Adult Social Care in England

Lord Warner Excerpts

Tuesday 10th October 2017 Lords Chamber

[Lord O’Shaughnessy]

The noble Baroness speaks from experience here. On the point about paying care staff, one of the greatest beneficiaries from the new national living wage are and will be care staff. That will increase over time and is one of the reasons why increased funding needs to go into the system. She also talks about the interface with local authorities. She will know that it is a very fluid market, with providers registering and deregistering all the time. We are trying to make sure that there is a proper review of the quality of the interface between local authorities and the National Health Service. Some do it very well, with very few delayed transfers, while others have huge problems. We get people in beds who should be in a care setting, either in a nursing home, in community care or at home. Those reviews are taking place and should highlight some practice that is not good enough. The challenge will be to work with those councils to make sure they do something about it.

[Lord Warner (CB)]

My Lords, is the Minister aware that the CQC has drawn attention to the loss of 4,000 nursing home beds in the last year? Does he accept that this is a loss that the NHS could do without? What action are the Government taking to increase the number of nursing home beds in this country?

[Lord O’Shaughnessy]

The noble Lord is quite right that the CQC report highlights that. It also highlights a broadly stable residential care home situation. What is changing the nature of care provision is the increase in the amount of domiciliary and community-based care that is being provided; we are seeing a shift there. The CQC report also shows big discrepancies across the country in terms of the proportion of beds per head of population. That is one thing we are trying to address, to make sure there is much more evenness of care.

Brexit: Risks to NHS Sustainability

Lord Warner Excerpts

Wednesday 12th July 2017 Lords Chamber

Asked by

[Lord Warner]

To ask Her Majesty’s Government what assessment have they made of the risks to NHS sustainability arising from the United Kingdom’s departure from the European Union.

[Lord Warner (CB)]

My Lords, we now come down to earth from outer space. This debate combines two public policy areas with what I would say are well above average risks of disaster and on which there seems to be a collective governmental denial of the seriousness of the challenges and dangers we face in both areas. Even without Brexit, the NHS has to cope with major challenges to its sustainability, which is why this House set up the Select Committee on this subject. I was a member of that committee which, after collecting and analysing a massive amount of evidence, published on 5 April its report, The Long-term Sustainability of the NHS and Adult Social Care.

Let me start with what that evidence revealed. We have unrealistic and inconsistent funding for both health and social care, relative to the demands placed on both by the disease profile of an ageing population. The UK has historically spent less per capita on health than France, Germany, the Netherlands and Sweden. There is no long-term strategy to secure an appropriately skilled, well-trained and committed workforce. We have expected staff to work, for approaching a decade, under a system of unrealistic pay restraint; and we are overdependent on EU-trained staff for whom, since the Brexit result, the Government have shown little appreciation.

The NHS performs poorly on many acute area indicators compared with similar European countries in terms of survival rates from stroke, heart attacks and cancer. We are on a trajectory of worsening service access and increased rationing of that access. There are wide variations in provider performance; and the NHS is often a slow adopter of innovative technologies that could save money and improve patient care. Significant health inequalities persist, and we have failed to protect public health and prevention budgets in the middle of an obesity epidemic that could easily overwhelm us—and we are still restricting those budgets.

The provision of publicly funded adult social care is now at a tipping point, which presents the biggest immediate threat and challenge to the NHS. The Government’s proposed funding increases to 2020 are at least £2 billion too little, and they come too late; service providers are leaving the publicly funded care market in big numbers; and quality is falling, often to unsafe levels. A longer-term solution looks as far away as ever after the election fiasco on social care, and the Government will not even commit to a Dilnot cap on personal liability for social care costs, despite having the powers to do so.

The British public still strongly support a tax-funded NHS, free at the point of clinical need, and the Select Committee could find little international evidence to change fundamentally this funding system. But the public are losing heart and now 55% of them expect the NHS to deteriorate. Both these services—health and social care—need a much more consistent funding system, agreed on a more long-term basis, with a stronger real-terms link to GDP growth, which in turn requires an economy that is growing.

There is strong evidence that the way in which we deliver health and care services has to change radically and rapidly if the NHS and publicly funded adult social care are to be sustainable. We have to integrate fully health and care, with much more care delivered in primary and community care settings, and with a greater focus on public health and prevention, especially with our obesity epidemic. All this requires investment and the Government paying attention quickly to the kind of changes set out in the Select Committee’s report, with 32 significant recommendations for the changes required. Crucial to that service transformation are service transformation plans, which are now at various stages of development and implementation around the country. Many are controversial with local communities in terms of closure of hospital beds and services. They often need a supportive and robust Government to amend the failed Health and Social Care Act 2012, which all too easily hampers local reforms. A weakened Government now lack the authority and capacity to do this, as the Queen’s Speech made clear.

I am not going to discuss the Select Committee’s recommendations now. They are matters for debate another day, when the Government finally get around to responding to our report. What I am trying to do today is demonstrate that our health and care system is not in a good place. It requires a lot of political investment of time and money, preferably on a cross-party basis. It also requires a buoyant economy over the next few years to provide the investment that these critical and publicly supported services need. Yet the Office for Budget Responsibility last year projected a £15.2 billion hit to the public finances by 2020-21 after the UK leaves the EU, which would mean a loss of about £2.4 billion a year to the NHS—and even more if there is a more severe economic downturn than the OBR thought.

The harsh Brexit reality is that we face an exit from the single market, with poor transitional arrangements, the loss of trade with our near neighbours, fewer tax-producing financial services jobs, higher inflation and a shrinking economy. We have a dysfunctional Government with no credible plan for leaving the EU without serious damage to our economy over the coming years and not even any agreement on a sensible transitional arrangement. This Government continue to delude themselves about the willingness of the EU to compromise on its fundamental, treaty-prescribed principles.

I do not usually quote trade union leaders, but the head of the Transport Salaried Staffs’ Association seemed to me to sum things up rather well when he said:

“If Brexit goes ahead, future historians will look back and see a carpet-bombing of the British economy and the freedoms enjoyed by people living here”.


This set of circumstances does not bode well for our already fragile health and care system, and the prospects could become worse as a result of other things the Government seem willing to sacrifice in their rush to the EU exit. We have already virtually lost the EU pharmaceutical regulator—the EMA—from London, with the loss of high-quality jobs and the adverse impact on our life sciences sector that this brings.

The Government’s obsession with escaping from the European Court of Justice’s jurisdiction has led to the bizarre and ill-considered decision to quit Euratom, with no credible alternative civil nuclear regulator in prospect and—by the Government’s own admission, it would appear—without any proper assessment of the impact of quitting Euratom. Leaving Euratom now poses another threat to the NHS and its patients, as the Royal College of Radiologists has pointed out. Thousands of NHS cancer patients rely for diagnosis and treatment each year on radioactive isotopes imported from EU countries. The safety regulator for this activity is Euratom, governed by an EU treaty. The best interests of the UK and its citizens would be served by us remaining a member of Euratom, but the ideologues in No. 10 seem to have decided otherwise—despite the European Court of Justice never having made a ruling on Euratom.

On top of this, the health and care system depends on about 150,000 doctors, nurses and other care staff from the EU, because of our failure to train and retain enough home-grown staff. About 7% of our doctors are EEA-trained, and 40% of social care staff in London are from the EU. But the biggest problem may well be a shortage of nurses, because we import about 10,000 nurses a year from the EEA. Already the number of EU nationals registering as nurses in England has dropped by over 90% since the referendum. All this is becoming a serious problem. Because of the Government’s failure to move quickly to reassure EU nationals of their right to remain here after Brexit, many of these EU nationals no longer trust the Government’s belated assurances—in part because EU political leaders do not trust them, either.

In conclusion, this is a hell of a mess. A fragile health and care system badly needing reform and new investment from a growing economy is now facing economic retrenchment, political uncertainty, loss of a key staffing source and collateral damage from ideological obsessions with the ECJ. This is today’s reality, in contrast with the leave campaign’s lies on its red bus about Brexit providing £350 million a week more for the NHS. In the coming months, more people will realise where the Government’s approach to Brexit is taking this country economically and its implications for public services. Then we will see how committed they really are to Brexit. I ask the Minister: what plans do the Government have to protect our fragile health and care system over the next two or three years of great political uncertainty?

Adult Social Care Services

Lord Warner Excerpts

Thursday 6th July 2017 Lords Chamber

[Lord O'Shaughnessy]

I reiterate the point I made to the noble Baroness, Lady Wheeler. I completely agree that safety is paramount: it is the beginning of any good care setting. As I said, the new regime highlights issues of safety where they exist so that operators and commissioners, whether that is local authorities or whoever, can demand turnaround in those services. As I said, the response to that has been demonstrated.

I mentioned that more staff are, of course, getting the national living wage, which will continue to attract people to the sector. The noble Baroness is quite right about skills, which is why we have the skills for care programme.

It is also worth pointing out that one thing the CQC report did show, as indeed you would hope it would, is that 79% of settings provided either good or outstanding care. There is no doubting the motivations of the people who work in this sector, and we all pay tribute to them. It is about making sure that there are enough of them and that they are properly skilled. That is precisely why we have put additional money into social funding, to enable real-term increases over the next three years to address the fact that we have an ageing and growing population.

[Lord Warner (CB)]

My Lords, I declare my interest as a member of the Dilnot commission. I am sure we all welcome the idea of a longer-term set of proposals for consideration later. However, does the Minister not realise that the money the Government have said they are putting in over the next three years, including the current year, merely puts back a lot of the money that was taken out before, and certainly does not meet the proposal for immediate funding made by your Lordships’ Select Committee on the sustainability of the NHS and by the King’s Fund? This year, the Government are about £1.5 billion to £2 billion short to meet the needs. Does the Minister understand that this is not just about quality but about quantity? People working in publically funded care are leaving in droves. Is this on the Department of Health’s risk register? What are the Government going to do if the tipping point is reached on providers not providing publically funded social care?

[Lord O'Shaughnessy]

First, I congratulate the noble Lord on the work he did on the Dilnot commission in setting out the challenges we face and the kinds of solutions that we need to put the sector on a long-term footing. I merely reiterate the point that extra funding is going in, at a time when we are still addressing the £150 billion deficit that the Government inherited in 2010. That is enabling real-terms increases. Of course we need to keep going with that, because there are more older people and their care is increasingly complex.

I want to come back to the changes we are making on delayed transfers of care. Making sure that the interface between the NHS and social care is as quick, smooth and suitable for patients as possible is critical. That is why there is renewed emphasis to make sure that the money going in is addressing one of the major problems that is preventing the quality of care that we want.

Queen’s Speech

Lord Warner Excerpts

Thursday 29th June 2017 Lords Chamber

[Lord Warner (CB)]

My Lords, the gracious Speech raises more questions than it answers as far as the NHS and social care are concerned. These questions relate to funding and workforce issues but also to the modernisation of professional regulation and mental health services. I will focus on these issues.

First, on funding, £124 billion a year is spent on health services in England. By the end of this Parliament, the Government have promised to spend another £8 billion. On the Minister’s own figures, this is a real-terms increase of less than 1% per year for five years. This proposed increase makes it impossible to lift the 1% pay cap, given that two-thirds of the NHS budget goes on pay. The Labour Party did rather better: it promised another £11 billion. On present forecasts, it would cost another £13 billion for the NHS to keep up with GDP growth. This was the recommendation of the House of Lords Select Committee’s April report on NHS sustainability, to which the Government have yet to respond. None of these figures, however, matches the OBR forecasts or realistic estimates of the increases in NHS costs and demand. Can the Minister tell us whether the Government will reconsider their position on the £8 billion, in the light of the evidence of its inadequacy from your Lordships’ Select Committee and elsewhere?

Secondly, there is the crucial area of social care, which a number of people have mentioned and which was handled with such crassness by No. 10 during the election. Even after the council tax precept increases and the extra £2 billion for social care over the next three years that the Government have already announced, there will still be a shortfall of at least £2 billion by the end of 2019-20. Publicly funded care providers—residential and domiciliary—are now leaving at scale, as the recent ADASS survey shows.

More than a million older people now have unmet social care needs, which means that the hard-pressed NHS will find its acute hospitals even more full of older patients who should not be there and do not want to be there. We will all be interested to see the Government’s promised consultation paper on the future funding of social care—let us hope it is a bit more convincing than their manifesto. But social care needs more money now—this financial year in fact—to halt the attrition of publicly funded social care providers.

If the Government can produce in a fortnight or so an extra £1 billion for Northern Ireland, which has less than half the population of Greater Manchester, they should be able to do no less for the elderly and disabled people across England. Can the Minister say whether the Government will try to find for the next three years, starting now, at least £2 billion for English adult social care over and above the money already promised? Will they keep on increasing the adult social care budget at least in line with the growth of the NHS, which is another recommendation from this House’s Select Committee?

Thirdly, there are the serious workforce issues caused by Brexit mishandling. There are some 60,000 EU nationals working in the NHS, many of them doctors and nurses, as well as 90,000 working in social care, a high proportion of them in the London area. Registrations of nurses from the EU are falling significantly, and many doctors qualified in EEA countries—who amount to about 7% of the NHS’s medical workforce—are seriously considering leaving the UK. This flight of valued professionals is entirely of the Government’s own making, through their failure to produce any credible reassurances to EU citizens living and working here. The new White Paper looks unlikely to do that, and when the proposed immigration Bill comes to this House, we may have to help the Government do a proper job in this area. In the meantime, can the Minister tell us what bespoke measures the Government will take to give greater reassurance to staff from the EU currently working in the health and care sectors?

Fourthly, there is considerable need for clarification on the gaps between the Government’s manifesto and the gracious Speech on regulatory matters. Legislation to reform outdated laws on mental health, now 34 years old, was promised in the manifesto, but is not in the Queen’s Speech. When are we going to see that legislation, at the very least in draft form? Again, the manifesto promised to,

“reform and rationalise the current outdated system of professional regulation of healthcare professions, based on the advice of professional regulators”.

Legislation is badly needed, by both the GMC and many other regulators. Can the Minister say when we will see the legislation to reform this antiquated system— which is, again, 34 years old, and again as recommended by this House’s Select Committee?

Finally, I draw the attention of the Minister and his senior colleagues to the latest British Social Attitudes survey, published yesterday. This shows that an increasing majority of people in this country support higher taxes for better public services, especially education and health. I remind the Minister that it was penny-pinching on the NHS in the 1990s that contributed to the Conservatives’ landslide loss in 1997, helped of course by a Labour leader who knew how to actually win elections—three on the trot, as I recall.