NHS: Primary and Community Services
Baroness Pitkeathley Excerpts(8 years, 2 months ago)
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Lord Prior of Brampton
My Lords, delayed and inappropriate discharges are clearly a huge issue for the whole health and care system. Again, this is something the STPs are designed to address. The five-year forward view is explicit in saying that there are 5.5 million carers in England and their continuation goes to the very sustainability of the NHS. The importance of care is not in dispute. The Care Act, which the noble Baroness’s party and mine put through in the last Government, recognised that so as to give them parity of esteem with those they care for. There is no question but that better communication with carers would go a long way to improving the problems we have with inappropriate discharges.
Baroness Pitkeathley (Lab)
My Lords, the Minister has acknowledged that discharge from hospital is an important time for carers. You can literally become a carer overnight when your relative is discharged without warning. The carers strategy is currently being refreshed. Would the Minister consider an input into the carers strategy that meant it was incumbent on the National Health Service to consult carers and get their agreement before discharges are made?
Lord Prior of Brampton
My Lords, I am not sure we could go so far as to say that one should always have their agreement—sometimes, discharges from hospital are incredibly complex and difficult—but there is no doubt, arising from the Carers UK report, that where there is proper communication with carers, the discharge procedure is much better for everyone, from the point of view of the carer, the patient and the hospital. If proper arrangements are not put in place, delays arise long after the patient should have been discharged home. It could be to do, for example, with a care package or altering the patient’s home.
NHS: Health and Social Care Act 2012
Baroness Pitkeathley Excerpts(8 years, 4 months ago)
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Baroness Pitkeathley (Lab)
My Lords, I too thank my noble friend for bringing forward this important debate, and I congratulate him on getting the time.
I always thought that the best thing about the Health and Social Care Act was its title. I was not alone in thinking that. It gave us hope that, at long last, the issue of social care would be put on a par with health in the delivery of services. Over the many years that I have been concerned with these issues, I have lost track of the number of times I have heard people say, “You cannot run a patient-focused NHS without regard to the whole patient experience”, which of course includes their experience of social care. Admission, discharge, post-discharge and follow-up are all inextricably entwined, especially for those with long-term conditions. So we had high hopes from that title and were repeatedly assured that the Government understood the importance of social care, that the new arrangements would ensure collaboration and co-operation between health and social care providers, and that adequate funding would be provided to local authorities to ensure that their obligations could be met.
Like many noble Lords, I had major misgivings about the disruption that the Health and Social Care Bill would cause and the money it would cost—especially as the promise had been made that there would be no top-down reorganisation of the NHS, as my noble friend Lord Rea has reminded us. The Bill appeared to presage not just a top-down but a bottom-up reorganisation. However, the idea of better integration certainly appealed to me. In 40 years of working in this area, I have noticed two things repeatedly. First, there is the absolute inability of any patient of any kind to understand the lack of integration, or sometimes the lack of communication, between the two services. Patients will always say, “But I don’t understand—why are they so different? Why don’t they talk to each other?”. Secondly, there is the repeated response of any professional involved in delivering patient care that more integration and co-operation is not only desirable but essential. So the test which I now apply to the Act is how we are doing on integration.
The Government were warned at the time that their proposals for structural reform were going too far, too fast. So far as social care is concerned, it is perhaps not fast and far enough. We have seen a social care system which is neither well funded nor sustainable and which, as a consequence, contributes to the problems in the NHS that so many noble Lords have mentioned. Two weeks ago, I visited an elderly friend in an acute ward. She had been ready for discharge for two full weeks but was unable to be discharged because of the lack of social care provision. Eight more people in the ward she occupied were in the same position.
A well-funded and sustainable social care system underpins a sustainable NHS. Delayed discharge is possibly the most pressing concern for the NHS and the Department of Health at present. It is inextricably linked to rising social care demand, caused by the greatest social and political challenge of our time: the ageing population. That ageing population is of course also a triumph and we should celebrate it, but we cannot ignore the strain that it puts on our provision of health and social care services. Social care is the largest area of spending at local level and has been hit hard by central government-enforced austerity. Meanwhile, demand for social care is of course rising; it is predicted to increase by 44% by 2030. More people are living longer with more complex, long-term conditions that require a higher level of expertise and intervention. The Nuffield Trust has estimated that by 2020, there will be a funding gap in adult social care of between £2 billion and £2.7 billion, despite the social care precept and the better care fund.
I hope the Minister will not use the better care fund and the precept as a panacea, a cover-all, for these difficulties because they are already inadequate and do not compensate for the 37,000 social care beds which will be lost before 2020 nor for the introduction of the national living wage.
The Health Select Committee conducted an inquiry into the impact of the spending review on health and social care, and the chair, Dr Sarah Wollaston, concluded:
“Historical cuts to social care funding have now exhausted the opportunities for significant further efficiencies in this area. Increasing numbers of people with genuine social care needs are no longer receiving the care they need because of a lack of funding. This not only causes considerable distress to these individuals and their families but results in additional costs to the NHS. We are concerned about the effect of additional funding streams for social care not arriving until later in the Parliament”.
Will the Minister say when additional funds will be achieved and when they will arrive, and will he give us his estimate of how they are going to cope with many of these problems? I remind him that ADASS calculates that the sector will need £1 billion per year just to allow it to stand still and that most local authorities say that they will have to spend the whole of their budgets on social care within five years or so.
I have been disappointed in my hopes for social care from the Act, but I have also been disappointed in my hopes for the strengthening of the patient voice which was promised. Local Healthwatch and local health and well-being board organisations have been patchy, as we warned the Government at the time that they would be, while the disempowerment of Healthwatch England by denying its independence and clipping its wings has not been an edifying spectacle.
As far as social care and integration is concerned, there are some excellent examples of good practice, as the Prime Minister acknowledged yesterday, but they are far too few and, as she also said, further review is necessary. I was very pleased to hear her say that at PMQs yesterday. I hope the Minister, who is so knowledgeable on this topic, will assure us that this review will take place soon, as it could not be more urgent.
NHS: Unsafe Hospital Discharges
Baroness Pitkeathley Excerpts(8 years, 7 months ago)
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Lord Prior of Brampton
My Lords, there are millions of interactions between patients and consultants and doctors every day of the year, and there will be some mistakes. We cannot draw conclusions from one or two desperate situations. In so far as they reveal systemic problems, it is valid to draw attention to individual cases of this kind, and there are some systemic issues lying behind the PHSO’s report. In particular, it states:
“We are aware that structural and systemic barriers to effective discharge planning are long standing and cannot be fixed overnight … health and social care … have historically operated in silos”.
That is the issue on which we should be focusing.
Baroness Pitkeathley (Lab)
My Lords, I ask often in this House and elsewhere about co-operation between health and social care. Does the Minister agree that one thing we lack is a cohort of people, be they nurses or paid professional carers, who can work across health and social care in hospital and follow patients into the community? Will the Minister update the House on what is happening to encourage that kind of cohort?
Learning Disabilities: Transforming Care
Baroness Pitkeathley Excerpts(8 years, 7 months ago)
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Lord Prior of Brampton
All the transforming care partnerships will comprise both CCGs and local authorities, so all the experiences learned by local authorities should be paid into the process.
Baroness Pitkeathley (Lab)
My Lords, does the Minister agree that when such in-patients leave in-patient care, much of the responsibility for looking after them actually lies with their families? As this is Carers Week, would the Minister update the House on the Government’s attitude to this with the revision of the carers’ strategy?
Lord Prior of Brampton
I think we have a direct Question on carers next week. We are absolutely committed to supporting carers. Where people who have been in hospital for more than five years are discharged back into the community, as it were, the CCGs will provide them with a dowry to cover their costs. It will be very clear that the funding of those patients will stay with the CCGs.
NHS: Hospital Overcrowding
Baroness Pitkeathley Excerpts(8 years, 10 months ago)
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Lord Prior of Brampton
My Lords, a lot of what was said by the person, whose name I cannot remember, to whom the noble Lord refers, was absolutely right, but when he said that there were no more efficiencies to be gained he was completely wrong. We can still achieve huge efficiencies throughout the whole healthcare system, in the context that the NHS is one of the most efficient systems in the world, but it can be better. It would be completely wrong to say that no more efficiencies can be achieved.
The Lord Privy Seal (Baroness Stowell of Beeston) (Con)
My Lords, it is the turn of the Labour Benches. While I am on my feet, I remind noble Lords that we should not be reading out questions at Question Time.
Baroness Pitkeathley
My Lords, will the Minister agree that there is bound to be overcrowding in hospitals if we have a point of entry without any guaranteed point of exit? Therefore, unless social care is adequately funded and organised, we will always have this problem of overcrowding, particularly where old people are concerned. I would be very glad if he did not refer me to the better care fund as the answer to this, because it is already oversubscribed many times.
Lord Prior of Brampton
My Lords, I will not refer to the better care fund, but I agree with the noble Baroness that flow through a hospital is essential. Blockages at the end of the flow can cause problems further down the line in A&E departments. I entirely agree with the noble Baroness’s analysis, but it is more complex than just looking at social care. Two-thirds of the delayed transfers of care are caused internally within the NHS, compared with only one-third by social care, but the noble Baroness makes a very strong point.
National Health Service
Baroness Pitkeathley Excerpts(9 years ago)
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Baroness Pitkeathley (Lab)
My Lords, I am indebted to my noble friend Lord Turnberg not only for securing this debate but for his long-term contribution to health debates and the development of health policy in your Lordships’ House. Like him and many noble Lords speaking today, I am greatly committed to the NHS. In fact, I owe my life to it. No price can ever be put on that, and no acknowledgment is enough.
Many statistics will be traded here today but I am not going to engage in that. I shall focus on the wording of the debate so far as future demands are concerned and offer my thoughts on what the NHS needs in order to be the institution we know, love and admire into the next century.
In my view, there are two essentials. First, to have a viable health service you have to have a social care service which works. We are all familiar with the reasons why the post-war settlement set up different systems of care: men died at 66—one year after retirement—and women at 68 or 69, so you did not need much social care in those days. Now, with our ageing population, the contrast between a health service free at the point of use and a social care system which is means-tested and publicly funded only for those with heavy needs results in a lottery, so the type of ailment you have will determine the financial support you get to cope with its effects. There is no equity. Moreover, efficiency is hampered by a lack of integration in organisation as health and social care are separately commissioned. Look at the 3,000 hospital beds today occupied by people fit to leave but stuck there because funding or assessment has not been resolved. The economic cost of this is huge but to it must be added the cost of the human misery caused by this situation.
We simply must move to a single, ring-fenced budget for health and social care which is commissioned in one place and within which entitlements are understood. We hear constantly that health and social care are becoming better integrated. In the 18 years I have been in your Lordships’ House, I have lost track of the number of times I have heard that assurance from Ministers on all sides of the political divide, but progress is piecemeal at best. We have to hope that somewhere, sometime and soon we will have a Government with enough vision and courage to disregard the five-year focus of any Government and propose a proper reassessment of the post-war settlement to reflect the current and future needs of our ageing nation. It can be done with vision and commitment, as my noble friend has shown us in Salford.
The second thing the health service needs—here I echo the noble Lord, Lord Fowler—is to focus not so much on curing illnesses but on the prevention of illnesses. Statistics are legion about the illnesses which are debilitating to the individual and expensive to the NHS, and the obvious way of tackling them is to prevent them arising in the first place—for instance, diabetes, so associated with obesity; strokes, so associated with high blood pressure; and lung diseases, so associated with smoking and lack of exercise. Yet time and again we hear that nowadays prevention programmes run statutorily or by the voluntary sector are being cut because they are long-term investments and may not pay off, so to speak, for as much as 10 or even 20 years, so they make easy targets. Does the Minister agree that this is short-sighted? We are at a point where only far-sighted, perhaps controversial, but courageous actions will preserve for the long term our much-loved and much-admired NHS.
Four Seasons Group
Baroness Pitkeathley Excerpts(9 years ago)
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Lord Prior of Brampton
My Lords, I could not see where the question was coming from. I am not fully briefed on the financial instrument that my noble friend—I am sorry; the noble Baroness—referred to. I will have to research it and get back to her.
Baroness Pitkeathley (Lab)
My Lords, does the Minister agree that Four Seasons, which is the subject of the Question from my noble friend on the Front Bench, is only one of the groups facing financial crisis? It is estimated that by 2020 there will be a funding gap of £3 billion for the residential care sector, and 15 social care groups warned the Chancellor of this before the Autumn Statement. Have the Government any long-term plan for funding and improving social care or are they committed to short-term solutions and to saying that it is a matter just for local authorities?
Lord Prior of Brampton
My Lords, clearly, it is a matter principally for local authorities. However, the Government are making available in the spending review another £1.5 billion for the better care fund and allowing local authorities to raise a special precept of 2%. The oversight provisions of the CQC cover 45 providers, which cover some 20% of the market. It is intended that that will give early warning to local authorities of any likely collapse.
Residential Care: Cost Cap
Baroness Pitkeathley Excerpts(9 years, 1 month ago)
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Baroness Pitkeathley (Lab)
My Lords, I thank my noble friend for the opportunity to debate this important issue and congratulate her on her timing, in a week when so many relevant reports are being published.
Your Lordships will know that it has become axiomatic to say that social care is in crisis. The situation faced by care homes is an integral part of that, but I must first acknowledge the improvements in the care provided in care homes since I was first involved in this issue more than 40 years ago. We have moved a million miles away from the old pattern of local authorities providing a very low level of care, to a mixed economy of mostly private and voluntary care home owners commissioned to provide care by local authorities. Our standards are now higher. Single rooms with en-suites were unheard of in the 1980s. Now they are of a standard to which everyone aspires, although sadly, financial pressure is now leading to concerns about the quality of the care.
While we must acknowledge improvements, we cannot turn away from the problems faced by the care home sector. It is proving more and more unstable as cuts to local authority budgets bite and financial pressures lead to concerns about the quality of care and the amount of care available in the future. The delayed implementation of Part 2 of the Care Act, the new means-test levels and the increased pressure on local authorities to arrange care at the request of self-funders all contribute to the crisis. I, like other noble Lords, would like to know what has happened to the saving the Government accrued by not implementing the care cap. I am sure the Minister will tell us that. It was to be hoped that following the Autumn Statement, we might have been more optimistic but there is widespread agreement among care home providers and others that the Chancellor missed an opportunity. Indeed, it has been called another setback for social care. Of course, the major review announced by the Chancellor into integrating health and social care by 2020 is welcome, although I would be more hopeful of this if it were not the umpteenth time I have heard such a pledge over my lifetime. Indeed, in the 18 years I have been in your Lordships’ House, I do not think there has been a year when we have not had a debate—sometimes I have been sandwiched between the noble Lords, Lord Lipsey and Lord Warner, as I am today—in which better integration of health and social care was called for and promised. We are still waiting.
Councils, as we have heard, will be able to raise council tax by up to 2% to fund adult care, but not every council will be able to levy this much as their cost bases are so different and it will not be uniform across the country in any case. If every council raised it by the full 2%, this would only raise about £800 million—a fraction of the shortfall of £2.9 billion. And we still have a major problem with the relative clout of health and social care, as the noble Baroness, Lady Brinton, has reminded us. We tend to focus on hospitals and healthcare, while social care in any form is seen as a poor relation. It is news if hospitals are under pressure, much less so if local authorities are, and even less if care homes are. I, too, want the crisis in social care and the care home sector to be given as many column inches as the floods have been given this past week.
Undoubtedly, care homes will begin to close when the national living wage is introduced in April. No one disputes that this is the right thing to do but we have to recognise the strain it will put on care homes, especially the small operators. One group of providers estimates that it will cost £10 million to put their 14,000 employees on the national living wage. Care homes which provide for self-funders will no doubt put their fees up to accommodate this, but those who depend on state-funded residents have already suffered a real-terms cut of 5% in fees over the past five years. Even if councils do manage to raise more via council tax and raise fees accordingly, I fear that many homes will shut.
Nor should we confine our concerns to the private home care sector. Thousands of people in residential care are provided for through the voluntary sector, and these homes are often preferred by residents for the understanding they bring to particular conditions or particular ethnic groups. Many voluntary organisations have in fact been subsidising the care home sector for years. Financial pressures are now catching up with these organisations too as their fundraising becomes more difficult and local authority support is being withdrawn. Naturally, this will be of great concern to family carers. For many, care homes are a last resort, contemplated only when the carer is absolutely at the end of his or her tether, often after years and years of coping alone or with minimal support. I remind your Lordships that the latest assessment of what carers save the nation is £132 billion a year—the cost of another complete health service.
Sometimes, having a care home available in the background or to provide respite care, if only for a weekend or the odd week once a year, enables the carer to continue. Therefore, carers’ needs must be factored in when we contemplate the future of the care home sector. Even when the cared-for person is eventually admitted to the care home, the family carer often visits every day and spends many hours seeing to the needs of their loved one, becoming part of the care team.
Good care that meets the needs of the person being looked after can improve a carer’s ability to cope for longer periods. If care is poor, it can have a huge and damaging effect on carers as well as residents—not only directly on the amount of care they have to provide themselves, but on their emotional and physical health and their finances. If residential care becomes a less viable option in certain areas, the consequences are stark for families as well as for those in need of care.
We have concentrated today on the problems faced by the care home sector. Many will be solved by more money but we really need—as so many of us have been saying for so many years—a five-year plan for social care as far reaching as the one for the NHS: a fully integrated service with budgets and services that are not differentiated. That would be possible if the will was there but, sadly, there is no sign of this so far. I am sorry to sound cynical. I hope the Minister can convince me otherwise.
Social Care and Support: Funding
Baroness Pitkeathley Excerpts(9 years, 2 months ago)
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Lord Prior of Brampton
I thank the noble Baroness for those comments. I do not recognise the size of the cut to which she alluded. The figures that I have seen indicate that in cash terms it has been broadly neutral over the last four years, representing a real-terms cut of probably more like 10%. However, I think we are cavilling over numbers here because I agree with her broader comments about the state of the social care sector. We have, indeed, noted the savings gained from the delay in implementing the Dilnot proposals, which have been brought to the attention of the Treasury.
Baroness Pitkeathley (Lab)
My Lords, while I recognise the Minister’s concern about the spending review, does he accept that the lack of proper provision of social care has a very profound effect on the rest of the economy? I offer as evidence a family carer to whom I spoke last week. She is a single mother. She looks after her mother, who has Alzheimer’s, and a son with severe learning difficulties. She has been doing so for many years. She has been receiving two afternoons a week of respite care for the son and gets one day of daycare for the mother. This rather minimal provision has just about enabled her to cope. Both those services have now been withdrawn. I fear that she will have a breakdown because she is so distressed and under pressure. If she does, all three of those people will be a charge on the state. Will the Minister explain how that makes any kind of economic sense?
Lord Prior of Brampton
There is no doubt that what the noble Baroness says is true: the impact on other parts of the economy will be significant. It is also true that the impact on the healthcare system of reduced resources in social care will have an effect, which is why we are developing the better care fund and why we believe that more of the health and social care budgets should be pooled and used as one. Again, that is an integral part of the Five Year Forward View. At the risk of being boring, I am afraid that I will repeat myself: we will have to wait until the end of November before we know what the financial settlement is.
Social Care
Baroness Pitkeathley Excerpts(9 years, 3 months ago)
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Lord Prior of Brampton
The position on the savings from deferring the introduction of the Dilnot proposals is that they are being taken into account under the spending round and I cannot comment further today.
Baroness Pitkeathley (Lab)
My Lords, is the Minister aware that data from the Health & Social Care Information Centre show that without doubt the social care system is not just under pressure, as he has said, but at breaking point? The figures also show that family carers are under increasing pressure and receiving far less support and back-up. In fact, their quality of life and satisfaction with social services have dropped hugely in the past two years and now only 39% of them say that they have as much social contact as they want and need. Does the Minister agree that support for family carers is an absolute priority and must be maintained since they are, after all, the main providers of social care?
Lord Prior of Brampton
The noble Baroness says that the care system is at breaking point. The CQC’s report out today says that it is “fragile”. I think it is very variable. Some care providers are finding life extremely difficult but it is highly variable; it depends very much on the mix of clients that care providers are looking after and the extent to which they are funded by local authorities and the extent to which they are funded privately. But I take on board what the noble Baroness says and take it very much to heart.