government did not accept the amendments for regular reviews of the workforce put forward by the noble Baroness, Lady Cumberlege, when the Health and Care Act was going through. To address shortages, Governments, regulators and employers must succeed in retaining existing professionals and recruiting and training additional ones. This may mean that they have to challenge conventions about education and training and be far more flexible in how we deploy that workforce. How many times have I heard calls in this House for integrated training across health and social care, but has any real progress been made?

Being more flexible about patient need requires some professions to give up their protected status and to recognise that a nurse, physiotherapist, pharmacist or healthcare assistant can meet patient needs as well as or—dare I say it?—even better than a doctor. It is a pity that radical reforms of the regulation of the health professions have never been tackled, in spite of many promises.

The new Prime Minister said that the NHS will be a strong focus for her Administration. She will always find those who work in health and care committed, dedicated and willing to embrace change. What they ask for in return is honesty about the problems they face and recognition of their devoted service.