NHS and Social Care: Winter Service Delivery

Baroness Wheeler Excerpts

Thursday 25th January 2018 Lords Chamber

Moved by

[Baroness Wheeler]

That this House takes note of the impact on front-line social care of Her Majesty’s Government’s NHS plans and the delivery of services over the winter period.

[Baroness Wheeler (Lab)]

My Lords, the most appropriate place to start this debate is with the WhatsApp open letter of 12 January to the Prime Minister from the heads of 68 accident and emergency departments in England. Its signatories included St Thomas’s in London, Heartlands in Birmingham, Addenbrooke’s in Cambridge, the Royal Liverpool, and Frimley Park, where Mrs May issued her new year apology for cancelling 55,000 non-elective surgical operations. With figures showing over 300,000 patients waiting more than four hours in A&E, a record half a million-plus emergency admissions, and 75,000 patients waiting more than 30 minutes in the back of an ambulance, these front-line doctors wrote about the hundreds of patients a day, some of whom were dying prematurely, being treated on corridors and about patients sleeping in clinics turned into stopgap wards.

One of the main purposes of the messaging was to swap practical tips about how to become “corridor specialists” as hospitals become overwhelmed with patients. This speciality includes the Red Cross delivering tea and blankets and sitting with patients waiting on their own. I can think of nothing worse than, for example, being a sick, elderly patient on a trolley without a carer or friend to stay with them, speak up for them or make sure they are being looked after. For the A&E doctors, their reality was that the Government’s winter plans,

“have failed to deliver anywhere near what was needed”.

Their key demand was more hospital beds and an urgent boost to social care. The president of the Royal College of Emergency Medicine warned:

“Our emergency departments are not just under pressure, but in a state of emergency”.


All this, of course, has a huge knock-on effect on social care while arising from the Government’s failure to fund and provide the everyday healthcare and community support, for millions of people who need it, which could stop many of them turning up at A&E and occupying hospital beds in the first place.

We know that the Minister’s response will be his repeated mantra about the extra £337 million the Government made available to trusts this winter and the £1 billion extra in social care funding allocated in the 2017 March Budget. Of course extra funds are welcome but, first, trusts were not told about their allocations until a few days before Christmas, so effective on-the-ground advanced planning was severely hindered as they had no idea of what money there was to spend. Secondly, the Government’s instruction was for half of the £337 million to be spent on servicing trust debts, not on emergency planning. Thirdly, such debts will be further increased by the cancellation of 55,000 non-elective surgical operations. Finally, as all the health think tanks, specialists and everyone involved in the provision and delivery of NHS and social care services have attested, the extra funding was simply nowhere near enough even to begin to redress the huge cuts that have been made in NHS funding and local government funding of social care over the past eight years.

The Government need to acknowledge and own up to the scale of the crisis. The Minister knows that the Budget did not provide extra funding for social care in the short term or address the predicted funding gap of £2.3 billion by 2020. Specifically on A&E care, can the Minister tell the House how the Government will assess the actual impact that providing additional funding in November and December had in dealing with the worst winter crisis the NHS has faced in decades?

On social care, as the very comprehensive Lords Library brief for today points out, we talk of adult social care mainly in terms of the needs of older people, but it also includes care and support provided to physically disabled people, people with learning disabilities, people with mental health problems, drug and alcohol misusers and the carers involved in caring for them. That is the scale of the demand and the need that has to be addressed. I will focus today on carers and older people.

I am a carer, as many noble Lords will know. Emergency care, hospital admission and then discharge is a make-or-break time for carers and their families. Many people become carers for the first time when this happens, as I did. It heaps pressure on families and, despite all the guidelines, most discharges take place with little notice, particularly when there is a national directive to free beds to make way for winter. If you speak to carers, particularly if discharge takes place when the patient is medically unfit or without the proper facilities and care available at home, they will tell you that this is one of the most traumatic times for them.

The number of carers is increasing every day. It is now estimated at 6.8 million, an increase of 1 million over the past 15 years. As Carers UK has stressed, families are caring more, not less, as some would have it. On top of this, we see in the press that carers have been asked by one trust to collect their elderly from hospital to help with the discharge process and ease the winter crisis. Is this really where society wants to head?

For carers, frequent GP and hospital visits, providing and arranging transport and so on are a routine part of looking after partners or relatives with disabilities or co-morbidities or of caring for frail and elderly people. Cancelled operations mean desperately trying to reinstate the cancellations in domiciliary care support made for the hospital stay and, of course, dealing with huge upset and disappointment.

There is the added winter threat of norovirus or flu and the impact this will have on carer and cared for or on both together. Where there is a carer involved in A&E corridor waits, they will be there with their loved ones, doing their best to care for them in very difficult circumstances and sharing their anxiety and concern. Acknowledging the vital role carers play as partners in the health and social care system has to be backed up by providing the resources that are needed to undertake the caring role.

Can the Minister update the House on the call to action that the Government have promised in place of the national carers strategy refresh that carers were expecting two years ago? It was due in the new year and we are nearly at the end of January. Can he tell us when it is to be published and ensure that it provides the support and resources that carers need?

As Labour has emphasised, the winter crisis has consequences not only for those in urgent need, but for everyone using the NHS. The panic cancellations of elective operations and outpatients clinics in the face of hospitals running at full capacity will have a major impact on the many older people who rely on NHS services to stay well and on their carers. As Age UK has stressed, waiting for a hip or cataract operation or having an appointment postponed will leave many people experiencing pain, discomfort and anxiety. It will result in a need for more support in the home or from primary care and could even accelerate people’s need for urgent and emergency care.

The noble Baroness, Lady Campbell, wanted to participate in this debate today, but had a previous commitment. She asked me to raise the key issue of the impact that the winter crisis has on people with acute, long-term conditions and disabilities, such as muscular dystrophy, cystic fibrosis or acute asthma, who, if they go down with flu or chest infections, need emergency care in specialised respiratory units. The availability of these beds is increasingly under pressure because hospitals are unable to discharge severely disabled people occupying those beds back into the community if they require more social care support than they had before. She faced this very perilous situation three years ago when her local specialist unit was full to the brim for many days and a suitable, high-dependency placement could not be found, and she lives in fear of that every winter. Will the Minister undertake to write to her on the urgent measures and steps that will be taken to ensure that people with acute and long-term disabilities receive the integrated and joined-up care they need?

Planning for winter means planning across health and social care. As NHS Providers said last year:

“Too often winter pressures has just been about acute hospital capacity. Last winter showed that ambulance, community and mental health capacity are just as important, as is primary and social care capacity”.


Social care’s extra £1 billion pounds last year was designed to reduce delayed transfers of care and free beds, but only 28% of trusts managed to secure any commitment from hard-pressed local authorities to spend the money on delayed transfers. Most would have simply been unable to meet that commitment.

Over last winter the lack of capacity to deal with expected demand across the whole system was clear: 64% of trusts lacked ambulance capacity; 71% lacked acute capacity; 76% lacked community capacity; 80% lacked mental health capacity; 91% lacked social care capacity; and 92% lacked primary care. Can the Minister explain why the Government’s winter crisis plan for this year did not take account of all these factors? Was this really the effective planning the Government insist went on? Will the lessons be learned for this year’s promised winter crisis ministerial review?

On delayed transfers we know that the NHS needs to get its act together. More than 58% of delayed transfers in November 2017 were attributable to the NHS, mainly through patients having to wait for further NHS non-acute care; 34% of delayed transfers were due to social care. What was the main reason? It was patients awaiting a care package in their own home. Financial penalties on local authorities or instructions to trusts to use the limited extra funding to reduce their debts do not address the crisis in either sector. As the Local Government Association puts it, delayed transfers,

“are a symptom, not the cause, of the pressures on the NHS and in many cases the solutions will lie in investment in prevention, primary care, community services and hospital avoidance schemes ... There cannot be a sustainable NHS without a sustainable adult social care system”.

We know that as a result of the cuts to local government, the availability of adult social care packages has fallen so dramatically that 90% of councils are now able to respond only to people with critical and substantial needs. At least 400,000 fewer people are getting publicly funded help. Age UK’s estimate is that there are now 1.2 million people with unmet needs for help with essential daily support, such as bathing, toileting, taking medicine, cooking, shopping and other everyday tasks.

All this makes it vital that the Government’s Green Paper this summer does not deal just with a cap in care costs or any disastrous proposal for a care cap floor, unless, of course, Jeremy Hunt throws in the towel and recognises that the Dilnot proposals that we all spent two years working on are actually the best chance we have for bringing fairness and some equity into the health and social care system in the near future. The Green Paper must also address how we can achieve the fundamental integration between health and social care that is needed to meet the scale of the current crisis and the rising demand and to provide the care and support that people should be getting.

The Government have tried very hard to make the change of Jeremy Hunt’s title to Secretary of State for Health and Social Care sound like a fresh and important sign of action and purpose. I must say that I am one of those who thought he was supposed to have that role anyway. However, if it means that the Green Paper will be health and social care-led—rather than led by the Cabinet Office—and that Jeremy Hunt will take leadership responsibility instead of, as is his frequent habit, blaming the health and social care crisis on everybody else, then that is at least a start. His recent recognition of the need for a 10-year strategy is also a step in the right direction.

Can the Minister confirm that the Green Paper is still scheduled for the summer? Can he be any more specific about its aims, scope and publication date? What work will be done alongside the Green Paper to produce a national integrated staff recruitment, training and development strategy for health and social care? Currently, Health Education England provides the NHS staff strategy and Skills for Care deals with social care staff. Is this not a key issue that needs to be addressed to ensure integrated working? Will the chronic low pay problems, particularly in social care, that are one of the root causes of staff shortages and low morale be tackled? How will health and social care budgets be joined up?

I am grateful that this debate has attracted so many experts among noble Lords, and I am very much looking forward to it. I close by paying tribute, on behalf of us all, to the extraordinary efforts and work of our NHS and social care staff, particularly over this Christmas and new year and this winter.

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[Baroness Wheeler]

My Lords, I thank noble Lords for their thoughtful and wide-ranging contributions. I am not going to deal with them in detail because we want to move on to the next debate. I hope the Minister will write to noble Lords in response to the questions he has not been able to deal with and that he will draw the attention of the Secretary of State for Health and Social Care to everything that has been said today.

Motion agreed.