Social Care

Baroness Walmsley Excerpts

Thursday 1st December 2016 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been an excellent debate with many thought-provoking speeches, including, in particular, that of the noble Baroness, Lady Pitkeathley, in introducing the debate and that of the noble Baroness, Lady Cavendish.

Yesterday morning, there was a story on Radio 4’s “Today” programme that neatly illustrated how problems with social care affect the whole health and care system. The story was about ambulances and the fact that in the past year 500,000 extra hours were spent by ambulance crews waiting outside A&E departments, unable to discharge their patients, while other serious and urgent cases stacked up awaiting their arrival. The head of emergency medicine for the NHS gave an account of new ways of working that may help put a sticking plaster on the problem. However, the story illustrates very clearly the interaction between the various parts of the health and care system.

Of course, the reason ambulance crews have to wait so long is that A&E departments are full, unable to move their patients to beds in the wards because they are full too. One of the reasons that the wards are full is the delays in discharging patients to appropriate care in care homes or their own homes with a suitable package of help—and we know that people go to A&E, where the lights are on, because they cannot get an appointment with their GP. Nearly 570,000 bed days were lost in acute hospitals during the second quarter of 2016-17 as a result of delays in discharging patients, with problems in arranging social care now the main reason given by hospitals for these delays. This comes at a cost to the NHS of £820 million a year. The story illustrates why we need to sort out social care, apart from the need to ensure that elderly and disabled people get the care they need in a timely and dignified way.

The Care and Support Alliance of 90 charities points out that, as well as relying on help with everyday tasks such as washing, dressing and eating, social care plays a vital role in supporting recipients and their carers to move into, or stay in, employment, and in preventing avoidable expenditure, particularly in other parts of the health service. The charity Sense, which works for deafblind people, points out that in the past year alone 11.4% fewer people with sensory impairment were able to access services. This has greatly curtailed their community involvement and life chances.

The whole system is like a pack of dominoes that will fall with a great clatter unless something is done. That is why I, along with others who have spoken today, was shocked and horrified that, despite all the evidence that has come forward about the dreadful state of care funding, the Chancellor said not one word about it in the Autumn Statement and provided not one extra pound. The interoperability of all parts of the system of health and social care indicates strongly the need for a cross-party consensus on how we fund it in this country—I welcome the support on that from the noble Lord, Viscount Hanworth. While I look forward to the report of your Lordships’ ad hoc Select Committee on sustainability in the NHS, chaired by the noble Lord, Lord Patel, we need to go much further, as my right honourable friend Norman Lamb has so often proposed. We need to look at all the options: insurance schemes, the German scheme, the Japanese scheme, general taxation and national insurance.

The nearest thing we have to an independent commission is the King’s Fund and the Nuffield Trust, which work together and with others to inform the debate. Since the disaster of the Autumn Statement they have said that they now expect a funding gap of at least £2.4 billion in social care next year. That means that the intense pressure on services will continue to grow, increasing the burden on older and vulnerable people, their families and their carers, as the noble Baroness, Lady Farrington, has told us.

In its recent report on the sector, the CQC said that social care is at a tipping point. The CQC does not often use such language, but it should know, since it inspects all the services. However, it did report that 72% of settings were good or outstanding, and that is a credit to all those working in the sector who do their very best for the service users despite all the problems. The facts, however, are dismaying. Following multiple cuts to local authority funding over the past six years, 26% fewer older and vulnerable people are receiving services, while demographics mean that demand is rising. Because the potential for most local authorities to do any more within existing resources is limited, my colleagues in local government tell me that they will soon struggle to meet even basic statutory duties.

As we have heard, companies providing places in care homes are handing back contracts to local authorities because they cannot provide adequate care—the sort of care they want to give—with the funding that they get. Some are concentrating on self-funders. Indeed, self-funded service users are subsidising state-funded users in some places, and I agree with the noble Baroness, Lady Browning, that that is not fair. The national minimum wage—I still refuse to call it a national living wage because one cannot live on it—is putting enormous pressure on already small margins. Aside from the quantity of care available, good-quality care matters for many reasons, not least of which is that good care homes, working with their local GPs and community pharmacies, keep people out of A&E and other hospital departments.

Domiciliary care fares no better. Fifty-nine councils have had home care contracts terminated, affecting nearly 4,000 people. Three large national domiciliary care providers with multiple contracts have withdrawn from the market or are planning to do so. The critical condition of home care services threatens to undermine policies to support people at home, which, as we have heard, is where most people prefer to be, near their families and friends who can often help with care and are happy to do so within their capabilities. An estimated 1 million people now have unmet needs for care and support in England and research on disabled adults suggests that at least two in five are not having their basic needs catered for.

The new 2% precept increase that local authorities are allowed to raise does not help deprived areas where the majority of care users are state-funded and low council tax receipts from low-value properties will not raise anything like the amount of money needed. In those places, the potential for cross-subsidy from self-funders is minimal too. Besides, the precept, if fully applied overall, will raise only two-thirds of the cost of the increase in the national minimum wage in a sector where most employees are on that level of pay. At the same time, the Government have delayed until 2020 the implementation of Part 2 of the Care Act 2014, which introduces a cap on care costs and changes to means testing. These are reforms proposed by the Dilnot commission in 2011 and this breaches a Conservative Party manifesto commitment. So can the Minister say when it will happen, since many people are now doubtful as to whether these reforms will ever see the light of day?

The King’s Fund believes that our starting point for reform should be the Barker commission recommendation of a new settlement for health and social care, based on ending the historical divide between the two and moving to a single budget and single local commissioning of services. I agree with that, but there is also a very large elephant in the room, and that is the looming Brexit. We spoke about this at length in last Thursday’s debate. A damaged economy, resulting in a lower tax take, and uncertainty about the future of the many thousands of care staff who come from other EU countries cast an enormous shadow across an already staggering system. When will the Government do the right thing and offer them certainty?

It cannot be right that the care and support received by older and disabled people increasingly depends on where they live and how much money they have—a postcode lottery—rather than on their real needs. Although additional funding is badly needed in the short term, in the long term reform is what is required. The only game in town on that front at the moment is the sustainability and transformation plans, funded by the Better Care Fund, but there is evidence that, first, the emphasis is on sustainability rather than transformation and, secondly, that local authorities, patients and care providers are the last ones to be consulted on the plans. How can services be integrated when crucial parts of the system are not being properly consulted and funds that should be used to develop and pilot new ways of working are just being used to prop up budgets in deficit?

As the King’s Fund said:

“England remains one of the few major developed countries that has not reformed the way it funds long-term care in response to the needs of an ageing population … A number of commissions and reviews have been set up over the years and made recommendations about how to place social care on a sustainable footing. However, successive governments have failed to grasp the nettle”.

I am a gardener and I know the value of nettles: they support wildlife and you can even make nourishing soup out of the small leaves at the top of the plant. So will the Government grasp the nettle, because they may find it good for them?