NHS: Sustainability and Transformation Plans

Baroness Pitkeathley Excerpts

Monday 20th March 2017 Lords Chamber

Asked by

[Baroness Pitkeathley]

To ask Her Majesty’s Government what assessment they have made of the impact of any hospital closures resulting from the implementation of Sustainability and Transformation Plans on Accident and Emergency departments.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, sustainability and transformation plans, or STPs, are about local health stakeholders coming together to make sure that NHS services are placed on a sustainable footing and are being transformed for the future. Any significant changes outlined in the STPs will have to meet the four reconfiguration tests of strong public and patient engagement, a clear clinical evidence base, support for patient choice and support from clinicians.

[Baroness Pitkeathley (Lab)]

I thank the Minister for his reply but, in view of the problems about which we heard in the last Question and the fact that accident and emergency departments and other hospital services deal with many social care needs, does the Minister agree that it is vital that there is sufficient capacity in the community to manage the demands for community services which closures will inevitably cause, and that this must be established before any closures take place? Will the Minister therefore tell the House specifically when, by whom and how this assessment of the adequacy of community services will take place?

[Lord O'Shaughnessy]

As the noble Baroness has pointed out, it is important that there is sufficient capacity in the social care service and in the NHS. In fact, the NHS accounts for more of the delayed discharges, for example, than does social care. Simon Stevens, the head of NHS England, has been clear that, in addition to the four reconfiguration tests, any bed closures would need to show that there was redundancy in the system, that there is alternative provision—to come to the noble Baroness’s point—and that there is clear potential for efficiency. It is clear that the STPs must be able to plan ahead and provide alternatives if there are going to be changes to A&E or other services.

Social Care in England: Older People

Baroness Pitkeathley Excerpts

Monday 20th March 2017 Lords Chamber

[Lord O'Shaughnessy]

I of course associate myself with the comments made by the noble Baroness and apologise for not saying so before. However, I am not going to sing in tribute.

Around 17% of the care workforce comes from abroad and some 7% of the total are from the EU. The key is to make sure that we have, as far as possible, a care system that attracts workers domestically. We are doing that through improving the training packages available and through better pay under the national living wage, which I mentioned.

[Baroness Pitkeathley (Lab)]

My Lords, we heard this morning that the domiciliary care scene is under pressure and many domiciliary care agencies are in fact not tendering for contracts. The care home sector is also under pressure. The people who are not giving up, as the Minister points out, are the family carers— 6 million of whom are picking up the pieces from an inadequate social care system. May I press him a little more on the carers strategy, please? It was due to be published last September. Has he a date yet?

Adult Social Care: Funding

Baroness Pitkeathley Excerpts

Thursday 16th March 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Lord has done much work on the sustainability of social care, including his work on the Dilnot commission. He is quite right to point out that there are lessons to be learned from other countries, and certainly we will be learning them from Japan, Germany and elsewhere. He will know that the measures announced in the Budget are specifically designed not only to help adult social care but also to help the interface between the NHS and social care to provide exactly the kind of sustainability he is talking about.

[Baroness Pitkeathley (Lab)]

My Lords, some of us in this House are veterans of social care reviews that have led to very little change. Can the Minister therefore tell the House whether he is confident that the Green Paper will lead to urgent action? Will it consider controversial issues such as helping families prepare for care, savings products in the insurance market and perhaps even care vouchers?

National Health Service: Nurses

Baroness Pitkeathley Excerpts

Wednesday 22nd February 2017 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is quite right to raise the issue of retaining nurses and bringing them back into the profession. That is why, last year, to aid retention, there was an average 3% increase in pay for nurses. Health Education England has also introduced a return to practice campaign, which has brought 900 nurses back to the front line in the last three years.

[Baroness Pitkeathley (Lab)]

My Lords, we hear constantly that better integration between health and social care is the way to solve the problems that both services are currently experiencing. What progress is being made with training nurses who can work across both health and community services?

[Lord O'Shaughnessy]

The noble Baroness makes a very good point. In fact, the workforce figures out today, which show the increases I have described, also show an increase in the number of nurses with general qualifications who are capable of working across multiple specialties and different sectors.

Residential Care

Baroness Pitkeathley Excerpts

Monday 6th February 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank my noble friend for making a very important point. Clearly, the capacity in the care home sector is important for ensuring that there is a proper flow of patients out of hospitals and into a more appropriate setting. In regard to the county that she was talking about, North Yorkshire, I think the overall number of beds has been broadly flat over the period in question, but there has been an increase in domiciliary and supported accommodation, which is increasingly the way that care is being structured across the country.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister agree that where there is a shortage of residential or, indeed, nursing home care beds, the onus on care falls on the families? Will he take this opportunity to update his honourable friend in the other place, the Minister for Health, who last week exhorted the nation to care for its elderly relatives? He apparently forgot that there are 6.5 million people who already do so at great personal cost to themselves.

[Lord O'Shaughnessy]

The noble Baroness is quite right to highlight the work that carers do. There is now, of course, a national carers strategy to support those who are supporting their families, often in very difficult circumstances. The point that my honourable friend in the other place was trying to make was that there is an important role for families to continue doing so—in the way that parents care for children, children should do the same for their parents in return.

Mental Health and NHS Performance Update

Baroness Pitkeathley Excerpts

Monday 9th January 2017 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Lord for his question. There are many strategies, going forward. One is the reform of social care, which includes additional funding, with the precepts being front-loaded now. The second is making sure that, in hospitals, those people in beds who would be better served in a different care setting are able to leave through step-down services, or other such services. Of course, the other factor is to make sure that there is appropriate general practice, and not simply A&E departments, although these can be effective in some areas. We want to make sure that there are more GPs and that we spend more on general practice, as we will in the spending review period, for patients who would be better dealt with without going into A&E, if the kind of care that they are receiving would be more appropriate in a primary care setting. We have to remember that, for patients such as those with dementia, the prospect of going into A&E could in itself be frightening and worrying.

[Baroness Pitkeathley (Lab)]

My Lords, I cannot resist the opportunity to remind the new Minister, as I always used to remind his predecessor, about the importance of Britain’s 6 million family carers, when we look at both the issues that he has brought to our attention today. First, he talks about speeding up discharge. You cannot speed up discharge in the social care sector unless you also provide support to the family carers, many of whom are elderly themselves, who will provide that care, when somebody comes out of hospital who is still barely recovered and those carers are expected to perform nursing functions, such as changing catheters. As for mental health, carers are often expected to be full-time carers for young people with very challenging behaviour, and they are often deprived of any information that would help them, on the grounds of confidentiality. What is the Government’s position on helping those informal carers in both these situations?

NHS: Community Pharmacies

Baroness Pitkeathley Excerpts

Tuesday 6th December 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I do not recognise the figure of 7.4%. The actual reduction is 4% next year and 3.4% the following year. I echo my noble friend’s comments and recognise the huge importance of community pharmacy. If we look forward 10 years, we will see a much greater role for community pharmacy within the NHS in supplying many of the services that are currently supplied by more conventional NHS services.

[Baroness Pitkeathley (Lab)]

My Lords, the Minister mentioned clinical skills. Does he agree that in rural areas in particular, community pharmacies play a role much wider than their clinical function in giving advice, information and sign-posting to patients and their families? Does he agree that that is a very important part of their function that should continue?

Social Care

Baroness Pitkeathley Excerpts

Thursday 1st December 2016 Lords Chamber

Moved by

[Baroness Pitkeathley]

That this House takes note of the challenges in the current system of social care and of proposals for reviewing it and for longer-term reform of the system.

[Baroness Pitkeathley (Lab)]

My Lords, here we are again. This is not the first time I have led a debate on social care in your Lordships’ House and I have been wont to call those who join me the usual suspects, because we are the relatively small band who bang on about this subject whenever we get the opportunity. There are new faces as well as old ones here today. It is particularly welcome that the noble Baroness, Lady Cavendish, has chosen this debate for her maiden speech, to which we all look forward.

I have to tell your Lordships that it makes pretty depressing reading to go back to the other debates on social care in which many of us have participated, because the problems remain the same and so little progress seems to have been made. If I felt that before all the other debates—in nearly 20 years in your Lordships’ House, I have rather lost count of the number of times I have focused on this—how much more I feel it this time, when endless reports and newspaper articles are telling us all how bad it is. Your Lordships will be all too familiar with some of the headlines of recent weeks. One said that,

“social care is at a tipping point”,

another that it was “Slow, patchy, cruel” and that social care funding is “not fit for purpose”. Others said that the bed-blocking crisis hit a new high and that local authorities,

“join NHS chiefs in call for extra … funds”.

It may surprise your Lordships to know that I have managed to find some comfort in these terrible analyses, because perhaps they show that at long last there is agreement across all areas about what the problems are. That will be evident in the briefings which your Lordships have received for this debate. It is not as though we have not agreed before, but perhaps not so strongly and not across all areas. When even the chief executive of the NHS, not to mention the chair of the Health Select Committee, and two former Secretaries of State say that if there is any extra money it should be put into social care, maybe we are at last ready to address the issues.

Am I being too hopeful? Perhaps. Certainly, the announcements we were hoping for in the Autumn Statement provided no comfort by their total lack of appearance or even mention. I bow to no one in my desire to have better broadband in rural Herefordshire but, really, can we get our priorities straight? How the Chancellor could ignore the pleas from all sides is beyond me. His decision has been met with incredulity and dismay and called shameful. Nevertheless, I am determined to spend less time today on the problems of social care, which are well known to your Lordships anyway, and more on what the possible options are.

Let me summarise the problems and leave others to elaborate. There is a shortfall in social care funding of about £2.5 billion between what is available and what is required. Four out of five councils do not have enough provision, especially for care at home, and at least 1 million people are going without the care that they desperately need. Much more stress is falling on family carers, who increasingly find it difficult to cope. The results of these shortfalls are all too apparent: too many people end up in acute and very expensive hospital care in hospitals which are already bursting at the seams, even before winter pressures begin to bite.

The situation is bad for everyone. It is bad for councils, which will face legal challenges if they are unable to meet the obligations placed on them by the very welcome Care Act; it is bad for the NHS, as hospitals fill with people who could and should be treated at home; it is bad for care homes that increasingly find it difficult to balance the books, with the resulting threats to the quality of care which recent TV programmes have illustrated; it is bad for family carers. In short, it is bad for anyone who cannot afford to pay for their own care. Even if you are a self-funder, it is bad for you because you have to contribute to underfunded local authority places if you are in a care home. So much for the so-called society “which works for everyone”.

I could go on with endless examples of the bad but I will not. I turn instead to offer options, in the hope that the culture in which we operate is finally changing enough to encourage bold and courageous action. They say that humans and cultures never change unless we are forced to do so. If that is the case, we are forced to do this now before the whole system is not just at tipping point and in crisis, but in danger of breaking down completely. I should say here that I always worry about the danger of too much criticism sapping the morale of the dedicated staff who work in social care and do their best. They are usually paid at the very lowest levels. We owe it to them as much as to the frail, old and disabled to think boldly.

We must first tackle the different methods of funding health and social care, which have been so difficult to overcome and such a barrier to the co-ordination and integration of health and care services. In 1948 when the system was established, men died on average at the age of 66, one year after retirement, and women at about 68. There was no need for the type and range of care we now need. It did not matter so much that while health was free at the point of delivery social care was always means-tested, because you were not going to need very much social care. Social care has been paying the penalty ever since for those decisions, which at the time they were made were perfectly logical. What we need now is a decision of the level and quality that our forebears made then in relation to the NHS. But this time it must be about reshaping health and social care around today’s needs, not those of the population of post-war Britain.

Various attempts have been made and we all remember them: the royal commission, the Wanless review, the Dilnot review, the King’s Fund commission on the future of health and social care and the Barker commission—but no government response has been sufficient. It is evident that what is really needed is a long-term, cross-party approach which takes an open and honest look at the system and, above all, is open and honest with current and potential care recipients about what they can expect.

I think we are now at a crossroads and can make one of two decisions. We can go on as we are, muddling along, trying to do more with less, managing demand by just not meeting it. That is how we are managing demand: we are just not meeting it. I remind your Lordships that, of the more than 1 million people who it is estimated are not receiving care, most have already been assessed as having high-level needs, because helping those with moderate needs is already a thing of the past in most areas. We can keep promoting independence—that is always a good thing—we can keep trying to get individuals to manage their own care better and, above all, we can keep trying to integrate the budgets for health and social care. There are some excellent examples of integrated care at local level which, no doubt, noble Lords will illustrate, but the overall picture is patchy and still too cautious and too hedged about with suspicion and lack of willingness to give up power over budgets, still less to transfer it to other professionals. A single pooled budget for the health and social care needs of a whole population would enable NHS and social care providers to agree the very best use of the public pound and to focus on services which reduce the need for long-term care.

I am sorry to go down memory lane, but I have been talking about this, as have many other people, for almost 40 years—it is probably over 40 years, in fact. My first book was published in 1978. It was about hospital discharge for older people. Funnily enough, it showed that proper co-ordinated care can happen only if there is a single budget in the control of those who provide the services, free from political control and including the contribution of the private and voluntary sectors too.

If we are going to go on with the current system, if we are going to go on trying to muddle along, then I must make a plea for honesty. No Government—and I include my Government in that—have ever made it clear to the public that responsibility for paying for care and for arranging it rests with individuals and their families and that public funding is available only for those with the least money and the highest needs. Most people are aware that NHS care is generally free at the point of use, but their understanding about social care is far less clear, and people therefore have inappropriate expectations. If I had a pound for every carer who has said to me, “My mum has paid taxes all her life, and I can’t understand why her house has to be sold or all her savings used to pay for her care”, I would be a millionaire. That carer is a perfect example of a person who is just about managing, caring for her mother and probably teenage children too, trying to balance paid work with caring responsibilities and so on.

As we are not transparent, no one ever prepares or plans for care, and they have to scrabble to arrange and pay for it at a time when they are anyway distressed by the very need for it. If they are not prepared to reform the system, the Government must surely be prepared to promote clearer public understanding of how the system works and what people can expect and, more importantly, what they cannot. People plan ahead for pensions, and it is possible they could similarly plan ahead for care, but only if they know they have to.

However, it will not surprise noble Lords to know that this sticking-plaster solution is not my preferred option. I believe we must embark on long-term reform of the system because this problem is not going to go away; it is only going to get worse. All international evidence shows that spending on health and social care rises inexorably as the population grows and ages. The question is not whether these costs will arise, but how they will be met. Will they be met by the public purse or by private individuals? We can talk for ever about achieving more with less and delivering better value, but that will never release resources of the scale required to meet the widening funding gap.

Every independent review of the past 20 years has recommended that in future funding of social care, as well as healthcare, should come from public, not private, finance. The needs of individuals cannot be divided up neatly into health or social care needs, as all those of us who over many years have tried to fathom the difference between a health bath and a social care bath have long acknowledged, and now is the time for us as a society to acknowledge that the funding cannot be neatly divided either.

We must embark on a frank and open debate about how to fund health and social care on a sustainable basis into the future and remind everyone that such a debate cannot be settled in a single Parliament, so we need to secure cross-party consensus on shared principles to guide that reform. We have enough research and excellent material to enable us to do so; we just need the will to do it. We know all the questions about social care, so let us not embark on any more questions about what social care needs. What we need now is answers.

To those who say that this is not the time to do this with public finances in such disarray and with so many other problems, which we have just been hearing about in the previous debate, I remind your Lordships that our forebears tackled reform in the middle of a world war when the country was pretty well bankrupt and not the fifth-richest nation on earth, which we keep being reminded that we are. The Wanless review called for this debate 10 years ago. It has never been more necessary, and it is now even more urgent. I beg to move.

--- Later in debate ---

[Baroness Pitkeathley]

My Lords, we have had an excellent debate and I thank all noble Lords who have taken part, especially the noble Baroness, Lady Cavendish, for her thoughtful speech which makes us eager to hear more from her. The topics covered today have been as wide-ranging as the issue itself but there has been agreement about the crisis which exists, if not yet on how to address it.

I did not of course expect the Minister to announce from the Dispatch Box the great public debate that I have called for today. Many others have called today for such a debate and it is of course way above his pay grade—but that does not mean that I resile one iota from the calls for that debate. We must have it; it is inevitable and it would be better to have it sooner than later—before the system really does collapse, as many people have warned us it will.

The Minister has had many suggestions and, with his usual courtesy and honesty, has certainly addressed some of them. I welcome his focus on the strategy and I certainly acknowledge the progress made, as he reminded us, with some STPs. However, a couple of examples that I have had remind us that the STPs should not be about just health and social care but should include carers and the voluntary sector. It is important to bear that point in mind as we go forward with the STPs.

The emphasis has been on the interdependence of the health and social care services, as well as on the needs of users, carers and care staff. I get the impression that the time is right, and I think that the Minister has confirmed this. The people at the top—even, dare I say it, at No. 10—have realised that something must be done. If you have a philosophy which says that the Government must work for all and that you must help people who are “just about managing”, or even the “not managing at all” as the noble Lord, Lord Warner, reminded us, I hardly think that you can avoid addressing this issue. If that is the case and there is agreement that something must be done, I hope that this debate can be required reading. Readers will find calls for more resources but I do not want that to frighten them off, because they will also find in this debate a wealth of practical and deliverable suggestions on how to address these issues. So although I am a bit depressed, I am not totally depressed. Like the Minister, I am not without hope and I certainly hope that by the next time the usual suspects meet here to discuss this, we will have made some more progress. I beg to move.

Motion agreed.

Adult Social Care

Baroness Pitkeathley Excerpts

Tuesday 15th November 2016 Lords Chamber

Asked by

[Baroness Pitkeathley]

To ask Her Majesty’s Government what is their response to the warning by the Care Quality Commission in their State of Care report, published in October, that adult social care is approaching “tipping point”.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, we welcome the State of Care report. We know there are serious pressures on the care system. That is why we are giving local authorities access to up to £3.5 billion in new support for social care by 2019-20 so they can increase social care spending in real terms by the end of this Parliament.

[Baroness Pitkeathley (Lab)]

I thank the Minister for his usual courteous reply, but I think he knows that the funding he has announced there for the better care fund is both too little and too late. Does he agree that there have never been so many challenges for the social care system? There is terrible pressure on the NHS and on caring families, and many people have no care at all at home, however great their needs. Does he further agree that there has never been so much consensus about what needs to be done? Across all professions and political divides, we hear that what is needed is more money, and more money now. I am well aware that asking for commitments in the Autumn Statement is above the Minister’s pay grade, but could he please assure the House that he and his colleagues are stressing the urgency of this matter to the Chancellor of the Exchequer and asking him to make more funding for social care an urgent priority?

[Lord Prior of Brampton]

My Lords, I think most people in the health and care system, whether it is Simon Stevens, the chief executive of the NHS, or the Secretary of State, realise how serious pressures are in social care. There is no question about that. The State of Care report from the CQC supports that view. That is why we are putting in more money towards the end of this Parliament. It is back-end loaded—I accept that—but on the other hand the £3.8 billion that went into the NHS this year is front-end loaded. I think everyone agrees that the only way out of the difficulties we are in is for health and social care to work much more closely together.

NHS: Cancer Patients

Baroness Pitkeathley Excerpts

Wednesday 9th November 2016 Lords Chamber

[Lord Prior of Brampton]

There are lies, damned lies and cancer statistics. It is extremely difficult to make comparisons on survival rates with other countries. There is evidence that we are behind the best in Europe on five-year survival rates. There is also considerable evidence that we are making good progress—but, of course, other countries are making good progress at the same time. If we implement the cancer task force recommendations, it is estimated that we will save an extra 30,000 people’s lives per annum. We have a very ambitious programme to improve cancer outcomes, but I accept that we are starting from some way back from the best performance in Europe.

[Baroness Pitkeathley (Lab)]

My Lords, does the Minister accept that early diagnosis depends on patients or potential patients recognising the symptoms? Notwithstanding the pressure on services, are the Government continuing to encourage patients to recognise potential cancer symptoms?