NHS and Social Care Commission

Maria Caulfield Excerpts

Thursday 28th January 2016 Commons Chamber

[Maria Caulfield (Lewes) (Con)]

I speak in this important debate as a nurse who is still working in the NHS, although not as much as I would like. I welcome the sentiments from both sides of the House about working towards a much more cross-party way of discussing the NHS and health and social care, but I am nervous about setting up a commission, because much of this work has been done already and what we need to do is roll the solutions out, not discuss the issues again and rehearse old stories. I speak as a nurse now, not a politician. My feeling—and the feeling of a number of my colleagues in the NHS—is that the interventions by a series of Governments over decades have got the NHS to where it is now, and if healthcare professionals and social care managers had been allowed to get on with their job we would not be in that situation.

No healthcare professional would agree that health and social care should be as divided as it currently is. If we had been allowed to get on with our job many years ago, that gap would be a lot smaller. That gap was created when the NHS was invented. There was a natural gap between what was deemed healthcare and what was deemed social care. That was compounded by the Nurses Act 1949 which clearly set out the view of what a nurse did, as opposed to what social care did. Over time, with the invention of various bodies and structures, both national and local, those rigid boundaries between health and social care have become stronger.

Funding streams have emerged, with NHS funding being protected and ring-fenced and increased over time. Social care has not had that luxury. Its funding is mainly given to local authorities, which have had to merge it with other budgets and also make cuts. They have not ring-fenced it. Many hon. Members today, including my hon. Friend the Member for Totnes (Dr Wollaston) and the hon. Member for Central Ayrshire (Dr Whitford), have eloquently described how that has been a penny-wise and pound-foolish approach, in that much of the preventive and public health work has been cut, with the NHS ultimately picking up the bill.

During my training as a nurse, we were taught an holistic model of care. We were taught that the patient’s physical care could not be separated from the emotional care, the spiritual care or the psychological care. However, when we practise in the real world, we are forced into separating physical care from mental health care and social care. When I was working on a ward, I would never question whether something was a nurse’s role or whether someone else should be doing it. If I was bathing a patient, getting them up in the morning or walking them in the hospital grounds so that they could get some fresh air, there was never a notion of “Is this the nurse’s role? Is this really healthcare?” It was all about looking after the patient as a whole.

As a result, when I was feeding someone, I was not only feeding them but looking at whether they had taken their medication that day, at whether they were eating, at whether they were perhaps a little bit more confused than they were yesterday or last week, and at whether there was an infection brewing. This is not just about ticking a box to say that that patient has been fed and had their medication. It is about holistic care, but the systems that are in place today do not allow us to practise that. In a hospital, we have the freedom to take on what is deemed a social role, but in the community we have no choice at all.

I know that things are changing, but we still see elderly patients who are struggling to stay at home, and they could have up to five visits a day from five separate people, and from five different people the following day. A nurse will go in to administer medication or to look after a catheter or a stoma, then someone else will come in to make a cup of tea or heat up a meal. There is no continuity of care, and there is no holistic care. That is simply because health budgets are run by the NHS and social care budgets are run by local authorities. It is no one’s fault; it is just the way that this has emerged.

I really welcome the work that has been done on NHS England’s “Five Year Forward View”. I also welcome the work of the Barker commission, which has not only identified the problem but come up with solutions and said that funding must be ring-fenced and combined. We cannot continue with separate funding for healthcare and social care. If we do, it will be a false economy and the constant divide will do nothing for patients and carers.

I welcome the notion of a commission and of cross-party working, but I am really nervous that we could undo much of the work that has been done. My local clinical commissioning group is doing fantastic work to ensure that the local authority and the local health services are starting to work together in a combined way. We hear a great deal about how hard it is to get social care packages together, and that is often why elderly patients get stuck in hospital. That is not always because of funding; it is often because we cannot get people to do the jobs. That is because there is no real reward in going in and having 15 minutes to make someone a cup of tea. It would be so much more rewarding if that person could have half an hour with the patient, in which they could help them to take their medication and not only make them a cup of tea but ensure that they drank it. However, the current system does not allow that to happen.

My nervousness about the commission is that we might undo many of the recommendations that we know need to be carried out, and that we could still be left with this divide between healthcare and social care a year down the line. The other cause of my nervousness is that a national one-size-fits-all model will not work. What works in my rural community of Lewes will be very different from what is needed in a London borough, for example. I therefore welcome the idea of local CCGs identifying what action is needed to merge health and social care and co-ordinating what will work best in that place.

Speaking as a politician, I urge other politicians to take a step back and allow health and social care professionals to take a lead on this. We have identified what the problems are and we have identified many of the solutions. We are committed to joint funding, so let’s get on and do it. Our role as politicians is to lobby if that funding does not come through, to enable healthcare professionals to get the resources they need. Our role is also to identify examples of good practice that could be rolled out in other areas where things might not be working so well. It is not our job constantly to debate what the issue is. We know what the issue is and we know what the solutions are. We just need to get on with it.

I welcome the comments made by my hon. Friend the Member for Bracknell (Dr Lee). I do not dismiss the need for a commission. A commission on health and social care is a great idea, but I think the timing is wrong. I think we have missed the moment. We need to have a cross-party debate about the structure of the NHS and about perhaps having fewer specialist units. Cottage hospitals were mentioned earlier. There are problems getting people out of hospitals and preventing them from going into them in the first place, but holistic care would enable them to stay in their own home. There also needs to be a step in between being at home and being admitted. We have moved away from that, at a cost not only to patients but to those who work in the healthcare sector.

I shall not repeat much of what has been said this afternoon. I am very supportive of cross-party working; I believe that we need to take the NHS out of the game of political football. I welcome all the comments that have been made today; I do not think that anyone has said that health and social care should not be combined either in practice or in relation to funding. However, my fear is that another commission would simply delay the good work that is starting and that needs to be carried on. I thank the right hon. Member for North Norfolk (Norman Lamb) for bringing forward today’s debate. I hope that we will not be standing here again in five years’ time, debating the matter further.

[Caroline Flint (Don Valley) (Lab)]

It is a pleasure to follow the hon. Member for Lewes (Maria Caulfield). We have heard from a few doctors this afternoon, so it has been good to hear the perspective of someone who worked as a nurse in the NHS. Judging by her comments this afternoon, I am sure that she keeps closely in touch with it.

I agree with the hon. Lady that much good work is being done in different parts of the UK on providing health and social care. However, we also know from the data and outcomes that that is not uniform. Some doctors, nurses and other health professionals are willing to rise to the challenge of putting public health on the same standing as treatment and of providing innovation in mental health services. Like all professions, however, it contains some who are not so willing to embrace change. They might, for different reasons, be stuck in a way of working that is not providing the outcomes that their patients want.

The hon. Lady rightly cited the example of people in our communities who need social care services and who are getting three, four or five visits a day from different people, all of whom feel that they have a role in providing for those individuals. When I listened to her telling that to the House, it took me back about eight years to when I went out shadowing some community matrons in my constituency. I spent time going out on the rounds with them and finding out what they did. The post of community matron was created to provide better links between hospitals and the support in the community. Each of them had a caseload of patients, all of whom had to have five or more conditions that were preventing them from getting the most out of their daily lives. Some of them were pensioners; some were not. Those women—the people I shadowed in my constituency were all women—formed the link between what was happening in the GP surgery and what was happening in hospital. If one of their patients had a fall, for example, and ended up in A&E, the people in A&E would look to see who their community matron was and get on the phone to them. Before the patient had even had their treatment in hospital, the hospital would be working with the community matron to arrange how they would be looked after outside. Sadly, all these years later, those community matrons no longer exist. We have to address the fact that some good ideas start off in the NHS but are gone in some years, for whatever reason, perhaps because they are used as political footballs.

Today’s motion is not about stopping the good things that are happening. A commission would not paralyse us and stop us continuing the good work in the NHS and the good parts of the forward view. When it comes to health and social services, five years is the blink of an eye. We need to be thinking about not just 10 but 20, 30 or 40 years down the road. What can we do today to determine what NHS and social care should look like in 50 years? That is the big challenge before us and it is why a commission would enable us to take some of the politics out of the debate and allow us to move forward together.

[Maria Caulfield]

I was out visiting a GP’s surgery last Friday in the constituency of my hon. Friend the Member for Brighton, Kemptown (Simon Kirby), which borders mine. There are still community matrons there. The matron on duty when I was there prevented a 90-year-old chap from being admitted to hospital for the weekend because she was able to fast-track a social care referral and get some help out to him on a Friday afternoon. A national roll-out does not always fit with what is happening locally. Some really good work is still happening at local level.

[Caroline Flint]

I hope that I have not given the impression that good work is not happening and good services do not exist. In my constituency not long ago, our district nurses were supporting treatment and care in the home for people who had problems with their legs and needed them bandaging. For a couple of months, those patients were incredibly nervous because they had heard that the nurses would no longer come to their home and they would have to go to the GP’s surgery for bandaging. Fortunately, it did not work out like that, but the stress about the future of their treatment caused those people a problem.

We can all talk about things that are working or not working in our constituencies. We can all point to good practice. It is a frustration of mine, not just in health, that best practice is not the driver for good practice everywhere. I do not know why we keep reinventing the wheel. We have to look at the bigger issues, and that is why I commend the right hon. Member for North Norfolk (Norman Lamb), my hon. Friend the Member for Leicester West (Liz Kendall) and the hon. Member for Central Suffolk and North Ipswich (Dr Poulter) for securing the debate today.

We have an important role in this House. It is not only about holding this or any Government to account; it is about shining a light on the social problems that our country faces and offering solutions that are not just for one term of a Parliament. The motion helps to highlight an ongoing generational problem and proposes a path to find some sort of solution.

The UK is an ageing society. We are a society growing older. Looking around the Chamber today, I am tempted to say, “Put your hand in the air if you are under 50.” Five.

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[Jeremy Lefroy]

That is an excellent point. I declare an interest, being married to a GP. Many GPs are already doing that—many have specialist interests. Perhaps there could be a specialism of generalism, if that is not a contradiction in terms—the idea that it is possible for someone to say, “I want to practise my medical career in a smaller place where I do a wider variety of tasks, but I have the knowledge to recognise the limits of my competence and when to refer onwards.”

I welcome the motion and the commission, although I will suggest some boundaries to it. The points that have been made about not going over old ground and not making the commission’s remit so broad that it is of no earthly use are valid. The Barker report has done some tremendous work in that respect and I will come on to that. There are other reviews going on, which I am sure have not escaped Members’ notice. The maternity review under Baroness Cumberlege, to which I have made a submission, is extremely important.

Here again, we see the contrast. On the one hand, we want the best possible care for mothers, pregnant women and their children when they are born; on the other hand, women want to be as close to home as possible. In some cases, and with midwife-led units, which we have just got in Stafford to replace our consultant-led unit, that can work for a limited number of women, but probably only about 30% of women will be able to go into such units; 70% will have to go further afield. We need to think about whether that is the right model. In the UK the largest unit, I believe, is in Liverpool, with more than 8,000 births a year. In Germany the largest is the Humboldt in Berlin, with about 4,500 births a year. Is there something to learn from that model, from the French model, from the Dutch model? I am hoping that Baroness Cumberlege’s report will show us that and give us a clear path for maternity and newborn care in the NHS.

I welcome the Government’s commitment to fund the five-year plan. That was not an easy step to take, but it was extremely important. As far as I can see, funding has been increased even since the election, but as others have said, it is a very challenging plan. Nobody has ever managed to achieve £20 billion or £22 billion of savings and we are already seeing some potential problems with that. I was lobbied yesterday by community pharmacists, who are seeing potential cuts in the sums allocated, which may result in the closure of pharmacies in the future. Of course, reform is needed, but the Government need to look carefully at that area.

I welcome, too, the additional money for child and adolescent mental health services. I chaired a roundtable of mental health providers in my constituency a couple of weeks ago. The additional money, the first part of which is just coming through, was welcomed and should plug some of the gaps in that service, although there remains an awful lot to do, as the right hon. Member for Sheffield, Hallam so eloquently pointed out.

I shall focus on two areas—integration and financing. At present the two main acute hospitals serving my constituents, the Royal Stoke and the County hospital in Stafford, are full. As other Members have pointed out, this is at a time when we have not had a major flu epidemic or abnormal winter pressures. We have something like 170 beds at the Royal Stoke with patients who should really be out of hospital but cannot leave, and in the County hospital we have around 30 beds. Of course, that means it becomes more difficult for their A&E departments to meet their targets.

I must say that the people in those departments are doing a great job. I urge Members to watch the little online video recorded in the Royal Stoke by The Guardian and see just how hard they are working in a hospital that this time last year was going through a very difficult time. It shows exactly what we are talking about, with people working long shifts and putting patients first, as they are in the County hospital and, indeed, in hospitals up and down the country.

We clearly have a problem in getting people out of hospital. As Members have said, that was raised 10 years ago, but we have still not fixed it. That is a real reason for integration. It is something the commission needs to look at, not to reinvent the wheel, but to look at where things are working and say, “Let’s get this right across the country.”

I think that the supported housing review, which was discussed in yesterday’s Opposition day debate, is critical. If a lot of the funding for supported housing goes as a result of changes to housing benefit, we will see a greater problem, with more pressure on A&E departments and in-patient services.

I very much endorse what Members have said about community matrons and district nurses, who perform a vital role. Only this week my wife was talking about the work of the district nurses in Stoke-on-Trent and how valuable and appreciated it is. However, not many of them are available at any one time, particularly over the weekend, which means a lot of juggling to see when they can go out to see her patients. Members have talked a lot about integration, and they have far greater knowledge than I have. I will just make the point that the commission needs to look at best practice.

I want to spend some time focusing on financing. It is absolutely right that the commission should examine all the options, but I have to say that, having looked at this quite carefully over a number of years, I do not think that we have too many options. I tend to agree with the Barker commission on that. Its report states that there should be a ring-fenced budget for NHS and social care, and it rejects new NHS charges, at least on a broad scale, and private insurance options in favour of public funding.

I have come to that view because I do not think that there is any other way in which the volume of extra resources needed will be raised. At the moment—I stand to be corrected on this—we probably spend between 2% and 3% less of our GDP on health than France or Germany does, which could amount to an additional £35 billion to £45 billion a year that we need to raise and spend.

I have to say that the NHS is a very efficient system. Given that efficiency, just think what would be possible if we came up with that extra 2% to 3% of national income, as our neighbours in France and Germany do. I am not talking about the 18% that the US spends, which in my view is far too much. A huge amount is wasted in the US system, and it does not necessarily achieve the right outcomes, particularly for people who are uninsured—thankfully that is changing as a result of recent reforms—or in lower income groups.

That is where we will run into political problems, which is why it is so important to put it into a cross-party, non-party political commission. In our fiscal system we lump together many different things and call them public expenditure, but what is called public expenditure is, in fact, made up of very different categories of spending. There is spending on state functions, such as defence, policing and education, and then there is spending on individuals, of which the biggest categories are pensions, welfare and, of course, the national health service, yet we are coming to a situation in which we talk about it all as if it is tax. So often in politics tax is bad, yet a lot of this spending is good; the two things do not make sense. In countries such as Germany, the latter forms of expenditure—the more personal ones—are often provided more through income-based social insurance. In the UK we started with that system more than 100 years ago, with national insurance, but over the past 50 years we have allowed national insurance to become less relevant, except in relation to eligibility for the state pension and certain benefits.

[Maria Caulfield]

On finance, I know from talking to my local council leaders that because for the past few years there has been a cap on how much they can raise their council tax by, they have not been able to raise it in order to pay for social care. I speak to residents who say that they would be more than willing to pay more if it was ring-fenced for social care and meant that there were more home helps and more services available. I welcome the announcement in the spending review of the 2% ringfence for social care because the NHS has had to pick up the bill due to the inability to properly fund social care.

[Jeremy Lefroy]

My hon. Friend is absolutely right. In fact, last year Staffordshire County Council raised its council tax by 1.9% but ring-fenced that part for social care, so it was ahead of the game. I believe that it is looking at doing the same this year, possibly taking advantage of the Government’s welcome proposal.

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[Helen Whately]

The right hon. Gentleman makes an important point about the need to look at and confront the long-term future funding settlement. I just do not think a commission is necessarily the right way to do it. The fact that we are having a conversation about it now, here in this House, is in its own right a good thing.

[Maria Caulfield]

Does my hon. Friend agree that NHS England is non-partisan and that the “Five Year Forward View” is non-partisan? It has considered all the aspects, and the role of a political party is to decide whether to support that or not. Too often, it is the politicians making the suggestions, not the NHS.

[Helen Whately]

I agree with my hon. Friend that the “Five Year Forward View” was a landmark document in that it set out the NHS’s own plan for its own future, supported by political parties. The more it can be encouraged and enabled to have that autonomy—and for organisations within the NHS to have that autonomy —to determine its own future, the better.

Another proposal is that the commission should focus on the integration of health and social care. In many ways that is already in progress, with many different models being pursued—it is one of the important features of the “Five Year Forward View”. One thing I am wary of is that the commission might come up with a one-size-fits-all model for integrated health and social care. If we have seen anything in recent years, it is that one-size-fits-all is not a good idea. One of the good things going on at the moment is the development of different models, whether in Manchester or in a local vanguard area such as down the road in Whitstable, looking at different ways of doing things. That is healthy. Each area could and should work out for itself the way to bring health and social care together. What we, and Government, should do is enable, support and encourage areas to move forwards and be bolder, and not necessarily impose a single template of how it should be done.

I am very mindful of the problems and outcomes challenges the NHS has on a national level, but in my constituency I have two trusts in special measures. My 100-year-old grandmother is, right now, in an acute hospital. If the system was working better, she would not be there. The health service has many problems, as well as many strengths. We should focus on how the NHS can get on with things that are in the pipeline. There have been many allusions to recent reports and evidence of best practice that is not being replicated enough across the system. There is a lot going on: the development of the vanguards, devolution, integrated care organisations and so on. All that good stuff is happening and we just need to get on with it.

We need to shift care, especially primary care, out of hospitals and, as people who can hold the Government to account, we need to make sure that the funding follows that shift. That is something that concerns me, and let us keep an eye on it. We also need to shift towards, and provide the funding for, parity of esteem for mental health and to improve the quality of care through transparency, technology and developing a learning culture in the NHS, with a greater focus on outcomes. This is happening, but we need more of it.

I am particularly concerned about the terrible morale among the NHS workforce. About 80% of junior doctors have said that they do not feel valued by the organisations they work in, and the figure is similar for other members of the healthcare workforce. That is an enormous problem. If I was to call for a commission on anything, I would call for one to look into why the workforce is so downbeat and demoralised. That is a fundamental but specific issue about which something could be done.

Overall, the NHS needs to get on with achieving the productivity opportunity that it identified and committed itself to in the “Five Year Forward View”. Many people are sceptical about the NHS’s ability to make £20 billion of efficiency improvements in the coming years. To do that, it needs to be bold and make the most of technology to reduce the enormous wastage in the NHS. It needs to solve the problem of patients not being discharged or coming to hospital unnecessarily. It needs to join up with the social care system around the NHS and address the shortage of nursing beds, for instance, which is an acute problem in my constituency and one of the major reasons patients are in hospital unnecessarily. I want all these things happening more quickly, on a larger scale and with greater boldness. The NHS and the social care system need to direct their energies at doing that, instead of being distracted by a commission covering the wide range of subjects mentioned today.

To conclude, I welcome our having a conversation that feels a lot less party political than many conversations about the NHS and which looks to the long term, as well as the near future, but I do not support the commission proposed by the right hon. Member for North Norfolk.

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[Debbie Abrahams]

I entirely agree. That was another of our manifesto pledges. I also thought that what the hon. Lady said in her speech was spot on.

Let me return to what I was saying about distractions. We also need to look at the issue of funding and resources. The hon. Member for Totnes (Dr Wollaston) said something about that as well. Real-terms growth in spending in the last Parliament was the lowest in the history of the NHS, at less than 1%, whereas between 1997 and 2009 it was about 6%. The figure in the last Parliament was about 7.5% of GDP, slipping below the European Union average. We are now moving towards the bottom of the league, which is where we started in 1997.

So far, we have not even talked about devolution. I am a Greater Manchester Member of Parliament. The devolution offer to Greater Manchester was £6 billion, although the current collective health and social care economy is worth £10 billion. There has been no talk of contingency arrangements for, say, a flu pandemic. It is an absolute disgrace.

I also agree with the hon. Member for Totnes about the lack of an evidence base for decisions. I have provided an evidence base: our committee looked into resources and funding and how both quality and equity could be improved, and found vast disparities across the country, as well as disparities in outcomes for different groups of people. We should repeal the Health and Social Care Act and ensure that the NHS is the preferred provider.

[Maria Caulfield]

Will the hon. Lady give way?

[Debbie Abrahams]

I hope the hon. Lady will not mind if I do not. I have spoken for some time, and I am being pressed by you, Mr Deputy Speaker—[Interruption.]

[Debbie Abrahams]

Go on, then.

[Maria Caulfield]

The hon. Lady spoke of repealing the Act. As a former NHS employee, I am frustrated by the fact that there has been too much reform, reorganisation and reinventing of the wheel. I issue this plea: please do not make any more structural changes.

[Debbie Abrahams]

I have chaired a trust, I am a former public health consultant, and I entirely agree with the hon. Lady. In the run-up to the election, we committed ourselves to repealing the Act without a reorganisation, because we thought that we could integrate and bring together health and social care in a better way that would not have required that reorganisation.

We need to feel confident that our NHS and care system is there for all of us, and for our parents and our children. It should be based on people, not on profit.