Social Care Provision and the NHS

Cheryl Gillan Excerpts

Thursday 3rd May 2018 Westminster Hall

[Dame Cheryl Gillan (in the Chair)]

Unfortunately, the hon. Member for High Peak (Ruth George) was delayed, but I have taken advice and now that she has arrived, I think it is in the interests of the House and all hon. Members present if we proceed with the debate.

[Ruth George (High Peak) (Lab)]

I beg to move,

That this House has considered the effect of social care provision on the NHS.

Thank you, Dame Cheryl. I was moved to initiate this debate by the experience that I had just after Easter, when I spent a 12-hour shift with colleagues in the ambulance service based at the depot in Buxton; they are trained and very experienced paramedics. I have had a lot of cases involving constituents who have been concerned about ambulance waiting times—the time that it takes ambulances to get to patients in our very rural area—so I spent a day with staff to see what the pressures were.

I expected those pressures to be on the NHS, but what I found from spending a day with the ambulance service and the excellent and hard-working crews, who said that it was not in any sense untypical, was that we spent the day going around seeing elderly patients in their own homes. They might have had family carers or received occasional visits from professional, paid carers, but they were left on their own for a lot of the time. They often had ongoing health conditions that flared up from time to time and caused them and their carers great concern, and that would escalate to calling out an ambulance. I therefore spent a lot of the day sitting in the back of an ambulance and talking to elderly patients. That was quite a pleasant way to spend a day—I like talking to older people and have helped with care for my own family—but it is not really what we want our paramedics to be doing.

I receive calls from constituents about their family members who have to wait in dire circumstances at times. In one recent case, an elderly lady had had a stroke. The GP was begging for an ambulance to come to her, but it took five hours for it to get there. Unfortunately, that lady subsequently died. We cannot say that that was because of the delays in the ambulance arriving, but a lot of time is taken up by ambulances travelling around to elderly and isolated people, and that is happening more and more.

Age UK says that there has been an increase to about 1.2 million in the number of people who need care but whose care needs are not being met. It is a vicious circle, which ends up impacting on our NHS. The winter crisis seems to be going on and on. There are almost 4 million people on hospital waiting lists. Every week at my constituency surgeries and coffee mornings, I see constituents who are waiting for treatments such as hip replacements. I saw a lady in Buxton who had been waiting almost a year for a hip replacement. She used to be an avid walker of the countryside, but now is practically housebound. That has obviously impacted on her quality of life.

There are also waits to see a GP. We have gone from waits of 48 hours, as a maximum, eight years ago to waits of two weeks now. People have to book an appointment some way ahead; and often, if people phone any time after about 8.20 in the morning, the surgery will say that it has no appointments left, even for two weeks’ time. People have to say that it is an urgent case in order to be seen and then they are seen more quickly. The situation is impacting on GPs as well.

In accident and emergency departments, only 85% of people are seen within four hours. At my local hospital, Stepping Hill, patients are queuing on trolleys in the corridors and are given a bell to ring if they feel that their condition is deteriorating, because there are just not enough staff even to keep an eye on them. The staff rely on patients themselves being able to give an alert if they feel that they are in urgent need of care.

I saw the impact of the long ambulance waits in A&E. They are backed up, sometimes seven at a time, outside our hospitals while they wait to be able to discharge patients. The staff now face an overtime ban, despite the great demands on their service. Even two weeks into the financial year, they were already banned from overtime, so young trainee paramedics are staffing ambulances on their own at night, which is not what I want to see in my constituency and not how we should be treating the staff.

BBC 2’s “Hospital” programme showed what is happening in A&E at the moment. We saw a frantically overstretched service and every hospital bed full, but staff estimated that 80% of the patients should not actually have needed a bed; they should have been in social care. This comes back to the cuts in social care.

According to the Association of Directors of Adult Social Services, £6.3 billion has been cut from social care budgets. Nationally, 400,000 fewer people are receiving social care, more than a quarter less than in 2010, despite increasing demand. In Derbyshire, my county, the number of people needing care has risen by more than one quarter, from 32,000 to 40,000 people.

Social care cuts do not make good television, though. They are invisible to the outside world. Patients are not lined up, queuing on trolleys. No one could really make a drama about it, but it is a crisis in the homes of the 1.2 million people who need and are waiting for care and cannot get it. We see that crisis only when we step inside the NHS, with paramedics or GPs who have to visit those elderly patients or in A&E departments. Then we see the people who are falling through the gaps in social care. That is echoed in my own constituency, where one of the GP surgeries tells me that 19 patients in one small town are on a waiting list for a care package. They are either in hospital, taking up a hospital bed, or at home with family carers, who are struggling to cope.

Palliative care is particularly difficult. At the end of life, patients typically need four or five short visits a day. Particularly in a rural area, that is very hard for our care services to cope with in the way they are financed and paid for. The lack of palliative care means that patients are stuck in hospitals where they are often many miles away from their loved ones. In a tragic recent case, one of our GP surgeries told me about an elderly gentleman crying to the GP because he had never been separated from his wife before. They were both in their 80s. She was terminally ill in hospital and he could not get to see her. That GP surgery pulled out all the stops. It got its district nurses to go in and allow that lady to go home for the final few days of her life. However, they cannot do that for every patient. The NHS simply does not have the resources and it impacts on other patients it needs to see.

The surgery in Hope in my constituency in the rural Peak district tells me that patients are being cared for in the community by relatives much more than used to be the case. That is good for the individuals in many ways. That is where they want to be. However, it puts more strain on GPs having to visit more frequently those patients with more complex needs. A poll by MediConnect in 2010 found that almost nine in 10 GPs believe that the reductions in social care are leading to extra pressures on their surgeries, which is leading to extra pressures on GPs. Buxton is seeking to fill six GP vacancies out of a total of 12 across the town. That is not sustainable.

That also leads to extra pressure on A&E departments and increased delays in discharges from hospital. In 2016-17, there was a 12-month average of 188,000 days of delayed care, which is 73,000 more than the four years from 2010 to 2014, when the situation was fairly stable. The King’s Fund has estimated that patients waiting for a care package in their own home accounted for the largest number of delays—in other words, more than 20% of all delays in discharge.

The cuts to social care are creating more expense for our NHS, but it would be cheaper to resolve such cuts. The NHS spent approximately £168 million on delayed transfers of care for patients awaiting a home care package in 2015-16. That could have funded more than 5 million hours of home care in that year—431,000 hours a month or nearly 15,000 hours a day—helping thousands of patients to stay in their own home with the care they need.

The Multiple Sclerosis Society has done a lot of work on the issue, because sufferers of MS frequently need care but a lot of that need is not being met. It says that in 2015-16, emergency hospital admissions for people with MS in England cost the NHS a total of £46 million. A large proportion of that emergency care was for problems that could have been avoided with proactive, preventive care, and earlier diagnosis and intervention in the community. For example, 14% of emergency admissions were for urinary tract infections, costing more than £2,500 per patient, which could have been avoided.

The reductions in social care are not simply down to Government cuts, hard as they have been for local authorities to sustain. There have also been huge increases in demand of more than 25% in the past eight years. The cuts to local authorities—they are gradually cutting the amount paid to care homes and to carers who provide care to people in their homes—are having a detrimental impact on the whole sector. It is really coming to a crisis point. A 2017 survey of directors of adult social services found that 39% had home care providers ceasing to trade in the previous six months and that 37% had contracts handed back.

My constituency of High Peak has real difficulty recruiting staff to work in care services. The staff do an absolutely fantastic job, but the pay is very low. Over half of staff nationally are on zero-hours contracts. Particularly in expensive rural areas, such as the Peak district, one cannot afford to live on the wages of a care worker. Ironically, however, there are more and more elderly and infirm people in those areas. In High Peak, our volunteer services run a professional, not-for-profit care service arm, but it is operating at a loss and has to cross-subsidise its care services from other services, which it cannot afford to do much longer.

This is a particular problem in rural areas. Patients are scattered, meaning more travel time and extra costs for companies. Our private care companies, the agencies, cherry-pick the areas they will cover, so they avoid the very rural areas, which cost them far more in mileage and travel time. A Rural England report found that rural councils pay 13% more on average than predominantly urban councils, but they still report more problems in commissioning services. Several home care businesses commented that they did not feel that councils paid enough and that was reflected in the handing back of contracts. Everyone says that council providers are needed, which would not cherry-pick based on areas that are profitable.

Even though Derbyshire is one of the few areas where our Labour-run council kept on directly employed care staff on the proper living wage, it cannot recruit enough staff, so we have to rely on agency staff. There are about 90,000 vacancies across the country for agency social care staff. They are at an absolute premium and our local jobcentres are always trying to recruit people into care jobs, but it is not for everyone. It is a difficult, often gruelling job, both physically and emotionally. It pays very little. Care workers often have to be able to run their own car and find their own way around. They have to like older people—the patients. That is a hard thing to do, particularly if they are caring for a parent or have other caring responsibilities. It is a lot for anyone to take on. It is no wonder that the turnover of care workers is running at nearly four in 10 every year.

Funding cuts are now having a detrimental impact on care quality as well. One in five adult social care services received the poorest overall ratings from the Care Quality Commission and almost one quarter of services had the poorest ratings for safety. Some 22% required improvement and 2% were deemed inadequate. The Government, however, do not seem to be seeking to tackle those problems of quality. Skills for Care, the skills organisation for care services, has a budget of only £21 million, or £14 per care worker, whereas Health Education England has a budget of £4.6 billion. The National Audit Office criticised the Government for failing to have an up-to-date workforce strategy for the care sector—the last work- force strategy was produced in 2009, under a Labour Government.

Last November, the Competition and Markets Authority did a study of care homes, which stated that, in general, care homes are struggling. Local authority-funded homes, which are now very much in the minority, cover their operating costs but not their total costs. That suggests that while those care homes may be able to operate in the short term, they may not be able to undertake future investment to update their existing capacity, prevent closure or increase their capacity for local authority-funded residents. The Salvation Army runs excellent not-for-profit care homes, including one in my constituency. When I visited the home over the Easter recess, the increasing gap between the rate paid by the local authority and the amount it costs to run a care home was highlighted to me.

All those cuts impact on the NHS and then the NHS cuts, as part of a vicious spiral, impact back on social care. As I have said, our own north Derbyshire clinical commissioning group is £24 million in the red, a huge sum for a relatively small CCG. It has been taken into special measures by NHS England and cuts are being imposed. Our specialist dementia care assessment unit has closed. The support that went to the families and patients who went into that ward on an ongoing basis is no longer there. The staff who were at threat of redundancy had a huge number of skills in adult mental care, mental health service care and specialist dementia care. The respite beds on that ward have also closed. One patient with early-onset dementia was managing at home, with one week in six of respite for his wife, but he now needs full-time nursing care, as his wife cannot cope at home without that week of respite.

Rehabilitation beds are no longer a halfway-house option, because they are being closed as well. Even worse, patients are being sent home from acute care without a care package in place. Many end up with infections or have a downturn in their condition and end up back in hospital unable to cope. It becomes a spiral that impacts on family carers at home.

Carers are struggling. They do an incredible job. The Carers Trust estimates that there are 5.5 million unpaid carers in England and 2,300 in High Peak alone. People do not often meet carers who are caring for someone with a long-term condition, because they are isolated. When I visit the GP surgery or the hospital with my family, I can sit down and talk to some of the carers about the isolation that they experience and how difficult it is because they cannot stop, because they love the person they are caring for and feel that they have no other option.

Some 61% of carers report having a long-term health condition. They are more likely to report problems with depression, pain and mobility, but they do not attend their own health appointments. The Carers Trust found that 57% had cancelled or postponed a health appointment because their caring role took precedent over their own health. It is no wonder that 81% of older carers surveyed said they felt lonely and isolated.

The Government are looking to do more work on carers, and have commissioned studies such as the 2014 Department of Health impact assessment, which estimated that spending an extra £300 million on carers in England would save councils £430 million in replacement care costs and would result in “monetised health benefits” of £2.3 billion. Each £1 spent on supporting carers would save councils nearly £1.50 in replacement care costs and benefit the wider health system by nearly £8. However, the money to put into those services and to make that sort of investment is not there, because the NHS, social care and local authorities are firefighting. Of course, the greatest impact is on the patients who do not receive the care they need and are left isolated, confused and sometimes in pain.

The MS Society says that one in three people living with multiple sclerosis do not get the support they need with essential everyday activities such as washing, dressing and eating. That has an adverse impact on their physical and mental health, resulting in a greater reliance and increased pressure on the NHS, which already faces significant financial and demographic strain. I hope hon. Members can see that it adds up to a vicious circle of lack of investment and funding and constant cuts. People who provide services are trying to do their best with what they have, but constant cuts in one area are offset by the other; cuts in social care lead to an increased reliance on the NHS, while cuts in NHS services lead to huge extra costs for long-term care in nursing homes or by carers.

I am pleased that the Government have combined health and social care into a single responsible Department, but until councils and the NHS are not simply trying to drive down costs to meet their savings targets by offsetting against each other, and until we have combined budgets at a local level, the vicious circle will not end, and the problems for patients and their carers, and the strain on the health service as a whole, will not end either. I hope the Government will listen and take action.

--- Later in debate ---

[Caroline Dinenage]

I have already recognised the fact that all local authorities have had to make some really tough decisions. We know it has been difficult for everybody. Taking that action to control the deficit and get the country’s finances under control has meant that we have turned a corner and we are now beginning to put that funding back in. I do not think we can deny that there were years that were very difficult for all local authorities. There is dedicated funding in adult social care; the funding goes to a specific cause, which is really important, and allows local authorities to support and sustain a more diverse care market. It also goes on to help relieve pressure on the NHS, including by supporting more people to be discharged from hospital as soon as they are ready.

The money is already beginning to have an impact. Delays of transfers out of hospital due to adult social care hold-ups have reduced by more than a third over the past 12 months, freeing up 820 beds. A key tool in developing more and better out-of-hospital services is the better care fund, which is a mandatory, national programme for integrating health and social care. It joins up services so that they are designed around people’s needs, enabling them to manage their own wellbeing and to live as independently as possible. By mandating the pool of funds, the better care fund has helped to join up health and care services and incentivise local areas to work better together with increasing amounts of funds being used in that process. Some 90% of local leaders have reported that the better care fund has helped them to progress integration in their areas.

We know that the burden of care cannot and should not continue to fall simply on hospitals. We need to move care into the home and into the community. There are great examples of how that is working in practice up and down the country. Public Health England, the Chief Fire Officers Association, the Local Government Association, NHS England and Age UK already have a joint working approach to establish how local fire and rescue services, for example, can be commissioned to check on people in their homes, to check on the safety of people’s homes, and to check on things such as trip hazards—all things that can lead to people being admitted to hospital or needing the support of social care services. They work together to encourage joint working around intelligence-led early intervention and, in doing so, reduce preventable hospital admissions.

Evidence has indicated that longer hospital stays for older patients can lead to worse health outcomes and an increase in their care needs on discharge. We know that for a healthy older adult, 10 days of bed rest leads to a 14% reduction in leg and hip muscle strength and a 12% reduction in aerobic capacity, which is the equivalent of 10 years of their life, which is a massive incentive to make sure we get people back into their own homes and active as quickly as possible, in the interests of their own wellbeing.

I am particularly interested in understanding how intermediate care—step-up and step-down services—can reduce the impact of health crises on individuals. A relatively minor infection or a temporary worsening of a chronic condition should never spiral into a prolonged hospital stay with a detrimental impact on long-term quality of life. The real goal of integrating health and social care is not simply a benefit to the system, but an emphasis on person-centred care. We need multi-disciplinary teams working around a person to maximise the effectiveness of interventions, and therefore minimise disruption to the individual.

The hospital to home programme brings together practitioners across health and social care to develop solutions for more patient-centred care, focusing on how to keep people at home. It shows how urgent and emergency care services, community services, primary care and social care can all work together to make sure that people get the right care at the right time and, crucially, in the right place. That partnership goes through everything that local partners do, whether providing interlocking services or commissioning the right pattern of services.

How can we push forward these aims and create a sustainable settlement for social care? In March, the Secretary of State for Health and Social Care outlined seven principles for the Green Paper on care and support and for adult social care reform, and he put a key focus on the need to integrate services around the individual for a seamless, whole-person approach to both health and care. We have committed to publishing the Green Paper by the summer, and when it is published there will of course be a full public consultation, through which we want to seek the broadest possible range of views. I look forward to the contributions of Members under that national discussion.

[Dame Cheryl Gillan (in the Chair)]

The hon. Member for High Peak has a couple of minutes to wind up if she so wishes.

[Ruth George]

I will not take up that much of hon. Members’ time, but I will thank Members who have contributed to the discussion. I am pleased to have had the opportunity to have this discussion today—thank you, Dame Cheryl, for allowing me to do so. I hope it opens the door to looking more broadly at the impact of health and social care services on one another, and on patients and their carers.

[Dame Cheryl Gillan (in the Chair)]

I am most grateful to the Clerk for his advice in Westminster Hall today. I am very glad that we were able to have the debate.

Question put and agreed to.

Resolved,

That this House has considered the effect of social care provision on the NHS.