Social Care: Sleep-in Payments

Baroness Wheeler Excerpts

Thursday 7th December 2017 Lords Chamber

[Lord O’Shaughnessy]

It is not our position that they will not be funded. That is one of the options being explored at the moment. A huge amount of work is going on with providers and all parts of government. In the end, however, the Care Act 2014 means that local authorities have a responsibility to take on the commissioning of and, ultimately, provision for providers, if they are looking at exiting the market, to make sure there is proper and comprehensive provision in the local area.

[Baroness Wheeler (Lab)]

My Lords, it is absolutely right that sleep-ins are defined as working time and therefore subject to payment of the national minimum wage. However, the Government’s November compliance scheme proposal not only failed to offer support for hard-pressed providers but also means that thousands of care workers, who are among the lowest paid in society, could be waiting until March 2019 to get paid what is owed to them. Does the Minister agree that these low-paid workers should not have to pay the price for the Government’s £6 billion cuts in social care or their failure to take action on addressing the social care funding crisis?

[Lord O'Shaughnessy]

I am grateful that the noble Baroness has raised the compliance scheme. For those providers that enter it, the scheme offers the opportunity to take 12 months for self-review and then report to HMRC, which will then allow a further three months for the providers to pay. That gives a 15-month leeway compared with the usual default enforcement period of 28 days. There is clearly a balance to be struck between the financial challenges posed to providers and the money that staff, rightly, need to take. I think that the compliance scheme provides that balance so that we can do it in a way that is sustainable.

Nurses: Tuition Fees

Baroness Wheeler Excerpts

Wednesday 29th November 2017 Lords Chamber

[Lord O'Shaughnessy]

The system that we have means that the people who benefit most from higher education are those who pay for their higher education and, in doing so, they subsidise those who go into the professions that my noble friend has mentioned, which are extremely worth while but might not be that well paid.

[Baroness Wheeler (Lab)]

My Lords, the Health Foundation research has shown that the change in nurse training funding arrangements in England has led to a fall in student numbers, rather than the Government’s promised increase. One of the most alarming statistics shows a 31% shortfall in the number of applicants aged 30 and over, just the group with the background and experience the NHS needs, many of whom are care workers with hands-on experience wishing to develop their skills by becoming qualified nurses. Does the Minister agree that these are the very people whom nursing needs, but for whom taking on a huge debt, often at a time of heavy financial commitment, seems an impossible hurdle? Does this not all underline the need for urgent reinstatement of nurse bursaries?

[Lord O'Shaughnessy]

I think that the figure on shortfalls that the noble Baroness has given is not right. If one looks at the UCAS data, it shows, as I said, a small drop of around 6%, but the numbers going into training are comparable to 2014-15. She is quite right about the need for additional financial support, and there is £1,000 available for childcare support for those who need it, as well as exceptional support funds of up to £3,000.

Mental Health Care: Vulnerable Children

Baroness Wheeler Excerpts

Tuesday 28th November 2017 Lords Chamber

Asked by

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they are taking to address the concerns raised by the Care Quality Commission in its review published in October about the particular difficulties faced by children and young people in vulnerable circumstances, such as looked-after children and those with learning disabilities, in accessing mental health care.

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

My Lords, improving children’s and young people’s mental health is a priority for the Government, especially for the most vulnerable. The Government welcome the CQC’s recent report in this area, which was commissioned by the Prime Minister in January. Government initiatives to improve the mental health of vulnerable children include piloting new approaches to the mental health assessments that looked-after children receive as part of their initial health assessment, and testing models for personal budget use for looked after children.

--- Later in debate ---

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his response. With the Green Paper promised before Christmas, I hope we will not have to wait until the next CQC review for the urgent action that is needed, given the scale of unmet need for mental health care among vulnerable children. Barnardo’s recent survey showed that one in four looked-after children faced a mental health crisis on leaving care, and yet nearly 65% of them did not receive any statutory support; and whilst in care, local factors such as a lack of permanent or settled placement can lead to support action being denied. On children with learning difficulties, in all my research for this Question I was truly alarmed at the lack of information that is available on the scale and problems of this vulnerable group of children. What action is the Minister taking to ensure that the CQC, Ofsted and, sadly, the police and probation inspectors combine their efforts to investigate this issue as closely as it deserves?

[Lord O'Shaughnessy]

The noble Baroness is right to highlight these disturbing facts about the mental health of looked-after children. Nearly 50% of looked-after children have a diagnosed mental health disorder, so that is what we are up against. In terms of how we are dealing with it, the increases in funding to raise the number of treatments that are taking place by 70,000 will obviously help vulnerable children, and there is the additional assessment that I have talked about. She asked particularly about children with learning difficulties. I am sure that she is aware of it, but I would point her and other noble Lords to the Lenehan review, which set out several recommendations, all of which the Government have adopted. One of the actions that stems from that includes new guidance from the Local Government Association and NHS England on commissioning mental health services for children with learning difficulties.

NHS: Wound Care

Baroness Wheeler Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what plans they have to develop a strategy for improving the standards of wound care in the NHS.

[Baroness Wheeler (Lab)]

My Lords, in my noble friend’s unavoidable absence, I shall ask the Question standing in his name on the Order Paper. Wound care is a massive challenge to the NHS, but it currently lacks priority, investment and direction. This debate is designed to press the Government to recognise the need for urgent action and for the development of a strategy across care providers for improving the standards of wound care.

I am delighted that so many noble Lords with expertise on this highly important matter have put their names down to speak. It will ensure that we can cover a wide range of issues across medical, nursing and patient care and the quality of medical supplies. It will also give the Minister the stepping stone for developing the national strategy that I hope he will recognise is sorely needed.

A staggering 2 million patients are treated for wounds every year at a cost of more than £5 billion. The overwhelming majority of this figure goes towards paying for nursing care costs rather than products such as bandages. In other words, the cost is more than, for example, we spend on tackling obesity, which is the centre of major national campaigns. Treatment costs include more than 700,000 leg ulcers and 80,000 burns. Pressure sores also feature highly, with estimates of an 11% increase overall each year.

While 60% of all wounds heal within a year, a huge resource has to be committed to managing unhealed wounds. The NHS response is very variable. Healing takes far too long; diagnosis is not good enough; and inadequate commissioning of services by clinical commissioning groups compounds the problem, with undertrained staff and a lack of suitable dressings and bandages. There has also been a very worrying drop in the number of district nurses, whose role in ensuring safe and effective wound care in the community is crucial.

Ideally, 70% of venous leg ulceration should heal within 12 to 16 weeks and 98% in 24 weeks. In reality, however, research shows that healing rates at six months have been reported as low as 9%, with infection rates as high as 58%. Patients suffer and the cost of non-healing wounds is substantially greater to the NHS. The failure to treat wounds swiftly and effectively can lead to more serious health problems, such as sepsis, which is often the result of an infected injury; we also know that foot ulcers on diabetics can lead to amputations if they are not dealt with properly.

The situation will only be turned around with a nationally agreed strategy to reduce variation, prevent wounds getting worse and improve outcomes. Wound care therapy strategies are needed and national care pathways for wounds must be established to cover the complexity and variety of wounds, using evidence-based health economic data and academic and clinical expertise. The Bradford study and survey that is summarised in the Lords’ Library brief for this debate—a good brief but sadly received only yesterday—underlines the point about the importance of evidence-based care, with nearly one-third of patients interviewed in the study failing to receive an accurate diagnosis for their wound. As the study puts it:

“Wound care should be seen as a specialist segment of healthcare that requires clinicians with specialist training to diagnose and manage. … There is no doubt that better diagnosis and treatment and effective prevention of wound complications would help minimise treatment costs”.


Dedicated wound clinics in the community are also needed, alongside a co-ordinated treatment plan to achieve best outcomes for patients. A focus on the prevention of wounds, as well as treatment and healing of wounds, is also very important. The NHS must also invest in high-quality bandages and dressings, in contrast to the current skimping that takes place in many areas. We know, however, that with the NHS as financially hard pressed as it is, there is huge pressure to reduce the costs of medical equipment and clinical supplies such as dressings. The result is that in the procurement of dressings and other forms of treatment, there is not enough emphasis on the cost of patient care and too much focus on the unit cost of products. Not only does this lead to poorer and more costly outcomes for patients but there are a number of unwelcome side-effects. Products will be less innovative and effective; a reduced amount of educational support will have a detrimental effect on patients; there will be fewer appropriate treatments available; and all this will lead to job losses if there is less sourcing from high-quality British suppliers and manufacturers.

With cost as the primary driver, suppliers to the NHS will have a race to the bottom, compromising quality. Poor-quality dressings simply cannot withstand the rigour required to produce effective healing. It is massively counterproductive. Reduction in the availability of clinically appropriate dressings, which comprise only 10% of costs, will result in patients suffering as wounds take longer to heal. An increased burden on the NHS will follow and the result is longer hospital stays, particularly for the elderly, more readmissions, compromised quality of life and repeated visits to GPs and community services.

Of course, we fully support improvements in the way that medical equipment and other supplies are procured. I am not sure whether, in his absence, I have to declare my noble friend Lord Hunt’s interest and commitment to these matters as president of the Health Care Supply Association but I am sure he will value it being mentioned. We also support the work of my noble friend Lord Carter and his 2015 review on how the NHS can avoid unwanted and unnecessary variations in the cost of supplies. The overall aim of his review was to see how the NHS could reduce spending by £5 billion by the 2020-21 financial year. It proposed £600 million in savings for supplies, half of this to be saved before October 2018; limiting the NHS to 40,000 products instead of 300,000, with an overwhelming majority of this—80%—going towards a newly revised supply chain process; as well as replacing local formularies with a national formulary.

Although we welcome the report’s efforts at saving the NHS money, we need to ensure that any shift in focus to the short term will not lead to the knock-on effect of costs rising in other clinical areas. There is also strong concern that the short-term focus could lead to a scarcity of supplies in the future. I would be grateful to hear reassurances from the Minister on the steps being taken to guard against these two unwanted outcomes. Evidence clearly shows that the current problems can only worsen. The average number of adult wounds that every CCG will have to manage is expected to rise from 11,200 in 2012-13 to 23,000 in 2019-20.

The Government urgently need to get a grip, with a nationally driven strategy. Without it, patients will receive worse care for their injuries and the financial burden on other parts of the NHS will continue to increase because patients will develop chronic wounds or catch an infection that could lead to potentially life-threatening illnesses. I look forward to the contributions of noble Lords to this very important debate and to the Minister’s response.

NHS: Deficit

Baroness Wheeler Excerpts

Wednesday 22nd November 2017 Lords Chamber

[Lord O’Shaughnessy]

The Chancellor has confirmed that he will fund an Agenda for Change, as it is known, pay deal on the condition that the pay award enables improved NHS productivity and is justified on recruitment and retention grounds.

[Baroness Wheeler (Lab)]

My Lords, is the Minister aware that the number of GPs has fallen sharply over the past year, despite the government pledge to increase the supply of family doctors by 5,000 by 2020? How many more targets are likely to be missed by the Government? When did the NHS last achieve the A&E 95% target or the 92% 18-week treatment target? What will the actual impact of today’s funding announcements be on the Government’s performance on these key targets and their ability to ensure that planned improvements in priority areas of care such as cancer and mental health will not be stopped, as Simon Stevens has warned?

[Lord O’Shaughnessy]

The noble Baroness has pointed out the disappointing numbers as regards GPs. I should point out that there has been an increase in training places for future years. It is critical that we deliver those places and bring more staff into the service. I am glad that she drew attention to where the additional funding will go. There will be £340 million to help the NHS through this winter, £1.6 billion of additional revenue in 2018-19 and £900 million in 2019-20. That is precisely, as the Budget pointed out, to improve A&E waits, turn waiting list growth around and improve performance against the RTT targets.

Health: Flu

Baroness Wheeler Excerpts

Monday 30th October 2017 Lords Chamber

Asked by

[Baroness Wheeler]

To ask Her Majesty’s Government what preparations are being made to deal with the anticipated rise in flu cases this winter.

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

My Lords, it is too early to predict the impact of flu this winter. As part of the Government’s preparedness, every trust has developed plans for the coming winter season. The seasonal flu vaccination has been offered to those at particular risk of flu, and to all health and social care workers. A nasal spray vaccine will be offered to all children aged two to eight years old to help to protect them and their families.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Last week’s Healthwatch report showed an alarming increase in the number of hospital readmissions, which have risen by nearly a quarter in four years. The survey also showed a rise of 29% of people readmitted to hospital as emergencies within 24 hours. Does not this raise huge concerns about patients being discharged unsafely and before they are medically fit in order to meet the Government’s empty beds targets, not to mention the trauma and upset caused to the patients themselves and their carers and families? Do the targets take account of readmissions? What additional funding and contingency plans are in place across NHS trusts and local authorities, if there just are not enough beds to cope with the winter flu crisis? Is not the Government’s flu preparedness in urgent need of review?

Mental Health Services: Children and Adolescents

Baroness Wheeler Excerpts

Monday 17th July 2017 Lords Chamber

[Lord O'Shaughnessy]

That is what we are moving towards with the mental health first aid training for teachers in all schools. The noble Lord will recognise that schools come in all different shapes and sizes and that it is easier to do that initially in secondary schools, which are bigger than, for example, rural primary schools which might only have a staff of 10. It is critical to make sure that there is at least one member of staff who is highly trained in spotting and dealing with the initial signs of mental health problems and signposting them to the relevant authority—local health authority or whatever it is—for further care.

[Baroness Wheeler (Lab)]

My Lords, the recent survey by the Children and Young People’s Mental Health Coalition has shown that the problems young people are now presenting with have become even more severe. Can the Minister reassure the House that funding earmarked for local CAMHS transformation plans will reach local services this year? How are the Government making sure that this happens and preventing funds from being diverted to other desperately stretched services?

[Lord O'Shaughnessy]

The transition from CAMHS is now one of the mandatory national indicators in what is called the Commissioning for Quality and Innovation scheme which provides incentives for performance, so I can reassure the noble Baroness on that. She is also quite right to highlight the issue of severity. That is why, under the plans that we have set out for CAMHS, by 2021 the service will be able to see 70,000 additional children per year for evidence-based treatment.

Older Persons: Care and Human Rights

Baroness Wheeler Excerpts

Tuesday 11th July 2017 Lords Chamber

[Lord O'Shaughnessy]

There is a prospect to look forward to. If we will be living to 150, there are a lot of middle-aged people in this Chamber. The noble Baroness is right. There is a particular issue around frailty as people move into old age. That is why the GP contract introduces responsibility to look out for frailty, as well as making sure that there are named GPs for the over-75s and, if necessary, annual health checks, to make sure that there is both health and social care provision for older people.

[Baroness Wheeler (Lab)]

My Lords, my noble friend is to be congratulated on his excellent report, bringing together key issues that would enable older people to maintain their independence, dignity and quality of life and to receive the care that they need. The report underlines the importance of countries having an enabling legal framework for the provision of integrated health and social care. What action will the Government therefore take in the light of the conclusions of last week’s IPPR report, which calls for our existing national legislation to be amended to enable pooled budgets and integration, and also says that if everybody has to carry on working round the 2012 Act, as at present, STPs and accountable care systems could both be blocked?

[Lord O'Shaughnessy]

I will read the report that the noble Baroness mentioned. She is quite right that integration of health and care budgets is the way forward, particularly as the burden of disease changes away from infectious diseases towards lifestyle and complex diseases of old age. The better care fund is beginning to start the kind of integration she is talking about, but of course we need STPs and accountable care systems, as set out in the five-year forward view. We feel there is, at the moment, the legislative freedom we need to move ahead with that.

Adult Social Care Services

Baroness Wheeler Excerpts

Thursday 6th July 2017 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I am grateful to the Minister for repeating the Answer, but once again the Government seem to be in complete denial about the reality of the situation facing us in social care. A year ago, the Care Quality Commission first warned that social care could be approaching a tipping point. Today, Andrea Sutcliffe, Chief Inspector of Adult Social Care, has said that,

“the danger of adult social care approaching its tipping point has not disappeared. If it tips, it will mean even more poor care, less choice and more unmet need for people”.

Why have the Government neglected to tackle the issues facing our social care sector and failed to give it the money it needs? This report highlights safety concerns in one in four care homes. Age UK described choosing a care home as Russian roulette. Does the Minister believe that it is acceptable to force people to take these kinds of risks with their loved ones?

According to the Care Quality Commission report, 4,000 fewer nursing-home beds are now open than in March 2015. Is the Minister concerned about this drop, and what actions is he taking to ensure that there are enough nursing-home beds for those who need them and enough nurses to staff them?

This week marked the sixth anniversary of the Dilnot commission report into social care. The Government accepted the commission’s recommendations; they legislated for them; and they announced that the cap on personal funding would be £72,000, after which the state would intervene. Why did the Government abandon all that in favour of their ill-fated dementia tax? Why are this Government no closer to finding a solution for funding social care? Can the Minister tell the House why his Government have wasted seven years and failed to take any action to solve the social care crisis?

[Lord O'Shaughnessy]

I shall respond to the several questions that the noble Baroness asked. She is right that the CQC made that warning last year, and that is precisely why the Government have chosen to put in additional money—£2 billion extra was announced in the spring Budget—to support the social care system and provide real-term increases in funding.

It is worth pointing out that today’s report shows that 79% of care settings received a good or outstanding rating, compared with 72% last year. There are obviously differences in the kinds of settings that were inspected; nevertheless, it shows an increase in the number of good or outstanding settings.

I completely agree with the noble Baroness’s point about patient safety. I think that the phrase “the Mum test” is both accurate and evocative. Clearly, nobody wants to choose care settings that do not pass that, and any care that is inadequate is unacceptable. However, the reason we have that information about unacceptable care settings is that this Government, in coalition with the Liberal Democrats, introduced a very tough inspection regime in 2014. I believe that today’s report shows that four out of five settings that were judged inadequate on the first inspection had improved on reinspection, so the inspection regime is itself a critical part of dealing with the issue that she rightly points to.

The noble Baroness highlighted the number of beds and staffing. Around 165,000 more staff are working in the care sector, but of course care is moving more from residential homes to domiciliary settings, so the nature of care is changing there. However, more staff are going into the service and they are now being paid the national living wage.

Finally, it is fair to say that no Government have a completely unblemished record in getting to grips with the problem of funding care. The Labour Government had Green Papers, royal commissions, the Wanless review and so on; we have had other investigations. However, to go back to the beginning, the point is that we cannot wait any longer—we need to get on with this—and that is why I set out in the Queen’s Speech debate last week that the consultation that we will publish at the end of this year will look not just at an open question but at very specific proposals around floors and caps, and I hope that we will be able to build a consensus on the need to move forward.

National Stroke Strategy

Baroness Wheeler Excerpts

Wednesday 5th July 2017 Lords Chamber

Asked by

[Baroness Wheeler]

To ask Her Majesty’s Government why the National Stroke Strategy, which expired in March 2017, has not been updated or renewed.

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

My Lords, decisions about the development of disease-specific strategies are made by NHS England. Its current view is that, rather than focusing on specific diseases, it is better to promote plans and policies that cut across several disease areas. So, while there is not going to be a new strategy, stroke is high on the list of NHS England’s priorities in terms of both prevention and treatment.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. Stroke is the largest cause of all adult disability in this country and costs billions of pounds in health and social care, disabilities and work and related costs. However, all the evidence from STPs is that they are not prioritising stroke care. They are focused mainly on acute hospital care rather than on commissioning the whole stroke care pathway, which provides the rehabilitation and community support that stroke survivors need. They are also very short on specifics on how preventive services for stroke or any other key services will be delivered or funded. With such overwhelming evidence from STPs that improvements to stroke services will stall or come to a complete halt, will the Government now put pressure on NHS England to review its decision not to renew the national strategy?

[Lord O’Shaughnessy]

I know that the noble Baroness has a deep commitment to ensuring the best possible stroke care. She is quite right to highlight the economic and personal costs of stroke. There is a good picture in this country in so much as mortality from stroke and the incidence of stroke have halved over recent years—so the picture is improving. The stroke strategy the noble Baroness mentioned was superseded in 2013 by a cardiovascular disease outcome strategy that is obviously broader but includes stroke. That builds on the work that has already happened. I am realistic about the fact that there is obviously more to do, but we now have a number of hyperacute centres that are rolling out new treatments, such as thrombectomy, which will help treat stroke and make sure that we bring mortality down even further.