Local Government and Social Care Funding

Debate between Tom Brake and Norman Lamb

Wednesday 24th April 2019 Commons Chamber

[Norman Lamb]

I am deeply concerned about the future—or lack of a future—of the transforming care programme. One of the problems is that it is often NHS England that is funding care in an institution, and when a local authority is under financial stress, there is not much of an incentive to take that person out of the institution and make them the responsibility of the local authority. There has to be a way of funding the building of infrastructure to support people in the community. That is what has failed to happen so far.

This is not a static issue that we face. There is growing pressure. We are all living longer, often with chronic conditions that in the past used to kill us. That is a great triumph of man and womankind, but there is a cost attached, yet we have no mechanism to address the increasing funding needs of social care and, in particular, dementia.

The hon. Member for Chelmsford (Vicky Ford), one of the valued members of the Science and Technology Committee, made the point that the cost to society of dementia is about £26 billion every year, but that is going to rise dramatically. Whatever we say about spending money efficiently—I completely agree about the need to spend money efficiently and to innovate and do things in a more effective way—the dramatic rise in demand inevitably means that we will have to spend more as a society on supporting people with dementia and on research to find cures for dementia.

[Tom Brake]

Will my right hon. Friend give way?

[Norman Lamb]

I will briefly, but I am having glowers directed at me by you, Mr Deputy Speaker.

[Tom Brake]

Does my right hon. Friend agree that one of the ways of supporting people who need care, such as dementia sufferers, is to support their carers, and that there is a very important role for organisations such as the Sutton Carers Centre in providing support to the network of carers who support people with dementia and others with long-term conditions?

[Norman Lamb]

I very much agree, and those organisations do incredibly important work.

I want to mention the Care Act 2014, which I was responsible for taking through Parliament. I think it was widely regarded as good legislation, but I fear that it has been undermined by a failure to commit sufficient resources to really realise the transformation that it was designed to achieve in personalising care and putting the individual at the heart of everything that local authorities do. In particular, we legislated for a cap on care costs in that Act, but as soon as the Conservatives got rid of the Lib Dems from the coalition, that commitment was abandoned. All the work that we did in consulting and legislating for a cap on care costs to protect people from catastrophic cost has been lost. Of course, we know that in the 2017 general election the Prime Minister paid dearly for that politically, because the replacement proposal was sorely lacking and amounted, in many people’s eyes, to a tax on dementia.

I am conscious that you want me to shut up very soon, Mr Deputy Speaker, but I want to say something very briefly on future funding. It seems to me that if we are to achieve a sustainable settlement, we have to work on a cross-party basis and the Government have to embrace that. The motion still prompts the question of where the money is going to come from—it does not answer that question.

There are a range of solutions. My party and I have proposed a dedicated health and care tax that would appear on people’s pay packets so that everyone could see where the money was going, and which would be informed by an independent assessment, perhaps every five years, of how much the health and care system needed. It would take the politics out of the calculation of how much the care system needs. Then the parties could argue about whether they were prepared to meet those needs through an increase in that dedicated tax.

If we are to solve this, it will require political will. There has been a failure of the political class, not just in the last few years but ever since the late ’90s, when a royal commission established by the then Labour Government came up with proposals that were never implemented. It has been kicked in and out of the long grass ever since, and we are still waiting for a solution. It is time we found one, because we are letting down too many people in our country.

Customs and Borders

Debate between Tom Brake and Norman Lamb

Thursday 26th April 2018 Commons Chamber

[Tom Brake]

Thank you, Mr Speaker.

It is a pleasure to follow the hon. Member for Totnes (Dr Wollaston). I agree that we need a dose of Brexit reality. In fact, I agree with everything she said. I am sure she will share my concern about the recent figures on the number of EU nurses who have gone off the register, and indeed the number who have left the country, just at a time when we have significant vacancies.

Just as I agree with everything the hon. Lady said, I disagree with everything said by the hon. Member for Vauxhall (Kate Hoey), who is no longer in her place. However, at least she had the courage to be here to present that hard Brexit line. Where are the hard Brexiteers on the Conservative Benches? Where is the Foreign Secretary? Where is the Secretary of State for International Development? Where is the Leader of the House? [Interruption.] Oh, there is one. They should be here to hear what they are inflicting on the country. Perhaps the reason they are not here is that they did not want to hear some very well-judged, measured contributions from Members on their own Benches explaining precisely the damage that they are causing.

[Norman Lamb]

I agree with everything my right hon. Friend is saying. Does he share my complete confusion that many of those hard Brexiteers have spent their political lives fighting to cut red tape, yet here they are gratuitously proposing to massively increase red tape? What sense does that have?

[Tom Brake]

Absolutely, and I will come on to that very strong point shortly. The chaos those people have caused is being added to on a daily basis. Today, for instance, we have the Home Secretary refusing to confirm that the UK will come out of the customs union, and on the same day, we have the Foreign Secretary threatening to resign if we do. Well, there you are—what a well-run Cabinet delivering Brexit for us in this chaotic manner.

Why does the customs union matter? Before I touch on that, I should point out that, if people look at the literature circulated during the campaign, they will see that it was about spending Britain’s cash in Britain, it was often about immigration, it was about posters such as Nigel Farage’s poster scaring people with that picture of all those refugees. He did not have a massive poster saying, “What do we want? To come out of the customs union. When do we want it? Now.” Of course that was not a major feature of the campaign. Anyone who suggests otherwise is speaking somewhat remote from the truth.

Why does the customs union matter? Many Members have referred to the Irish border; it is a real pity that the Secretary of State only went to the border for the first time a couple of days ago. It also matters for the Dover border. I understand that “BBC South East Today” has confirmed that, so far, not a single Minister from DExEU has been to the port of Dover. I find it incredible that they have not managed to visit the port of Dover. If they had, they would have been able to see directly the impact of the customs union on our largest port.

I could touch on the impact on BMW and its ability to manufacture cars in Oxford, or indeed the issue of red tape for small businesses. There is also the cost of roughly £30 for every small business that exports to the EU to process electronic paperwork that it does not have to process at the moment.

What have the Government offered in return? What is their solution? Under a customs partnership, the UK would collect duties “on the EU’s behalf” for goods destined for the European Union. Think about what would happen if the EU put the reverse offer to us, whereby the EU collected duties on the UK’s behalf for goods destined for the UK. Would the Brexiteers on the Conservative Benches say, “That’s a brilliant idea. That’s exactly what I want the EU to do for us”? Of course they would not, because it is absolute nonsense to suggest that and they would not possibly support that if the EU suggested it.

The UK has recently been threatened with a nearly £2 billion fine for failing to handle imports at its ports effectively, leading to significant VAT losses in other EU countries. I cannot see the EU queuing up to give us responsibilities for something that we are not handling very well at the moment. As for the highly streamlined customs arrangement, no one has been able to identify the technology for it, and that technology needs to be in place, I suggest, by the end of 2019 to be properly run in and tested.

On the position of the Labour Front-Bench team, I do not know whether seeking a final deal that gives “full access” to European markets and “maintains the benefits” of the single market and the customs union is anything other than having your cake and eating it, but the Liberal Democrats still think we are better off in the European Union, in the single market and in the customs union, and we want to secure a final say on the deal for everyone in the country, to do this democratically.

NHS and Social Care Commission

Debate between Tom Brake and Norman Lamb

Thursday 28th January 2016 Commons Chamber

[Tom Brake (Carshalton and Wallington) (LD)]

My right hon. Friend may be coming on to this point, but what I want to understand is how the commission, and the output of that commission, can help with some of the very difficult hospital reorganisations that we all face in our constituencies—mine being St Helier hospital—and how we can ensure that we strike the right balance between acute services and care in the community. How will the commission help with that?

[Norman Lamb]

My right hon. Friend comes to the central point. As someone once said, the NHS has the status of a national religion. In this partisan atmosphere in which we all work, there is a danger that anyone who proposes a change to the NHS will get condemned from on high, because of the political points that can be scored in so doing. If we are to think about what we need from a modern health and care system that focuses on prevention, and to make changes in a rational way, we must give Government the space to think afresh about how we can sustain the system and guarantee care for those who need it. We have a choice now: we continue to drift until, ultimately, the system crashes, or we grasp the nettle and come up with a long-term solution.

All parties should commit to the proposal. If we want a good example, we should look at the commission of Adair Turner, which was established by the Labour Government to look at the long-term sustainability of pensions in this country. He managed to secure cross-party buy-in. He came up with proposals that led to change and reform. It was a process that gave people the space to look at a very difficult challenge and to come up with solutions. That is one model we could follow. It should be strictly time-limited. Somebody made the point that we are talking about not a royal commission, which goes into the long grass for three or four years, but a time-limited commission of up to one year with the aim of coming up with solutions that are then implemented. It should engage with the public, with patient groups and, critically, with staff, who, as the right hon. Member for Sutton Coldfield (Mr Mitchell) said, often feel that they are under intense pressure and that they are not listened to by Governments of all political persuasions. They, together with unions and civic society, should be centrally engaged with this commission. At the end of the process, we should seek to come up with recommendations that can then be implemented and can give everyone in this country the assurance that there is a long-term settlement for the NHS and for care.

Finally, let me raise one or two things that the commission needs to consider. It needs to look at the divide between the NHS and social care and at the adequacy of funding. How much as a society are we prepared to pay to ensure that we have a good, well-functioning health and care system? At the moment, funding for our health and care system comes through three different channels: the NHS, local authorities and the benefit system. Does that make sense? Should we look again at that system?

We also need to look at how we, as a country, are spending money on our older people. Are we spending it effectively enough? Are we targeting it at those older people who most need Government help? We need to look at intergenerational fairness and at where the money comes from—a point very well made in a recent book by the respected former Cabinet Minister, David Willetts. We also need to consider how we can give power to people to help them to self-care. David Wanless, when he reported for the Labour Government, made the point that his projections about how much extra money the system would need was based on people being engaged in their health—I am talking about self-caring more effectively. That has not happened in the way that he proposed.

We also need to consider the case for a dedicated health and care tax, which can be varied locally. Even protecting NHS spending results in disproportionate cuts in other areas of Government spending, distorting sensible, rational decisions. As this is an area on which spending inexorably rises, there is a case for carving out such a tax.

Mental Health: Out-of-Area Placements

Debate between Tom Brake and Norman Lamb

Thursday 3rd December 2015 Commons Chamber

[Norman Lamb]

Such a story makes one weep and leaves one feeling that there is a degree of incompetence somewhere. I will come to that point. Much of what I want to see happen can be done by better organisation, rather than by providing more money. I strongly believe that we need more investment in mental health services, but a lot can be done just by organising things much better.

[Tom Brake (Carshalton and Wallington) (LD)]

Will my right hon. Friend commend the work that South West London and St George’s Mental Health Trust has done with a number of local authorities in the area, including mine? The police work with a nurse, to ensure that if the police are dispatched somewhere where a person has a mental health problem, there is someone who is able to assess them immediately and ensure that they go to a place of safety, as opposed to going to a police cell.

[Norman Lamb]

Absolutely. My right hon. Friend is talking about something called street triage—I am sure that the Minister is familiar with it—which we introduced in many areas of the country over the past two to three years with a bit of pump-priming grant. Some pioneering areas, such as Leicestershire, just went ahead and introduced it before the national pilots started. The evidence is dramatic. Where we have that collaboration between the police and mental health services, with a nurse embedded in the police team, we achieve amazing results. We completely reduce the number of people being taken in under that legislation, because the nurse can find alternative solutions or provide care at home. Where it is necessary to take somebody to a place of safety, the numbers having to go into police cells falls dramatically. That innovative work was very much part of the crisis care concordat that I pioneered when a Minister, the aim of which was for the first time ever to set standards in mental health crisis care.

[Norman Lamb]

I agree. My own county of Norfolk, with its widely dispersed rural communities, suffers from the same challenges. Sometimes having a nurse in a car with a couple of police officers does not work in a big rural area. However, we can do other things, like having a nurse embedded in the police operations room so that whenever an issue arises they can speak immediately by telephone or, if necessary, get a resource to the scene. Depending on the geography, there are ways of dealing with those challenges. We need to be much smarter in doing that. I applaud the innovation across the country.

Our whole approach in the crisis care concordat was rather different from the traditional Government approach, which is sort of to impose a straitjacket. The crisis care concordat said, “These are the principles. You come up with your plan for implementing them, working with the police, mental health services and the local authority, in a way that works for your locality.” That generated the most amazing degree of innovation across the country, and real progress has been made. Although I initiated it, I have enormous admiration for the people on the ground who got on and did it. It was inspiring.

[Tom Brake]

Will my right hon. Friend give way?

[Norman Lamb]

I will give way, but then I really ought to make some progress.

[Tom Brake]

I want to return to the point my right hon. Friend started with. We had an issue in Sutton where the mental health facility is based on what had been the Sutton hospital site—it was shut down mainly because Legionnaires’ bacteria were discovered. Patients now have to travel to Springfield hospital. As we see more people being treated at home, which is what we want, and therefore fewer people in acute crisis, how does he deal with the fact that, because hopefully fewer people will need to be treated in specialist centres, there is likely to be a smaller number of them?

[Norman Lamb]

My right hon. Friend makes a good point. Again, it means that we need to think afresh and innovate. The third sector has been very good at coming up with concepts such as crisis houses, where at quite low cost a facility can be provided in a locality where someone can go at a moment of crisis. They therefore might not need a formal hospital admission, and it might be a much more therapeutic place to be as they get through their crisis. I recently visited the Hertfordshire Partnership NHS Foundation Trust, which, in addition to crisis houses, has host families that someone can go to be with, if that is appropriate, for a week or however long is necessary. That might be exactly what is needed, rather than the cold, clinical environment of a hospital ward. That sort of innovation is what we need in order to ensure that we have services that meet patients’ needs.

I want to share with the House the testimony of a constituent who has experienced an out-of-area placement. It has been anonymised, for obvious reasons, but it is very powerful none the less. It is quite shocking. It reads as follows:

“I was admitted to accident and emergency at Norfolk and Norwich Hospital on a Wednesday afternoon, following a suicide attempt. I regained consciousness the following day, having been transferred to the Acute Medical Unit, and it was quickly decided that I needed to be admitted to a mental health ward.

I had previously been on Glaven Ward at Hellesdon.”

That is the mental health hospital in Norwich. My constituents continues:

“At this point I was very woozy, suffering from a dangerously low mood, and angry that my suicide attempt had failed. I was at grave risk of making another attempt on my life. Throughout the Thursday and Friday efforts were made to find a mental health bed.”

That is what happens in the system.

“My parents were frantically trying to find out what was happening, as they were desperate for me to be looked after locally. For a time we were told that I would be going back to Glaven Ward at Hellesdon, but the news kept changing between there and a unit in London.”

London is between 120 and 130 miles away from Norwich, and further away from my constituent’s home.

“I was expecting to go to Hellesdon on Friday morning, but we were then told later that day that I would be going to south London. During the Friday, I twice walked off the ward and out of the hospital, without my absence being noticed, and went down to the Watton Road”—

which is near the hospital—

“with the intention of walking in front of a bus or a lorry. The main reason I didn’t go through with it was that I did not want the vehicle to swerve into an oncoming car and cause death or injury to someone else.

Meanwhile, my parents resorted to contacting the crisis team, as they could not get any information from the bed team. A member of the crisis team took responsibility for finding out what was happening and he was able to let me and my parents know that I would be transported to south London later that Friday evening.

Finally, after more uncertainty”—

this is really shocking—

“two men arrived to take me to London. At 10 pm, feeling suicidal, frightened and confused, I got into the back of a private ambulance (which was no more than a pretty austere minibus) and was driven away from the Norfolk and Norwich Hospital. Throughout the three-hour drive, I was spoken to just once by one of the two men, and felt more like a prisoner being transported than a patient.”

That is the way our NHS deals with someone who is acutely ill. It is really shocking. It ought not to be accepted. My constituent went on:

“At 1 am, by now completely disorientated, I arrived at the front door of the mental health unit in south London. After lots of knocking at the door, someone answered, and I was handed over with a quick ‘good luck’. I was booked in and shown to my room. I felt isolated and scared. My room was nice, but the unit felt like a prison. The internal doors were like cell doors, and there was a tiny outdoor area, fringed by a high fence with spikes on the top. It was a mixed ward, both in terms of sex and in terms of illness: people with depression and anxiety were alongside those with psychosis, personality disorders and acute problems.”

It is really shocking that a whole load of people with completely different conditions were thrown together like that. It is probably the least therapeutic environment imaginable. That is about containing people, not caring for them, and it ought to be a thing of the past.

[Norman Lamb]

It is absolutely critical that that happens —not only monitoring but proper treatment. As I will go on to describe, that is not what happened in this case.

The constituent continues:

“The following morning, I had a meeting with my named nurse. Extraordinarily, it was the only real conversation I had with him until I was discharged back to Norfolk 10 days later.”

That is not therapeutic care—it is neglect. I have asked whether there are any contractual requirements on the private provider who provided that “care” and received a substantial sum of money for it. I have been told that it was understood that there would be therapeutic care but no apparent requirement that that should be undertaken in return for a substantial amount of public money being spent on his care. He goes on:

“The care was unacceptable. It felt as though I was being kept in a holding facility, and my mental health deteriorated, with my suicidal thoughts increasing. In stark contrast to Glaven at Hellesdon, the staff were holed up in an office with a heavy steel door that you couldn’t see into. I was being checked up on every 15 minutes, as I was a suicide risk.

But I rarely had a conversation with a member of staff. My parents came down from Norfolk twice to see me, and were horrified by what they encountered—both the level of care and my deterioration. They were constantly contacting Norfolk and Suffolk mental health trust to try to get me moved back to Hellesdon. The stress made them both ill.”

That shows the impact there is on families as well. He continues:

“Thankfully their persistence paid off, and after 10 days, I was told that I was going to be recalled. I had a brief period of uncertainty, as I didn’t know whether I would be going to Hellesdon, King’s Lynn or Great Yarmouth.

Eventually, I was told it would be Glaven at Hellesdon, and I got into a taxi with a member of staff and was driven from south London to Glaven Ward.

When I arrived there, I cried, mainly through relief. I was greeted with compassion and understanding by the staff, and—after 10 wasted and expensive days—my recovery finally began.”

That experience, sadly, is repeated day in, day out across the NHS. It is a scandal that it continues. One of the things I will put to the Minister when I conclude is that I want his commitment to end this practice, because it is intolerable that it continues in this day and age.

I mentioned cost. An analysis has been done by the national confidential inquiry into suicide and homicide by people with mental illness, which, having looked at 29 providers, says that the cost of out-of-area placements went up from £51.4 million to £65.2 million in 2014-15. That is an extraordinary amount of money to spend on an unacceptable practice, demonstrating that with smarter use of the resources available it should be possible to bring that practice an end.

The national confidential inquiry also found that being treated out of area increases someone’s risk of suicide. The pattern is most apparent in England, where suicides by in-patients and patients recently discharged from hospital have fallen, although suicides following discharge from an out-of-area ward have increased. The annual number of suicides after discharge from a non-local unit has increased from 68 in 2003-07 to 109 in 2008-12. Experts have warned that mental health patients are at the highest risk of taking their own lives in the first two weeks after being discharged from hospital, and these figures confirm that. When we are talking about a risk of people actually losing their lives, surely we have to see the absolute importance of bringing this practice to an end.

I want to refer to a recent report by the Independent Mental Health Services Alliance called “Breaking Down Barriers: Improving patient access and outcomes in mental health”. It says that we must prioritise something that I have argued for consistently—the introduction of comprehensive waiting time standards in mental health so that someone with a mental health problem has exactly the same right of access to treatment as anyone else. It also says that people who end up in an out-of-area placement, sometimes a long way from home, get “lost in the system”; they are almost forgotten about. They are away from the commissioners and the normal provider, and they can sometimes languish in these centres for far too long. That, again, is completely intolerable.

The report also refers to the problem of delayed discharge. It says:

“We have found that between 2013/14 and 2014/15, the average number of days of delayed discharge per month for trusts providing mental health services increased by 22.2 per cent. This indicates that delayed discharges are having an increased impact on patients’ access to appropriate care.”

In other words, if beds are clogged up by people who are ready to leave and go home or to go to another facility, but they cannot because nothing else is arranged for them, then someone else at a moment of crisis cannot get access to a bed and is shunted off, sometimes to a place a long way from home. That is a completely unacceptable practice.

The report refers to children and young people’s mental health services. The Minister will be particularly aware of the acute concern about children being shunted off, often to places hundreds of miles away from home—an intolerable practice. I know that that has happened in the south-west, where there has been a particular shortage of beds for children. A team within NHS England undertook an inquiry that came up with recommendations for eradicating that problem. The taskforce’s report, “Future In Mind”, which we published shortly before the general election, pointed to the absolute need to care for people close to home and to have better crisis support to avoid admissions where possible. Yet the practice continues, and it must be a priority for the Minister to bring it to an end.

One of the things that “Future In Mind” sought to address is the perverse incentive that exists in the system with the awful tiering of care within children’s mental health services. If a child is put into tier 4 from tier 3 because it is judged that they need more acute in-patient care, then the financial responsibility for their care is transferred to NHS England. There is therefore an incentive for local commissioners to push them into the top tier, which is precisely the opposite of what ought to be happening. We ought to be focusing our incentives on preventing deterioration of health, not shunting people into the most acute care, too often away from home. Imagine what it must be like for the parents of, say, a 14-year-old child who is taken to a unit 100 miles or 200 miles away from home. It is really shocking, and I hope that the Government will feel the need to commit to eradicating that practice as quickly as possible.

When the issue came to my attention as a Minister, I asked my officials to provide me with data to find out what was happening around the country. I was confronted by freedom of information requests by campaigning organisations and by news reports of shocking things that were happening in the system, but I had no information on which to base my own judgment. I was told by the officials that they did not collect data on the issue. The Government are operating in a complete fog, and we have to rely on campaigning organisations to make inquiries under the Freedom of Information Act 2000.

Incidentally, I urge the Minister to use what powers of persuasion he has to argue against undermining the Freedom of Information Act. At the moment, a process is under way that runs the risk of doing precisely that. It seems to me that freedom of information is a really important way of holding the Government to account.

I was faced with having no information or data on that practice, so we initiated a process to collect such data. We have now collected those data. They are still in experimental form, but they are better than nothing. The data show that there is extraordinary variation around the country. That brings me back to the point that this is about not just extra money, but good practice. It is about learning from areas of best practice. We now discover that many mental health trusts have no out-of-area placements, but they are funded in broadly the same way as those in areas that have a persistent and unacceptable problem.

There is a three-month delay before the data are published, so the latest data are those from the end of August, but 2,198 people were in out-of-area placements at that time. We are not entirely clear about whether the drift upwards is caused by the collection of more data or by a worsening of the problem. I do not want to draw the wrong conclusion from the numbers, but they certainly do not appear to be going down.

I want to raise with the Minister the issue that the data are incomplete because some private providers refuse to return data. Under their contractual dealings with the NHS, they are obliged to return those data. When I was a Minister, I raised that matter with officials and with the information centre. Surely, it is completely unacceptable. I have no difficulty with a good private provider providing a good service, but they must absolutely play by the same rules as everybody else.

[Tom Brake]

To return to my right hon. Friend’s earlier point about freedom of information—in fact, there is a case for extending it—is it not right to ensure that private companies doing public work are covered by FOI in exactly the same way? That applies to the health sector, as well as to many other sectors.

[Norman Lamb]

I agree. There should be a level playing field, which there is not at present. We now have the unacceptable situation that data are incomplete because some private providers refuse to play ball. That leaves one suspicious, because if they do not provide data about how many people are held, it is impossible to hold the system to account or, indeed, to hold such private providers to account. The Minister must find a way to hold those providers to account and to ensure that they return the data they are obliged to provide.

A horrific number of people are still sent a considerable distance away from home. In August, 501 people were sent more than 50 km away from home. Surely that practice is intolerable, given what I have said about the increased risk of suicide, the fact that it does not provide therapeutic care and that it can lead to someone being confined for 10 days at enormous cost to the public purse. It seems to me that this is the most outrageous misuse of public money.

There are areas where that problem is persistently at its greatest. In August, the Devon Partnership NHS Trust had 45 people in out-of-area placements. The caveat is that we do not know precisely where responsibility lies, and whether this is a commissioning or a provider issue. However, that is the local provider, and one would normally expect such people to be in a bed provided by the local provider. The figure of 45 people means that significantly more than one person a day is shunted more than 50 km away from home, which is outrageous.