Health and Social Care

Baroness Warwick of Undercliffe Excerpts

Thursday 15th December 2016 Lords Chamber

[Baroness Warwick of Undercliffe (Lab)]

My Lords, I thank my noble friend for introducing this debate and commend him for his continuing interest in this issue. I join with other noble Lords in offering condolences to the noble Lord, Lord Prior. The headlines earlier this week following the Care Quality Commission report sharing the experiences of families seeking information about the death of a relative make this, regrettably, a timely debate. I declare an interest as chair of the National Housing Federation, and in a moment I will say something about the importance of the role of housing associations in supporting users of social care. First, however, I will support my noble friend in his comments about Healthwatch England.

Just over a year ago, NHS England published its Patient and Public Participation Policy, which pledged to,

“work in partnership with patients and the public, to improve patient safety, patient experience and health outcomes; supporting people to live healthier lives”.

Those are laudable aims. The problem in achieving them—as the King’s Fund and others have pointed out—is that it is not entirely clear what involving people in health means; and when you attempt it, difficulties arise because often this challenges vested interests and the established way that people do things. Yet, as the chief executive of the CQC, David Behan, has said, what distinguishes many of the good and outstanding services that exist is the way that they work with others: hospitals working with GPs, GPs working with social care, and all providers working with people who use services.

Those services, we hardly need reminding, are under increasing pressure. This makes the role of Healthwatch England and local Healthwatch groups all the more important. As other noble Lords have said, having a local voice for users of the health service is critical to the development of the service. They are the only organisations with an overall view of an entire local health and well-being system. Their responsibility to use public experience to drive service improvement is a vital one. We now have a network of local Healthwatch organisations across England’s 152 local authorities, supported by more than 6,000 volunteers. Almost four years on, it is certainly right to ask about their effectiveness.

I share the concerns already voiced about Healthwatch England’s independence. When it was established in 2012, it was hosted by the CQC but reported directly to the Department of Health. A restructuring this year means that the national director now reports directly to the chief executive of the CQC and aims to “work more closely” with the CQC. How free will Healthwatch England be to criticise the CQC if it is embedded within it? A too cosy relationship makes it harder to be a critical friend.

I think that the point about relationships is particularly important when it comes to local Healthwatch groups, which are commissioned by local authorities. Large organisations such as local authorities and NHS bodies tend to understand the world through analysis of quantitative data and research evidence. This contrasts with the way that individuals and communities operate, where the emphasis is on personal experiences and the stories that describe them. To be effective, local Healthwatch needs to operate between the two—to bring the public into the discussion in a way that is understood and accepted by these large organisations.

However, I believe that the groups must also be at arm’s length from local authorities. They must be prepared to ask difficult questions and to have enough knowledge to square up to consultants or hospital chief executives, and perhaps tell them that they are not doing a good enough job. We know that this was part of the problem in the tragedy of Mid Staffordshire.

It is easy to forget that local Healthwatch groups are still small and relatively new organisations, still developing their expertise. I wonder to what extent local authorities and health trusts are helping Healthwatch by, for example, including an explanation of the Healthwatch role in inductions for new staff, by briefing managers on the role and activities of their local Healthwatch, or by agreeing what good practice should be when working with the local Healthwatch on an investigation. The effectiveness of a local Healthwatch can be helped by bigger players in the system.

My noble friend also referred to the capacity of Healthwatch England and local Healthwatch. It is a concern to me that the funding for local Healthwatch groups is still not ring-fenced. I have heard the arguments for local autonomy and the rationale for not telling local authorities what to do but, if the end result is that some regions or councils are not using the money for its intended purpose, this can surely only harm the local community and the patients in those areas.

I should like to mention here the work of housing associations. Our social care system is at crisis point for both patient and taxpayer. A recent National Audit Office report, Discharging Older Patients from Hospital, highlights a problem that we are all too aware of but the figures are still startling: £820 million of taxpayers’ money is spent every year on unnecessary acute care and 2.7 million patient days are wasted waiting for transfers from hospital which have been delayed. If we did more to help older people recover at home, rather than in hospital, the estimated savings would be around £640 million every year. Housing associations are helping to make this happen, and I want to give one example.

Curo, a housing association in the south-west of England, has over 13,000 properties and a successful care and support division. Its “step down” service is made up of six homes that have access to a care team round the clock. Patients are discharged from hospital and move into a home in the service for a set period of time, agreed with their clinician when they leave hospital. They receive individually tailored care and support, and are given opportunities to familiarise themselves with telecare options for when they move on from the service. This reduces the likelihood of further readmissions to hospital.

The step down service was commissioned in 2011 by Bath and North East Somerset Council and the local clinical commissioning group with funding from the better care fund. It has enabled emergency discharge from hospital as part of a wider “discharge to assess” pathway, providing a value-for-money route for hospital discharge where assessments can be conducted outside a primary care setting. It has been recommissioned and continues to deliver a cost-effective solution for discharge and reablement, particularly for older people.

The financial benefits are huge. It is estimated that an excess hospital-bed day costs £303 per day or over £2,000 per week. In contrast, Curo’s step down facility costs £60 a day. In 2015-16, Curo delivered 1,721 days of step down from hospital, equating to a saving to Royal United Hospitals Bath NHS Foundation Trust of over £520,000—or £390,000 once costs are taken into account. Feedback from patients who have benefitted from Curo’s services reflects the value, independence and dignity of care from a housing-led service around hospital discharge.

This is just one example of a housing association scheme that is saving the NHS money and helping people to recover with dignity. Working in partnership with the NHS and local Healthwatch groups, so much more could be done. If the Government wish to ensure that the health and social care system works for everyone, more incentives to work together need to be provided to encourage new and alternative approaches to delayed hospital discharge. The current consultation into the future of supported funding offers the perfect opportunity for the Government to work with the sector to end this crisis in provision.

It is clear to me that now, more than ever, we need independent evidence-based thinking to address key public health concerns. Healthwatch England’s special inquiry last summer into the lack of care for vulnerable people discharged unsafely from hospital made the headlines and highlighted the need to put patients at the centre of health and social care. But reports have real value only if they are listened to and acted on. The case for supporting Healthwatch England and local Healthwatch organisations to grow their expertise and experience in undertaking this sort of work is undeniable.