Residential Care: Cost Cap

Baroness Walmsley Excerpts

Thursday 10th December 2015 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, I, too, thank the noble Baroness, Lady Wheeler, for allowing us to have this very long-awaited debate. There is so much to say about this issue that one hardly knows where to start. So many excellent points have been made in this debate. I think we all agree with the right reverend Prelate the Bishop of Bristol that this is about people. We must always bear that in mind.

The main point I want to make is that failure adequately to fund social care does not just impact on those people whose needs are currently not being met at all or only partly so, and their families, important though that is. This failure affects all of us now and in future. Although we will not all need social care in future, we all at some time will need the services of the NHS. The failure to deal adequately with social care is already impinging on the sustainability of the NHS and will continue to do so to an even greater extent in future unless something is done. The Government must not plan on a budget surplus by 2020 if it is at the expense of vulnerable old people in the short and long term, and the viability of our precious NHS which serves us all. It is simply not right and not logical. If they fail on social care, they cannot claim that the NHS is safe in their hands.

As the noble Baroness, Lady Wheeler, outlined, the unanimity among providers about the facts are impressive so there is no doubt about the impact social care cuts are having on services. In a recent survey from the NHS Confederation, 99 % of NHS leaders said social care cuts are increasing the pressures on the NHS and the most prominent impact noted by four out of five of them was the increased time people remain in hospital. This is not new, and many noble Lords mentioned it. For a number of years now, the Government have been alerted to this and yet spending pressures continue to be tolerated. The 2015 spending review finally recognised the funding gap but the remedies are totally inadequate. The Five Year Forward View developed by NHS England and the other NHS arm’s-length bodies is clear that plans for addressing the NHS funding gap are based on an assumption of social care services being sustained. So the ability of the NHS to make unprecedented savings in this Parliament relies on the Government addressing the social care funding gap. If the Government choose not to close that gap, they are choosing not to support the delivery of the Five Year Forward View.

As my noble friend Lady Brinton said, directors of adult social services estimate a £4.3 billion gap by 2020-21. The spending review proposals are unlikely to cover this or the inevitable additional costs of the introduction of the euphemistically named “national living wage”. I absolutely agree with the comments of the noble Lords, Lord Turnberg and Lord Lipsey, about that. Neither will it meet the future growth of demand due to our ageing population. In addition, as we have heard, the Government have back-loaded the better care fund until towards the end of the Parliament. By that time the system will have collapsed—the money is needed now.

Local authorities and social care providers are somehow expected to fill the gap. Many local authorities have prioritised social care. We heard from the noble Baroness, Lady Redfern, about North Lincolnshire. I think that many of us will want to move to Utopia, otherwise known as North Lincolnshire, before we get much older. It currently accounts for 35% of its total budgets compared with 30% at the start of the last Parliament. Spending on adult social care has already been reduced by £4.6 billion, about one-third of the budget in real terms. There is a limit, which we are fast approaching, to how long this can go on.

While all this is happening, vulnerable people are missing out. The reduction in spending has resulted in eligibility thresholds being tightened so that often only the most severe needs are met through state-funded social care. In total, around 400,000 fewer people have their assessed needs met. If they reach crisis point, they will have no choice but to turn to the NHS for support. Then they are more likely to stay in hospital for longer because it is too risky to transfer them home without the support of social care services. A social worker I know said to me recently that the problem is that social care funded by the state is used mostly by poor people who do not have a voice, and Governments therefore feel that they can get away with not doing anything. That is the impression that the Government’s failure to act has given to people out there.

I wish to raise another issue relating to the quality in the sector. I agree with all noble Lords who talked about the importance of quality, especially most recently the noble Baroness, Lady Dean. It is about the new arrangements for funding student nurses. I understand that in order to remove the cap on student nurse places—and, by the way, remove the debt from the Government’s books—the Government plan to remove their bursaries and fees and offer student loans instead. We certainly need more student nurse training places since there are already four applicants for every place. However, any expectation that hospitals would pay off the debt of newly qualified nurses who would go to work for them is unrealistic in the extreme. I am told that while there is going to be some scope for NHS provider organisations to reimburse staff for their training, it will be completely at the discretion of that organisation. The group of HR directors that I heard from said that it would happen very infrequently, due to cost. This does not mean that the occasional exceptional candidate may not be reimbursed, but, without funding through the NHS tariff to cover staff training, it would represent an exceptional cost. The expectation is therefore that private healthcare providers and care home operators would not reimburse either, but, again, could do so at their own volition.

Given that the margins in social care provision are so tight, I am concerned that those nurses who would like to work in that sector will have a problem. I cannot see any care home providers being able to offer this pay-off, yet those who provide specialist nursing services really need well-qualified nurses to supervise them or they will not be safe. It is a matter of maintaining quality. What does the Minister suggest is done about this? Following the spending review, there are so many additional costs that will already have to be met by providers of all kinds that I would be very surprised if any of them were able to reimburse a nurse’s training costs. These vital professionals cannot expect to be highly paid when they qualify, so where does the Minister think they will get the money for, in effect, an additional 9% on their income tax after qualification? This is short-sighted and will do nothing to increase the number of UK nurses, especially in the lower-paid social care service, where I anticipate the highest impact of this change. If you add all this to the announcement in the spending review that care homes, along with other providers, will have to pay the full cost of their mandatory CQC inspections, you have a system that is ready to implode.

What steps are the Government taking to ensure that the proposed 2% levy per year on council tax in the form of a social care precept will deliver the money required to ensure the right levels of social care and do so equitably? The authorities that need the most additional money have the least ability to raise it through taxes. When will self-funders get some certainty enabling them to plan for their old age? I echo my noble friend Lady Brinton in asking where the £6 billion saved from the failure to introduce all the Dilnot reforms has been distributed. It certainly has not gone into the social care budget. I am just as curious as the noble Lord, Lord Warner, to find out where this amazing disappearing £6 billion has gone. How will the Government ensure that newly qualified nurses will not be deterred from entering service in the social care sector?

Finally, I am very puzzled about one thing and I wonder if the Minister can help me. All the acute hospitals are in deficit and somehow the Government manage to bail them out. I wonder why that is when they are not prepared to bail out the social care sector. Perhaps it is because they have already spent the money and, of course, next year some of the extra money already announced for the NHS will have to go towards next year’s projected deficit as well. Perhaps it is because local authorities and private and voluntary care providers cannot spend money that they have not got and therefore it cannot be refunded. However, it occurs to me that if the Government were prepared to spend that couple of billion pounds every year doing something about social care then maybe we would not have such a big deficit in the NHS at all.

Health: Liver Disease

Baroness Walmsley Excerpts

Wednesday 9th December 2015 Lords Chamber

[Lord Prior of Brampton]

I have read the Lancet report and I noted this rather unusual omission in the north-west. I do not understand why the north-west does not have a specialist liver facility. It is something that I will follow up and find out. I will write to the noble Lord if I can.

[Baroness Walmsley (LD)]

My Lords, the Lancet said that the majority of people with obesity have non-alcohol related fatty liver disease. Does the Minister agree that we need restaurants and takeaways to publish the calorie, fat, sugar and salt content of their dishes? Some of the best do it, but not many do. Will he also consider further restrictions on the advertising of high-calorie junk food to children?

Health: Adult Pneumococcal Vaccination

Baroness Walmsley Excerpts

Tuesday 8th December 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, there is a huge and growing role for community pharmacy in delivering services that have traditionally been supplied by the NHS. If we were to discuss this in five years’ time, I am sure that we would see a far greater role played by community pharmacy. I am not sure that I can give the noble Lord a specific answer on vaccinations. I can just say that the flu vaccination rate so far this year to date is 66%. Last year, by the end of the winter, it was 72%, so we are roughly on target to do the same as last year.

[Baroness Walmsley (LD)]

My Lords, the service standards say that local authority directors of public health have a key role to play in ensuring good coverage of vulnerable groups in their area. Given that fact, what assessment has the Minister’s department made of their ability to carry out that role, given the recent large cuts in public health budgets?

[Lord Prior of Brampton]

My Lords, the principal role for pneumococcal vaccination—the subject of the Question—lies with GPs. Take-up of the PPV for those aged over 65 is 70%; for those aged over 75, it is 80%. For young children, the rate is more than 95%.

Sex-selective Abortion

Baroness Walmsley Excerpts

Monday 7th December 2015 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, with which stakeholders are the Government working in order to fulfil their commitment to explore pressure and coercion on women in relation to boy preference and its possible link with domestic violence?

[Lord Prior of Brampton]

My Lords, I have a long list of stakeholders, which covers all the usual suspects in this area, if I can put it like that. In the way that the methodology was developed to assess whether there was a population basis for gender abortions taking place, we took advice from the Office for National Statistics and a number of the royal colleges.

Accident and Emergency Departments

Baroness Walmsley Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, I thank RoSPA and the Royal College of Emergency Medicine for the important work they have done in producing this report, and the work done by Queen Mary’s College in substantiating it. The Government’s policy is to put the main responsibility for children under the age of five in the hands of local authorities in the belief that they, by knowing the local conditions better than central government, can have a greater impact.

[Baroness Walmsley (LD)]

My Lords, given that 15 to 24 year-olds are another of the three most vulnerable groups that are liable to have accidents, will the Government consider looking carefully at the national curriculum and ensure that PSHE, including personal safety and accident prevention, is taught in every single maintained school?

[Lord Prior of Brampton]

That is an interesting question. However, the report shows clearly that the main problem exists with the under-fives. Of course, there are issues at all ages, including falls and other aspects of accident prevention at the end of life. The interesting work that LifeForce has done in Birmingham shows that, for not very much money, we can have a big impact. Using the health visitors who are now employed by local authorities is a very important way in which we can address this important issue.

Junior Doctors Contract

Baroness Walmsley Excerpts

Monday 30th November 2015 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am very grateful to the Minister for repeating the Statement. My understanding is that since the Statement was read in the other place, progress has been made in the ACAS talks. Perhaps the Minister will update the House in response to my comments. I very much welcome the outcome of those ACAS discussions.

The Minister knows that the dispute has been very damaging to workforce morale. He also knows that many junior doctors have already voted with their feet, or are planning to over the coming months. What action is his department taking to stop the brain drain of our brightest medics to countries such as Australia and New Zealand? It is clear that the past few months have been very bruising to junior doctors and it is vital that this is turned around so that they come back to a positive view of working in our National Health Service. I hope that the progress that has been made this evening will mark a change in tone and approach on behalf of the Government.

No one disagrees that if you go to hospital in an emergency on a Sunday you should get the same treatment as you would on a Tuesday. But the Health Secretary has repeatedly failed to make the case for why reforming the junior doctors contract is essential to that aim. My honourable friend Mrs Heidi Alexander has made a genuine offer to the Health Secretary to work with him on a cross-party basis to do everything possible to eradicate the so-called weekend effect and to support any necessary reforms to achieve that aim. But in return, the Health Secretary needs to be absolutely clear about what needs to change in order to deliver that.

As many studies have concluded, there needs to be much more research into why there is a weekend effect so that we can make sure we focus efforts on the actual problem. We hope that the Health Secretary will commit to commissioning new independent research into how reforming staffing arrangements at the weekend might help improve the quality of weekend services. Will the Minister say what other steps are being taken to ensure that we have consistent seven-day services, including making sure that social care is available outside the working week?

We welcome the fact that the Health Secretary finally agreed to ACAS talks last week and I very much welcome the news from those talks tonight. Nobody wants patients to suffer and let us hope that we can put the whole sorry saga behind us.

[Baroness Walmsley (LD)]

My Lords, I, too, thank the Minister for repeating the Statement. I, too, understand that the junior doctors have now agreed to call off tomorrow’s strike. Will the Government therefore apologise to the 4,000 patients whose treatments tomorrow will have been delayed by this going right up to the wire and the Government being so reluctant to go to ACAS for negotiation?

I understand that more detailed negotiations will now take place. Will the Government be entering those negotiations without prejudice and with the well-being of patients—and the well-being of doctors, upon which the well-being of patients depends—in their minds as they negotiate? Will they take very seriously the concerns that have been put to them by conscientious junior doctors, who work very hard for us?

I, too, have some scepticism about the data in relation to the so-called weekend effect. I echo the call of the noble Lord, Lord Hunt, for some independent research into the causes of the less good outcomes that undoubtedly occur in some places—to what degree, we do not know. I am quite sure that the junior doctors and their contract are not the only cause of any such weekend effect.

[Lord Prior of Brampton]

My Lords, first, I am very pleased to confirm to the House that in the past few minutes the BMA and the Government have reached an agreement, which will allow time for negotiations to take place. The BMA has agreed to suspend industrial action, including that planned for tomorrow, and the Government have agreed not to proceed unilaterally with implementing the new contract. By any standards, that is very good news.

The noble Lord referred to the brain drain. The best thing we can do in the short term is to sort out the contractual dispute with the junior doctors. That is absolutely fundamental to restoring morale among doctors. There is a feeling among some junior doctors that they are not properly valued. This goes way beyond some of the issues being discussed on the contract. It is about their training and a lot of other issues that bear on this.

There have been, I think, two studies published in the BMJ now about the weekend effect, along with studies in other parts of the world as well, such as the US. There is no doubt that there is a weekend effect. It is to do with lack of senior cover at the weekends, diagnostics and all those kinds of issues. This is a broad issue, which can be addressed only if we have a seven-day service. It is certainly not just about junior doctors.

We do not have much time but I will say this about the Secretary of State: patient safety is his motif. If he wishes to be remembered for anything, it is patient safety. That is why he agreed to go to ACAS when the BMA suggested it. He was absolutely right to do so and I congratulate both the BMA and the Secretary of State for coming to this agreement just in time.

NHS: Food Banks

Baroness Walmsley Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, the people running the schemes in the two hospitals in Birmingham and in Tameside are to be congratulated. I am not sure that there is a similar scheme in Newcastle. I know from experience of homelessness how difficult it is, for example, to discharge patients when they have nowhere to go, with the risk of discharging people onto the street who will then come back into hospital. The work they are doing in those two hospitals is to be applauded. We have a welfare safety net in this country. Tragically, anywhere around the world there will be some people who fall through that net. The fact that there are voluntary groups and charities prepared to help pick those people up is a cause for celebration. It is that combination of a state welfare net with an active civic society which makes this country as good as it is.

[Baroness Walmsley (LD)]

My Lords, does the Minister agree that the location of food banks should not be at the top of the priority list of cash-strapped NHS hospitals, most of which are in deficit at the moment? Does he also agree that food banks need to be conveniently located so that those who need them can visit them regularly? I would rather hope that those people would not have to visit hospitals regularly.

[Lord Prior of Brampton]

I do not think that anyone is saying that the food banks in the hospitals in Birmingham and Tameside are their top priority, I just think that it is a very human reaction of people working in those hospitals who want to help very vulnerable people who are being discharged.

Health

Baroness Walmsley Excerpts

Thursday 26th November 2015 Lords Chamber

[Baroness Walmsley (LD)]

My Lords, this has been an excellent debate with some fascinating speeches. I shall certainly go on the website. There were three interesting maiden speeches. I was fascinated by my noble friend Lord Foster of Bath’s examples of how business and the arts can contribute to our health. Of course, I would say that as a founder member of the Parliament choir—although I am not sure that last night’s excellent concert has particularly enhanced my health.

Last September at the Liberal Democrat party conference, I made a speech about the future of health provision in the UK. I did not spend all my time talking about the NHS because, like the noble Lord, Lord Crisp, I believe that the crisis in the health service cannot be resolved by the NHS alone. The noble Lord and I are clearly on the same wavelength, so I very much welcome this debate.

As many have said, health affects everything: how long we live and our well-being, achievements, family life, contribution to society and, of course, happiness. Yet the NHS is struggling. Some say it has become a sickness service rather than a health service, spending a huge amount of resource fire-fighting preventable diseases, dealing with the complex needs of an ageing population and providing ever more wonderful, but expensive, treatments.

The pressures on NHS staff are enormous, and it seems that no matter how hard they work, how much they care and how much the Government spend, it is never enough. However, it is incredibly cost effective. Despite spending less per capita on health than most developed nations, the NHS is top in most rankings but next to bottom on living “healthy lives”. So unless we can turn around our public health problems, the pressures on the NHS will continue.

So I agree with the noble Lord, Lord Crisp, that we must stop dealing with health policy in isolation when its implications are so broad. Health should be a “whole government” responsibility, not just the job of the Department of Health. As I said to my party conference, suggesting that health is just the responsibility of the NHS is like expecting the goalkeeper to win the match on his own without the help of the other players. It should be very obvious that the rest of the team have to play their part, too.

The keys to the sustainable future of the health and social care systems are prevention, integration, innovation and “getting it right first time”. If 40% of ill health is due to diet and lifestyle, it is therefore preventable. New ways of working are also vital, and the vanguard sites, set up in response to the NHS Five Year Forward View, demonstrate that better care can be delivered for less if people will only work together. However, we need to ensure that competition legislation does not get in the way of providers working together. They also need the £3.8 billion announced this week to achieve that transformation, yet the Treasury says that the money will be spent on more treatments. Either the money is there to cover part of the shortfall in NHS budgets or it can be used to initiate new ways of working which will bring cost benefits in the future. It cannot do both—you cannot spend money twice.

“Getting it right first time” is the mantra of a number of ground-breaking hospitals that have shown that it is cheaper in the long run to provide excellent services first time round rather than have a lot of readmissions. We also need a complete overhaul of patient discharge and transfer arrangements, which cause bottlenecks and waste money. I am delighted that former Health Minister Paul Burstow is leading a commission on behalf of NHS providers to identify and disseminate best practice on transfers of care. More efficient working will enable the NHS to fulfil its important ambition in the wider picture of sickness prevention, and it should start at the very beginning.

A good start for a baby depends on the health and well-being of its mother and her ability to bond with her child, but perinatal mental health services are patchy—yet this is health creation at its most basic. We need a new standard, delivered everywhere, to promote the future health of the baby and the well-being of the mother. Academics believe that UK children are at a higher risk of premature death than their western European counterparts because of the growing gap between rich and poor and a lack of targeted public health policies. But if a child is born into a low-income family, he is not automatically on a pathway to ill health, as several imaginative interventions have already shown. A new, holistic approach to child health would tackle health inequalities at source.

Moving beyond the NHS’s own role in the health-creating society, it is clear that poverty is a major cause of poor health. According to Sir Michael Marmot’s recent book, 200,000 people die prematurely every year in the UK simply because they are poor. Dealing with the economic divide would go a long way to improving the health of the country and address health inequalities.

Since the foundations of a healthy life are laid in childhood, the Department for Education has a role to play. Liberal Democrats support mandatory personal, social, health and economic education in all state-funded schools, but we still fall far short of that. Children need to know about a healthy diet, the importance of physical activity, how to recognise a respectful relationship as opposed to an abusive one, and about the dangers of tobacco, drugs and alcohol, and so on. Therefore they need good-quality PSHE.

A love of sport is often developed at school, and this can stand a child’s health in good stead in the future. I really commend the daily mile, run or walked by every child in St Ninians primary school in Stirling every morning. But many children drop sport as soon as they leave school. This is where the Department for Culture, Media and Sport, local sports clubs and local government come in. But the cuts of the last five years have made it very difficult for them to provide the facilities needed—we just need to look at the number of swimming pools that have closed.

Local authorities are ideally placed to deliver public health interventions that will improve community health outcomes. Yet within a month of being in power on their own, the Conservative Government announced an immediate £200 million cut in public health funding, putting further at risk the health service’s ability to make ends meet. This and yesterday’s further cuts to local authorities are appallingly short-sighted. How can the Government justify them?

Then there is housing. Cold, damp homes foster colds, bronchitis and many other problems. We need more decent affordable homes for families to rent as well as buy, and smaller, well-insulated homes for older people. I am one of those who is currently about to downsize to a highly insulated passive house—a home for life, I hope. Successive Governments have failed on this for decades and, as the cost of energy has risen, even people who have decent homes are finding it hard to heat them. We know that the most cost-effective way to reduce energy bills is good insulation, but much of our old housing stock is poorly insulated. The Green Deal home improvement fund provided funding for energy efficiency improvements to homes, making them greener, cheaper, warmer and of course healthier. But the Conservative Government decided to cut it. Where now will people get help to make their homes warmer and healthier?

The Department for Transport does not escape responsibility. Air pollution causes major problems for asthmatics such as myself and others. Transport policies therefore play a part. I have heard it rumoured that, alongside cutting the subsidy for solar and wind power, the Government are now planning to cut the £5,000 subsidy for electric cars. Can the Minister confirm or deny this?

If health is a whole-government issue, which I believe it is, it requires proper oversight. My answer is very slightly different from that of the noble Baroness, Lady Jay. I would like to see the Government beef up the Cabinet Committee on Health, headed by a senior Minister and involving all relevant departments at a senior level to ensure that all government policies can be scrutinised as to whether they contribute to the better health of the nation. There can be no better focus for a Government if they are truly concerned about the well-being of their people. I also believe that the Chancellor of the Exchequer should be answerable to Parliament for the health consequences of his policies.

The NHS is supported by the whole nation. It must be supported by all of government, national and local. Let us not leave it to the goalkeeper. Let us ensure that the whole team contributes to winning the cup.

Gender-based Violence: Women with HIV

Baroness Walmsley Excerpts

Wednesday 25th November 2015 Lords Chamber

[Lord Prior of Brampton]

The noble Baroness raises the very profound point about stigma. Where people suffer from both HIV and domestic abuse, they are extremely vulnerable and feel it very difficult to raise these issues. The Government have done a lot to try and remove the stigma and make it easier for these very vulnerable women to come forward. I am sure that the noble Baroness is aware of the sexual assault referral centres. There are now 43 of those, funded by NHS England, the police and local authorities. They are a good example of cross-government support.

[Baroness Walmsley (LD)]

My Lords, in 2012 the coalition Government set up a new research and innovation fund to collect information about violence against women in 10 African and Asian countries with the view to setting a new prevention strategy. Could the Minister tell us anything about how that strategy is progressing? Given the risk of HIV to many of these women, will that issue be covered in the strategy?

[Lord Prior of Brampton]

I think I am right that there are some 16 million women worldwide who suffer from HIV/AIDS so it is a huge problem, particularly in sub-Saharan Africa. I am not familiar with the innovation fund to which the noble Baroness referred, but I will investigate that and write to her.

NHS: Costs of Operations

Baroness Walmsley Excerpts

Monday 9th November 2015 Lords Chamber

[Lord Prior of Brampton]

My Lords, hospitals do know their costs; they know their reference costs and their HRGs. Increasingly, we will want to get patient-level costing into all our hospitals, as is already the case in some hospitals. If you know the actual cost by patient, the hospital management can have a much better discussion with hospital clinicians. Patient-level costing is important going forward in hospitals. For GPs, we have a calculated payment, as my noble friend will know: currently £75.77 per capita on the list, adjusted for various matters. A capitated figure for GPs is probably better than a much more detailed breakdown of costs.

[Baroness Walmsley (LD)]

Do the figures for hospitals discriminate between those that have to service expensive PFI contracts and those that do not? If so, and if the former are more expensive than the latter, is the department funding them appropriately to enable them to pay those costs?

[Lord Prior of Brampton]

The noble Baroness makes an important point. We have what we call a “market forces factor”, which is applied to the tariff to make adjustments for unavoidable differences in costs—for instance, providing care in London compared to providing it in a cheaper place. The way we measure the cost of capital is not entirely satisfactory, though, and if an individual trust has a very expensive PFI, that is not properly compensated for by the market forces factor. We should spend some more time looking at that issue.