Hospitals: Unsafe Discharge
Baroness Wheeler Excerpts(9 years, 6 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what response they have made to the Parliamentary and Health Service Ombudsman’s Report of investigations into unsafe discharge from hospital, published in May.
Baroness Wheeler (Lab)
My Lords, this very shocking report of nine deeply disturbing cases showing what happens to patients when hospital discharge goes wrong was published in May. Since then we have had a plethora of reports from the National Audit Office, the Public Accounts Committee and now, more recently, the CQC itself, which underline the wider context in which these cases cited by the health ombudsman have happened, and the increasingly desperate situation in many hospitals and in social care.
The ombudsman’s report came just over a year after Healthwatch England’s extensive Safely Home report on hospital discharges. This did not cover just nine case examples, but was the result of an extensive, in-depth inquiry led by people experiencing unsafe hospital discharge, with a particular focus on mental health and homelessness. The ombudsman’s cases all involved vulnerable, frail, elderly people, some with dementia, who were either discharged before they were clinically ready to leave hospital; were not properly assessed before discharge, with neither they nor their carers being consulted or even informed about discharge arrangements; and where no care plan was in place for how they might cope at home. Alternatively, patients were kept in hospital much longer than necessary due to poor co-ordination across services, or, in reality, no provision or support being available in the community.
Vulnerable, desperate, homeless and mentally ill people are covered in the Healthwatch inquiry. The failure to consider the full range of their needs before discharge from hospital or a care setting means for the homeless that no support housing or benefits structures are in place to enable patients to recover, leading to what the St Mungo’s charity cites as “revolving door” readmissions to hospital and huge anxiety and suffering for the individuals concerned. As regards mental healthcare, poor communication and co-ordination between different services and lack of desperately needed community support services so often resulted in patients being unnecessarily kept in hospital settings for months.
The National Audit Office report shows that overall the number of delayed hospital transfers has risen by a third in the past two years to 1.15 million, with two-thirds being a result of delays caused by the NHS and one-third caused by problems of non-availability of social care. Age UK’s estimate is that 184,000 nights are lost to the NHS on patients who cannot be cared for at home, or for whom no affordable residential care can be found, costing the NHS £820 million a year, a 70% rise in the last two years. The NAO’s comparable cost figure of care in the community for those patients is about £180 million.
Extended stays in hospitals demoralise older people, cause institutionalisation and dependency and put them at serious risk of losing mobility, muscle strength and the ability to do everyday things, such as bathing and dressing. There is also an increased risk of infection. The fact that there are almost twice as many people in hospital beds unnecessarily as a result of the NHS failing to get its act together rather than through lack of social care provision in the community is particularly striking.
Moreover, the PAC report clearly shows the huge variations and range across the country. In 2015-16, for example, there were 10 bed days lost in Northumbria and nearly 18,000 days in Lincolnshire. Many areas are getting it right under difficult and challenging circumstances. The NHS itself needs to do much, much more to get its own house in order, and that is why national leadership and action are so important. In response to this situation, the PAC’s comments are very telling. It accuses the Department of Health and NHS England of relying too easily on differing local circumstances as a catch-all excuse for not securing improvement in NHS performance. The PAC says:
“Those areas which are doing best are the ones where all the local system owns all of the problem but this practice is all too rare”.
In other words, it is not enough to wring one’s hands over the variability problem.
The Healthwatch report points to guidance aplenty having been issued over the past decade including from NICE, the Department of Health and the recent transition quality standard. However, as it says with all this,
“it is not clear why further individual initiatives will make a difference without something more fundamental changing in the system”.
The crying need for national and local leadership and system-wide ownership, action and change brings us on to the strategic and transformation plans—about which we know little real detail but are told are NHS England’s only show in town. Some 44 “footprints” are to plan for a health service focused on people living with long-term conditions in the community. The Minister has underlined his optimism about the plans, most of which are “genuinely local” and are being drawn up by “collaboration” between hospital trusts, CCGs and local authorities.
The deadline for STPs is now upon us, so can Minister tell us more about how NHS England will be evaluating, assessing and analysing the plans at national level to ensure that they meet the vision set out in the NHS forward view for integrated health and social care? Is he confident that they will focus on better care rather than on just reducing finance? He said earlier this week in response to my Question on carer support that plans,
“will include radically improved out-of-hospital care through stronger integration and improved access to primary care”.—[Official Report, 7/11/16; col. 889.]
From the STPs we know about to date this looks to be funded by cuts to acute services—such as accident and emergency and maternity services—which we know will be difficult to make and will be vigorously opposed both locally and nationally. In this regard, the King’s Fund assessment is worth repeating, namely that STPs,
“will not be credible unless they demonstrate how money and staff”,
for services outside hospital will be found. Does the Minister acknowledge this? Are the Government ensuring that STP outcomes are focused on long-term sustainability rather than on short-term savings and cuts? How are the 44 footprints to be made into a coherent national forward journey?
On social care funding, the latest CQC report must surely have set alarm bells ringing right across government. Drawing on 20,000 inspections of hospitals, care homes, A&Es and mental health services, the CCQ tipping-point warning on the sustainability of adult social care is surely a game changer for the Government. The chief executive David Behan was reported as saying he was more worried than at any time in his 40-year career about council care for the elderly—200,000 more people than five years ago are being denied everyday help with basic tasks of washing and dressing and the number of care home beds is continuing to fall, with council-funded places in care homes falling by 26%. In A&E, there were 1 million more visits than five years ago, with half a million more emergency hospital admissions of people aged over 65.
The CQC is reinforcing what stakeholders, staff, campaigners, social care voluntary organisations, think tanks and patient organisations have been telling the Government at every opportunity, particularly during the passage of the Care Act, ahead of every government financial statement and Budget, and ever since they postponed the Dilnot social care funding proposals until 2019. Yesterday we saw the joint letter to the Chancellor from the Nuffield Trust, the Health Foundation and the King’s Fund pleading for urgent action in the Autumn Statement. Surely the Government must finally acknowledge the extent and the scale of the crisis in social care funding and take the action that is needed now.
We are nearly into 2017, less than two years to go until the promised action on Dilnot agreed under the Care Act is due to commence. I remind the Minister that nearly £6 billion of Government funding was committed to its implementation, the substantial part of which has never been spent on social care. Can the Minister reassure the House that the Government are not trying quietly to abandon Dilnot and most of the rest of the provisions of the Care Act that have ongoing financial costs?
I conclude with raising again the Carers UK Pressure Points report which echoed the ombudsman’s finding that growing demand on the NHS is forcing people to be discharged from hospital too early, often without proper support at home and without proper consultation or notice given to their carers. As a carer myself, and someone who speaks to a lot of other carers as a trustee of our local carer support group, the discharge process can often be the most traumatic experience you face, next to the shock of almost overnight becoming a carer of a person with long-term needs and all the uncertainty and anxiety of how you are going to cope with the huge change in your life and of course, in the person you care for. The Government’s long-awaited updated national carer strategy must surely tackle this crucial issue of improved communications between hospitals and carers head on so that carers are fully involved and get the vital support they need. I hope the Minister will be able to reassure the House that this will be so.
Baroness Wheeler
I asked the Minister about the national carers strategy. Could he please write to me on that?
Lord Prior of Brampton
I will certainly do that. I should just say that the theme that comes out of the carers strategy is better communication. When half of carers say that they feel that a hospital admission could have been avoided or that the discharge could have been easier if only there had been better communication, that is clearly a critical area.
NHS: Primary and Community Services
Baroness Wheeler Excerpts(9 years, 6 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what is their response to the Carers UK report Pressure Points: carers and the NHS, concerning problems faced by carers in accessing primary and community support services for the people they care for.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, we recognise that far too many people who could be treated at home or in their communities attend A&E. Sustainability and transformation plans are bringing together commissioners and providers to deliver the five-year forward view locally and will include radically improved out-of-hospital care through stronger integration and improved access to primary care.
Baroness Wheeler (Lab)
My Lords, I thank the Minister for his response. The report identifies major problems for carers accessing primary and community support services for the people they care for, and who therefore have no real option but to take them to A&E. Many of these emergency hospital admissions could have been avoided with adequate social care support at home, better access to a district nurse or essential local support for carers themselves. On carers’ support, councils across the country are having to cut back on vital services. My own council in Surrey has a programme of cuts of 33% over three years. With the CQC’s dire warning that social care is at a tipping point, is it not time for the Government finally to acknowledge this and use the Autumn Statement to provide the increased funding and investment that is urgently needed for carers and the people they care for to get the support they deserve?
Lord Prior of Brampton
My Lords, I acknowledge that there is tremendous pressure in the social care system. Looking back over the last 20 years, not enough support has gone into primary, community and social care relative to what has gone into acute care. The sustainability and transformation plans are designed to bring together social care and healthcare. They are being published intermittently as I speak.
Breast Cancer: Innovative Drugs
Baroness Wheeler Excerpts(9 years, 6 months ago)
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Lord Prior of Brampton
The noble Baroness is absolutely right. The delay in bringing a new drug to the market can very often be between 12 and 14 years, which is a huge amount of time. Part of the reason for that is indeed the regulatory process. The whole purpose of the Accelerated Access Review is to truncate that time. The report talks about reducing for some drugs the time it takes to bring them to market by up to four years, which would be very considerable progress. In terms of international regulatory bodies, if one takes the EMA in Europe and the FDA in the US, clearly they do work together at one level but probably not closely enough, and I suspect that there is too much duplication in regulation. Certainly, as we leave the European Union, we need to be very careful that we do not have a duplicatory regulatory system in this country.
Baroness Wheeler (Lab)
My Lords, the Minister will know that since 2014 the Government have received nearly £1.5 billion from the branded pharmaceutical sector as part of the PPRS to hold down pharmaceutical costs. Why is not some of that sum being used to fund innovative drugs for breast cancer?
Lord Prior of Brampton
My Lords, I think it is a mistake to regard the PPRS and the savings made in that scheme as a separate pot of money. Any savings generated from the PPRS are funnelled back into the NHS. As for new innovative drugs, the cancer drugs fund has been changed substantially and one should regard it now largely as an incubator fund with the same purpose as the Accelerated Access Review, which is to bring forward new drugs more quickly.
Carers over 80: Support
Baroness Wheeler Excerpts(9 years, 11 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government what additional social care resources they will provide to support the numbers of carers aged over 80, in the light of estimates that half of those are providing over 35 hours caring per week.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, we recognise the invaluable contribution carers make to society and that many provide long hours of wonderful care. We support wholeheartedly the implementation of the improved rights for carers established by the Care Act 2014, providing just over £186 million of funding to local authorities for these improved rights. We are committed to continuing to improve support for carers through the publication of a new national carers strategy by the end of 2016.
Baroness Wheeler (Lab)
I thank the Minister for his response. Research by Age UK, Carers UK and independent age charities shows that the older the carer, the more hours of care they tend to provide. That, surely, cannot be right. Many carers over 80 are providing as much as 50 hours of care a week, often without any support because they do not meet the new eligibility criteria and councils just do not have the money in their social care budgets. Will the Minister undertake to ensure that the new carers strategy tackles these high and increasing levels of unmet demand? With councils across the country having to cut back on carer support, what specific support and funding will the Government provide to help councils offer real support to carers?
Lord Prior of Brampton
The noble Baroness is absolutely right. Nearly half a million people over 80 are providing more than 35 hours a week of care to their partner or loved one, which is a huge commitment and often has profound implications for their own health and well-being. We are all singing from the same hymn sheet on this and I am sure that the carers strategy coming out at the end of the year will address the particular requirements of that age group. The Government will continue to support carers’ rights. I mentioned the £186 million being given to local authorities to do that.
Southern Health NHS Foundation Trust
Baroness Wheeler Excerpts(10 years ago)
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Baroness Wheeler (Lab)
My Lords, I thank the Minister for reading the response to the UQ on the CQC’s serious concerns about the safety of mental health and learning disability patients at Southern Health Trust. The whole House is deeply shocked by the inadequate and completely ineffective response to the Mazars review’s findings, following the tragic death of Connor Sparrowhawk over two years ago. The CQC’s stark assessment that serious risk to patients in ensuring their safety was still not driving the senior management or board agenda beggars belief in the light of the Mazars review and the CQC’s repeated concerns and warning notices. There are still no robust governance arrangements in place to investigate incidents and there is still a lack of effective arrangements to identify, record or respond to concerns about patient safety raised by patients, their carers, staff and the CQC. A particular concern is the continuing failure to act over important specific safety concerns about ligature risks in acute inpatient mental health and learning disabilities services and, given the terrible cause of Connor’s death, the board’s failure to give urgency to approval of the specific protocol for safe bathing and showering of people with epilepsy. Can the Minister assure the House that these will receive urgent attention by the new chair in his task of building new leadership and direction for the board and in an urgent programme of action for the trust?
Patients and their families need to see robust, urgent action and real accountability. When the Secretary of State responded to December’s UQ on Southern Health, he rightly said that, more than anything, people will,
“want to know that the NHS learns from … tragedies”,—[Official Report, Commons, 10/12/15; col. 1141.]
such as these. That clearly has not happened, so I ask the Minister what guarantees he can give to current patients and their families in the care of Southern Health that they are safe. Where is the accountability, culpability and responsibility? Can the Minister tell the House about the content and timescale of the review of the adequacies of the trust’s leadership that the new chair has been tasked with undertaking? Finally, will he listen to the heartfelt pleas of victims’ families, campaigners and all those who are demanding a full public inquiry into Southern Health and into the broader failure in adequately investigating preventable deaths?
Baroness Tyler of Enfield (LD)
My Lords, I, too, thank the Minister for repeating the Statement. The original Mazars report highlighted two profoundly shocking issues: the tragic and preventable death of Connor Sparrowhawk and the fact that too many unexpected deaths among those of learning disabilities and older people with mental health problems were even being investigated. Why did a full three months elapse after the Mazars report was published—and, indeed, only after a BBC investigation covered it—before Monitor finally appointed an improvement director to go in to work with the trust on urgently needed improvement? Why the delay?
Secondly, despite a series of national reports—we have just heard about the CQC report—warning notices, monitoring and progress meetings, all referred to in the Statement, nothing has been said about the precise changes that have happened or improvements that have taken place in Southern Health Trust. When can we hope to hear about specific and tangible improvements to the care provided by Southern Health Trust to some very vulnerable people?
Thirdly, it is crystal clear that new leadership needs to be in place if the trust is to retain any credibility, particularly among the people and families who use its services. Why have there been different responses to Mid Staffs and Southern Health? Both are about the neglect and death of vulnerable people in NHS care. There have been serious consequences for those in leadership positions in Mid Staffs, but not so at Southern Health. What does that say about the value placed on the lives of people with learning disabilities and older people with mental health problems?
Sugar Tax
Baroness Wheeler Excerpts(10 years, 3 months ago)
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Lord Prior of Brampton
My Lords, it is interesting that in the plans put forward for consultation by Simon Stevens of NHS England they are looking at a levy of 20% on sweetened beverages. In Mexico, they brought in a sugar tax of 10%, which according to a study by the Lancet resulted in a reduction in consumption of some 12%. But it is very difficult to isolate the particular impact of tax when many other measures are being used at the same time.
Baroness Wheeler (Lab)
My Lords, Simon Stevens, the NHS chief executive, recently pointed out that obesity is the new smoking, and that Britain spends more on obesity-related healthcare than on the police, the fire service, prisons and the criminal justice service combined: £6 billion and rising. He has promised to raise the price of sugary drinks sold on NHS premises to staff, patients and visitors as another small step. Cannot the Government take steps to introduce this policy across all government departments and institutions?
Lord Prior of Brampton
My Lords, public procurement certainly has a role to play in tackling obesity. I am sure that that is one of the issues that will be addressed in the forthcoming strategy.
NHS: Preventive Medicine
Baroness Wheeler Excerpts(10 years, 3 months ago)
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Lord Prior of Brampton
My Lords, good design is very much part of any long-term strategy towards improving the lives of our citizens, so it is a hugely important part of our longer-term strategy.
Baroness Wheeler (Lab)
My Lords, we know that smoking is by far the biggest cause of death in the UK and research shows that two-thirds of smokers want to quit, yet the recent ASH survey has shown that the cuts in public health funding and in council budgets have led to 40% of local authorities having to cut stop smoking services. Last year these were used by more than 450,000 people. They are three times more likely to quit if they get the vital support of these services. How can it make sense to cut services when for every £1 spent on cessation services, £10 is saved in future NHS and health gains?
Lord Prior of Brampton
Successive Governments have had a huge impact on reducing smoking levels, which are now down to 18%—the lowest they have ever been.
Four Seasons Group
Baroness Wheeler Excerpts(10 years, 4 months ago)
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Baroness Wheeler
To ask Her Majesty’s Government, in the event of the financial collapse of the Four Seasons Group, what contingency plans are in place to provide alternative accommodation, care and support to ensure the safety and well-being of over 20,000 residents currently residing in Four Seasons homes.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, managing provider failure in the adult social care market is a local responsibility. I cannot comment on the finances of individual providers. However, the Care Quality Commission has financial oversight of the larger providers and would supply local authorities with early warning if one of the businesses were to fail and its regulated activities to cease, allowing time for local contingency plans to be implemented. The Department of Health would co-ordinate any appropriate national response.
Baroness Wheeler (Lab)
I thank the Minister for his response but it is disappointing that he cannot be more reassuring on government contingency plans for the fallout that would result from the collapse of major and small providers in the care industry. The problem goes wider than Four Seasons, given the rising costs of care, the postponement of the care cap and the inability of cash-starved local authorities to increase fees to meet rising costs and demands. The Southern Cross collapse affected 31,000 frail and elderly residents, who had to be found alternative care. Surely the Minister recognises that and the fact that there needs to be a wider government strategy to ensure the financial sustainability of the sector and to deal with the huge scale of closures that will happen unless the funding problems are addressed.
Residential Care: Cost Cap
Baroness Wheeler Excerpts(10 years, 5 months ago)
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Baroness Wheeler
That this House takes note of the quality and viability of the residential care sector in the light of the Government’s decision to delay the implementation of the care cost cap.
Baroness Wheeler (Lab)
My Lords, when I was researching for this very important debate, amid all the statistics, press coverage and reports on the cliff-edge financial state of the sector and the impact of the spending review, the one figure that most stood out showing the frightening scale of the crisis in residential care was the Care England figure of £2.16 per hour. This princely sum is the average fee paid by local authorities in England to care home providers to care for residents unable to pay for themselves. Of course, there are other ways of coming up with an average figure across the sector, but I am sure that none of them would produce a very different amount. Care England represents large and smaller scale residential care providers and, as its press release prior to the spending review put it:
“You can’t provide quality care for £2.16 an hour, no matter who you are”.
According to the Public Accounts Committee, local authorities have faced a 37% overall funding cut in real terms since 2010. They have found it impossible to raise residential care fees to try to keep pace with increasing demand and costs. Data from the residential care industry analysers, LaingBuisson, show that 1,500 care beds have been lost in England this year and that councils gave an uplift in baseline fees of just 1.9%—lower than the estimated 2.5% increase needed simply to keep pace with care home cost inflation. Out of the 166 councils providing information, 53 made no uplift in fees, and the remaining councils had either given increases below the standstill band uplifts, or fee revisions within the standstill band.
The residential care sector is home to 425,000 residents in about 18,000 homes across the UK. One in six residents is over 85 years old, an age group set to double by 2035. Care home residents have a prevalence of long-term conditions, particularly dementia, stroke and diabetes-related conditions. Many residents can have up to six comorbidities. Some 70% of residents in the top three care home providers are publicly funded which makes them especially vulnerable to continuing pressure on council budgets. It is clear, therefore, that throughout the sector self-funders of care help to keep homes viable and in operation.
There is no underestimating the blow for people with long-term health conditions, their families and the providers of care that came from the Government’s decision in July to delay implementation of the cap on liability for care costs for four years. Some 35,000 people would have benefited from the cap immediately. The Government's spending review repeated their commitment to introduce the cap in 2019-20, but with no money allocated. Nor was there a commitment to use fully the previously allocated £6 billion funding allocation for the care cap to ease the growing crisis in day-to-day social care services instead.
Prior to the spending review, there was no shortage of press coverage, providers and social care organisations pointing out the dire state of the sector to the Chancellor. There was the precarious financial state of Four Seasons Health Care—Britain’s biggest care home group providing 21,000 beds in 470 homes. It is reported to be on the brink of financial collapse, struggling with debts of £500 million. Last month it closed seven in its words “loss-making and unviable” homes in Northern Ireland. The group has a looming £26 million repayment instalment due, part of £50 million a year it has to pay to service its debts, which it is currently struggling to do.
There were also two separate joint letters to the Chancellor. The first came from the five largest providers—Bupa UK, HC One, Four Seasons, Care UK and Barchester—warning that failure to raise funding would mean that,
“thousands of older people could be left without a home”.
Secondly, a letter from 15 social care and older people’s groups, including Age UK and the Alzheimer’s Society, underlining the urgent need for more central government funding. They predicted a £2.9 billion funding gap across domiciliary and residential social care by 2020 and that,
“up to 50% of the care home market will become financially unviable and care homes will start to close their doors”.
Finally, there was the very timely ResPublica study of the private residential care sector. It warned that the funding gap specifically for older people’s residential care by 2020 would be £1.1 billion, a third of which will be the cost of the national living wage and which could mean the loss of 37,000 beds. The failure and collapse of Southern Cross two years ago affected 31,000 people. Other private providers eventually provided replacement care for them, although not without huge upset and trauma for the people involved, their carers and families.
As ResPublica points out:
“Given the perilous state of the industry, there is no private sector provider with the capacity to take in the residents who would be affected by the loss of other providers’ beds. Consequently … the worst outcome is the most likely: that the vast majority of care home residents will end up on general hospital wards”,
costing the NHS £3 billion a year.
Moreover, while public attention has been on the large-scale providers, we know that 75 % of providers are, in fact, small, local organisations—small group homes run by small teams of owners and staff or, in many of the smaller homes, just by the owners themselves. The Local Government Association estimates that for residential and homecare contracts the national living wage will cost an additional £300 million in the first year, rising to £834 million in the second. Does the Minister acknowledge that small care homes will be the first to go to the wall if the cost of the implementation is not properly funded by central government? We applaud and welcome the introduction of the national living wage—it is vital to the future of social care, but it must be properly funded.
The spending review offers two solutions to all this, under the ironic heading “A sustainable health and social care system”. The first is to allow local authorities the power to raise council tax by up to 2% in their area from next year, to bring in £2 billion a year; the second is a £1.5 billion allocation from the better care fund for councils to access in two years’ time. This, we are assured in the spending review, will be enough for councils to shore up core services, increase residential care fees and pay for the implementation of the national living wage from April next year for 900,000 care workers. But how can this limited additional funding be anywhere near enough to address the scale of the problem facing us? Can the Minister explain to the House how this can possibly make the current failing social care system sustainable?
I am sure that the Minister will come back with a string of figures on the amount of money that has gone into social care, but the fact is that the detailed analysis from the LGA, the King’s Fund, the Nuffield Trust, the private, charitable and voluntary sector providers and the patient and user organisations such as Age UK, Independent Age and Carers UK all show that this is nowhere near enough. Will he undertake to provide detailed analysis of the Chancellor’s sustainability plan for social care? How much of the better care fund allocation is new money into the system, or is it just money shuffled about the system or taken from the NHS?
Earlier this week, the King’s Fund put the amount that could be raised by councils as, at most, only £800 million per year, which underlines that areas in the north, Midlands and inner London with the greatest need for social care will lose out because they will be able to raise too little income for the increase to have any impact. Care England’s response is that the 2% addition, even if raised across all councils, would not even touch the sides of the problem. The charity Independent Age has calculated that a 10% increase would be needed to plug the social care funding gap, which would of course not be locally acceptable.
Meanwhile, Four Seasons remains in a very precarious financial state. This weekend, we saw reports of the devastating consequences for families and their elderly and frail relatives in its Northern Ireland care homes, which are to be shut down with 12 weeks’ notice. Four Seasons is on course to sell 19 homes this year, which will result in their closure, and it has 12 homes under embargo and barred from taking any new residents until the quality of care improves. Can the Minister reassure the House that an impact assessment has been made, that the situation is being closely monitored and that contingency plans are in place in the event of Four Seasons’ financial collapse? Four Seasons is also selling homes to other providers, so what checks and measures are in place to ensure that the care and well-being of residents is the top priority in such sales? Does he acknowledge that this is likely to be part of a growing trend, as the smaller group homes struggle to survive?
This debate is also very much about the quality of care in care homes and the people who are cared for, their families and carers. This is the first debate focusing on the residential care sector that we have had in this House in recent years. I am most grateful that we have such a broad range of experience and insight among the speakers today, which will ensure that the full range of key issues facing the sector can be addressed, particularly the impact of the NHS on the rest of the sector. The ResPublica report makes a very telling comment. It says that,
“the residential care system … has been overlooked as a partner in the integration of care”,
and in developing person-centred care across the NHS and social care. Its report looks to care homes becoming the agents of early intervention and the management of chronic conditions, preventing those conditions escalating and individuals funnelling in to the acute sector, swamping A&E units and local hospitals.
The NHS Five Year Forward View has a number of care home vanguards—the first time that the sector has had specific projects and funding—which reflect some of this thinking on trying to promote enhanced health in care homes. The projects have tight criteria for joint working and integration with the NHS and social care on care planning, residents’ health and the management of frail and elderly patients. In a number of areas, funding has been partly used to pay a higher fee to care homes so that they can focus on improving care standards and paying staff more, with new and extended job roles. This will mean that they are able to provide the care that ensures fewer residents are admitted to hospital or become permanent residents, rather than being able to go back into their homes after a short period of care following hospitalisation.
The recent CQC report on the state of care shows, as usual, the extent of the excellent care that takes place in many care homes across the country by trained, caring, dedicated nursing and care staff, as well as the reality and scale of the challenges that need to be addressed. The CQC’s five tests—that care is safe, efficient, caring, responsive and well-led—have been used for care home inspections since October last year, focusing on homes for residents aged 65 and over. Of the 300 homes inspected, 50 were rated good but 125 were deemed inadequate and 125 required improvement. Almost half of the homes—49%—were in breach of Regulation 18 on staffing, and a third—32%—fell short of Regulation 13, designed to safeguard service users from abuse and improper treatment.
Staff shortages in nursing and care staff, and the needs to attract the leadership and management which a good care home manager provides and make social care an attractive career for young people and people seeking work, underline the importance of the national living wage. The key training gaps identified by the CQC covered the areas of dementia care, safeguarding, mental capacity and deprivation of liberty safeguards which seek to ensure that the care provider does not restrict the liberty of vulnerable residents. Social care is failing dismally to attract new and younger people into the sector. The National Care Forum’s recent survey showed that just over 11.5% of staff employed in its member organisations are under 25, while more than half are aged 45 or older. These are all issues that the national living wage, if properly funded, can begin to address.
As a carer myself, I would like to see residential care integrated much more into the care plan for people with long-term conditions living in the community, with regular respite care planned, dated and available as part of the care pathway—and as part of the medium and longer-term planning for the person being cared for, not seen as a last resort. Carers UK testifies to how hard it is to book respite care in care homes in advance as part of a planned package of support, because the sector has too much focus on responding to emergency care and placements and cannot give a definite yes if you want a short stay on a specific date. The answer is often “Ring us nearer the time”, which of course is no good at all.
I will end with one case study from my experience as a trustee of our local carer support charity, which sums up the current situation faced in many parts of the country. One of our 73 year-old carers had cared for her husband for four years, through stroke, incontinence and then dementia. She needed a hip replacement. He went into residential care near the couple’s home while she had the operation, but when she came out she realised she could not care for him any longer. He stayed in the care home for two years, publicly funded by the council, with our carer regularly able to visit and help with care and feeding. His incontinence problems got worse and he was catheterised, but frequently pulled the catheter off due to his dementia. District nurses could not keep visiting the home, so frequent hospitalisation took place from the care home until it said it could no longer care for his needs. He did not meet the NHS continuing care criteria and stayed in hospital for months while social services looked for a nursing home near to his wife so she could visit. Finally, he is now in a step-down bed in a nursing home, a specially fully-funded intermediate placement bed at full care home costs to free up an NHS bed. The home meets his needs and his wife can visit him regularly, but he cannot stay there and must be moved in the next few weeks to a social service placement within the council’s baseline fee. The search goes on.
Social care is in dire need of a strategic, ambitious, forward-looking strategy and vision like the NHS Five Year Forward View, which has broad cross-party support and support from stakeholders, even if there is concern and scepticism about how the future plan can be delivered in the face of the realities on the ground. Dumping on councils so that they have to raise the money and then take the blame is not a strategy. As this week’s joint letter in the Guardian from the CEOs of the King’s Fund and Nuffield Trust put it, the spending review provisions are:
“another setback for people who need social care … These are sticking plaster solutions and no substitute for adequate funding”,
that social care desperately needs now.
Baroness Wheeler
My Lords, I thank noble Lords for their contribution. I said in my speech that their experience and insight would produce a very thoughtful and thorough debate and a comprehensive picture of both residential care and the wider social care, and that proved to be the case. It is important to develop a clear view of the role we want the residential care sector to play in integrating social care and I hope this debate has helped that, particularly across the care pathway. There were a number of speakers on that theme. We have debated these things a number of times but this is the first time we have focused on residential care and I think that has been very helpful. Many noble Lords stressed that this debate was about people. My example of my local carer was very much in that vein and other noble Lords gave examples of good care in their own experience. That is very valuable and it is well to remember that. CQC underlines that there are many well-led homes that are caring, safe and efficient with trained and dedicated nursing and care staff, but equally it gives the other side of the picture and the problems that we need to address.
I thank the Minister for his thoughtful response. He did not have a chance to reel off some of the statistics I was expecting. I was particularly looking out for his comment on the assessment from the noble Lord, Lord Warner, that we have seen only £70 million of the £6 billion that was to be introduced for the social care cap. I did not hear that but he is going to write to us and that is very welcome. I was a bit disappointed that he was not able to give us some reassurances on the monitoring that is going on of Four Seasons and other care homes. I understand the need for confidentiality but I think we need to be reassured that the Government are keeping it closely under review, particularly the issue of replacement care. On the care cap, I am glad it is still a postponement. The Public Accounts Committee has called for an urgent and clear timetable on implementation and I think the Government ought to take heed of that. In my view the overall debate has shown the clear need for a strategic, ambitious, forward-looking strategy and I am pleased the majority of noble Lords supported that. With those comments, I beg to move my Motion.
Atrial Fibrillation
Baroness Wheeler Excerpts(10 years, 6 months ago)
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Baroness Wheeler (Lab)
My Lords, I, too, congratulate the noble Lord, Lord Black, on securing this debate and pay tribute to his work highlighting the importance of early detection and effective management of AF. I also very much welcome the important walk-in clinic initiative he is promoting within Parliament, with AntiCoagulation Europe providing pulse checks to help prevent strokes and blood clots for people with AF, and hope that as many MPs, noble Lords and Parliamentary staff—if they are included—as possible will go along on 10 November.
I am also very grateful for today’s debate because it sets the scene for my own debate on 18 November on the updating of the now eight year-old national stroke strategy. The strategy runs out in April 2017 and today’s focus on AF underlines the priority it needs to have in the future strategy for preventing stroke and reducing the number of people who have strokes that could have been avoided.
As a vice-chair of the All-Party Group on Stroke, as well as being the carer of a disabled partner who had a major brain haemorrhage stroke in 2008, I am sure that noble Lords will understand why most of my remarks on AF will focus on stroke-related aspects. Better diagnosis and treatment through early detection and effective management of AF with an anticoagulant would result in the prevention of more than 4,500 strokes and 3,000 deaths across England each year. Untreated AF is a contributing factor in 20% of strokes in England, Wales and Northern Ireland, and, as we have heard, more complex disability can result from AF-related strokes.
We have heard a number of figures about the scale of the problem. The Stroke Association’s figure, cited by the noble Baroness, Lady Masham, is that an estimated 16,000 strokes could be prevented every year. The association hears many accounts from stroke recoverers about the devastating consequences of poor detection of AF, so it is worth putting on the record just two of those case histories.
David had a stroke at 62 which had a considerable impact on his life. He now has reduced mobility and this impacts on his job as an electrical engineer. David was not diagnosed with AF until after he had the stroke, and when discussing how to reduce the risk of having another stroke caused by AF, his GP seemed keen for him to take aspirin rather than an anticoagulant; that is, clot-reducing medication. However, David conducted his own research and then pressurised his GP into prescribing an anticoagulant drug.
Another stroke recoverer, Brenda, suffered a stroke thought to be caused by AF. She initially had a mini-stroke and was told by the hospital she was taken to that she had had an arrhythmia; there was no mention of AF. She went on to have a stroke 18 months later. Often AF is discovered only after patients are admitted to hospital with a stroke, and obviously by then it is too late. The Sentinel Stroke National Audit Programme found that only 28% of stroke patients known to have AF when admitted to hospital were on the anticoagulant medication they should have been on. The noble Lord, Lord Colwyn, gave this figure as 38%, I noticed.
Significant underdiagnosis and undertreatment remain, despite the incentives mentioned by noble Lords in the quality and outcomes framework, last year’s reissued NICE guidelines and the new quality standard on AF. It is imperative to address the low level of knowledge among GPs of the importance of early detection and the appropriate treatment of AF. The toolkit AF: How Can We Do Better?, developed by the Stroke Association for GPs and others in primary care, is one of a number of key actions that would lead to the increased awareness and understanding that are needed, particularly about the link between AF and stroke. Government support for NHS Improving Quality’s new GRASP-AF guidance on AF risk assessment and stroke prevention within GP practices would also make a significant difference.
How will the Government be supporting these initiatives? Does the Minister acknowledge that if swift and routine pulse checks were included as part of every GP visit, huge progress could be made and thousands of lives saved? Does he agree that the current low levels of awareness among health professionals are not conducive to developing better understanding among the public? Finally, I support the inclusion of indicators on detection and treatment of AF in the public health outcomes framework. Local health trusts need to be assessed on the efforts they are undertaking to prevent strokes and other major conditions that can arise from AF to ensure that vital opportunities to save lives are not missed.