Social Care

Maria Caulfield Excerpts

Wednesday 16th November 2016 Commons Chamber

[Barbara Keeley]

It is indeed. The gap in my Salford local authority area is £1.1 million. We can raise only £1.6 million from the social care precept, while just paying the national living wage in the care sector is costing us £2.7 million.

Let me return to the matter of where the promised funding sits. In our motion, we call on the Government once again

“to bring forward promised funding”

for 2019-20

“to address the current funding crisis”

in social care. I am sure that the Health Secretary hears plenty about the impacts on the NHS of the missing funding for social care, but let us also think about the impacts on the people who actually need that care.

The hon. Member for Faversham and Mid Kent (Helen Whately) mentioned the thousands of patients stuck in hospital. We should be aware that keeping them there longer than necessary can have a number of detrimental effects. Long stays can affect patient morale and patient mobility, and of course increase patients’ risk of catching hospital-acquired infections.

Effects on mobility can be particularly keenly felt by older patients. As Professor John Young said in the 2014 national audit of intermediary care:

“A wait of more than two days negates the additional benefit of intermediate care, and seven days is associated with a 10% decline in muscle strength.”

As my hon. Friend the Member for Hackney South and Shoreditch (Meg Hillier), the Chair of the Public Accounts Committee, observed when the Committee published its own report on discharging older people from hospitals:

“Delayed discharge is damaging the health of patients and that of the public purse.”

Cuts to the funding of social care also affect a larger group of older and vulnerable people, and those cuts are now having a major impact on family carers. Age UK estimates that more than a million older people in England are living with unmet social care needs. I was struck by what the Unison staff told me about the many people they see during their care visits who are lonely and isolated.

Social care services have clearly failed to keep pace with increasing demand. Carers UK tells us that the drop in social care support, in the context of the increasing needs of our ageing population, is having a profound impact on the unpaid family carers who are stepping in to provide more care than ever before. It also tells us that the increase in the number of people providing care, and the increased number of hours of care that they provide, are being delivered at a huge personal cost to those family carers if they are not well supported—as, in all too many cases, they are not.

[Maria Caulfield (Lewes) (Con)]

The hon. Lady is making a case for more funds for social care. May I ask how the Labour party would raise that money? Would it give more to local authorities, or would it increase council tax precepts further?

[Barbara Keeley]

Our motion asks for promised funding that is backloaded to 2019-20 to be moved forward. The LGA and ADASS wanted it to be moved last year, and that is what we keep asking for.

--- Later in debate ---

[Maria Caulfield]

I thank the hon. Lady for giving way again; she is being extremely generous. Will she tell me, however, whether she is committing her party to delivering that money to local authorities directly, or to allowing them to increase their precepts?

[Barbara Keeley]

We do not even know what the Chancellor is going to do next week. The hon. Lady has invited me to make a declaration today, and it was a nice try, but we did not hear a word from Ministers about their plans during Health questions yesterday. I will, however, make what I think is an important point to the hon. Lady and to any other Member who raises the same issue. Labour would not have put our councils in this position to start with. If the hon. Lady looks back at our spending plans, or looks at the analysis by the Institute for Fiscal Studies relating to the different parties, she will find that our plans meant that we did not have to make the cuts that her party has made. This Government’s cuts will take £5 billion out of social care. I will send her the link to the IFS analysis if she wants to read it.

--- Later in debate ---

[Maria Caulfield (Lewes) (Con)]

I shall not be supporting the motion. While I agree that there are pressures on social care, the answer is not just financial. As many Members have pointed out, notably my hon. Friend the Member for Totnes (Dr Wollaston), we need to change the system and combine health and social care.

I have worked in the NHS for more than 20 years, and I still work as a nurse. I have always found it odd that health and social care are delivered separately, funded separately, and seen as separate entities. When I trained over 20 years ago, we were taught to treat people as a whole, not to treat them in terms of their social care needs or their health needs. I have spent most of my time working as a nurse in a hospital, and it is very different there. If someone needs personal care—if they need washing or feeding—we just get on and do it because we are looking after that patient as a whole. When patients are discharged home, they get their healthcare needs and medication delivered by the NHS, but if they need feeding, washing or dressing, they have to wait sometimes for many hours for someone else to provide that separately. I find that increasingly difficult to see.

Healthcare and personal care in hospitals is delivered by trained nurses and healthcare assistants who have had much training and are very well respected and valued. Personal care, however, is often delivered by people who are paid less than the living wage and who very often have had little or no training. Is it any wonder that this goes wrong, and that people are readmitted into hospital after ending up at home with healthcare problems? It is no wonder at all that we are facing this issue, and that is because the system is not working, not necessarily because there is not enough finance.

We need to appreciate the skill involved in social—or what I call personal—care. Washing someone is not just washing someone; if a person’s health needs are being looked after properly by a highly trained nurse who washes them, they will be checking whether they have eaten and taken their medication, and whether they are a little more confused today, and if so, why? Is a urinary tract infection brewing? Are their opiates too much? Are they hypoxic or constipated? There might be a whole host of reasons, and that nurse gets on top of those things and keeps that person well. Without that knowledge and skill, delivering social care on the cheap is never going to work.

We have seen hard evidence of this today from a pan-European study that says that the risk of a patient dying in hospital increases by a fifth for every nurse replaced by a healthcare assistant. I am sure if that study were extended to social care and into the community, those figures would be even worse. There has been an historical undervaluing of social care, which has been the Cinderella service in the care sector. I believe we should stop referring to healthcare and social care and just call it care.

The answer is not just to throw more money at the problem. I agree that money is needed, but the answer is to combine both things: health and social care need to be jointly commissioned, jointly paid for and jointly delivered. Currently, social care does not work for patients. They often have multiple visits—four or five visits in a day by four or five different people, with one person who can give them their medication but is not allowed to wash them, and the next person who has to say, even if they need medication, “Sorry that’s not my job. You’ll have to wait for your next visit.”

We heard from a previous Labour Secretary of State, the right hon. Member for Leigh (Andy Burnham), that attempts have been made to join health and social care together, but these have not made progress. I congratulate the Government on bringing forward sustainability and transformation plans and the better care fund in an attempt to make that difficult transition to merging health and social care. We are hearing about the progress that is being made, and the Secretary of State said that in places where this is starting to work admissions are dropping by 40%, which is welcome.

I passionately believe health and social care need to be combined. That will improve outcomes and reduce spending and admissions, but most of all it will improve patient care. The only way forward now is to be bold and brave, and when we have groups such as the King’s Fund with its Time to Think Differently programme recommending this as a new model of care, we have to move swiftly.

I cannot support this motion. While I believe that social care is under huge pressure, finance is not the only answer; we need a combined service, and we need to free up healthcare professionals to look after their patients holistically and free up bodies such as CCGs to commission services jointly. I support the Government’s efforts in trying to do that.

Community Pharmacies

Maria Caulfield Excerpts

Wednesday 2nd November 2016 Commons Chamber

[Dr Whitford]

We recently debated STPs and the potential they provide. The danger is that at the moment we are seeing finance-centred care, instead of patient-centred care. Going back to place-based planning, which is what we have kept in Scotland, where we still have health boards, means that we can look at integrating services, and pharmacies definitely need to be part of that. They have the potential to be a significant front-line player.

[Maria Caulfield (Lewes) (Con)]

I am interested in the experience in Scotland, although we do not have the same system in England. What does the hon. Lady think about moving pharmacists into GP surgeries? I think that it is a mistake. I would much prefer the approach that is being taken in Scotland, where pharmacies are expanding by having consulting rooms of their own.

[Dr Whitford]

Scotland actually has both. We do have pharmacists who are in a consulting room within a practice, and our Government have put £85 million into taking on an additional 140 pharmacists who work in primary care with GPs. We are not, as has been done in the past, saying, “Everyone on drug A must change to drug B because it is cheaper,” without giving any thought to how that affects the patient. We are consulting patients, who are often on 10 or 15 medications, all of which interact and have different side effects, and then rationalising that and giving the patient advice. We are therefore providing a clinical service rather than just a changeover service.

Our community pharmacy system has been running for 10 years, so it is quite mature. Patients register with a pharmacist in the same way as they register with a GP. The aim is for all people to be registered with whomever they consider their local pharmacist to be, as that means that they can access minor ailment treatment. It also means that people who are on chronic medication have a chronic medication service, with their prescription sent electronically to the pharmacy, which then keeps track of when it is due and therefore ensures that patients do not run out of medication. The pharmacies also provide an acute medication service for people who have not signed up to the other service but suddenly find they have no tablets, as they had not thought to re-order them with their GP. If they are regulars at the pharmacy, a single round of drugs can be prescribed for them there so that they do not have a gap in their treatment. The important thing is that our vision is to have all our pharmacists as prescribers by 2023, and to have our public registered with pharmacists by 2020.

--- Later in debate ---

[Oliver Dowden]

My hon. Friend is absolutely right that pharmacies play a crucial role in relieving the frontline of NHS services. However, that does not mean that reforms are not necessary. Of course we need to incentivise the kind of advantageous behaviour we have talked about; but we also need to recognise some of the problems with the provision of pharmaceutical services.

We know the basic problem; it has been referred to by other Members. The pharmacy budget has increased by 40% over the last decade. Even taking into account all the changes that the Government are proposing, funding for community pharmacies will still be 30% higher than when this Government first came to office in 2010. Equally, we have the problem of excessive clustering—a situation where there are many pharmacies within a short distance of one another.

Those who argue that there is no need for reform really need to explain where the money will come from. If we are not recycling these services to the frontline, we need to look for other savings, or we need to look at lower levels of service in the frontline of the NHS, whether that is services for diabetes or for cancer. There is no magic money tree. We have to take these difficult decisions in order to provide for the frontline, so I completely agree with the overall thrust of Government policy.

We can take an intelligent approach towards this issue. As we have heard, there is a big difference between various types of pharmacies. At one end of the scale, there are the very large pharmacies that are often in large retail outlets such as supermarkets and sit at the very back of the store. They are there, in essence, to encourage customers to go through the rest of the store to purchase other goods. They could easily take a larger cut than is being proposed, because they are just operating as loss leaders for those stores to get customers in the door in the first place.

[Maria Caulfield]

My hon. Friend is making an excellent point. I was slightly disappointed that the shadow Minister did not really understand the principle of vertically integrated pharmacies. Some big national companies are making a lot of money out of pharmacy at the moment.

--- Later in debate ---

[Maria Caulfield (Lewes) (Con)]

I will not go through the many arguments made by hon. Members, but the reason I do not support the Opposition motion is that I do not agree with their argument about funding. The current funding system for pharmacies in this country is not working. Pharmacies have grown organically in a haphazard way, not necessarily meeting the needs of patients or the changing demands of healthcare.

I find it extraordinary that Opposition Members are satisfied that big national companies such as Sainsbury’s, Boots and Asda, many of which make profits of £1 billion a year, are being funded with NHS money, which goes to each and every one of their branches. That is completely unacceptable. [Interruption.] I will not give way because there is not enough time. I agree with the hon. Member for Central Ayrshire (Dr Whitford) that the money that is saved through these changes must go to community pharmacies and away from big business.

I have severe concerns about the proposals on the table, however, and I have met the Minister to raise them. The first is my fear that the role of the pharmacist is not properly understood. As a practising nurse, I see at first hand every day the role that pharmacists play in safeguarding patients. Doctors often make out prescriptions that are wrong or do not take into account current medications a patient is on. That is where the pharmacist comes in. Thinking that pharmacists simply stand at a counter, pick a box off a shelf and put a sticker on it is misguided; they do a huge amount more.

Another concern is the proposal or recommendation that we move towards either GP dispensing or GP practices housing pharmacists. I know from talking to my GP practices that they are bursting at the seams. It is not as simple as installing a pharmacist at a practice; pharmacists need storage space for their medication, temperature-controlled rooms and space to make up that medication. I know that my GP practices do not have that space right now. I also have concerns about GPs’ taking on dispensing; as I have said, pharmacists have a crucial role in safeguarding patients. Who will pick up those mistakes, or look at patient medication or drug interaction if no pharmacist is there?

My biggest concern—again, this point was made by the hon. Member for Central Ayrshire—is that this is a huge missed opportunity. We are doing things the wrong way round. We should be looking at the system and at patients’ needs. We should follow the excellent model currently running in Scotland and learn from it, rather than thinking, “We need to save money. How can we best do that?”

As many Members have mentioned, there is some obvious stuff that pharmacists are doing now.

[Jim McMahon]

Will the hon. Lady give way?

[Maria Caulfield]

I will not—as I have said, time is short.

Right now, pharmacists are running clinics for asthma, blood pressure and thyroid issues. But we are not seeing what pharmacists could do. They are highly experienced and highly qualified. They should have registers of patients and be referring people to clinicians and hospitals themselves. They should be a second point of primary medical care. I cannot support the Opposition, because they are wrong that this is only about saving money. It is much bigger than that, and should be an opportunity to improve primary care overall.

Oral Answers to Questions

Maria Caulfield Excerpts

Tuesday 11th October 2016 Commons Chamber

[David Mowat]

I have made it clear that we should all be working together to defeat cancer. We know that the best way of doing so is early diagnosis. We have made a lot of progress on that in England over the past few years but have a lot further to go. We are of course willing to talk to the devolved Administration about what they can learn from us—and perhaps vice versa.

[Maria Caulfield (Lewes) (Con)]

T7. Will the Secretary of State look again at the decision not to fund second stem cell transplants for adults and children with blood cancers, given the significant clinical evidence of their benefit for those who relapse? He should not just take my word for it but should take it from the Anthony Nolan Trust and the 36 specialists who have written to him asking him to review the decision.

[David Mowat]

This is a very difficult area, but decisions on priority are clinically driven and must continue to be based on peer-reviewed data. The most recent review determined that less than one third of second transplants would result in survival after five years; that is why they were not funded. There will, however, be a further review next April, and to the extent that the data have changed there will be a new evaluation at that time.

NHS Sustainability and Transformation Plans

Maria Caulfield Excerpts

Wednesday 14th September 2016 Commons Chamber

[Dr Sarah Wollaston (Totnes) (Con)]

It is a pleasure to follow my colleague on the Health Committee, the hon. Member for Central Ayrshire (Dr Whitford).

I absolutely agree that we should see this as an opportunity to move away from a fragmented system where people are perhaps commissioning and providing care in isolated silos to one that looks across the whole system, and across geographical areas, so that we can move towards a truly integrated approach between health and social care. To do that, local authorities, as well as the health system, need to be involved in the STPs—and crucially, we need to involve local people. The lesson that we learn from every major reorganisation has been that if we take local people with us on the journey, and on the thinking behind it, it is much more likely to be successful. We should not see genuine local consultation and engagement as an inconvenience but as something that improves the eventual plans.

It is a real shame that this debate has developed a hashtag of “secretNHSplans”. I am afraid that NHS England now has to look at that, take a step back, and ask how it could have been better at engaging local communities—and those who represent them. It is a great shame that Members across this House were unable to see the draft plans until they were leaked to the press. That is not the right way forward for any genuine engagement.

[Maria Caulfield (Lewes) (Con)]

Does my hon. Friend agree that if staff, whether nurses, doctors, physios or pharmacists, had been involved right from the start of the process, that would have helped staff morale in the NHS, which is struggling, and that they probably have the best ideas of anyone as to how the STPs could progress?

[Dr Wollaston]

I absolutely agree. This is about local communities and their representatives. Public meetings are important, but so are involving bodies such as HealthWatch and making sure that under-represented groups are involved. The right hon. Member for North Norfolk (Norman Lamb) talked about the need to involve mental health services in these plans. It is very important that we make sure that under-represented groups are involved, and that does include those who use mental health services.

--- Later in debate ---

[Maria Caulfield (Lewes) (Con)]

Before I start, I wish to declare an interest as a registered nurse. I welcome this debate this afternoon as STPs are a really important issue and, as many Members have said, they have a huge potential to transform care at a local level, bringing in social care and third sector organisations. They represent a huge opportunity, and not one that we want to get wrong.

However, because many of these 44 STPs have not shared or consulted on their plans, there is a suspicion, rightly or wrongly, that they are an excuse to bring in cuts or to bridge financial deficits. I would welcome the Minister’s thoughts on this, and a signal that consultation will happen. That consultation is not happening at the moment, which is part of the problem. It enables those who want to perpetrate this myth and this fear that this is all about cuts to have some breathing space.

My area, which falls into the Sussex and East Surrey STP, has not published its STP. Although it makes great claims to be working with hospitals, clinical commissioning groups, local councils, GPs and HealthWatch, no one I know, and certainly no local MPs, has been involved in discussions about the process. I am very disappointed that some of our key community groups in Lewes and Seaford, such as our senior forums, Families for Autism and many other groups have not been consulted. It is right that STPs should submit their plans to NHS England to ensure that there is a co-ordinated approach across the country, but it is vital that there is time for consultation. I am worried that there is only a short period after October for that to happen.

However, what I say to the doom-mongers who are trying to instil fear into my constituents is that if current investment is anything to go on, I am optimistic about what our STP will look like. My constituency does not have a hospital. We depend on either the Royal Sussex county hospital in Brighton or Eastbourne district general hospital. We are seeing huge investment by this Government: £480 million on a new redevelopment of the Royal Sussex county hospital; £58 million promised for Eastbourne district general hospital; and a new multi-million pound radiotherapy suite at Eastbourne. Only last year, a new dialysis unit was opened in Polegate, which means that patients do not have to travel to Brighton three times a week for dialysis. Working with my hon. Friend the Member for Eastbourne (Caroline Ansell), we have been involved in developing a new state-of-the-art GP practice surgery in Eastbourne. There is a new Macmillan cancer centre in Sussex, and I could go on. There has been huge investment and new services that provide local treatment for local patients.

With all this investment, why are local people so worried about cuts? Despite an increase of £10 billion a year in funding, the NHS has to deliver £22 billion of savings. My constituents know that there is a 6% a year increase in demand for services, that more treatments are available that are costly and that there are more conditions that can be treated. There are concerns that we have not tackled wastage in the NHS, such as in the case of the chief executive of the troubled Southern mental health trust who was offered £240,000 for a new job instead of being investigated for the many hundreds of deaths that happened while she was in her previous role.

[Mims Davies (Eastleigh) (Con)]

To be efficient and effective, the NHS must stop these non-jobs. The creation of highly paid advisory roles is not helpful in letting patients be heard in this process, yet executives are heard, in terms of being given new offices and new pay cheques.

[Maria Caulfield]

Absolutely, and £240,000—

[Madam Deputy Speaker (Natascha Engel)]

Order. Andy Slaughter.

Junior Doctors Contracts

Maria Caulfield Excerpts

Monday 18th April 2016 Commons Chamber

[Mr Hunt]

We have two cases ongoing, and we are defending them vigorously.

[Maria Caulfield (Lewes) (Con)]

I, too, have been contacted by a number of junior doctors who are increasingly disillusioned by the way that the BMA is handling the dispute, and especially by the militant tendency, which has been hell-bent on strike action for many months. Will the Secretary of State meet other groups of junior doctors who want to resolve the dispute, recognise that a reformed contract is needed, and want to get back to looking after patients?

[Mr Hunt]

Of course I am delighted to engage with junior doctors, and I have been talking to a number of them over recent months. I agree with my hon. Friend. My observation from talking to junior doctors is that most of the time I am with them, they are not talking about things they do not like about the new contracts. They are concerned about things to do with their training and quality of life—things that I think we can sort out outside the current contractual negotiations. As my hon. Friend has correctly been passing on to them, there are many things in the new contract that will benefit junior doctors, and we should make sure that everyone knows about them.

Oral Answers to Questions

Maria Caulfield Excerpts

Tuesday 22nd March 2016 Commons Chamber

[Maria Caulfield (Lewes) (Con)]

Will the Minister join me in welcoming the Government announcement of funding for a new radiotherapy machine in Eastbourne district general hospital, which will improve cancer survival rates for patients from Seaford, Alfriston, Polegate and East Dean in my constituency?

[Jane Ellison]

Absolutely. My hon. Friend again highlights where we are investing, upgrading machines and putting in money, effort, people and resources to make sure that we can achieve world-class cancer outcomes. As I say, we are on course for record outcomes in terms of patients surviving 10 years beyond a diagnosis. However, we always want to do better, so I applaud the local efforts that she has highlighted.

NHS: Learning from Mistakes

Maria Caulfield Excerpts

Wednesday 9th March 2016 Commons Chamber

[Maria Caulfield (Lewes) (Con)]

I congratulate the Secretary of State on his statement this afternoon, and welcome the culture change that he is introducing to the NHS. My experience of working in the NHS under a number of Governments over the past 20 years was that when mistakes happened, a scapegoat was identified and it was thought that the problem had been dealt with. That is why people were reluctant to report problems, but often it is not one individual but a system of failure. We need to learn from that, so I welcome the Secretary of State’s comments. Relatives and patients have said to me that they do not want just to identify the problem; they want to ensure that it never happens again, which is exactly what my right hon. Friend said. I chaired a primary care seminar this morning with GPs, doctors, nurses and pharmacists—

[Madam Deputy Speaker (Mrs Eleanor Laing)]

Order. I am sure that the hon. Lady will quickly come to her question, or we will run out of time.

[Maria Caulfield]

Thank you, Madam Deputy Speaker. People are fed up with the NHS being talked down by Labour Members, and there was a plea to showcase the good work that is taking place in our NHS today.

[Mr Hunt]

It is so good to have someone with nursing experience in the House, and I hope that my hon. Friend will make an important contribution for many years to come. She knows what it is like on the front line, and why it is important to get this culture change. She also knows how important it is not to run down the NHS, which is doing extremely well.

End of Life Care

Maria Caulfield Excerpts

Wednesday 2nd March 2016 Commons Chamber

[Maria Caulfield (Lewes) (Con)]

I thank my hon. Friend the Member for Totnes (Dr Wollaston) for her excellent work in leading the Health Committee. I will not repeat points that a number of Members have raised, but there is a consensus that the issue of end-of -life care is growing in prominence and importance. The debate on assisted dying last September drove that discussion, and since then a number of Adjournment debates have focused on why end-of-life care is so important.

We know that 480,000 deaths a year occur in England and according to Macmillan Cancer Support, only 53% of people die in a place of their choice. We know that there are gaps in provision—not just in access and quality, but also according to disease type. As a cancer nurse, I was fortunate to have access to excellent palliative care, not just locally but for patients nationally. However, for those suffering from many other diseases, such as multiple sclerosis, Parkinson’s or Alzheimer’s, there is little or no access to good end-of-life care. As a result, there have been a number of reviews. We heard about the “Choice” review, which identified gaps and gave some solutions for meeting them, and last year the Health Committee delivered its report on how end-of -life care could be improved. The report by the Parliamentary Health Service Ombudsman, “Dying without dignity”, identified the same gaps. We know what the problems are, and now we need to deliver the solutions.

As this is an estimates debate, I will flag up the figures in those reports. We must invest £400 million annually in NHS community services to move end-of-life care out of hospitals—where most people do not want to die—and into the community, and we need roughly £100 million each year for local social services to provide the social care to back that up. That would deliver a saving of £370 million for the NHS and the acute services that are now picking those people up, but from my experience I think the savings will actually be much higher.

In the short time I have been an MP, many constituents have written to me, including an elderly gentleman of 92, who, a couple of weeks before the last Christmas that he would spend with his family, was stuck in hospital—not because of symptom or pain control, but for the lack of a feeding pump. He had a feeding pump in hospital, but because he wanted to go home to die and the community did not have one, he had to stay in hospital. That cost thousands of pounds a day, but more importantly it took precious time away from him and his family, just for the lack of a feeding pump. Such things cost a few pounds—I would have given the money myself if that is what it would have taken.

We know that £500 million would deliver district nurses to provide care, pharmacists, social services, and not just the seven-day-a-week NHS that we are proud we want to achieve, but the 24-hour care that most of those patients need. That would improve care and choice for those patients, and once that initial investment had been made, just £130 million a year would help to sustain it for health and social care. It would be money well spent if we could find it.

I bring good news for the Minister: we do not just need money. I make a plea for him to consider the Access to Palliative Care Bill that is currently finishing its passage through the other place, sponsored by Baroness Finlay. It shows that such an approach has a proven track record of delivering end-of-life care without needing a huge amount of investment, because it forces local CCGs to commission palliative care. That is what we are missing at the moment. Placing such care in the hands of CCGs makes them locally accountable, because what will deliver good palliative care in a London borough is very different from what will work in a rural constituency such as mine. It is important that CCGs take on that responsibility. I know from working in acute cancer care that unless something is commissioned and paid for, it does not happen.

[Mr Robin Walker (Worcester) (Con)]

My hon. Friend is making some excellent points. Does she recognise that there is a particular challenge when commissioners can seem almost to get something for nothing, with local hospices taking on more and more responsibility? It is important that local commissioners—wherever they are in the country—recognise that the services they rely on from hospices need to be paid for. As those services have increased in recent years, commissioners need to think about allocating more of their budget to them, which could then make savings for the other services that they commission.

[Maria Caulfield]

Absolutely. Those commissioning services realise their value. Hospices have taken up a lot of care. We all value our hospices, but that work is not necessarily valued financially. From working in cancer care, I know that my trust was commissioned to deliver day services, chemotherapy and radiotherapy. It was paid on a case-by-case basis. As soon as someone had finished their treatment and needed end-of-life care, however, everyone washed their hands of the responsibility because no one was getting paid for it. That is the reality of the situation. We need commissioning for end-of-life care to happen.

The Access to Palliative Care Bill, which has just gone through the other place, establishes four clear guidelines that would greatly improve end-of-life care without the money needed to back it up. First, on pain and symptom control, we should have an evidence base of what works for each disease and make sure that that is what happens. Secondly, there should be education and training for all staff and not just for those in end-of -life care. There is a huge amount of palliative and symptom control that staff, whatever their speciality—intensive care units, cardiac units, renal units and so on—can provide without needing specialist knowledge. All staff need to know is the point at which they need specialist advice. Simple education and training would enable that to happen and improve greatly the care that patients receive.

Research is the third guideline set out by Baroness Finlay in the Bill. Never underestimate the difference that research can make to end-of-life care. When I was a new nurse in the early ’90s, patients with hypercalcemia were admitted all the time. Hypercalcemia is when there is too much calcium in the bloodstream. Patients are confused and dehydrated, and they spend their last few days and weeks unable to communicate with their relatives. However, with research and the advent of bisphosphonates, it is very, very rare to see a case of hypercalcemia. Research into end-of-life care made that difference. Finally, as my hon. Friend the Member for Totnes pointed out, having the CQC inspect end-of-life care would make a huge difference, not just in the acute setting but across the board.

Other Members want to speak on this important subject, so I will just say that if the £500 million needed to implement the “Choice” review is not available, that should not stop us from improving end-of-life care. Many of the aspects of the Access to Palliative Care Bill would make a huge difference to patients and their families. I urge the Minister to consider them in his closing remarks.

Junior Doctors’ Contract Negotiations

Maria Caulfield Excerpts

Monday 8th February 2016 Commons Chamber

[Ben Gummer]

The right hon. Gentleman will know that we are looking at the contracts for GPs, consultants and junior doctors: they are of a piece. We cannot see one clinical group in isolation, when they work together. He should know, therefore, that in concluding discussions with junior doctors, consultants and GPs, we need to ensure that we give hospitals and primary care settings the ability to roster staff consistently through seven days of the week.

[Maria Caulfield (Lewes) (Con)]

I have met junior doctor colleagues over the last few weeks and months, and I know that many of them are cautious about the new contract and that strike action is the absolute last resort for them that they would rather not take. I met one of my constituents from Polegate this morning whose operation is going to be cancelled this week, thanks to the strike action. I welcome the Minister’s comment that the door is still open even at this late hour to call off the strike. Would he find it helpful if the shadow Secretary of State also condemned the strike and asked the doctors to call it off, so that patients do not become the real losers in this dispute?

[Ben Gummer]

My hon. Friend points to an interesting fact—that despite these many months of discussions, we have never had a clear line from the shadow Secretary of State or from the Opposition generally on whether they condemn or support the industrial action. It would be helpful if they made that clear because we would know at least whose side they are on. Are they on the side of patients, where we are trying to eliminate the weekend effect, or are they on the side of the BMA’s leadership?

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.

--- Later in debate ---

[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.

--- Later in debate ---

[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.

--- Later in debate ---

[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.