Personal Social Care: Funding

Baroness Pitkeathley Excerpts

Tuesday 16th October 2018 Lords Chamber

[Lord O'Shaughnessy]

I thank the noble Baroness for raising this important issue. She is quite right that extra funding is needed, which is why we have pledged £20 billion extra for the NHS and want to get this long-term funding settlement for social care. There are many proposals in the Independent Age document—nine, I think—and we are looking at a range of different options. As I said, there needs to be a fair balance between those who are working today and those who need care today, an issue that has evaded a number of Governments and which we sincerely hope to solve. On how the two plans will work together, the intention is that the long-term plan and the Green Paper will be published together around the same time and will therefore be complementary in trying to achieve the goal of integrated health and care.

[Baroness Pitkeathley (Lab)]

May I press the Minister further on his Answer to my noble friend about the consideration of free personal care? Those of us who were at the memorial for Lord Sutherland earlier today remember that he chaired a Royal Commission that came up with a proposal for free personal care. Sadly it was not implemented then, nor has it been implemented by any of the endless reports we have had on this issue in the ensuing 20 years. We need to consider free personal care as one of the options. I ask the Minister again: will it be considered?

[Lord O'Shaughnessy]

I shall have to disappoint the noble Baroness: the proposals will be set out in the Green Paper and I will not give a sneak preview today.

Adult Social Care

Baroness Pitkeathley Excerpts

Wednesday 11th July 2018 Lords Chamber

[Lord O’Shaughnessy]

That sounds like an excellent idea, and I would be delighted to consider it, as well as any other ideas that the noble Baroness has.

[Baroness Pitkeathley (Lab)]

I welcome the Green Paper but it is only a Green Paper. Does the Minister have any assessment of how long it will be before legislative changes can be brought in to make new initiatives a reality?

[Lord O’Shaughnessy]

I do not have that information, but it will be set out in the Green Paper.

Long-term Plan for the NHS

Baroness Pitkeathley Excerpts

Tuesday 19th June 2018 Lords Chamber

[Lord O'Shaughnessy]

My noble friend sets a tremendous personal example in this case. He is a fearless and tireless campaigner on the causes of obesity. He knows that it is our hope and intention that we will return to this topic so that we can start to reduce this plague on children and adults.

[Baroness Pitkeathley (Lab)]

My Lords, in the Statement the Minister referred to full integration between health and social care. Does he mean full integration of services, workforce and budgets? If so, is he confident that it can be done without the kinds of reorganisation that all of us dread?

[Lord O'Shaughnessy]

The noble Baroness makes a good point from her experience. There is agreement across the House—and, indeed, across both services—that there needs to be an integrated service. It is clearly not satisfactory to delineate in the way that we have done historically. How we get there will obviously be difficult. We need the NHS and local government to take the lead and to come up with proposals. If we believe that those proposals will deliver what we want without creating upheaval, it is incumbent on us all to get behind them.

Carers: Health and Well-being

Baroness Pitkeathley Excerpts

Tuesday 12th June 2018 Lords Chamber

Asked by

[Baroness Pitkeathley]

To ask Her Majesty’s Government, in the light of the results of the 2011 Census that showed that those caring for 50 hours per week or more are twice as likely to be in poor health as non-carers, what steps they are taking to improve the mental and physical health and well-being of carers.

[Baroness Pitkeathley (Lab)]

I beg leave to ask the Question standing in my name on the Order Paper. In doing so, I draw attention to my interests in the register.

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

My Lords, the Government recognise and value the work that carers do and are committed to supporting carers so that they can provide care without compromising their own health and well-being. That is why, on 5 June, my department published a carers action plan, setting out a cross-government programme of support for carers. Furthermore, there will be a clear focus on carers in the forthcoming social care Green Paper.

[Baroness Pitkeathley]

I thank the Minister for that reply and for the action plan. The process was a bit protracted, as he will remember, but I am glad that the department managed to get it out in time for Carers Week. However, by its own admission it is a short-term plan only to bridge the issue of carers in the run-up to the social care Green Paper. In new research published for Carers Week, 70% of carers said that their own mental health had been adversely affected, while 60% said that their physical health had worsened, and two out of five said that they doubted their ability to go on caring unless they had more support. Given that that care is valued at £130-odd billion a year, that is a time bomb that must be addressed in the Green Paper. Can the Minister reassure the House that the needs of carers will be central to any plans for social care reform? Will he also understand that, as well as the moral imperative for supporting carers, to which I know he is personally committed, there is a very sound economic case for doing so?

[Lord O’Shaughnessy]

I thank the noble Baroness for her question and for her tenacity in pursuing me on this topic. I am glad that we were able to publish the action plan. It is appropriate during Carers Week to pay tribute to the amazing work that carers do. Yesterday, I had the opportunity to meet carers who were struggling, often against their own health needs, to care for those they love.

The action plan that we published is a two-year plan. It has some immediate actions but is not purely short-term and contains some actions for the medium term. I highlight one of those, which is important, particularly given these concerns about carers’ health and well-being: a commitment to creating equality standards for carer-friendly GPs. Carers mentioned to me yesterday how important it is for GPs to validate the fact that they are carers and signpost them in the direction of care. I can confirm that carers and support for carers will have prominence in the Green Paper.

The Long-term Sustainability of the NHS and Adult Social Care

Baroness Pitkeathley Excerpts

Thursday 26th April 2018 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, in my 20-odd years in your Lordships’ House I have lost count of the number of times I have spoken on health and social care issues and called attention to the challenges of maintaining and developing a system of health and care on which we all depend. Like many others in your Lordships’ House I owe my life to the NHS, and in my professional life I spent 40 years campaigning for the rights of carers, on whom so much of that system depends.

The last few times I have made speeches here, as well as mentioning the problems in the NHS and care system—which we all know are legion and have been expertly detailed here today—I have said that I ventured to see a little more hope than I had hitherto, a ray of light at the end of the tunnel. If there have been rays of light—little chinks, perhaps—the report of the noble Lord, Lord Patel, was more like a search-light, a shaft of sunshine, perhaps even a new dawn. I congratulate him and his colleagues on their excellent report dealing with the difficulties and, above all, suggesting practical solutions and emphasising that the time for action is now. The emphasis on integration of health and social care, on realistic and consistent funding, on public health and prevention are music to the ears of anyone who has ever worked in or with our systems.

The call towards a lasting political consensus is also to be welcomed. The official government response is, to say the least, pedestrian. However, the ideas and flexibility which I think we see coming from the Secretary of State now give us hope that this time we will see a long-term solution. This is the time for a new Beveridge, as some have termed it. Let us remember that our forebears managed to agree and implement those Beveridge reforms at a time of world war and when the country was bankrupt, so being preoccupied with Brexit and periods of austerity is really no excuse.

The report gives many details on how the much-needed reforms could be implemented. I support them all. I say to the Government three important things they should remember as they develop ideas for NHS reform and the Green Paper on social care. First, be bold. Adopt the bold and far-sighted recommendations this important committee has made. Try to put out of your minds the fact that bold proposals in the past have been labelled death tax or dementia tax, according to what various parties have said, and the resultant media furore. This has always resulted in those previous bold proposals being kicked into the longest possible grass. Have the courage to take a long view.

Secondly, be inclusive. You must take the views of those who know the areas of health and social care well and are familiar with trying to navigate around their problems to deliver services. Consult the directors of adult social services and the voluntary sector. Charities have the ear of consumers and are familiar with operating on tight budgets. Above all, take the views of the patients, users and carers. Do not let this be a top-down operation.

Thirdly, be honest. No Government of whatever colour or combination have ever made it crystal clear to the public that outside the NHS the responsibility for paying for care and arranging it rests with individuals and their families, with public funding available only to those with least money and the highest needs. As a consequence, no one ever prepares or plans for care. They scrabble around at the last minute when the crisis occurs and the truth dawns on them, so proposals in the report that new mechanisms should be introduced to make it easier for individuals to save for and plan for care are welcome.

In addition, the expectation has grown up that savings and property assets can be passed down to our children and grandchildren. We have to rethink this, which requires political honesty and courage. I endorse what the noble Lord, Lord Warner, said: we must tackle that other sacred cow, the protection of older people. Well-off older people should not be exempt from contributing. Why should they be exempt from national insurance? Why should they have all the freebies that we enjoy? How many noble Lords need the £200 the Government are generous enough to give them at Christmas?

The report of the noble Lord, Lord Patel, emphasises that patients too must take responsibility for their own health, a view which many of us will endorse. However, when we are thinking about responsibility, we cannot and must not ignore the role of the family and the informal carers. No proposals for reform or the future can ever ignore the contribution of those 6 million people, whom your Lordships have heard me mention on many occasions and whom any Government ignore at their peril. This contribution based on family obligation and duty is worth more than £132 billion and, however well we organise and fund health and care systems, it will remain the bedrock and must be supported to continue.

Two years ago we were promised a new carer’s strategy, and much work was done on it. Thousands of carers were consulted and had their hopes raised about the new strategy. Then we were told it was going to be rolled up in the social care consultation. When that was first announced, the contribution of carers went totally unacknowledged. Perhaps by way of apology for that we were then promised in December a carer’s action plan in the new year. I have asked the Minister before: where is the action plan? He told me he was writing to me. I have not yet received a letter and it is now almost May. Above all I want to ask him how the 9,000 responses that carers sent in in good faith about a new carer’s strategy will be used and how those problems will be addressed. Every one of us will either be a carer or be cared for at some point in our lives—probably both. It is short-sighted to ignore their needs.

NHS: Winter 2017-18

Baroness Pitkeathley Excerpts

Wednesday 18th April 2018 Lords Chamber

[Lord O'Shaughnessy]

I do not believe that we have specific statistics on the demand from overseas visitors during winter. I say to my noble friend that overseas visitors are most welcome to use the NHS but it is important that they pay. We are reclaiming more money than ever from overseas visitors to go into funding the NHS.

[Baroness Pitkeathley (Lab)]

Is the Minister aware that the pressures on the health service are compounded by the difficulties in the social care system? We are promised a Green Paper. We were promised a carers action plan in January; it is now mid-April. Will he update the House on where we are with the carers action plan?

Prescription Drugs: Dependence

Baroness Pitkeathley Excerpts

Monday 19th March 2018 Lords Chamber

[Lord O'Shaughnessy]

I can attest to the benefits of both those courses of treatment. The review will look at prevention of dependency in the first place and in doing so will look at alternative courses of treatment. Of course, in the end there is a balance to be struck between the clinical needs of the patient and the right course of treatment. It is about making sure that clinicians are as informed as possible.

[Baroness Pitkeathley (Lab)]

My noble friend mentioned that many of the services for people who are addicted to prescribed drugs are provided by the charitable sector. He also mentioned that many of those services are under threat or have closed down because of a lack of local authority funding. Will the Minister consider what can be done to replace those vital services? Will the charitable sector, which is doing such good work in this area, be consulted in the course of the review?

[Lord O'Shaughnessy]

I completely echo the noble Baroness’s praise for the charitable sector. We have some very high-quality treatment centres in this country, provided both by the state and by charities. They do a fantastic job. In the most recently published figures, local authorities’ actual spend on funding for adults for drug misuse was about £490 million a year, so a substantial amount of money is going in. Of course, we need to make sure that it is getting to the people who are addicted to prescription drugs as well as illegal drugs.

NHS and Social Care: Winter Service Delivery

Baroness Pitkeathley Excerpts

Thursday 25th January 2018 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I have lost count of how many debates on these and related topics I have taken part in during 20 years in your Lordships’ House, but that does not make me any less enthusiastic about taking part in this one or make me offer any fewer congratulations to my noble friend on securing it when both the topics and the timing are of the utmost importance.

I might shock your Lordships today if I stand here and say that there is no winter crisis in the NHS and that there are no problems in the NHS. But in one sense, many would say that is right. The cancelled operations, the ambulances queuing, patients dying in corridors and all the rest are actually a crisis of social care, not of the health service. Health service budgets may be ring-fenced, but social care has lost about £6 billion from its total spend, and a 50% rise in the number of people especially elderly people, stuck in hospital is because there is nowhere for them to go in the community. Nearly 1,000 care homes have closed and 30,000 care home places have been lost because the providers can no longer afford to operate on the money they receive from the state, especially in areas where there are fewer wealthier self-funders, who cross-subsidise the places which are paid for by the state. By the way, this is another scandal waiting to happen, as it is in effect a stealth tax.

The last time that I spoke on social care I said that I was beginning to see a bit of light at the end of this long, dark tunnel, as there seemed to be some kind of consensus, at last, about the fact that this issue had to be tackled, even if there is no consensus as to how. Since then, we have seen the Secretary of State for Health add social care to his title, which I acknowledge is a step forward, even though there has been no change in how the budget works, with the purse strings for social care still apparently held at the DCLG. The result is the chaos we have seen all too frequently.

I am sure the Minister will tell the House about areas where pooled budgets are working well. I applaud those, but let us not forget that the reason we are seeing the growth of things like accountable care strategies and strategic partnerships is that local people are having to find ways to work around the fragmented system that was set up with the disastrous reforms of the Health and Social Care Act 2012, under which nobody knows who is in charge and decision-making is complex and fragmented.

Of course, what anyone who has been in A&E this winter will tell you are tales not only of chaos and pressure but of the hard work and commitment of dedicated staff doing their best against the odds. Another lot of people doing their best against the odds are the carers, already mentioned by my noble friend—who brings such valuable experience of her own as a carer to your Lordships’ House.

We must never forget the contribution of carers to social care, which is worth £132 billion every year, but neither must we forget the cost to the carers themselves. Three-quarters of carers report that their own health—physical or mental, and mostly both—is adversely affected by their caring responsibilities, while the financial strain of caring is well documented: not just the immediate costs of extra heating, transport and specialist food but the loss of future income because of lost earnings and lost pension provision. We should also remember that many people in the health and care workforce, struggling as they are to cope at present, are also juggling that work with their caring responsibilities. How are they supposed to make arrangements when they are given no notice of hospital discharges and given no choice at all about providing care for a loved one?

However, not involving carers is short-sighted and makes neither economic nor moral sense. That is why the failure to produce the long-promised carers’ strategy has been a great disappointment and disillusionment to the carer population—two years, we have waited for it. Of course the Minister will say their needs are to be included in the Green Paper on social care, but, as my noble friend asked, where is the action plan that was promised as a stop-gap? What will it cover? How will it be implemented? When may we expect to see it? We need urgent answers, and I hope today we are not going to be fobbed off with, “It will appear in due course”, which seems to be the Government’s answer to everything at present.

The Secretary of State is now in charge of the promised Green Paper and we simply must hope that he will find a way to rectify the decades of debate followed by inaction that we have had on social care. Heaven knows, debate has not been lacking: royal commissions, Wanless, Barker, Dilnot—your Lordships will be familiar with them all. But they have been followed by indecision upon indecision about how we are to tackle the complete unpredictability of the cost of care for families. It is literally a lottery where some of us pray we will die of cancer, and therefore get our care funded by the NHS, and not of Alzheimer’s, when we or our families will have to bear the burden. The only fair solution is to pool the risk between as great a number of people as possible so that everyone loses something but no one loses everything.

Of course, how social care is to be funded in future is a political decision, and surely if this winter has shown us anything, it is that such decisions cannot be put off and kicked into the long grass as successive Governments have done for 30 years. Is a consensus emerging, for example about a hypothecated tax? The chair of the Health Select Committee believes that national insurance could be extended to those over retiring age. Could some of us better-off pensioners—I include many in your Lordships’ House in that—forgo our £200 Christmas bonus and our free prescriptions? I know there are anxieties in all parties on this topic. My own party worries about the charges of a “death tax” that were made about our proposals in 2010, and no doubt the Government are still bruised by accusations about a “dementia tax” made at the time of the last election. But with the numbers of people over 85 set to double by 2039, there is no more pressing problem that our nation faces—even Brexit, although that will bring its own problems.

The snowdrops are out, the weather is milder and the winter crisis may be receding, but the respite is only temporary. Let us not have this self-same debate next January. We need political courage and leadership, and now is the time to show it.

Agency Nurses

Baroness Pitkeathley Excerpts

Wednesday 10th January 2018 Lords Chamber

[Lord O'Shaughnessy]

It is that last issue that we are trying to address. One factor is that there is now an hourly rate price cap on agency spend, precisely to drill down into that issue. The reason that the number of agency staff went up was in response to the Francis review and what it said about safe staffing levels in the service. The immediate response was to deal with that through agency staff. That was expensive, of course, which is why we have had to push down those costs. Nurses have to come from somewhere, and my noble friend is quite right that using existing nurses and support from nursing banks is one way of meeting demand with better value for money.

[Baroness Pitkeathley (Lab)]

My Lords, I noted carefully the Minister’s words about 10,000 extra nurses on the wards. Can he update the House on the position for community and district nurses?

[Lord O'Shaughnessy]

The number of those nurses has fallen—as have the numbers in mental health, which is worth pointing out—and we are trying to address this. I think I made a slip of the tongue a moment ago when I said that £5,000 more will be spent each year on training nurses; I meant that there will be 5,000 more student nursing places.

NHS: Staff

Baroness Pitkeathley Excerpts

Thursday 30th November 2017 Lords Chamber

[Baroness Pitkeathley (Lab)]

My Lords, I congratulate my noble friend Lord Clark not only on securing this debate but on his tenacity on this very important subject of NHS staffing. I endorse all that he said about the potential difficulties into the future—the near future of an institution which is so dear to so many of us and to which many, like me, owe their lives.

As my noble friend reminded us, this week has seen renewed fears about the safety of the care provided in our accident and emergency units, and other units, because of the lack of fully trained staff. There was also a disturbing statement earlier this week about the state of maternity services and the shortage of midwives. But I am going to widen this debate, as others have done, by focusing on another issue which fundamentally affects the efficiency—indeed, the very existence and continuation—of the NHS: social care. We need to consider other major workforces in conjunction with discussions about NHS staffing levels. I think there are three separate ones: those who work in the social care sector, the unpaid family carers, and the staff and volunteers in the charitable and voluntary sector.

It is simply impossible to consider anything to do with the running of the NHS without looking at the social care which precedes, follows or substitutes for NHS care, especially hospital care. Lack of adequate social care means more pressure on hospitals—often unnecessary pressure, as most people prefer to be cared for in their own homes; and if given proper support, they never go into hospital in the first place. Moreover, the levels of readmission rates if people are discharged without proper planning and follow-up are truly shocking, and we must be concerned about the pressure which families face if they are not given proper support with the care that most of them are only too willing to provide.

I have been concerned with social care for more than 30 years and have lost track of the number of times I have heard Ministers and others say that health and social care must be considered together, that we must have integrated services and that we must have staff who work across both disciplines. I have heard the noble Baroness, Lady Emerton, say that on many occasions. I thought it was axiomatic, but how wrong I was was proved by the Chancellor in his Budget last week. I could not believe that he failed to mention social care once. There is overwhelming consensus that the care system for older people and disabled adults is in crisis, but the Chancellor simply left it out.

Social care, which is always means tested, as we know, is provided by councils whose grants have been cut, and as a result the spending on social care has fallen by 30% in some areas since 2010. Three independent think tanks have produced a joint estimate that last week’s Budget will leave a £2.5 billion funding gap by 2019. Already, 1.2 million people are not getting the care they need, even with the enormous contribution of the 6.8 million family carers. The vast majority of care and support is provided not in hospitals and care homes but behind closed doors by family, friends and neighbours, and this is another huge workforce that we have to consider when we look at staffing levels in health and social care. Your Lordships will be fed up with hearing me refer to the value that this workforce provides but I am going to say it anyway—it is £132 billion every year, the cost of another NHS.

The number of people providing unpaid care has increased by about 1 million over the past 15 years, from 5.8 million to an estimated 6.8 million. It has far outstripped population growth. The number of carers grew by 11% over a decade. Families are caring more, not less, and therefore it is not good to hear Ministers even glancingly say that families should be taking more responsibility, because they could hardly take more than they are doing. Two years after the Care Act put in place stronger duties on local authorities to support carers, those new rights are not improving the lives of many carers in England. Carers’ assessments, which were put in place to look at the impact of caring on carers’ health and well-being, are too often failing to be put in place, and breaks and support are just not there. Some 40% of carers responding to Carers UK’s State of Caring 2017 survey said that they had not had a day off for more than a year. Imagine that, not having a day off for more than a year. In the context of this debate, the high rates of women carers and those in their 50s who are employed within the NHS means that supporting carers at work is particularly important for the NHS. Earlier this month, the Health Secretary himself highlighted the importance of flexible work and care leave for those juggling caring and working in the NHS.

The Autumn Budget did not provide additional support for social care in the short term to address the social care crisis and the predicted funding gap which I and others have mentioned, of £2.5 billion. The Chancellor offered a short-term fix to the NHS in his Budget—a sticking plaster, as it has been called—but did absolutely nothing about the long-term sustainability of health and social care funding. Sarah Wollaston, the chair of the Health Select Committee, said:

“We are failing to take the long view and see how serious the situation is. Health and social care is like a balloon—if you squeeze one part, another part pops out. The idea that you can fix the system in this way is nonsense”.


So here we are again. We have been here many times before, and it still seems many miles away from a solution to these problems. The history of our attempts is not edifying. Different parties calling each other’s proposals a death tax or a dementia tax is not helpful, and there have been endless commissions, royal and otherwise, all of which are languishing on the shelves of various Secretaries of State. The Minister will tell me that another consultation on social care funding is pending. My reaction? Oh please, not another one. Since 1997, there have been four independent commissions and five government papers on funding reform. As I said in my contribution to the debate on the Queen’s Speech earlier this year, we know the questions—we just need the answers.

I understand that the Government have now abandoned their commitment to the Dilnot commission proposals. Are we to start again then from scratch? Is all the work that the noble Lord, Lord Warner, and others did going to waste? Can the Minister please enlighten us? Have the very welcome plans for a carers’ strategy gone to waste in rather the same way? We have been working on that for some time, but we now understand that it will be rolled up with the social care consultation, which itself has been delayed, as the noble Lord, Lord Warner, reminded us. How the First Secretary of State could announce a consultation on proposals to reform social care without mentioning the contribution of 6.5 million carers is, frankly, beyond me. Discussions about a refreshed carers’ strategy have been going on for more than two years, and 6,000 carers sent in their views, at the Government’s request. Will the Minister tell me what is happening to those views, submitted by carers in good faith?

I know that last week, for Carers Rights Day, the Minister in another place announced there would be a carers’ action plan in the new year. That is a very welcome, although suspiciously late, initiative—perhaps to correct the unacceptable omission in the announcement by the First Secretary of State. None the less, I do not want to be churlish, and it is very welcome. But can the Minster tell me more about this proposed action plan and how carers and their representatives will be involved?

Finally, I want to refer to the workforce which operates in the voluntary sector. In the field of health and social care, charities are major players, providing care, developing innovative solutions to long-standing problems and representing those who have difficulty speaking for themselves. They often provide such services under contract from the local authority or a health agency, and are increasingly struggling to do so. As the Select Committee on Charities, which I had the honour to chair last year, said,

“there has been pressure on charities to reduce ‘back office’ costs and an increasing expectation that all money donated should go to the frontline … Charities cannot operate unless their core costs are met … commissioners should have regard for the sustainability of the organisations which they commission … and … realistic and justifiable core costs should be included in contracts, just as would happen in the private sector”.

Nobody would question that in the private sector.

My committee also recommended that the Government need to improve the way they consult the charity sector when developing new policies. We said:

“Poor consultation and ill-thought-through policy proposals have caused serious unease and disruption to the work of charities. We recommend that the Government reviews its approach to engagement with the charity sector before policy announcements are made, with a view to ensuring that charities feel better informed about legal changes which may affect them and have a greater opportunity to provide input on new policies”.


Although I still await the government response to the Select Committee’s report, I am glad to note that the Government have accepted this recommendation and that the Minister in another place has announced a cross-departmental initiative to improve communication. I am not expecting the Minister here to be able to respond to that, because I dare say it will not be in his brief today.

I support entirely my noble friend’s concerns about the NHS workforce but ask that the Minister also take into account the urgent needs of the social care workforce, including the unpaid carers and those who work in the voluntary sector.