Integration of Primary and Community Care (Committee Report)

Baroness Tyler of Enfield Excerpts

Thursday 9th May 2024 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, this debate is very timely as it picks up neatly from our recent debate on the long-term sustainability of the NHS. One of the key takeaways from that debate was the urgent need to move to a more preventive model of care, with investment moved upstream. It will be critical if we are to lower waiting times, improve access and reduce health inequalities.

It is indisputable that funding growth in the health and care system is skewed towards the acute sector. Despite the fact that the majority of daily NHS activity happens in general practice in the community, a large proportion of expenditure on health and social care goes towards acute hospital trusts. Community sector funding has grown at only half the rate of hospital trusts in recent years. The answer to overcrowded hospitals is not simply more hospitals; the health and care system must be radically refocused to put primary and community care at its core.

As we have already heard, a more radical shift to a preventive model of health was one of the key findings of our Select Committee, which was so superbly chaired by the noble Baroness, Lady Pitkeathley—whom I always think of as my noble friend. In short, our committee found that a lack of co-ordination between the everyday primary and community services relied on by people using the NHS was leading to substandard care, missed opportunities for home or community-based treatments, and an undue strain on already overstretched hospitals. Our report argued for a healthcare sector where patients were given the type of care they needed, when, where and how they needed it. That might be access to a GP, a pharmacist, a district nurse or a mental health nurse, along with greater focus on more joined-up preventive care. The evidence is quite clear that investing in primary and community care—which includes mental health—results in lower demand in hospital and emergency care. It really is not rocket science.

A wholesale shift in thinking and culture is required, and it goes a lot wider than funding, as our report said. As the King’s Fund has argued, it involves national measures and targets for the health and care system shifting towards longer-term goals to integrate care and ensure that services can focus on population health rather than being focused on short-term acute measures. This approach is very much backed up by the World Health Organization, which has argued that a primary and community care-focused approach is the most effective and sustainable way of improving the health and well-being of our population.

We have already heard about integrated care systems, which have an important role to play in delivering this change, particularly if they focus on population health, as was the original intention. From the evidence we received, it was clear that local leaders know the challenges for their local communities and the local landscape of primary and community care, and they know it best. Leaders of integrated care systems, place-based partnerships, including health and well-being boards, and primary care networks are best placed to design and deliver joined-up primary and community care.

ICBs should be held to account for their achievements in growing primary and community care services rather than for the performance management of hospital systems, and a stronger primary care voice on ICBs and representation from the voluntary sector would undoubtedly help.

It was clear, as we all know, that the workforce is crucial, not just in primary and community health but in adult social care and the voluntary sector. We need a skilled and well-valued workforce to support people to live independent and healthy lives. Surely the Government should now commit to fully funding and delivering the NHS long-term workforce plan, alongside developing an equivalent plan for social care, where workforce shortages are leading the sector to struggle to support those who need social care, in turn placing additional pressures on primary and community care. Can the Minister say when the Government will heed the calls of so many in this Chamber and in the wider sector to produce a workforce strategy for social care?

Other speakers will no doubt focus on the importance of data sharing for successful joined-up services. We must ensure that patient records can be easily accessed across the health and social care system, including in primary and community care. I found the government response to our recommendations on this issue vague and technocratic. Will the Minister please say exactly what the Government are doing to ensure this happens?

I will pick up on a couple of other specific points from the government response. Recommendation 2 of our report said that elected local government officials should be given the right to chair ICBs where that was the will of the board, underlining the truly joint and equal role of NHS bodies and local authorities in producing a holistic health and social care system. The government response did not make clear whether they were prepared to let this happen. Can the Minister please answer this specific point?

Recommendation 5 was for the Secretary of State to instruct the CQC to develop a specific integration index to compare how well ICSs co-ordinated different services in their areas. The government response does not commit to implementing this. Will the Minster say what the Government’s intentions are in this area?

Finally, recommendations 14 and 16 contained important proposals on training and job rotation. We saw a clear tension between our hospital-centric system of health and care, with increased specialism, and people having increasingly complex health and care needs, which need an integrated, holistic response, hence the need for a different approach to training and job rotation. I would like to see clinical and managerial health leaders strongly encouraged to work in community settings and develop experience across a range of sectors. I found the government response on this unsatisfactory—indeed, there was no response to the point about job rotations. I strongly urge the Government to think again.

NHS: Long-term Sustainability

Baroness Tyler of Enfield Excerpts

Thursday 18th April 2024 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I, too, thank the noble Lord, Lord Patel, for the debate and I congratulate the noble Baroness, Lady Ramsey, on her outstanding and moving maiden speech. As we have already heard today, public satisfaction with the NHS has fallen to an all-time low but, despite this, there is still strong support for its three founding principles: free at the point of delivery, primarily funded through taxation and available to everyone.

Last year, the King’s Fund published a report on the performance of the NHS compared with the health systems of 17 other OECD countries. Essentially, it was a scorecard which showed that, on the plus side, the NHS performs well in protecting people from some of the “catastrophic costs” of falling ill, and a relatively low share of the UK’s health budget is spent on administration—some might be surprised at that. On the minus side, the report concluded that the NHS has fewer key resources than its peers, below-average health spending per person, fewer doctors and nurses, less equipment such as CT and MRI scanners, and fewer hospital beds. In addition, the report said the NHS performs noticeably less well on outcomes such as survivable cancers, treatable mortality and life expectancy.

Various independent commentators have concluded that changing the funding model is not the primary answer. Nor, of course, is it either desirable or feasible to always just pour more money in. The important thing, as the Health Foundation has argued, and I concur, is to get the current NHS model to work better—that is, to reform the way it works. The key, surely, is to increase capacity in the right places. That is so simple to say but so hard to do. It is indisputable that funding growth is skewed towards the acute sector. Despite the majority of daily NHS activity happening in general practice and the community, a large proportion of expenditure on health and social care goes towards acute hospital trusts.

In my view, the answer to overcrowded hospitals is not simply more hospitals. As the noble Lord, Lord Patel, and others have said, the health and care system must be radically refocused to put primary and community care at its core if it is to be effective and sustainable and so that people can get access to their GP, a pharmacist and a district or mental health nurse.

That was one of the key findings of the Select Committee on Integration of Primary and Community Care, on which I had the privilege to sit, which was so expertly chaired by the noble Baroness, Lady Pitkeathley. The committee found a lack of co-ordination between the everyday primary and community services relied on by people using the NHS, which was leading to substandard care, missed opportunities for home or community-based treatments and overstretched hospitals being put under even further strain.

I turn now to productivity. Respected health commentators have been looking at what is called the productivity conundrum. A recent Institute for Government report found that, despite increased spending, much of which has gone on increasing staff numbers, there has been no resultant rise in productivity, if measured against metrics such as the number of patients treated. We really need to understand why this is. The report drew particular attention to the fact that most hospitals are running at above full capacity. They do not have enough beds and it is estimated that each day around 13,000 beds are occupied by people who do not need to be there but cannot be discharged because of lack of community and social care. We all know that, after years of neglect and underfunding, our social care system is in crisis.

Secondly, despite notable increases in the headline number of staff, the NHS is losing too many experienced employees and they are being replaced with junior staff who are naturally less experienced and need more support. Staff burnout, low morale and pay concerns are cited as the principal reasons for this. A recent IFS report also concluded that, while

“It is difficult to measure productivity … the NHS is less productive now than pre-pandemic”,


particularly in hospitals. The report was at pains to say that was not about staff not working hard but pointed the finger at Victorian estates, too few diagnostic machines and outdated IT systems causing communications problems within and between hospitals.

I believe that there should be far greater focus on retention and making the NHS an attractive place to work. That should be central to the NHS workforce plan, and we need a plan for social care, too. If not, we shall never clear the backlog or reduce waiting lists. We also know that valuable NHS equipment and operating theatres too often stand idle in the evenings and at weekends. Can the Minister say what plans the Government have to address this and whether they might include bringing in independent clinical teams from outside the NHS—a point raised by the noble Lord, Lord Reid.

Finally, are we going to see a productivity plan to set out how the productivity increases announced in the spring Budget, alongside the £3.4 billion additional capital investment will be achieved? In my view, Parliament needs to be scrutinising these plans.

National Health Service: 75th Anniversary

Baroness Tyler of Enfield Excerpts

Thursday 30th November 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords I start by expressing my heartfelt thanks to all NHS staff for the tremendously difficult and important job they do. I particularly pay tribute to the memory of close to 1,000 NHS and care workers who died while working to save others during the terrible Covid pandemic. We owe them a debt of immense gratitude. Like other noble Lords who have spoken today, I know that I and other family members owe our lives to the NHS, and that is why it holds such a central place in our country’s social fabric and in our hearts.

It is against that backdrop that I want to talk about the need for reform. As we mark the NHS’s 75th anniversary, it is right that we should reflect on its performance and what could and should be done to improve and renew it. We have already heard a lot of statistics about waiting times and numbers treated; I want to concentrate on the wider context for health and then look specifically at the thorny question of productivity.

It has been estimated that some 80% of the health needs of people across the country are not within the direct control of the NHS. We also see large inequalities in health outcomes between different groups and communities. The terms “NHS policy” and “health policy” are too often used interchangeably, but they are not interchangeable. Most policy which impacts the health of the nation—housing, transport, employment and so on—is made outside the NHS, which is why we need to focus on the wider determinants of health and devise cross-government strategies to improve health and well-being. It is also why it is so important to ensure that more money goes into prevention and public health rather than just into the NHS, a point just made so compellingly by the noble Baroness, Lady Taylor of Stevenage. Looking at health and well-being in the round, rather than simply at how we prop up the NHS in its current form, must be at the forefront of our thinking. We have already heard, and it is very concerning, that public satisfaction with the running of the NHS is at its lowest level in 25 years.

What is going on? In July this year, the chief executives of three health think tanks, the Health Foundation, the Nuffield Trust and the King’s Fund, wrote a letter to the three party leaders calling for an end to “short-termism in NHS policy-making”, warning that promising unachievable, unrealistically fast improvements without a long-term plan to address the underlying causes of the current crisis is a strategy “doomed to failure”. We would do well to heed that. The letter outlined four key areas to focus on: investing in physical resources; reforming adult social care; committing to a long-term workforce plan; and cross-government working on the underlying economic and social conditions affecting health.

Specifically, the letter pointed out three things. First, due to a decade of underinvestment compared to the historic average, and capital spending well below comparable countries, the health service has fewer hospital beds than almost all similar countries, outdated equipment, dilapidated buildings and failing IT. Secondly, despite long-term objectives to reduce reliance on acute hospitals and move care closer to the community, which I very much support, spending continues to flow in the opposite direction. Thirdly, while the NHS long-term workforce plan is to be welcomed, ambitious steps to increase the number of staff, through training, apprenticeships and international recruitment, et cetera, risk being frittered away if trainees continue to drop out and poor morale and sickness continue to drive staff to leave and retire early. In short, sustained action is needed to make the NHS a better place to work.

Finally, as we have said so many times in this Chamber, we cannot reduce pressures and improve the performance of the NHS without addressing the challenges faced by adult social care. I join the noble Lord, Lord Prentis, and ask, once again, what plans the Government have to provide a social care workforce plan to complement the NHS plan?

It is also worth comparing the NHS to the healthcare systems of other countries. The King’s Fund did this recently and concluded that, first, the NHS is neither a leader nor a laggard when compared to the health systems of 18 similar countries. Secondly, the UK has below-average health spending per person compared to those countries. Thirdly, the UK lags behind other countries in its capital investment and has substantially fewer key physical resources than many of its peers, including CT and MRI scanners and hospital beds. Finally, the UK has strikingly low levels of clinical staff, including doctors and nurses, and is heavily reliant on foreign-trained staff. All that is critical to productivity, which I want to turn to finally.

Respected commentators such as the IFS, the Institute for Government and the Health Foundation have been looking at what has been called the productivity conundrum. The Institute for Government report The NHS Productivity Puzzle found that despite increased spending, particularly since 2019, much of which has gone on increasing staff numbers, there has not been a resultant rise in productivity if measured against metrics such as the number of patients treated. It draws three conclusions. First and foremost, hospitals are running at above full capacity, they do not have enough beds, and too many of the beds they do have are full of people who should not be there. There is a lack of capital investment, low diagnostic equipment stocks, et cetera. Secondly, despite notable increases in the headline number of staff, the NHS is losing too many experienced employees, and they are being replaced with more junior people who are naturally less experienced and who need more support. Staff burnout, low morale and pay concerns are cited as key reasons. Thirdly, it says, the NHS is badly managed and all the changes over the last decade have made managers’ jobs a lot harder.

Finally, a recent IFS report came to similar conclusions about the reasons for the low productivity. It acknowledged it was difficult to measure productivity, and that point came out clearly when Amanda Pritchard was before the Health and Social Care Committee recently. She argued that it is hard to measure productivity, but what plans do the Minister and NHS England have to publish their own analysis of NHS productivity and ways to improve it?

There is much that we could and should be doing. My points and the IFS statement should not be interpreted as NHS staff working less hard. It is the other points that are most important. I expect they are many reasons, but the need to make the NHS an attractive place to work is critical and should be central to the NHS workforce plan.

Mental Health: Children and Young People

Baroness Tyler of Enfield Excerpts

Thursday 23rd November 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, it is always a great pleasure to follow on from the wise words of the noble Lord, Lord Laming. I congratulate my noble friend Lord Russell on securing and introducing this debate in such a moving and comprehensive way. It is such an important issue and is very dear to my heart. I also congratulate the noble and learned Baroness, Lady Hale, on her excellent and highly entertaining maiden speech. I was a bit perplexed when I saw that it was her maiden speech, but now I understand. I also thank the many charities and others in the sector who have sent me excellent briefings.

It has been an excellent and very well-informed debate. I will pick up on some of the main themes covered. Quite rightly, we have heard a lot about the state of children’s mental health in this country, and many of the statistics are indeed bleak. To summarise a complex picture, an increasing number of young people are experiencing mental health problems for a wide range of reasons, which have been highlighted compellingly today. Yet far too many are unable to access the help that they desperately need, either through school or NHS services.

Without doubt, young people’s mental health services are struggling to meet demand. As a result, thresholds for treatment are very high, with many young people turned away because they are “not well enough”. Those who do get accepted into CAMHS are often left waiting many months, if not years, for treatment, during which time their mental health often deteriorates.

I will say a few more things about demand for, and access to, services. Mental health providers are concerned that they are seeing an increase in both the severity and complexity of the mental health needs of children and young people—exacerbated by both Covid and the cost of living crisis, which we have heard about today. The NHS Confederation estimates that demand has increased by 89% and that mental health services are treating double the number of children and young people with eating disorders who need urgent care than before the pandemic—which we just heard about. That is the equivalent of six children in a class of 30. The number of referrals to CAMHS reached a record number in May of this year and the number of urgent referrals of children to crisis teams has also reached a record high. Particularly worryingly, suicide rates among young females have been steadily increasing.

Looking ahead, it is pretty daunting. It has been estimated that 1.5 million children and teenagers will need new or additional support for their mental health over the next three to five years. That is going to take a very different approach. The unpalatable fact is that only around a third of children with a probable mental health problem are, at the moment, able to access treatment. I think that shows how far away from parity of esteem with physical health we really are.

I am particularly concerned about the huge regional inequalities and the lottery of what support is available depending on where you live. My noble friend Earl Russell referred to an FoI investigation by the journalist Justine Smith, published in the House magazine in April. It revealed a postcode lottery in child mental health care, with some desperate young people waiting up to four years for help. Results from the 58 trusts and boards that responded to the request showed that the position in England was considerably worse than in Scotland and particularly Wales. Almost three-quarters of the English trusts said that they currently had at least one young person who had been waiting at least a year, and two-fifths had someone waiting at least two years. Funding ranged from £35 per child under the former Doncaster clinical commissioning group—0.5% of its total budget—to £135 per child in Salford, or 2.2% of its budget. That is a huge difference. I think variations of this scale are simply unacceptable. This data needs to be tracked and published regularly to throw a spotlight on what is going on locally.

On funding, years of underfunding and neglect of children's mental health services have taken their toll, as we have heard loud and clear. They have been subject to what I call the “double Cinderella syndrome”, or indeed the “double-8 syndrome”—by which I mean that only 8% of mental health services spending was spent on children and young people's mental health in 2021-22, and in 2022-23 just over 8% of the NHS budget was spent on mental health generally. To meet increasing demand, it has been estimated that funding for mental health services would have to rise to as much as £27 billion by 2033-34. That is the backdrop against which the very welcome but, frankly, relatively modest increases in government funding since 2017 should be viewed.

The NHS Long Term Plan, published in January 2019, included a welcome commitment that funding for children and young people’s mental health services should grow faster than both overall NHS funding and total mental health spending. But it has become harder to track whether this has happened in the switch from CCGs to integrated care boards, and with the changes to how the mental health investment standard and the dashboard operate. So could the Minister say when the NHS mental health dashboard is next due to be updated and whether, and by how much, the commitment in the NHS Long Term Plan has been met? If he does not have those figures to hand, could he please write to me.

A point not covered so far in our debate relates to the fact that mental health is now part of a new major conditions strategy, rather than having its own stand-alone strategy. I know that many consider that a regressive step. This occurred following the cancellation of the previous long-term mental health and well-being plan that had been proposed by the Government. With the new major conditions strategy focusing on a range of conditions such as cancer, heart disease, musculoskeletal disorders, dementia and respiratory diseases, there is a clear risk that it will focus mainly on middle-aged and older people and that the mental health of infants, children and young people will be neglected.

So, what is needed? A lot of it has been covered in today’s debate and I support others who have been calling for a comprehensive cross-government strategy, looking at all aspects of mental health support. There are a number of things that need to be included.

I will start with prevention; any good strategy should start with prevention. The Royal College of Psychiatrists has recently published a report calling on the Government to prioritise the mental health of babies and children. It set out evidence showing that intervening very early on may help stop conditions arising or worsening, and prevent babies and young children developing mental health problems in later life. This might include support for mothers in pregnancy, working with parents to promote attachment to their children and recommending parenting programmes in the early stages—many of the things that the noble Baroness, Lady Hollins, talked about. I very much hope that family hubs will develop such services so that they are available wherever people live. Could the Minister say whether this is the case? I fully endorse the calls today for the family to be supported as the primary source of emotional support and well-being.

I turn next to early intervention services. Again, we have heard today how crucial early intervention is to stop problems escalating. In other words, the earlier a young person can get support for their mental health, the more effective it is likely to be. That is why I have been a strong backer of the early drop-in support hubs for 11 to 25 year-olds. They are on a self-referral basis, which I think is exactly what is needed, and are embedded in the community. They have been championed by YoungMinds and many others. I very much welcome the £5 million announced by the Government last month for 10 existing hubs and I strongly support the call for a national network of hubs to support young people who do not meet the threshold for CAMHS support.

I move on to schools, which have an absolutely vital role to play, as my noble friend Lord Storey set out so eloquently. I have always supported the creation of mental health support teams in schools. I was struck by research evidence earlier this year from Barnardo’s, which delivers 12 such teams. The research found that the teams are effective at supporting children and young people with mild to moderate mental health problems. They improve their outcomes and, critically, are cost effective; they say that they save the Government £1.90 for every £1 invested. But, as we all know, the problem has been the frankly glacial rollout of this programme.

The high demand and long waiting lists for CAMHS that I talked about earlier place real pressure on these mental health support teams, which were not really set up to deal with the more severe issues. The Barnardo’s research identified a gap in the current model to address the needs of children with moderate or more complex needs, children with special educational needs and younger children. It recommended that the rollout should include school counsellors to fill this gap. I support this recommendation and am delighted that next Monday I will be introducing my Private Member’s Bill, which is designed to ensure that every school has access to a qualified mental health professional or school counsellor—a key Lib Dem policy, as we heard earlier. I hope that this will provide a much-needed boost to ensure that all schools are able to provide their pupils with the mental health support they need.

I turn briefly to CAMHS services. As the Children’s Commissioner pointed out in her annual report, the stark reality is that too many children still face high access thresholds, rejected referrals and long waiting times. Children’s mental health was looked at by the Lords Select Committee examining the implementation of the Children and Families Act 2014, which I had the honour to chair. We were shocked by the results of a survey we commissioned, which showed that in many places CAMHS had reached crisis point. I vividly remember one mother, who told us:

“Having had a seven-year-old son who was so dysregulated he was trying to throw himself out of windows and grabbing knives, there was no support for him (or us). The GP, after two failed CAMHS referrals as he ‘didn't meet the threshold’ told us, if we could at all afford it, even if it means borrowing money, to find support privately. That CAMHS will not accept a child unless they have made two viable attempts on their own life”.


I join my noble friend Lord Russell in asking the Minister what plans the Government have to implement the four-week clinical access standards for children and young people’s community health services, which have already been piloted? What have those pilots found? Will a fully funded plan be introduced to reach those standards?

In-patient care is another key area of concern that has come up today. It is estimated that some 3,500 children under the age of 18 are admitted to mental health in-patient facilities. As my noble friend Lord Allan said, despite the commitment to eliminate out-of-area placements, too often children are still being admitted to places far from home without a clear understanding of their rights and subject to restrictive interventions and inappropriate care. The right reverend Prelate the Bishop of St Albans made that point compellingly.

The transition to adult mental health services is just not working for too many young people. The NHS long-term plan set out an ambition to move to a nought to 25 model for young people. I supported that, but it is not clear what progress has been made towards it. Is the Minister able to say more about this? There is significant variation across the country in the age at which young people are expected to move to adult services. This transition is often abrupt and based on a person’s age rather than their readiness. Differences in threshold also mean that young people getting support from CAMHS may not meet the threshold for support for adult services, so yet again they fall through gaps.

I finish with a number of questions for the Minister. I ask him to write to me if he is unable to answer them now. What plans do the Government have to expand access to mental health support teams to children and young people across all schools and colleges in the country as quickly as possible? How do the Government intend to tackle the major regional inequalities in spending and wait times for CAMHS? Given the Government’s regrettable decision to roll back on previous plans to publish a stand-alone 10-year mental health plan, can the Minister say how the Government will ensure that the inclusion of mental health in the forthcoming major conditions strategy will properly tackle the huge challenges in children and young people’s mental health? Given the recent funding for the 10 innovative early support hubs, can the Minister clarify when this programme will report, what the evaluation will entail, and whether Ministers will commit to a rollout if findings are favourable? Given the postponement, yet again, of the long overdue reforms to the Mental Health Act, what immediate action are the Government taking to improve the plight of under-18s admitted to in-patient care units to ensure they and their families are aware of their rights and receiving appropriate care?

Today’s debate has shown that there is a lot of consensus on what we need to do. I hope the policymakers will listen to us so that we can make real progress.

King’s Speech

Baroness Tyler of Enfield Excerpts

Thursday 9th November 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, the central theme of the gracious Speech was long-term decisions to change this country for the better, but so very much was missing. I particularly liked the description we heard of it as thin gruel.

As other noble Lords have said, in appropriately trenchant terms, and my key point today, where was the long-awaited mental health Bill? It is beyond disappointing that a new mental health Bill to reform the 1983 Act was not part of the King’s Speech. Coupled with the abandonment of the 10-year mental health plan earlier this year, many in the sector and beyond are now understandably concerned that mental health is no longer a political priority.

I will just give a quick reminder of the facts. A new mental health Bill was a manifesto commitment from this Government in both 2017 and 2019. As we have already heard from the noble Baroness, Lady Watkins, and my noble friend Lady Barker, there is a totally unacceptable disparity between the white population and black and other racial groups when it comes to detention under the Act. This cannot go on. The 2018 independent review of the Mental Health Act, chaired by Sir Simon Wessely, set out very clear recommendations for modernisation, including greater legal recognition of detained people’s treatment choices. The Act simply does not work for children and young people, with many having bad experiences when detained in hospitals. Much time and effort has already taken place to reform the Act, including a White Paper, and a draft mental health Bill introduced last year, which underwent pre-legislative scrutiny, as we have heard, in a Joint Committee chaired by the noble Baroness, Lady Buscombe, earlier this year.

Given all of this, is it any wonder that Sir Simon Wessely expressed his deep disappointment in the summer at the prospect of the Bill being delayed yet again, when, to use his own words,

“we’re so close to the finishing line”?

He added:

“Lots of people have put a lot of work into this. It’s not controversial. Nobody seems to disagree with what we’re trying to do”.


I cannot help wondering whether that is at the heart of its non-appearance.

Can the Minister say when the Government will issue their response to the Joint Committee report and explain what they intend to do in the absence of this much-needed reform? Will the Minister explain precisely why the Government have reneged on their commitment?

The gracious Speech mentions that “record levels of investment” are expanding mental health services. This is of course to be welcomed, but that is only part of the picture. Simply put, the current levels of investment do not in any way match the level of increasing need. Mental health has not received any of the additional funding committed to bring down elective waiting lists. As a result, over 1.2 million are stuck waiting for mental health support and targets contained in the NHS Long Term Plan are slipping backwards on perinatal mental health, children and young people’s services, NHS talking therapies and mental health crisis care. On top of this, there are chronic shortages in the mental health workforce, with 20% of mental health nursing posts currently vacant.

It is welcome that the Government are restating their commitment to deliver on the NHS Long Term Workforce Plan. However, the plan is much weaker on retention measures and fails to address many issues that contribute to high attrition rates across the whole NHS workforce. As others have said, implementation of the long-term workforce plan simply will not work without an accompanying social care workforce strategy. We urgently need a national workforce strategy that raises the status of the social care workforce and ensures that career progression, pay and rewards attract and retain the right people in the right numbers. Can the Minister say if and when the Government will commit to such a plan?

The CQC State of Care annual report, published only last month, received surprisingly scant attention in this Chamber, despite drawing attention to how the combination of the cost of living crisis and workforce pressures has led to what it termed “unfair care”, with longer waits, reduced access and poorer outcomes for some people in accessing health and care services. Most worryingly, it reported that “unfair care” really means that those who can afford to pay for treatment do so and those who cannot face longer waits and reduced access. Research by YouGov shows that eight in 10 of those who used private healthcare last year would previously have used the NHS, with separate research showing that 56% of people had tried to use the NHS before using private healthcare.

As we have heard, smoking is a big contributory factor in health inequalities, particularly for people with mental illnesses. That is why I welcome legislation to create a smoke-free generation by restricting the sale of tobacco and e-cigarettes to children. But other than that, sadly, there was little of real substance to address the difficult and persistent issues facing many babies, children and young people. Although the Speech contained a pledge to

“ease the cost of living for families”,

there was no specific commitment to support the 4.2 million children living below the poverty line. According to ONS polls, the cost of living remains the most pressing issue facing the country, with 89% of respondents reporting it as an important issue. What plans do the Government have to tackle child poverty?

On financial inclusion, we have heard so much about people’s problems and concerns about the cost of living and about their lack of financial resilience. We urgently need clear leadership from the Government, with a national financial inclusion strategy joining up the work of government and industry, and building the long-term financial resilience of the country.

In conclusion, there is simply so much more to do to change this country for the better for all our fellow citizens. This requires a radically new approach.

Adult Social Care: Challenge Procedures

Baroness Tyler of Enfield Excerpts

Wednesday 19th April 2023 Lords Chamber

Asked by

[Baroness Tyler of Enfield]

To ask His Majesty’s Government what assessment they have made of the Equality and Human Rights Commission’s report Challenging adult social care decisions in England and Wales, published on 28 February; and what steps they will take to make local authority care challenge procedures more accessible and transparent.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Markham) (Con)]

The Government have noted the findings in the report. Encouraging a culture of feedback and learning is vital if we are to improve services and people’s experiences of social care. The CQC’s local authority assessment framework, which went live on 1 April, includes oversight of local authority assessment and eligibility frameworks for adults and unpaid carers accessing social care and support. This includes looking at transparency and accessibility and whether people can appeal decisions effectively.

[Baroness Tyler of Enfield (LD)]

I thank the Minister for his reply. The EHRC report clearly demonstrates the problems facing social care users who have challenged local authority decisions, and it is a pretty bleak picture. But while there is much for local authorities to do to improve their complaints system, there are also important recommendations in the report aimed at government, including making the Local Government and Social Care Ombudsman the statutory complaints authority for social care in England. When and how do the Government intend to respond to these recommendations? Does the Minister agree with me that the shortcomings at local level will be remedied only by long-term sustainable funding of adult social care—not made easier by the Government’s announcement on 4 April, when Parliament was in recess, to hold back £50 million of the money promised to help plug staff shortages?

[Lord Markham (Con)]

First, we will respond in detail to the report the noble Baroness mentions. On funding, as I have mentioned before, the £7.5 billion over the next two years is a 20% increase and is substantial by any measure. I spoke to Minister Whately about this issue this morning, and she was at pains to say that, in terms of funding and overall numbers, everything is in place in this latest programme. Also, £600 million is being held in reserve to follow up in the areas that really need it.

Social Care

Baroness Tyler of Enfield Excerpts

Thursday 30th March 2023 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords—follow that. As the excellent reports we are debating today make clear, we are failing those in our society most in need of our care. As we have heard powerfully in today’s debate, the social care sector is in crisis due to chronic underfunding and the repeated deferral of hard decisions. Fundamentally as a society, we are sending the message that we do not truly value caring and caregivers.

The care that people, both older people and those of working age, need to have a good quality of life is often either unaffordable or unavailable. People who could be supported to stay in their own homes are being moved into residential care and people who are medically ready to leave hospital are unable to, because the care they need in the community is just not there. This has knock-on effects throughout the NHS. We know from the CQC’s latest State of Care report that the health and care system is gridlocked and is unable to operate effectively or, in some cases, at all—as we heard so poignantly from the noble Lord, Lord Polak.

As we have also heard, demand for care is rising as people live longer and often with more complex needs. As my noble friend Lady Barker explained, we now have a growing number of people without children of their own. Recent analysis from the King’s Fund showed that overall requests for social care have hit an all-time high.

At the same time, as we have heard, the workforce is in near meltdown. I want to explain why I use that term. We know that there are severe staff shortages and problems both in retention and in recruitment, which mean that current needs are not being met. Without major change, things are going to get worse as demand grows. As we have heard, according to the King’s Fund, the current social care staff vacancy rate is the highest since records began: 165,000 unfilled posts is a huge number.

Looking ahead, Care England estimates that the number of adult social care jobs will need to increase by 27%, to around 2.3 million, by 2035. In reality, we are looking at the prospect of further workforce reductions over the next 10 years as the current care workforce, more than a quarter of whom are over 55, retire and are not replaced. Poor pay and conditions are key drivers affecting recruitment. One in three care workers is paid the minimum wage, or less as their travelling time between clients typically goes unremunerated. At the same time, other sectors are offering far higher rates for, frankly, less demanding work.

It is a scandal that the social care workforce is among the lowest paid in our economy and zero-hours contracts are prevalent. The Health Foundation has found that staff experience much higher levels of poverty and deprivation than other UK workers and health workers. For many in the sector, career progression is simply non-existent. Given all this, it is not a surprise that the workforce is in near meltdown.

The impact of these workforce shortages on both patients and the wider NHS is devastating. First, increasing numbers of people, especially the elderly, have unmet care needs. Due to a shortage of care workers, 170,000 hours a week of home care could not be delivered during the first three months of 2022. That is seven times more than spring 2021.

Secondly, there is a backlog in initial assessments and long waiting times for many people to have their needs assessed. Shockingly, people are dying while waiting for care. Age UK found that some 37,000 people died in 2020-21 without receiving the care that they were waiting for. According to the CQC’s recent State of Care report, only two in five patients are able to leave hospital without delay when ready for discharge.

Many of these problems, which so many noble Lords have talked about, are rooted in funding, which has been inadequate for many years. According to the Health Foundation,

“When the pandemic hit … government spending per person on social care was lower in real terms than in 2009/10”.


This is compounded by how social care funding is often piecemeal, with crisis cash in winter making planning harder. This is exacerbated by the fact that the actual costs of providing care, either in the home or in running a care home—wages, Covid expenses and the increased costs of food and heating—are rising, but many local authorities are rationing social care to those in greatest need due to inadequate funding from government. This point was underlined last year by the Local Government and Social Care Ombudsman. At an individual level, a failure to introduce a cap on lifetime care costs means that one in seven people over 65 faces catastrophic costs of more than £100,000.

Like other noble Lords, I was particularly alarmed to read recent press reports suggesting that the Government are poised to cut £250 million from investment in the social care workforce in England. I join the noble Baronesses, Lady Andrews and Lady Donaghy, in asking the Minister, when responding, categorially to either confirm or deny that this is the plan.

Of course, all of this results in an overreliance on informal unpaid carers, as demonstrated vividly in the recent report of the Select Committee chaired by the noble Baroness, Lady Andrews. According to Carers UK, in England the number of unpaid carers outnumbered the paid health and care workforce by at least two to one. Many other speakers have pointed this out passionately in our debate today. Millions of unpaid carers are having to bear the negative effects of social care workforce shortages and a lack of funding for social care. This leaves far too many of them with very little support, often feeling isolated and undervalued in the face of the relentless demands of caregiving.

Too many unpaid caregivers face financial hardships themselves, as they receive little financial support. Many find it hard to juggle staying in paid employment with caring. That is why I was so pleased to support the Private Member’s Bill put through the Commons by my honourable friend Wendy Chamberlain MP; it had its Second Reading here recently. It creates a new entitlement for employees to take up to a week of unpaid leave a year in order to provide or arrange for care. Yes, it is a very small step forward in improving employment rights for unpaid carers, but it is important none the less.

The most depressing thing in today’s debate has been the litany of broken promises of reform over the past decade. We had Dilnot, endlessly postponed; and White and Green Papers that never materialised. As my noble friend Lady Jolly reminded us, the Care Act 2014 was a seminal piece of legislation, but key provisions in it have been indefinitely postponed. The Government’s “Build Back Better” plan for health and social care, published in 2021, led to the passing of a law to collect a health and social care levy, but this was then reversed and the charging reforms outlined were subsequently delayed—again.

Despite all this doom and gloom, I want to end with some solutions to add to the others that have been put forward. There are five things on my immediate wish list which I am very much hoping to see in the long-awaited government social care implementation plan.

First, we need to invest in the workforce, pay wages people can live on and offer career progression by professionalising the care sector. That is why I am so pleased that Liberal Democrats are calling for a legal obligation to provide a carer’s minimum wage, to be set at a rate of £2 an hour above the national minimum wage. This much-needed boost is long overdue, and I know others have referred to it.

Secondly, the Government need properly to fund local authorities so they can continue to provide the social care services they are legally required to, and ensure that care homes are paid a realistic rate rather than relying on excessive cross-subsidisation by self-funders.

Thirdly, we desperately need to integrate services, so that there is a joined-up preventive approach which reduces the risk of reaching crisis point and needing care home placement or hospital admission. I hope the development of 42 integrated care systems can help bring this about, but concerns remain that social care sector providers struggle to get their voices heard within these systems.

Fourthly, we must provide more support for informal carers and introduce a statutory guarantee of regular respite breaks for unpaid carers.

Finally, as others have said—including, very powerfully, the noble Lord, Lord Bradley—the carer’s allowance must be reformed so that it no longer discourages carers from remaining in paid work. The carer’s allowance is the lowest benefit of its kind and does not reflect the contribution of unpaid carers; it must be increased.

I therefore ask the Minister: what assurance can he give me that the vital issues that I and others have underlined will indeed be addressed in the Government’s plan?

NHS Staff: Food Banks

Baroness Tyler of Enfield Excerpts

Tuesday 7th February 2023 Lords Chamber

[Lord Markham (Con)]

That is a concern; we want to resolve the pay dispute. I know personally how much time and energy are being put into this from our side as well. Clearly, more needs to be done. We are not there yet, but I am hopeful that we will get there. At the same time, we did try to protect those on the lowest incomes, as I mentioned earlier. Everyone received a minimum of £1,400, which is 9.3%. Clearly, we will need to do more for the next year, but we are trying to protect those in the most difficult circumstances.

[Baroness Tyler of Enfield (LD)]

My Lords, can the Minister tell the House what percentage of NHS hospitals have subsidised canteens that staff can use at the end of long shifts, and how many of these are open in the evening and during the night, when access to reasonably priced hot food is hard to find? If the Minister does not have those figures, could he please write to me with them?

[Lord Markham (Con)]

I do not have those figures so I will happily write to supply them to the noble Baroness. However, I have some examples, such as Newcastle upon Tyne, where they have good free meal cards that they can give out to help people buy their meals discreetly themselves, or the Birmingham Women’s and Children’s Hospital, which has subsidised £2 hot meals that are available at any time. So there are some good examples of what trusts are doing to help people in the space, but I will write to the noble Baroness about the other cases.

Care Homes: Staffing

Baroness Tyler of Enfield Excerpts

Wednesday 11th January 2023 Lords Chamber

[Lord Markham (Con)]

Yes, absolutely. I find—and I talk as a businessman of 30-odd years—that by paying people well, you attract and retain the most motivated staff. It is the best way to run an organisation.

[Baroness Tyler of Enfield (LD)]

My Lords, is it not the case that there will be sufficient staff in the social care sector—both care homes and domiciliary care—only when we have a truly integrated approach to workforce planning across both health and social care? Yes, pay will be absolutely critical, but so will progression and career development opportunities, and opportunities for things like joint posts and rotational arrangements between the two sectors. What plans do the Government have to look seriously at this critical workforce issue?

Hospital Beds: Social Care

Baroness Tyler of Enfield Excerpts

Monday 19th December 2022 Lords Chamber

[Lord Markham (Con)]

I thank the noble Lord. Yes, we are, and I think that is shown by the investment we are putting into place. As I say, that will be up to £2.8 billion next year and up to £4.7 billion the year after, which will be a 22% increase. That shows that we are very serious about this.

[Baroness Tyler of Enfield (LD)]

My Lords, we have already heard about the crisis in the social care workforce. NHS leaders are calling on the Government to introduce a new national minimum care worker wage of at least £10.50 an hour to stem the flow of social care staff to other sectors. Can the Minister say what plans they have to introduce such a minimum wage, which could hardly be said to be stoking inflation at that level?

[Lord Markham (Con)]

Of course, the noble Baroness is aware that it is the third parties, whether it be the local authorities or the private sector, that employ them. But what we have done in terms of setting the national living wage, which I believe is around that amount, is exactly making sure that there is a minimum amount that these people can get. About 65% of the funding going into the system goes through to wages, so the £2.8 billion increase next year will flow largely into wages and salaries.