NHS Winter Pressures

Lord Markham Excerpts

Tuesday 10th January 2023 Lords Chamber

[Lord Allan of Hallam (LD)]

My Lords, we welcome the fact that the Government are making a Statement, as it is abundantly clear to everyone that we have a crisis on our hands, and we on these Benches have been calling for this to be recognised as a national major incident. In that context, will the Minister clarify the status of the NHS recovery forum that was announced with great fanfare last week? Was it a one-off, or will it be meeting regularly and taking ownership of this crisis? If it is not the NHS recovery forum, what group within government will be taking us through the rest of the winter? This requires daily, serious leadership at the highest levels in government.

I have three questions on the specific measures outlined in the Statement. First, the Government have told us about the block-booking of care home beds, which should provide some immediate relief for hospitals, but they are much less clear on how they plan to increase domiciliary care so that people who can and should be in their own homes do not get stuck in care homes unnecessarily. The last thing we want to do is to move people out of one inappropriate care setting into another one, and domiciliary care remains the key to providing the best care for the vast majority of people who need neither hospital nor permanent care home residency. Can the Minister offer us any assurances on what the Government intend to do about domiciliary care provision?

Secondly, the Statement referred to the new NHS system control centres that will be in each integrated care board area, and which are a welcome development. There is published information about the data that will go into these new centres, but no information about what the centres themselves will make available to the public. Does the Minister agree that it would be helpful for people to know much more about the pressures on the NHS in their local area through these NHS system control centres publishing regular updates with as much information as they can provide to help patients make informed choices, with full knowledge of where the blockages are in the system?

Finally, the Statement referred to the use of artificial intelligence systems to help release patients sooner and track their progress through hospitals. There have been recent press reports about Welsh hospitals using tools developed by a British company called Faculty AI to improve patient discharges. Can the Minister add any insights into how these and similar technologies are going to be tested and deployed in England? I know that nothing is a silver bullet, but the reports suggest that they could make a significant difference to discharging people more efficiently and quickly. If that is so, we do not need to wait to deploy these technologies, and should be getting on with it.

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

My Lords, I thank noble Lords for their comments. As I mentioned in answering the previous Question, this is a reflection, from our part, of trying to understand the situation. We did some plans in October and looked at demand and supply, and that led us to make the announcements about the 7,000 extra beds and the £500 million adult social care discharge fund. It was clear to us that the bed occupancy issue was going to be at those danger points, and that was the plan.

Then, of course, as with any plan, you amend and review it all the time. Over the last few weeks of December, with the onset of flu beforehand, it became clear that we had higher levels of bed occupancy than we had planned for at that time because we had 7,000 or so extra beds taken up by flu while, at the same time, still requiring higher levels of Covid care than planned. It became clear from all this that the bed occupancy levels were still too high to be comfortable. This was causing the knock-on impact on the flow across the whole system, backing right up into the A&E wait times. That is why, very responsibly, we looked at the latest data, planned, and realised that we needed to do more. That was very much the components of the plan.

In answer to the point from the noble Baroness, Lady Merron, some of those short-term measures were about bringing in extra adult social care funding packages and, candidly, looking within every area of our budgets at what we really needed to spend over the rest of the year and at what we could prioritise. We managed to make some in-year savings through reducing headcount, particularly in admin and central areas, and then looked to redeploy that to make sure it was going to the front line.

As well as that, we looked at things such as the expandable modular space. This goes back to the flight control systems, which I would recommend to anyone. It is well worth a visit to Maidstone, where you will see what we plan for the longer term and what we are looking to do across the system in time for next winter. It became very clear there that, because it has the data, it can manage demand and supply. It sees the incoming from the ambulances; it sees the bed situation; it sees those people who are getting close to be ready for discharge. It is working with clinicians to say, “Actually, we’ve got some incoming and we need to free up that space. Let’s get the social care places ready. Let’s have transport ready and clean the bed quickly.” It is absolutely those micro-improvements and the Team Sky cycling-type approach that address it. AI comes in very much as part of that; you can speed up the flow all the time. It is not silver bullet stuff, but it is about looking at those micro-improvements as you go through it. That is very much the background to all this.

Dom care is an important aspect of that as well. I went through the stats with the team today, which said that of the 13,000 people ready for discharge, probably only 3% should require social care in the long term, and the other 97% should be in a home environment. Some of them might need a few weeks, which is where those care packages come in, and a lot of them need dom care, but 97% of them should not be in care going forward. That is why we need to focus these things towards that. That is the thinking behind this.

The modular space is an important component of this. Look at Maidstone again; it has looked very carefully at the patient flows and at where you can have same-day emergency care and get people out again so that they never have to go into a hospital. But you need extra space to do that. We have made this available so that the hospitals can decide where they most need that expandable space—whether it is pre-A&E, when they are finished in A&E and waiting in a decent space for a bed to come free, or step-down or discharge areas. It is about providing that flexibility and putting it in place quickly for them all.

What we were trying to do here was show flexibility and be fleet of foot to be able to course correct as time goes on; to put our hands up and notice when things were difficult and more challenging because bed occupancy was higher than expected—as I say, due to flu, Covid and other factors—and put in the measures to address them. That is exactly what we are doing in the short term.

In the longer term, next year—not that many people would say that nine or 10 months away is the longer term—we need to make sure that adult social care has further funding, as the House has heard me say many times. There will be a substantial increase next year, up to £1.7 billion, and a substantial increase the year after, of up to 20%. With flight control systems, expandable modular care and the rollout of virtual wards, we have a number of things that, on their own, are not a silver bullet, but, by putting them all together, you will start to get the changes and improvements that we expect to see. I say unashamedly that, if there are other facilities in the independent sector that we can make use of, be it making more use of pharmacies or expanding virtual wards, then we should do so.

I am sure there will be more questions as we go on in this debate, but I hope your Lordships can see that we have tried to respond to the challenges through a range of measures that we believe will make a difference. At the same time, we must be open to the need to do more; we will need to add more things and course correct as time goes on.

[Lord Patel (CB)]

The Minister may not agree, but the NHS is in crisis. He may say that the situation is “challenging”, but it could not be more challenging. Although infection rates related to Covid, flu and other infections may have exacerbated the situation, the genesis of the crisis is not of today’s making. It has been in the making for years. It is related to lack of capacity. Does he agree that the emergency measures now being put in place are not likely to work? If they are not likely to work, what is plan B? Importantly, what is the long-term plan to ensure that this does not continue into the spring, summer or next winter?

[Lord Markham (Con)]

I absolutely think these measures will improve the situation; I would not be putting them forward if I did not believe that. At the same time, just as we put out plans in October and are amending them now, I will continue to amend our plans. I think that is a flexible, responsible approach: you have a plan, you adapt that plan, you invest and you continue to improve. That is what we will continue to see and do; we will see those improvements go through this year and into the next.

[Lord Grade of Yarmouth (Non-Afl)]

My Lords, my noble friend the Minister mentioned pharmacies in his response, which clearly demonstrated a complete lack of understanding of the crisis that is going on in the independent pharmacy sector. They are closing at an alarming rate, yet they are the front line of the NHS, with record numbers of people coming to see them for free medical advice because they cannot get in to see their GP. There is a very serious crisis in the independent pharmacy sector, which is vital for healthcare. I have had many meetings, I have had letters, and I have got a campaign going in the media. It is clear from the responses that the department does not have a clue about the extent of the crisis and the closure of these independent pharmacies. Something needs to be done before they all close.

[Lord Markham (Con)]

I wholeheartedly agree with my noble friend that the pharmacies are the front line. We realise that they have been underutilised in the past. Actually, the plan of using them more for patients will put more funding their way, which I hope will support them, just as allocating Covid vaccinations to many pharmacies provided support. I hope my noble friend will see that this plan should add to the viability of a number of pharmacies by putting more business their way. They are a crucial part of the front line.

[Lord Turnberg (Lab)]

My Lords, this focus on the number of hospital beds may be at the wrong end. It is much more fruitful to think about why staff are so dissatisfied and unhappy that they wish to leave and do so in droves. We have to do more to improve the morale of the nursing and medical professions and, in particular, those who work in the community—the care workers. We are losing them in great numbers; they are not coping. The reason is partly their pay, and we must pay them a reasonable rate, but it is also that they are completely disillusioned as people do not take them seriously. They do not have a professional qualification or a proper training programme. They do not have the possibility of career progression. We must do more to encourage them and ensure that they have a satisfactory career. If we do, we could possibly get more patients out of those beds that were building up, and perhaps help reduce the queues of ambulances.

[Lord Markham (Con)]

I agree that we need a whole-system approach. Workforce is a key part of that, including the adult social care workforce. Again, as all noble Lords did, I welcome the advent of the agreement to do a workforce plan, which needs to take all these factors into account. We need to make sure that it is an attractive place to work, and that people see it as a career progression—and that it is modular so that you can start in social care and, if you want to, progress into other parts of the health service.

[Baroness Brinton (LD)]

My Lords, I declare my interest as a vice-president of the LGA and vice-chair of the All-Party Group on Adult Social Care. Nearly three years ago, the Government created Nightingale hospitals, which were much vaunted and had millions spent on them. Virtually all of them were useless because there was no staffing available for them at short notice. I listened to the question from the noble Baroness, Lady Merron, about the short, medium and long-term workforce plan. We are now in emergency time: there are 160,000 social care vacancies and 40,000 nursing vacancies, which includes those in social care. How is this unblocking of beds going to be staffed and by when?

[Lord Markham (Con)]

Obviously, prior to this, we were in touch with the adult social care sector to make sure that there was that capacity within the system for it. We have been assured that the capacity exists, but we wholeheartedly agree that we need to recruit the staff to fill those vacancies, which is why we have taken measures to recruit internationally as well as in the domestic recruitment programme. Those are all key components of the longer-term plan to solve this issue.

[Lord Kakkar (CB)]

My Lords, I remind noble Lords of my declared interest as chairman of the King’s Fund. The Statement made yesterday in the other place refers to a primary care recovery plan. It is well recognised that the hospital system is not sustainable if primary care cannot discharge its important gatekeeper function. Is the Minister able to confirm that, as part of that plan, there will be a radical review of options that might be adopted to ensure that primary care can deliver its important function?

[Lord Markham (Con)]

Yes, this is very much the focus of my colleague Minister O’Brien. I think it is understood that as many as half of the people who turn to up to A&E could have been looked after by the primary care system, so a lot of the pressures caused are as a result of that. It is absolutely a whole-system problem; many of the issues at the front end are about the GPs and at the back end they are about adult social care, which is why we need to address the whole system.

[Lord Balfe (Con)]

My Lords, last month, I had the dubious privilege of staying at one of the Minister’s hospitals. I was struck by the sclerotic way in which decisions were taken. It seems that the whole premium is on safety rather than looking after the patient. I would ask that the department looks into the way in which decisions are made, because I found far too often that a decision was made on the basis of what was safest. The multidisciplinary team, as it was called, was basically there to deflect anyone who wanted to do anything very adventurous. Will the Minister start looking, maybe in selected hospitals, at ways in which the decision-making and care process can be speeded up and made less sclerotic?

[Lord Markham (Con)]

I have seen very good examples of where that works. You have clinicians in the room with the data—the management and bed information. They make decisions according to the flow and number of people who they see are going to need a bed from the ambulances and the A&E situation, and the number who are ready to release. You have clinicians united with the information to make good decisions. Those are the best. The idea with the longer-term plan is to make sure those “best” have the tools in terms of the flight control system and have management processes in place so that they can adopt and follow best practice. It is key to what we are looking to make sure we have in place in time for next year, as the noble Baroness, Lady Merron, mentioned.

[Baroness Bennett of Manor Castle (GP)]

My Lords, the Minister replied to my Written Question on 5 January about commercial companies promoting strep A tests. The Answer said that these are “not currently recommended” by NICE

“for individuals aged five years old and over … with a sore throat”

and that UKHSA is conducting a

“bedside review of existing antigen-based lateral flow devices”

to

“identify the tests that are most likely to perform well”.

Given that, can the Minister explain why I have a number of emails from DAM Health headed “Concerned about strep A? Order your home test kit today. Only £12.99 per test kit. Quick and reliable results within minutes”? Can the Minister truly put his hand on his heart and say there is sufficient regulation and oversight of private testing companies, and indeed the broader private health sector? Is it not profiteering from the crisis in the NHS, potentially damaging the NHS and putting more pressure on NHS services?

[Lord Markham (Con)]

First, I declare an interest in this space. As many noble Lords will know, I set up a Covid testing company which never did any business towards the Government; I am very pleased to say that it served only the private sector. I am disposing of it as part of my obligations as a Minister. As the question relates to testing, I am quite keen to put that on the record.

Secondly, I would say “absolutely”. Dare I say it, but the reason my company was so successful is that we set the very highest standards according to the regulators. That is why we were able to win the crème de la crème—the Formula 1s and Wimbledons of the world. I cannot speak for other companies which may not be taking that high level of support, but there is absolutely a role for the regulator to make sure that only effective tests are marketed and those which are not effective should not.

[Baroness Armstrong of Hill Top (Lab)]

My Lords, I wonder whether the Minister—I hate to say this—will recognise that, too often, it feels that the Government have no institutional memory, have no ability to learn from what has happened in the past and keep trying to reinvent the wheel while the wheels are spinning away long before they get anywhere near. The King’s Fund recently published a report on how the last Labour Government brought down waiting lists. That report shows that you do not just have to shout about it; you have to put in place all the different steps, including the right financial flow.

From all that has been said today, it is clear that the right flow is to encourage more people into social care work and encourage and enable them to do more serious, high-level work like urine testing. The Government have not even begun to think about this. Until financial support for the whole flow and the financial incentives to change the things the Government need to change are there, and that is understood by Ministers, we will not get it. It is not enough to say, “We’re putting another £15 million or £50 million into this, that or the other”, without making sure that you know how it is going to be spent and that people are going to be there to deliver it.

[Lord Markham (Con)]

I have said before in this Chamber —and I will say it again—that we should be learning all lessons. I like to think that, three months into my role, I am learning some of those lessons. The noble Baroness will see that we have taken some backwards steps on the use of the independent sector, which, again, was pioneered 15 or 20 years ago, but hopefully we will move forward again. I unashamedly say that we can learn from those things. I have spoken to some colleagues from the noble Baroness’s side of the House, and will continue to, because I will adopt anything that works, and I agree that payment by results is one of those things. We can speak after these questions; my door is definitely open on those matters.

[Baroness Jolly (LD)]

My Lords, I have the privilege to chair the NHS national community nursing plan clinical reference group. We meet on a regular basis and look at how community nurses can keep people out of hospital and get people home from hospital. We have heard very little about that today. Can I have five or 10 minutes with the Minister at some stage to bring him up to speed on the work that is going on?

[Lord Markham (Con)]

As with my answer to the previous question, I look forward to that meeting and learning everything we can. I will repeat the statistics on that subject that struck me most: of those 13,000 people who are fit to be discharged, we think that only 3% need to be in social care in the long term; 97% could be at home, which is the best and most cost-effective place for them. We need to ensure that the support is in place to ensure that that option exists.

[Baroness Watkins of Tavistock (CB)]

My Lords, I declare my interests as a nurse and as a new appointment to the NHS England board as a non-executive director. There are two things missing from this discussion. First, there has been no reference to people waiting for mental health support. How can we ensure that people in mental health crisis are moved rapidly out of busy A&Es to be supported in quieter environments? There is a very good example across the road, at St Thomas’ Hospital, which is helping the A&E. Secondly, it is high time that we seriously consider giving full-time contracts to care workers in domiciliary services, because, as soon as somebody goes into hospital, the care worker’s hours are cut and, although they know that individual, they very rarely get reallocated to them when they are transferred back out of hospital. The lack of continuity of care often results in readmission, so what will the Minister do to ensure that, in the way that the noble Lord, Lord Turnberg, just outlined, we improve the lot of those particular care workers?

[Lord Markham (Con)]

First, I welcome the noble Baroness to the NHS England board, with high expectation of the value that she will add to it. I am very interested to understand her point further; I will speak to Minister Whately about that and respond to the noble Baroness in writing. Where people have knowledge of a patient at home, they can add that to their care when they come back out again.

[Lord Lansley (Con)]

My Lords, one of the lessons we learned, sometimes very painfully, during the earlier stages of the pandemic was the importance of working with, and often through, local government to tackle some of these issues. The same is true now. Would my noble friend explain how the NHS will use discharge funding and purchase social care provision? Will integrated care boards do that locally with local government, which has been managing social care purchasing for decades?

[Lord Markham (Con)]

I thank my noble friend. The best ICBs that I have seen have the local authority as part of their board and their decision-making on a day in, day out basis. One of the best control systems that I saw in an ICB actually had the local authority social care people in the room making the decisions with them, so they are a key element in all of this. On purchasing and funding, they are very much a strong player.

[Lord Watts (Lab)]

The Government have spent 13 years cutting the number of beds and they are now reversing that and starting to increase it, which is welcome. The other thing that they have done is to constrain pay in the NHS and social care. They have an opportunity to do something about that. Why are they not taking the opportunity to boost pay in both those sectors to address some of the problems that we face?

[Lord Markham (Con)]

I welcome what I hope, over the past few days, has been better mood music—let me put it that way—in this space. I hope from the different things that we see that we will get closer towards a landing zone where we can reach agreement going forward. We know from both sides that neither side wants to be in this dispute. My hope very much is that constructively—with good will on both sides, which we are seeing—we will find a way forward.