Health and Care Bill

Lord Bichard Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Lord Bichard (CB)]

My Lords, I begin by welcoming, with others, the noble Lord, Lord Stevens, and congratulate him on his maiden speech. To use an analogy that I think he will understand, in my experience maiden speeches are like kidney stones: they are much better when you pass by them.

I too welcome the emphasis that the Bill belatedly places on collaboration, integration and partnerships, which is something that many of us have been seeking for a very long time and that I was personally associated with when leading the Total Place initiative more than a decade ago. We have been seeking this because none of the major issues that afflicts us can be resolved by a single public service—even one as large as the NHS. As your Lordships’ own Public Services Committee has stressed in its recent reports, better collaboration is critical to successfully addressing challenges such as obesity, diabetes and child safety. It is not just collaboration within the health service and between health and social care; it goes beyond that.

Let us be clear: we cannot legislate for collaboration, we cannot structure it into an organisation, we cannot impose it from the top down—as we have so often tried to do—and it does not happen with the flick of a switch. Ultimately, it depends upon the culture of the organisation. I have to say that, while so much about the NHS is positive, it has never in my experience been an exemplar of collaborative working, so turning the collaborative thrust of the Bill into reality will take a real effort. I hope that, as it progresses through the House, noble Lords will be able to make some amendments that make that more likely.

In other respects, I am afraid that I am less positive about the Bill as it stands simply because, as others have said, it seems to me to ignore so many of the health-related problems that we need to address urgently —whatever “urgently” now means. It does not, for example, tackle health inequalities, which have almost certainly worsened during the pandemic. The extent of these inequalities is a stain on our society—I am not exaggerating for effect—and others have mentioned Professor Michael Marmot, who has long sought to evidence this. Could we not at least incorporate this into the new triple aim, as the King’s Fund and others here today have suggested? We have heard a lot about levelling up, but, to be honest, it means nothing to me unless the health inequalities that we are experiencing are addressed.

While the Bill was described as a health and social care Bill, there is little of real substance about social care, and the proposed changes to the social care cap are regressive, as I think most people now accept. I shudder to think how my parents would have responded to these proposals. One of their proudest achievements was to own their own home, and they would have been devastated by the threat of losing that as a result of provisions like this. I agree with the noble Lord, Lord Lansley, that this should be taken out of the Bill.

There is also nothing in the Bill to suggest that the importance of prevention and early intervention has been recognised—the noble Lord, Lord Bradley, touched upon this. The truth is that we are spending ever greater public resources on crises and ever less on prevention, not least in the way that we seek to improve the life chances of vulnerable children, for which the NHS has a major responsibility.

The extensive new powers given to the Secretary of State to intervene in local service reconfigurations, as drafted at the moment, fly in the face of the stated intent to give local places and communities greater power over local priorities. Surely there needs to be at least some stronger requirement in the Bill for local communities to be involved before such interventions are made.

There is nothing in the Bill to suggest, to me at least, that there is a real strategy for tackling current chronic staff shortages—or, indeed, for ensuring that users have a real say in the way that services are designed. We hear a lot about patient-centred care—the only way that you can achieve it is if patients and users are involved in the design of the services in the first place.

Finally, could we not resolve one of the greatest practical barriers to collaboration: the failure to share data effectively? Whenever you mention data, people switch off. It is really important. Part 2 of the Bill begins to address data sharing between adult social care and health, but, for reasons that I simply do not understand, it does not address the same issue where children are concerned.

As your Lordships’ Public Services Committee identified in its recent report on vulnerable children, this is a serious practical problem. I know that it has been at the heart of many of the most tragic child abuse cases over the last 50 years. Perhaps the Minister can say in replying why we have not taken this opportunity to address that practical barrier and whether he would be sympathetic to amendments which did. It is something which the DHSC and the DfE need to do together, and I hope they will.

Social Care in England

Lord Bichard Excerpts

Thursday 14th October 2021 Lords Chamber

[Lord Bichard (CB)]

My Lords, I am proud to count myself as one of the usual suspects that the noble Baroness, Lady Pitkeathley, referred to earlier. In that capacity, I congratulate her on winning this debate and on a quite brilliant opening speech.

As we all know, social care has been in need of urgent reform for a decade or more. When history is written, I think it will be one of the greatest failings of Parliament that so little has been done. Resources have been inadequate. Too many providers are struggling to survive, too many users are dissatisfied with the service they receive, too many unpaid carers are, quite simply, exhausted, and too few people see social care as an attractive career option. For people suffering the consequences of these failings, arguments about who is to blame and promises of future improvements feel a world away from their lived reality. Their lives cannot be put on hold; they have to be lived now. They should be, and they deserve to be lived well.

Sadly, the long-awaited White Paper has still not materialised. There was yet another promise that it will be with us in three months; I have lost count of how many of those I have seen. The recently published Build Back Better fails to address the real problems, focusing almost entirely on how to fund the cap on costs. Any future plan and the White Paper itself need to deal with the really big issues comprehensively.

First, we still need to deal with resources, because, as others have said, the Health and Social Care Levy Bill does nothing to increase the capacity of the sector. It is regressive, and somehow even finds a way to increase the financial burden placed on providers and on care staff themselves. The Economic Affairs Committee of this House judged that £8 billion was needed to bring the sector back to where it was a decade ago, and many have suggested ways in which this could be found by reallocating public expenditure if there was no new money available. It needs to be done.

Any future plan needs to ensure, as others have said, that care services are better integrated, but as the noble Lord, Lord Lansley, said in Monday’s debate, that will not be done by great promises about further major institutional changes—reorganisations that often mean nothing in terms of improved services on the ground. A national care service and integrated care services will not provide immediate succour for people suffering as they are. They need us to address the real barriers to collaboration on the ground. People in residential homes do not want promises about new structures; they want free, convenient access to GP services, 24/7.

Again as others have said, we have to confront the crisis of the workforce far more convincingly than Build Back Better does. Social care should be seen as the noblest of professions, not as a last resort for a career. Could we encourage former clients—care leavers, for example—to use their lived experience and join the profession? Could we extend initiatives such as Teach First and Frontline? Do we know enough about why and when people leave so that we can target our workforce planning? How can we improve and make training and development more attractive to the workforce? Nothing will change or improve without a committed, skilled and valued workforce.

Something that has not been mentioned today is that we need to sort out the benefits system. At the moment, you can apply for attendance allowance, higher-level attendance allowance, domiciliary care, residential care or continuing healthcare. Some of these are administered by the DWP, some by local authorities and some by the NHS. Some are means tested and some are not. Continuing healthcare seems to vary widely in the way it is administered across the country. This is a confusing mess. It costs money, but it brings huge stress to people when they are at their most vulnerable.

We could support providers better. Education leaders have been able to access information and support online for a decade or more, but social care providers are left to their own devices, struggling to balance the books, cope with increased regulation and cater for clients with increasingly complex conditions. Why do we not establish an innovation and improvement fund to give them some support in the immediate future? Are we using digital technology as well as we could, not just to help providers but to help more people to stay independent? I do not think we are.

What is the strategy for unpaid carers, so often and rightly mentioned today—13 million of them, saving the Exchequer nearly £200 billion a year? The Secretary of State highlighted the importance of these at conference, but they cannot be taken for granted, so where is the strategy to support them?

Finally, how can we give users and their families a greater say in the way that services are provided? The time should have gone when well-intentioned central bureaucrats decide how services should be shaped and delivered. We need more influence from lived experience.

Fixing social care is about fixing all those issues, not just putting a cap on care costs. I hope the Minister can reassure us on two things today: first, that we will finally see the White Paper by Christmas, and, secondly, that it will cover this comprehensive range of issues.

Queen’s Speech

Lord Bichard Excerpts

Thursday 9th January 2020 Lords Chamber

[Lord Bichard (CB)]

My Lords, it is a new year with a new Government and there is new energy with new ideas and new policies, and even, we are told, some money. There is a sense of anticipation and, in the words of the Prime Minister, the dawning of a new golden age. What could possibly go wrong? Quite a lot could go wrong because, on past evidence, Governments in this country have found it very difficult to deliver projects, improved services, policies, targets or promises. We have become a nation that is good on ideas, ambitions and aspirations, but rather weak on achievement. As chair of the National Audit Office, I see countless examples of that week by week.

Take a look at some of our recent reports. Take a look at Crossrail, which is over budget and still not there. Take a look at HS2. Take a look at the starter home target of 200,000 houses, which delivered, well, none at all, actually. If you have time, take a look at the Great Western Railway modernisation or perhaps the decommissioning of our nuclear submarines. That has been a policy commitment since 1990, which so far has led to no vessels at all being decommissioned and untold riches being spent on stockpiling disused submarines. We now have more submarines in storage than in operation.

You can add to those recent failures universal credit, countless failed IT projects and, as many noble Lords have said in the debate, social care—or the lack of it. We are wasting billions of pounds when resources are tight and at the same time failing to deliver policies, many of which would help some of the most disadvantaged people in our society. So I often ask myself: why does this happen and what could we do to improve the current situation?

We at the National Audit Office are not actually interested in being mortuary attendants; we would actually quite like to improve public services. So I make a few suggestions to a new Government who may be in listening mode. For a start, we could make clear, from the very top of government, that delivering outcomes successfully matters just as much as endless policy commitments. We could be careful to ensure that policies and targets are stretching but achievable rather than designed primarily to grab the headlines and capture short-term political advantage. We could limit legislation so that the programme for any Session of Parliament is realistic and manageable. We could do more to ensure that civil servants are equipped with the skills to deliver services and projects effectively. We could, for example, insist on officials being required to spend a reasonable amount of time in operational or project management posts before entering the Civil Service, because it was clear to me all those years ago when I was a civil servant that policy development mattered and was recognised much more than delivery, and I fear that that is still the case.

We could hold people, civil servants as well as Ministers, more accountable for failures and stop the recycling of incompetence. We could ensure that competent Ministers stay in post for longer than the current average of around 15 months and that civil servants are not constantly churned to benefit their careers at the expense of results. We could devolve more power closer to communities, because large centralised bureaucracies rarely deliver successfully, and, frankly, in recent times local government and the voluntary sector have shown themselves to be more competent, agile and trustworthy than large central government departments and agencies. We could do a lot more to learn the lessons of failure and from our mistakes rather than seek to explain away the inexplicable or defend the indefensible. Finally, we could better understand and exploit the potential of digital technology to transform health, social care and many other essential services.

There are many reasons why the reputations of both Westminster and Whitehall are at such a low ebb, but in part it is because people have lost trust in their ability to deliver improvements, not least in public services. Addressing that has to be a priority for this new Government, and success will not be achieved by yet more promises to do better or to try harder, or indeed by just throwing money at the problem. That is why I for one have welcomed the signals from No. 10 that the Prime Minister is supporting radical changes in the way we govern, even if I may not have used exactly the same words, but that support and interest needs to be sustained in the face of many other pressures. However, all revolutions have to start somewhere and maybe this one should start with the Government saying very clearly, “We will promise only what we can deliver, but we will deliver what we promise.” Or to put it another way, “Let us promise a little less and deliver a lot more.”