Health and Care Bill

Baroness Watkins of Tavistock Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Lord Davies of Brixton (Lab)]

My Lords, I apologise for the confusion at the beginning of this debate. My understanding of the ways of this House is still a work in progress. I gave notice of my intention to oppose the question that Clause 80 stand part to provide the Government with an opportunity to explain more clearly than they have their intentions for the management of hospital discharge. I hope in so doing they can allay the concerns that surround the proposal to revoke Section 74 of the Care Act 2014. For example, there are the concerns of the National Care Forum, which points to the danger that

“the removal of an assessment prior to discharge will result in less priority to undertake the assessment once someone has left hospital—for someone needing support to remain in their own home, this is concerning.”

The process of hospital discharge is a crucial element within the integrated care system established by this proposed legislation. From the perspective of the service user, this is where it all comes together. It must be done right. The Explanatory Notes tell us that this clause introduces flexibility for local areas to adopt the discharge model that best meets local needs, including an approach known in England as discharge to assess, the argument being that people will be assessed at a point of optimum recovery, allowing a more accurate evaluation of their needs. Who could possibly object?

The first problem is that there is a widespread lack of trust in the Government’s motives and intentions on this, like on other changes in the Bill. It is possible to argue that the change means that people will be assessed where most appropriate. But it is also possible to argue that the change will facilitate premature discharge that is in the interests of the service provider, not the people receiving the service. As well as explaining and stressing the advantages of the proposed change, the Minister needs to tell us what the Government are doing to ensure that it will not lead to the disadvantages that many of those involved in the process fear.

The second issue that the Government need to address is that hospital discharge is still seen predominantly as a medical matter, with concern that insufficient attention is given to the social care aspects. A survey from December 2020 of social workers who were involved in hospital discharges made it clear that the vital contribution of social work in the multidisciplinary team was being marginalised by the medicalisation of people’s journeys out of hospital. Most importantly, social workers were found to feel that the voice of the individual, the person receiving the service, was being lost, indicating that arrangements were being made without consent or against people’s views and wishes.

It is also important to understand the context within which this change is proposed. On the one hand, there is the current crisis in social care. Even without the impact of the Covid pandemic, demand is outstripping supply, there are waiting lists for assessments of need and support, and local authorities are operating with significantly reduced budgets following a decade of austerity. On the other hand, there is the widely understood pressure on the hospital sector, with increased demand and mounting waiting lists. Both these factors are the result of the long-term underfunding of our system of health and social care. This will have to be addressed—just let it not be at the cost of the service user.

We must ensure that community health teams and social care teams have the resources they need to provide a needs assessment as soon as an individual is discharged. Too often, the issue of hospital discharge is discussed in terms of the needs of the service and not of the individual person.

[Baroness Watkins of Tavistock (CB)]

My Lords, it is a pleasure to speak on this group of amendments, but I want to focus particularly on Amendment 219. There are around 6.5 million unpaid carers in the UK, a number which increased to 13.6 million, or about one-fifth of the population, during the height of the pandemic. Some 1.4 million people provide more than 50 hours of unpaid care per week. Unpaid carers are often relied on to provide this care, yet receive minimal or no formal support themselves. Instead, many report feeling isolated, undervalued and pressured by the challenges of stress and responsibility. Being a carer is emotional and physical labour.

A lot has been said about the Carers UK survey, which identified that 56% of unpaid carers were not involved in decisions about patients’ discharge, with seven out of 10 respondents not being asked whether they were able to cope with having the patient back home and six out of 10 receiving insufficient support to protect their own or the patient’s health and well-being. This lack of support reflects the absence of a unified and systematic approach to identifying and supporting unpaid carers. It demands urgent remediation, especially as we know that unpaid carers are twice as likely as non-carers to have ill health, and the majority have reported worsening mental and physical health during the pandemic.

I endorse Amendment 219 because it talks about carers who work with people who come into contact not just with hospital services but with NHS services. In my work as a community mental health nurse, in many instances I saw that people were not admitted to hospital for years—which was actually a very good outcome—but their carers’ needs were just as great in supporting them with long-term problems in their own homes. This amendment would create a duty in respect of any person receiving NHS care, whether that is in the community or in hospital. The NHS must identify unpaid carers, particularly young carers, and ensure that their health and well-being are properly considered. This is a vital public health duty.

[Baroness Tyler of Enfield (LD)]

My Lords, I strongly support this group of amendments. I particularly endorse Amendment 269 regarding young carers, which was spoken to so compellingly by the noble Lord, Lord Young.

I wish to speak primarily about Amendment 221, to which my name is attached. It is about protecting existing rights of carers. I know that the point has already been made, but it is worth repeating. Amendment 221 would retain existing rights being taken away by this Bill as it repeals the Community Care (Delayed Discharges etc.) Act 2003. I find that a pretty extraordinary position to be in.

I want briefly to focus on the impact of caring particularly on women and employment, without in any way wishing to diminish the very important role played by male carers within the family. It is just a fact that women are more likely than men to be carers. According to some research conducted by Carers UK with the Universities of Sheffield and Birmingham, women have a good chance of becoming carers 11 years before men. Women are also more likely to reduce their working hours in order to care, and they are more likely as a result to have lower incomes and end up under-pensioned in retirement.

As we have heard, hospital discharge can be a pivotal moment for people providing care, particularly women. This amendment would ensure that assumptions are not made about carers’ ability to care, even when they may be working at the same time, that a solution is discussed and, ideally, agreed between families and services, and that carers are provided with the support they need to enable them to care safely and well. For those carers who are juggling work and care, which I can relate to personally, it is essential that their health and well-being are supported. This also has a positive benefit for employers. During the pandemic, the Carers UK research already referred to found an increase of around 2.8 million in the number of people who were juggling work and care, the majority of whom were women. Prior to the pandemic, some 600 carers a day were giving up work to care. During the pandemic, as the noble Baroness, Lady Pitkeathley, reminded us, carers have become the backbone of the care system, protecting the NHS and social care in many cases from collapse.

The Carers UK research also found that 72% of carers providing substantial care and working were worried about continuing to juggle care and work, and 77% of carers said that they felt tired all the time at work because of their caring responsibilities. During the pandemic, 23% of working-age carers providing substantial care had given up work, lost their jobs, lowered working hours or lost income if they were self-employed.

As the NHS works to reduce the backlog of care, hospital discharges will become ever more critical, as will support for carers. The two go hand in hand, and we must not fail those who have so selflessly shouldered such a heavy load.