Thursday 3 May 2018
[Dame Cheryl Gillan in the Chair]
Social Care Provision and the NHS
I beg to move,
That this House has considered the effect of social care provision on the NHS.
Thank you, Dame Cheryl. I was moved to initiate this debate by the experience that I had just after Easter, when I spent a 12-hour shift with colleagues in the ambulance service based at the depot in Buxton; they are trained and very experienced paramedics. I have had a lot of cases involving constituents who have been concerned about ambulance waiting times—the time that it takes ambulances to get to patients in our very rural area—so I spent a day with staff to see what the pressures were.
I expected those pressures to be on the NHS, but what I found from spending a day with the ambulance service and the excellent and hard-working crews, who said that it was not in any sense untypical, was that we spent the day going around seeing elderly patients in their own homes. They might have had family carers or received occasional visits from professional, paid carers, but they were left on their own for a lot of the time. They often had ongoing health conditions that flared up from time to time and caused them and their carers great concern, and that would escalate to calling out an ambulance. I therefore spent a lot of the day sitting in the back of an ambulance and talking to elderly patients. That was quite a pleasant way to spend a day—I like talking to older people and have helped with care for my own family—but it is not really what we want our paramedics to be doing.
I receive calls from constituents about their family members who have to wait in dire circumstances at times. In one recent case, an elderly lady had had a stroke. The GP was begging for an ambulance to come to her, but it took five hours for it to get there. Unfortunately, that lady subsequently died. We cannot say that that was because of the delays in the ambulance arriving, but a lot of time is taken up by ambulances travelling around to elderly and isolated people, and that is happening more and more.
Age UK says that there has been an increase to about 1.2 million in the number of people who need care but whose care needs are not being met. It is a vicious circle, which ends up impacting on our NHS. The winter crisis seems to be going on and on. There are almost 4 million people on hospital waiting lists. Every week at my constituency surgeries and coffee mornings, I see constituents who are waiting for treatments such as hip replacements. I saw a lady in Buxton who had been waiting almost a year for a hip replacement. She used to be an avid walker of the countryside, but now is practically housebound. That has obviously impacted on her quality of life.
There are also waits to see a GP. We have gone from waits of 48 hours, as a maximum, eight years ago to waits of two weeks now. People have to book an appointment some way ahead; and often, if people phone any time after about 8.20 in the morning, the surgery will say that it has no appointments left, even for two weeks’ time. People have to say that it is an urgent case in order to be seen and then they are seen more quickly. The situation is impacting on GPs as well.
In accident and emergency departments, only 85% of people are seen within four hours. At my local hospital, Stepping Hill, patients are queuing on trolleys in the corridors and are given a bell to ring if they feel that their condition is deteriorating, because there are just not enough staff even to keep an eye on them. The staff rely on patients themselves being able to give an alert if they feel that they are in urgent need of care.
I saw the impact of the long ambulance waits in A&E. They are backed up, sometimes seven at a time, outside our hospitals while they wait to be able to discharge patients. The staff now face an overtime ban, despite the great demands on their service. Even two weeks into the financial year, they were already banned from overtime, so young trainee paramedics are staffing ambulances on their own at night, which is not what I want to see in my constituency and not how we should be treating the staff.
BBC 2’s “Hospital” programme showed what is happening in A&E at the moment. We saw a frantically overstretched service and every hospital bed full, but staff estimated that 80% of the patients should not actually have needed a bed; they should have been in social care. This comes back to the cuts in social care.
According to the Association of Directors of Adult Social Services, £6.3 billion has been cut from social care budgets. Nationally, 400,000 fewer people are receiving social care, more than a quarter less than in 2010, despite increasing demand. In Derbyshire, my county, the number of people needing care has risen by more than one quarter, from 32,000 to 40,000 people.
Social care cuts do not make good television, though. They are invisible to the outside world. Patients are not lined up, queuing on trolleys. No one could really make a drama about it, but it is a crisis in the homes of the 1.2 million people who need and are waiting for care and cannot get it. We see that crisis only when we step inside the NHS, with paramedics or GPs who have to visit those elderly patients or in A&E departments. Then we see the people who are falling through the gaps in social care. That is echoed in my own constituency, where one of the GP surgeries tells me that 19 patients in one small town are on a waiting list for a care package. They are either in hospital, taking up a hospital bed, or at home with family carers, who are struggling to cope.
Palliative care is particularly difficult. At the end of life, patients typically need four or five short visits a day. Particularly in a rural area, that is very hard for our care services to cope with in the way they are financed and paid for. The lack of palliative care means that patients are stuck in hospitals where they are often many miles away from their loved ones. In a tragic recent case, one of our GP surgeries told me about an elderly gentleman crying to the GP because he had never been separated from his wife before. They were both in their 80s. She was terminally ill in hospital and he could not get to see her. That GP surgery pulled out all the stops. It got its district nurses to go in and allow that lady to go home for the final few days of her life. However, they cannot do that for every patient. The NHS simply does not have the resources and it impacts on other patients it needs to see.
The surgery in Hope in my constituency in the rural Peak district tells me that patients are being cared for in the community by relatives much more than used to be the case. That is good for the individuals in many ways. That is where they want to be. However, it puts more strain on GPs having to visit more frequently those patients with more complex needs. A poll by MediConnect in 2010 found that almost nine in 10 GPs believe that the reductions in social care are leading to extra pressures on their surgeries, which is leading to extra pressures on GPs. Buxton is seeking to fill six GP vacancies out of a total of 12 across the town. That is not sustainable.
That also leads to extra pressure on A&E departments and increased delays in discharges from hospital. In 2016-17, there was a 12-month average of 188,000 days of delayed care, which is 73,000 more than the four years from 2010 to 2014, when the situation was fairly stable. The King’s Fund has estimated that patients waiting for a care package in their own home accounted for the largest number of delays—in other words, more than 20% of all delays in discharge.
The cuts to social care are creating more expense for our NHS, but it would be cheaper to resolve such cuts. The NHS spent approximately £168 million on delayed transfers of care for patients awaiting a home care package in 2015-16. That could have funded more than 5 million hours of home care in that year—431,000 hours a month or nearly 15,000 hours a day—helping thousands of patients to stay in their own home with the care they need.
The Multiple Sclerosis Society has done a lot of work on the issue, because sufferers of MS frequently need care but a lot of that need is not being met. It says that in 2015-16, emergency hospital admissions for people with MS in England cost the NHS a total of £46 million. A large proportion of that emergency care was for problems that could have been avoided with proactive, preventive care, and earlier diagnosis and intervention in the community. For example, 14% of emergency admissions were for urinary tract infections, costing more than £2,500 per patient, which could have been avoided.
The reductions in social care are not simply down to Government cuts, hard as they have been for local authorities to sustain. There have also been huge increases in demand of more than 25% in the past eight years. The cuts to local authorities—they are gradually cutting the amount paid to care homes and to carers who provide care to people in their homes—are having a detrimental impact on the whole sector. It is really coming to a crisis point. A 2017 survey of directors of adult social services found that 39% had home care providers ceasing to trade in the previous six months and that 37% had contracts handed back.
My constituency of High Peak has real difficulty recruiting staff to work in care services. The staff do an absolutely fantastic job, but the pay is very low. Over half of staff nationally are on zero-hours contracts. Particularly in expensive rural areas, such as the Peak district, one cannot afford to live on the wages of a care worker. Ironically, however, there are more and more elderly and infirm people in those areas. In High Peak, our volunteer services run a professional, not-for-profit care service arm, but it is operating at a loss and has to cross-subsidise its care services from other services, which it cannot afford to do much longer.
This is a particular problem in rural areas. Patients are scattered, meaning more travel time and extra costs for companies. Our private care companies, the agencies, cherry-pick the areas they will cover, so they avoid the very rural areas, which cost them far more in mileage and travel time. A Rural England report found that rural councils pay 13% more on average than predominantly urban councils, but they still report more problems in commissioning services. Several home care businesses commented that they did not feel that councils paid enough and that was reflected in the handing back of contracts. Everyone says that council providers are needed, which would not cherry-pick based on areas that are profitable.
Even though Derbyshire is one of the few areas where our Labour-run council kept on directly employed care staff on the proper living wage, it cannot recruit enough staff, so we have to rely on agency staff. There are about 90,000 vacancies across the country for agency social care staff. They are at an absolute premium and our local jobcentres are always trying to recruit people into care jobs, but it is not for everyone. It is a difficult, often gruelling job, both physically and emotionally. It pays very little. Care workers often have to be able to run their own car and find their own way around. They have to like older people—the patients. That is a hard thing to do, particularly if they are caring for a parent or have other caring responsibilities. It is a lot for anyone to take on. It is no wonder that the turnover of care workers is running at nearly four in 10 every year.
Funding cuts are now having a detrimental impact on care quality as well. One in five adult social care services received the poorest overall ratings from the Care Quality Commission and almost one quarter of services had the poorest ratings for safety. Some 22% required improvement and 2% were deemed inadequate. The Government, however, do not seem to be seeking to tackle those problems of quality. Skills for Care, the skills organisation for care services, has a budget of only £21 million, or £14 per care worker, whereas Health Education England has a budget of £4.6 billion. The National Audit Office criticised the Government for failing to have an up-to-date workforce strategy for the care sector—the last work- force strategy was produced in 2009, under a Labour Government.
Last November, the Competition and Markets Authority did a study of care homes, which stated that, in general, care homes are struggling. Local authority-funded homes, which are now very much in the minority, cover their operating costs but not their total costs. That suggests that while those care homes may be able to operate in the short term, they may not be able to undertake future investment to update their existing capacity, prevent closure or increase their capacity for local authority-funded residents. The Salvation Army runs excellent not-for-profit care homes, including one in my constituency. When I visited the home over the Easter recess, the increasing gap between the rate paid by the local authority and the amount it costs to run a care home was highlighted to me.
All those cuts impact on the NHS and then the NHS cuts, as part of a vicious spiral, impact back on social care. As I have said, our own north Derbyshire clinical commissioning group is £24 million in the red, a huge sum for a relatively small CCG. It has been taken into special measures by NHS England and cuts are being imposed. Our specialist dementia care assessment unit has closed. The support that went to the families and patients who went into that ward on an ongoing basis is no longer there. The staff who were at threat of redundancy had a huge number of skills in adult mental care, mental health service care and specialist dementia care. The respite beds on that ward have also closed. One patient with early-onset dementia was managing at home, with one week in six of respite for his wife, but he now needs full-time nursing care, as his wife cannot cope at home without that week of respite.
Rehabilitation beds are no longer a halfway-house option, because they are being closed as well. Even worse, patients are being sent home from acute care without a care package in place. Many end up with infections or have a downturn in their condition and end up back in hospital unable to cope. It becomes a spiral that impacts on family carers at home.
Carers are struggling. They do an incredible job. The Carers Trust estimates that there are 5.5 million unpaid carers in England and 2,300 in High Peak alone. People do not often meet carers who are caring for someone with a long-term condition, because they are isolated. When I visit the GP surgery or the hospital with my family, I can sit down and talk to some of the carers about the isolation that they experience and how difficult it is because they cannot stop, because they love the person they are caring for and feel that they have no other option.
Some 61% of carers report having a long-term health condition. They are more likely to report problems with depression, pain and mobility, but they do not attend their own health appointments. The Carers Trust found that 57% had cancelled or postponed a health appointment because their caring role took precedent over their own health. It is no wonder that 81% of older carers surveyed said they felt lonely and isolated.
The Government are looking to do more work on carers, and have commissioned studies such as the 2014 Department of Health impact assessment, which estimated that spending an extra £300 million on carers in England would save councils £430 million in replacement care costs and would result in “monetised health benefits” of £2.3 billion. Each £1 spent on supporting carers would save councils nearly £1.50 in replacement care costs and benefit the wider health system by nearly £8. However, the money to put into those services and to make that sort of investment is not there, because the NHS, social care and local authorities are firefighting. Of course, the greatest impact is on the patients who do not receive the care they need and are left isolated, confused and sometimes in pain.
The MS Society says that one in three people living with multiple sclerosis do not get the support they need with essential everyday activities such as washing, dressing and eating. That has an adverse impact on their physical and mental health, resulting in a greater reliance and increased pressure on the NHS, which already faces significant financial and demographic strain. I hope hon. Members can see that it adds up to a vicious circle of lack of investment and funding and constant cuts. People who provide services are trying to do their best with what they have, but constant cuts in one area are offset by the other; cuts in social care lead to an increased reliance on the NHS, while cuts in NHS services lead to huge extra costs for long-term care in nursing homes or by carers.
I am pleased that the Government have combined health and social care into a single responsible Department, but until councils and the NHS are not simply trying to drive down costs to meet their savings targets by offsetting against each other, and until we have combined budgets at a local level, the vicious circle will not end, and the problems for patients and their carers, and the strain on the health service as a whole, will not end either. I hope the Government will listen and take action.
I am pleased to be able to speak in the debate. For obvious reasons, I will not do a traditional summing-up, because I could not sum up the contribution of the hon. Member for High Peak (Ruth George) anything like as eloquently as she delivered it. I am pleased that she made it to Westminster Hall, and I thoroughly commend the decision to use discretion to allow the debate to go ahead. It would have been sad if the important points that she has made had not been heard. It is unfortunate that a number of circumstances mean that very few people are here, and that the debate will probably get very little publicity, because she has raised an issue of significant concern to a great many people throughout the United Kingdom.
Social care and health are wholly devolved to the Scottish Parliament, so it is not my place to tell or suggest to the Government what they should do, but I will make some comments about what is happening and what appears to work in Scotland in the hope that the Westminster Government will consider it. I do not do that by way of the “We’re good and you’re bad” kind of politicking that we see too much of, but as an attempt, in goodwill and good faith, to allow our experiences north of the border to help address the situation down here. The hon. Lady has raised issues that apply in all four countries of the UK and, I suspect, in a lot of other countries as well.
When I was a wee boy, my granny was an old lady. She hardly ever went out, but occasionally she managed to walk up to the wee shop to get some shopping. She was a very devout Catholic, and when she was fit, she would walk the half mile or so to the local church to attend mass. That was about it. She would be picked up and taken out to family events and then taken back home again. At that time, my granny was five years older than I am now. She was younger than a significant number of Members of Parliament—nobody in this debate, obviously, is over 60.
That is an illustration of how much the world has changed for the better. When people get to be 60, particularly women who are widowed, as my granny and far too many women were at that age in the old days, they are no longer expected just to sit at home and wait to die, or drink tea and watch the television. People of all ages expect to be allowed to lead a full and fulfilling life. People with significant medical conditions and disabilities are entitled to expect the same. As a society, it is incumbent on us to help them achieve that. To do that, we have to accept that there will be consequences; that sort of quality of care does not come cheap.
It is sad that when we debate healthcare or social care in almost any form anywhere in the United Kingdom, it can far too quickly turn into the usual Punch and Judy politics. Often we do not have the chance to have an open and honest debate about what changes are needed to make the system fit for purpose in the 21st century, and what the consequences are in relation to how much we are prepared to pay for it.
Positive changes in medical technology mean that people who would have been lucky to live to five years old some 40 or 50 years ago now live to 80. That is a great success story, but it also creates challenges. For example, a lot of adults with Down’s syndrome will outlive their parents. We cannot expect mum and dad to be lifetime carers, because they will not always be there. The fact that so many people are living so much longer is a great success story, but we have a responsibility to accept the consequences of that success.
There has been a lot of progress. In 1998 I started working with the then Fife health board. Fife has a population of about 350,000 people. At any time, about 1,000 of those people would be in-patients in a psychiatric hospital or in a hospital for people with learning disabilities. Today, rather than being in four figures, sometimes that number does not even get to two figures—it is usually in the tens and occasionally it is down to single figures. There has not been a reduction in the number of people with those significant mental health or mental disability problems—if anything, there has been an increase—but they are looked after in a much more appropriate way. They are looked after as human beings at home, or in an environment that feels as close to being a home as possible, rather than in a massive institution with hundreds of in-patient beds.
That is overwhelmingly what elderly people and people with long-term illnesses, and their families, tell us they want. That should be the gold standard. We should aim to fund and support services—whether we call them social care or healthcare services does not matter—that allow people to live in their own home, beside their own family and friends, for as long as possible. A critical factor in succeeding in that aim must be breaking down the boundaries that we have artificially created between different services. The hon. Member for High Peak rightly pointed out that if any one part of the system starts to come under pressure, that very quickly has a knock-on effect elsewhere.
In Fife there have been some quite surprising, and surprisingly wide, cultural differences between the council and the health board, which we have had to work on to ensure that the approach to looking after people and doing the job, rather than worrying about bureaucracy, was consistent. That means that there has to be an absolute, publicly stated and oft-repeated commitment from leaders at the very highest levels in our services, whether they are political, managerial or clinical, that the person receiving the service is the person who matters most. We should be prepared to change our organisations, to change the way we work and to change the way we ask our services to work, so that they suit the patients, rather than expecting patients to squeeze into the artificially narrow boxes we sometimes try to create for them.
The model used in Scotland has been known as local health and social care partnerships, which give a direct voice not only to the statutory agencies, but to voluntary third sector organisations and commercial providers, because they have a part to play, however uncomfortable some of us might feel about that. The model also gives a voice to staff organisations and staff representatives in trade unions, and to representatives of patient groups, who are the people who know best what does and does not work. That is done so that decisions are taken in the round and solutions can be found regardless of whether a service will be provided by the council, the health board or somebody else. What matters is that the service is provided and that we never forget who the service is being provided for.
Although today’s debate is entitled, “Social Care Provision and the NHS”, that could equally well have been turned the other way round, because if there is a problem in health service provision, social services and the local council will come under pressure very quickly as well. That could be extended further, because one of the reasons why social services are under so much pressure is that a lot of the unofficial support services are under pressure now. A lot of people are isolated from their families, as family members can live a long way apart. Local services, such as libraries, are also closed, so that old folk do not have a library to go to one or two days a week, just to have a chat, whether or not they borrow a book. Post offices are also closing; people are being expected to do things anonymously online instead of having a wee chat with someone down at the post office. Our dear and much-lamented friend, Jo Cox, was very keen to emphasise the scourge of loneliness in our society. I think that loneliness, in all its forms, is creating a lot of the pressures on the public services that we are talking about today.
Those services face enormous challenges in all our nations, but if we still really believe in providing a good standard of living for all our people—a standard that I am fortunate enough to enjoy and that I would always expect—we must be prepared to make hard choices. And people like me, who are on well above average earnings, must be prepared to pay a wee bit more in order to achieve that good standard for all. In Scotland, for example, for a number of years we have had a guarantee of free personal and nursing care for any elderly person who needs it. From 2019 that guarantee will also apply to younger people with long-term and serious disabilities. That change is known as Frank’s law, after Frank Kopel, a former professional footballer with Dundee United, whose case became the focus of a long and successful campaign in Scotland.
We need to be honest and admit that these things do not come for free. Demographic changes mean that even if we think we are increasing spending above inflation, we might not be doing enough to keep up with an increase in the number of people who need such support and, very often, an increase in the complexity of that support. However, almost every time we talk about social care or healthcare services, whether in this Parliament, the Scottish Parliament or council chambers, it turns into a Punch and Judy show. That happens far too often, and it is just not what people need. Whether it happens here or in council chambers the length and breadth of the land, opposition parties and politicians will always quote stories of things that have gone wrong, as well as the official statistics, and it is surprising how often the official things we measure in the health service are measurements of failure. Why do we not measure success instead of failure?
Opposition parties will come out with the stories to prove that things are going badly; Governments and council administrations will cite numbers to prove that they are spending lots of money on a problem; and all too often nobody actually talks about whether the services—the care that we are providing—are of good quality or not, and nobody talks about the difference that we are making and should be making to people’s lives. That kind of debate is happening, often in less high-profile and less public forums than this one, such as think-tanks or universities. Sometimes councils and health boards have discussions that are not particularly open to the public, to try to tease out these problems.
We need to be prepared to have an open debate about our individual and collective political philosophy. For example, how do we establish the balance between universal provision and means-testing? What standard of care and support do we think every single citizen of these islands is entitled to receive? What quality of life, or what compromises or reductions in quality of life, do we think it is acceptable to impose on somebody simply because of a disability or long-term illness? If the answer is, “We’re not prepared to accept imposing any reduction in quality of life,” then we, as Members of one of the Parliaments of these islands, have got to find ways of ensuring that there is no reduction.
If Members want to see how not to have a debate about the difficulties that our health and social care services are facing, they should look at Prime Minister’s questions yesterday. Frankly, I thought it was appalling that, although very serious issues were being raised, on one side it was all about how bad things were and how many failures there have been, and on the other side it was all about how much money is being spent, and nobody seemed to be talking about what we need to do to sort these issues out.
I enjoy a good political barney as much as anybody. With this subject, however, and possibly more than with any other subject, we need to stop being politicians and remember that we are human beings and we are here to represent human beings. The people who rely on these services, whether they are provided by councils, health boards or anybody else, are entitled not only to get the services they deserve, but to hear an open and honest debate. That will not necessarily come up with all the correct answers, but at least people will know that we have the courage to face up to some difficult questions.
I look forward to the House having the opportunity to have such a debate in the near future, and I sincerely hope that all 650 Members in the House will take that opportunity and have the kind of debate that the public need, rather than the kind of debate that all too often politicians like to deliver for them.
Thank you, Dame Cheryl, for calling me to speak; it is an honour to serve while you are in the Chair.
I, too, am glad that we are actually having this debate, now that we have all got here, and I congratulate my hon. Friend the Member for High Peak (Ruth George) on securing this important debate and on the way that she opened it. It is never easy for someone if they are rushing in at the last minute, because they were delayed by something outside their control. Nevertheless, what we heard from her was a comprehensive review of the issues in social care in her constituency, which I found very useful.
In addition, I thank the hon. Member for Glenrothes (Peter Grant), who is the Scottish National party spokesperson, for a thoughtful contribution. Broadly, I do not disagree with him, but part of the difficulty for Opposition parties is that we have some very substantial disagreements about spending priorities, which is what we end up talking about quite a lot.
Before discussing the effect of social care on NHS provision, which is the topic of our debate today, I pay tribute to both our hardworking NHS staff and the 1.4 million dedicated staff working in care, many of whom —as we heard in my hon. Friend’s contribution—are on low pay, undervalued and overworked. I keep that point in front of me, because it is a very important aspect of social care.
Nurses Day is on 12 May and I pay tribute to the outstanding patient care that nurses give, in the diverse roles that nurses have in healthcare teams, ranging from acute care, which is clearly very important to patients, to Marie Curie nurses in palliative care—there are not enough of them—and to Admiral nurses in dementia care, who are very important too.
Today’s debate is an important opportunity to discuss the interaction between social care and services provided by the NHS, but it is always important to keep in mind the positive role that social care plays in the lives of older people and younger people with care needs, because it helps them to live independent lives. The Secretary of State recently told a conference of social workers:
“We need to do better on social care.”
I agree with him, but the Government have had eight years to do better on social care and yet things have got worse. My hon. Friend rightly pointed to the eight years of cuts to council budgets, which have meant that more than £6 billion has been taken from social care budgets since 2010. That is a serious factor.
My hon. Friend talked about how Government cuts to local authority funding have had an impact on social care services in Derbyshire. I understand that there has been a 40% budget cut already, with further cuts happening this year. She also outlined how the clinical commissioning group, which is an important body in the work on integration and commissioning, is now in special measures because it is in the red. In whatever spirit we are approaching this debate, we have to take it on board that cuts have consequences. As we have heard, cuts to social care budgets have consequences for the NHS. For example, they tie up ambulance paramedics when they could be getting to stroke patients—patients they need to get to. Cuts have consequences for the quality of care and the burden that falls on family carers. I will refer to each of those issues.
We have heard about the diminishing care fees that councils are able to pay in light of cuts. That has further destabilised a care sector that, we have to face it, has been described as “perilously fragile”. The Association of Directors of Adult Social Services reported last year that two thirds of councils had seen care providers close in their areas, and that care providers handed contracts back to more than 50 councils. The Competition and Markets Authority has warned that many care homes could find themselves forced to close or to move away from local authority-funded care. As my hon. Friend said, local authority funding is only just covering day-to-day running costs. Just this week in Trafford, care provider Ampersand Care has closed two homes, blaming chronic underfunding of care for older people. It claims that it cannot provide safe care at the rates offered by Trafford Council. Those closures will see 78 residents face the upheaval of moving from their current home. The reality of our unstable care market is that such instances are becoming commonplace. In fact, just a few weeks ago the same care provider closed a care home in Swinton in Salford, which is my local authority. Now that care provider has only one care home left in the country.
There is a growing funding gap in social care that must be filled. We would not be suffering quite so badly from these issues if we addressed that. The Local Government Association has estimated that our social care system needs an immediate injection of £1.3 billion to fill the gap, and the King’s Fund reports that that will rise to £2.5 billion by 2020. What Members said about the different views people have was interesting. Cuts to social care have led to what the Secretary of State recently described as “unacceptable variation” in the quality of services. We will never address the future funding of social care while we have a quality problem. If we are expecting people to pay more, why should they pay more for services that are not good quality?
As my hon. Friend the Member for High Peak said, one in five care facilities receives the lowest quality rating from the Care Quality Commission. My party’s research revealed that more than 3,000 care facilities with the lowest quality ratings continue to receive the lowest ratings, even after being re-inspected by the CQC. The care facilities find themselves unable to get out of that situation. Cuts mean that providers have less money to pay staff and to invest in training or building renovations, and that can lead to what we are seeing now. Facilities are getting trapped in a cycle of poor quality care provision.
Care staff, who so often are underpaid, undervalued and overworked, are under intense pressure as a result of cuts. My hon. Friend spoke about the challenges with social care in her own constituency, much of which is rural. Many of the problems she described relate to staffing, and they are not isolated examples. Rural England’s 2017 report, “Issues Facing Providers of Social Care at Home to Older Rural Residents” discusses the challenges facing social care provision at home for people in rural communities. Rural populations are typically older. There is a lack of specialist housing for older people and housing stock is older, which may mean it is difficult to heat. Those challenges are compounded by difficulties in recruitment and retention, as we have heard today. Home care staff are typically being employed on zero-hours contracts and receiving payment for actual contact time only and not for travel time. That is true in London and Salford, but in rural areas, where the distances are much greater, that lack of paid-for travel time is a different issue. It could make the difference between people being prepared to work in care or not.
In addition, rural social care has to contend with such factors as a small pool of potential employees, competition from other employment sectors and a mismatch between the locations of care staff and those of people who need care. My hon. Friend gave an important example of one town where 19 people are waiting for a care package. Other national trends affecting the care sector also affect rural areas. They include: low pay, few career opportunities or chances to gain skills, and the increasingly complex needs of people in need of care.
People who need care in rural communities need the Government to think ahead and monitor emerging trends properly to ensure that there is proper coverage in their areas. Worryingly for the future of provision in these areas, Rural England’s report
“found scant regard to rural proofing”
in the sustainability and transformation plans that it had seen. Moreover, it said that:
“published statistics seldom provide, or...facilitate, any rural analysis.”
That needs to be rectified if rural social care needs are to be more than just an afterthought.
We have heard that a lack of good-quality care places an additional burden of caring on unpaid carers. Older rural residents are more likely to provide some form of care to one another—24% of people in rural areas do that, as compared with 18% in urban areas. The issues for carers are more marked in rural areas. I have worked on carer issues since 2002, when I worked as an adviser to the then Princess Royal Trust for Carers, which is now the Carers Trust. That work included the then largest ever national survey of carers to assess the impact of the Labour Government’s carers strategy, which was published in 1999, on carers’ lives. I researched and published three reports on the needs of carers. I wanted to highlight that work from before I was elected to underline how important a national carers strategy is to carers.
I want to raise with the Care Minister how carers have been treated by the Government in recent months with the abandonment of the promised carers strategy. Their needs are being subsumed into the Green Paper on social care for older people, and I want to highlight how one carer feels about that. Katy Styles is a carer and a campaigner for the Motor Neurone Disease Association. She contributed to the Government’s consultation on the national carers strategy because she hoped that her voice would be heard, alongside the 6,500 other carers who also contributed their views. She told me:
“Not publishing the National Carers Strategy has made me extremely angry. It sends a message that carers’ lives are unimportant. It sends a message that Government thinks we can carry on as we are. It sends a message that my own time is of little worth.”
Katy Styles started an e-petition on the issue. It is e-petition No. 209717, which is titled:
“Government must publish a Carers’ Strategy and not a Carers’ Action Plan”.
She sent me this message yesterday:
“Whilst unpaid carers save the UK economy an estimated £60 billion annually, this government fails to value our contribution.
As unpaid carers struggle financially, government fails to give them a reasonable allowance. Whilst unpaid carers spent precious time informing a Strategy, that time and effort was wasted as that Carers Strategy was apparently scrapped. That’s how much carers’ lives matter.
A national strategy would set the tone on how society should value and support carers. Without a strategy, carers have no hope of being valued and supported.”
I support Katy Styles and her campaign. She and other carers do not have much time to spare, and when they do respond to a Government consultation, their input should not be abandoned. As I mentioned last week in our Opposition day debate, this Government have launched more than 1,600 consultations since 2015. More than 500 of those consultations have not yet been completed, and it is sad to note that that includes the carers strategy.
Thinking of ourselves as a group of politicians, we have to be careful that we do not over-consult people. We cannot throw out consultations and reviews as things for people to respond to and then not care whether they get any review of their input or not do anything with what they say. The day that people feel it is not worth putting their time into consultations will be a serious point for us as politicians. It is important that people believe that their input is valued and that we take what they say into account.
I have only been a remote carer, but I feel that I have worked enough with carers to understand their issues. We should take what they say seriously. I hope the Minister can say more than what she has said in the past, which is that a carers action plan will be published shortly. Can she tell carers such as Katy Styles why the planned carers strategy was abandoned?
The funding crisis in social care also has an impact on the growing number of people who are in need of care, but get no care at all, as the hon. Member for Glenrothes mentioned. We know that more than 1.2 million people, many of them isolated and lonely, are now living with unmet care needs. Recent research has recognised that living in rural areas may exacerbate the social isolation of older residents, and of course that goes for their carers too. As the King’s Fund has stated:
“Access to care depends increasingly on what people can afford—and where they live—rather than on what they need.”
The impact of the lack of social care on NHS provision is most regularly seen in the context of delayed transfers of care—my hon. Friend the Member for High Peak talked about the situation in Derbyshire. Although the figures for delayed transfers of care attributable to lack of social care have dropped in recent months, they reached record highs under this Government, causing thousands of people to be stuck in hospital while waiting for arrangements to be made for their care at home, or for a place in a care home. The latest figures, from this February, remained stubbornly high relative to the same period in 2015 or 2011.
It is also open to question whether people are getting the care they need in the community when they are discharged from hospital, a point I raised in last week’s debate. A recent report from the British Red Cross showed that older people could become stuck in a vicious cycle of readmission to hospital because of a lack of adequate care in the community. Reductions in delayed transfers of care will mean very little if there is insufficient social care to support people when they are discharged.
As my hon. Friend said in her speech, a lack of suitable care at home for patients needing palliative care means that people have to remain in hospital to the end of their life, sometimes with heartbreaking consequences. I was glad to hear that at least one person managed to get his wife home for those last few days, because that is very important. However, if many other family members cannot reach the hospital to visit, that is very serious.
The 2015 national survey of bereaved people by the Office for National Statistics found that, while only 3% of those who stated a preference wanted to die in hospital, nearly half of the 470,000 people who died in 2014—some 220,000 people—died in hospital. A 2016 report from Marie Curie found that hospital admissions at that point were unsustainable, and too many people who were approaching death spent long periods in hospital due to a lack of alternative social care support.
I hope the Minister will address that point, and perhaps shed some light on what is being done to reduce the number of people who are denied a choice at the end of their life, in line with the Government’s response to the choice review, which said that the Government
“will put in place measures to improve care quality for all”
“will lead on end of life care nationally and provide support for local leadership, including commissioners, to prioritise and improve end of life care”.
From the examples that we heard from my hon. Friend, it sounds as if there remains some way to go on that in Derbyshire.
The social care system now badly needs sustainable funding from central Government, both for the future of the NHS and for the many people who now rely on social care. I remind those few hon. Members who are here that, at the 2017 election, Labour pledged an extra £8 billion for social care across this Parliament, with an extra £1 billion to ease the crisis in social care this year. It is important to keep looking at that figure, because that would have been enough to begin paying care staff the real living wage. It would have helped to ease the recruitment crisis that my hon. Friend has talked about in her area of High Peak, and would have enabled more publicly funded care packages for people with different levels of need. Most importantly, it would have allowed us to offer free end-of-life care to all those who needed it.
I believe we need urgent action to avert the care crisis, and the time to act is now, both for the sustainability of the NHS, which as we have heard is really being affected by shortages of social care, but most importantly for the people who depend on care to live independent, fulfilled lives.
It is a great pleasure to serve under your stewardship, Dame Cheryl. I thank the hon. Member for High Peak (Ruth George) for securing the debate and setting out the issues so articulately. I congratulate her on making it to the debate, and I thank you, Dame Cheryl, for allowing it to take place. It would have been a great concern to us all if that had not happened.
As hon. Members will know, I am relatively new to my role as the Minister for Care in the Department of Health and Social Care. That is why I am really grateful for the chance to focus on the interface between social care and health, and to outline how integration is absolutely at the heart of what we do. The renaming of the Department of Health as the Department of Health and Social Care must be more than just a change of title; it must provide a sense of direction and a change of culture. We know that health and social care are umbilically linked, and that one is a key driver of the other.
We recognise that many of our challenges stem from the very good news that people are living longer, which is to be celebrated. Worldwide, the population aged 60 or above is growing faster than all other age groups. In developed countries the proportion of the population aged 65 and above is expected to rise by 10% over the next 40 years. That means that, in England, by 2026 the population aged 75 and above, which currently stands at 4.5 million, will rise by 1.5 million. By 2041 it will have nearly doubled.
People’s expectations and wishes are also changing. The traditional model of social care is based on care homes, but we know that increasingly people want care to be delivered in their own homes. We want to encourage people to live independently and healthily in their homes, where many people want to stay. We know that nine in 10 older people live in mainstream housing, and that only 500,000 of those homes are specifically designed for their needs. Adapting homes to make them more suitable is therefore incredibly important. The disabled facilities grant has a vital role to play. Home adaptations and investment can be incredibly effective. Not only do such adaptations allow people to lead independent healthy lives, but our analysis shows that for every £1 spent, more than £3 is recouped, mostly through savings to the health and care system. Housing that enables people to live independently and safely allows us to reduce the number of people who need to go into hospital or have other social care requirements.
We have to look at the way we provide and fund services for the long term. Complex conditions must be addressed, and we must move to a system in which care, whether social care or health care, is individually tailored to people’s needs. The hon. Member for Glenrothes (Peter Grant) put it beautifully when he talked about how we need to stop using social care and our health service as a political football. We need to champion where there is good practice, not just talk about where it is bad. We need to look at how we can produce much more person-centred care, where we address an individual’s needs. We need to celebrate the amazing places up and down our country where it is going right, and we need to support the incredible workforce in this country—both the informal workforce, and the dedicated hospital and social care workforce. A number of pieces of work are ongoing. As the hon. Gentleman said, we need to have the courage to tackle the difficult questions, and that is what is happening.
A number of key pieces of work are happening at the moment to address many of the issues that the hon. Member for High Peak raised. Many of those issues will be tackled in the forthcoming Green Paper. We have an ongoing workforce strategy that is taking place jointly between Health Education England and Skills for Care. In order to address the challenges of our ageing population, we need to attract more people into the workforce. We need to ensure that they are properly rewarded for their work, that there is continuous development within that work, and that we attract people from a much more diverse range of backgrounds.
As the hon. Member for Worsley and Eccles South (Barbara Keeley) said, we also have a carers action plan, which is to be published shortly. She spoke about her constituent, Katy Styles.
I am grateful to the hon. Lady for clarifying that. I would say to Katy Styles that the decision about whether it is called a strategy or an action plan was taken before I was in my role, but an action plan sounds to me like a much more positive thing.
Actions speak louder than words. We are talking about not just a sense of direction, but what we are doing and how we intend to do it. That is why the carers action plan will be a really important piece of work. I massively value the work of carers up and down the country—indeed, my mother was one—and I want to ensure that we properly recognise and reward what they do. We must be doing what we can, and not just through the Department of Health and Social Care but in collaboration with colleagues across Government, to help and support carers and ensure that the issues they face on a daily basis are tackled.
It is worth clarifying this point while the Minister is talking about the action plan. I told her that I did that piece of work years ago on the first national carers strategy, which came out in 1999 and went right across Government. The difference I see is that that was signed by many Departments, with commitment from those Secretaries of State, but the action plans under the coalition, and those we have seen recently, are just signed by Social Care Ministers; they are very much smaller things. Departmental action plans are not the same as cross-Government national strategies, and I understand why carers feel that strongly.
The hon. Lady has a surprise coming—this action plan is signed by Ministers from across Government.
The hon. Member for High Peak raised cost pressures. We can all admit that local authority budgets have faced pressures in recent years. They account for about a quarter of public spending, so they have had a part to play in dealing with the historic deficit that we all know we inherited in 2010. That means that social care funding was inevitably impacted during the previous Parliaments. However, with the deficit now under control, we have turned a corner.
Thanks to a range of actions taken since 2015, the Government have given councils access to up to £9.4 billion of more dedicated funding for social care from 2017-18 to 2019-20. Local authorities are therefore now estimated to receive about an 8% real-terms increase in access to social care funding over the spending review. In Derbyshire, the hon. Lady’s local council has seen an increase of £33 million in adult social care funding from 2017-18 to £201.8 million, which is above the 8% figure—it is a 10.3% increase on the previous year. The Care Act 2014 places obligations on local authorities and the extra funding is designed to help them meet those obligations.
I did not want to turn the debate into a political tit-for-tat, but I do not want my constituents in Derbyshire to think that suddenly there is a £33 million increase and everything is rosy for social care. The council has seen its funding cut by £157 million over the past seven years. Unfortunately, that increase is a drop in the ocean. In particular, the rise in the cost of the living wage impacts on care costs. What the council is getting back is nothing like what it has lost.
I have already recognised the fact that all local authorities have had to make some really tough decisions. We know it has been difficult for everybody. Taking that action to control the deficit and get the country’s finances under control has meant that we have turned a corner and we are now beginning to put that funding back in. I do not think we can deny that there were years that were very difficult for all local authorities. There is dedicated funding in adult social care; the funding goes to a specific cause, which is really important, and allows local authorities to support and sustain a more diverse care market. It also goes on to help relieve pressure on the NHS, including by supporting more people to be discharged from hospital as soon as they are ready.
The money is already beginning to have an impact. Delays of transfers out of hospital due to adult social care hold-ups have reduced by more than a third over the past 12 months, freeing up 820 beds. A key tool in developing more and better out-of-hospital services is the better care fund, which is a mandatory, national programme for integrating health and social care. It joins up services so that they are designed around people’s needs, enabling them to manage their own wellbeing and to live as independently as possible. By mandating the pool of funds, the better care fund has helped to join up health and care services and incentivise local areas to work better together with increasing amounts of funds being used in that process. Some 90% of local leaders have reported that the better care fund has helped them to progress integration in their areas.
We know that the burden of care cannot and should not continue to fall simply on hospitals. We need to move care into the home and into the community. There are great examples of how that is working in practice up and down the country. Public Health England, the Chief Fire Officers Association, the Local Government Association, NHS England and Age UK already have a joint working approach to establish how local fire and rescue services, for example, can be commissioned to check on people in their homes, to check on the safety of people’s homes, and to check on things such as trip hazards—all things that can lead to people being admitted to hospital or needing the support of social care services. They work together to encourage joint working around intelligence-led early intervention and, in doing so, reduce preventable hospital admissions.
Evidence has indicated that longer hospital stays for older patients can lead to worse health outcomes and an increase in their care needs on discharge. We know that for a healthy older adult, 10 days of bed rest leads to a 14% reduction in leg and hip muscle strength and a 12% reduction in aerobic capacity, which is the equivalent of 10 years of their life, which is a massive incentive to make sure we get people back into their own homes and active as quickly as possible, in the interests of their own wellbeing.
I am particularly interested in understanding how intermediate care—step-up and step-down services—can reduce the impact of health crises on individuals. A relatively minor infection or a temporary worsening of a chronic condition should never spiral into a prolonged hospital stay with a detrimental impact on long-term quality of life. The real goal of integrating health and social care is not simply a benefit to the system, but an emphasis on person-centred care. We need multi-disciplinary teams working around a person to maximise the effectiveness of interventions, and therefore minimise disruption to the individual.
The hospital to home programme brings together practitioners across health and social care to develop solutions for more patient-centred care, focusing on how to keep people at home. It shows how urgent and emergency care services, community services, primary care and social care can all work together to make sure that people get the right care at the right time and, crucially, in the right place. That partnership goes through everything that local partners do, whether providing interlocking services or commissioning the right pattern of services.
How can we push forward these aims and create a sustainable settlement for social care? In March, the Secretary of State for Health and Social Care outlined seven principles for the Green Paper on care and support and for adult social care reform, and he put a key focus on the need to integrate services around the individual for a seamless, whole-person approach to both health and care. We have committed to publishing the Green Paper by the summer, and when it is published there will of course be a full public consultation, through which we want to seek the broadest possible range of views. I look forward to the contributions of Members under that national discussion.
I will not take up that much of hon. Members’ time, but I will thank Members who have contributed to the discussion. I am pleased to have had the opportunity to have this discussion today—thank you, Dame Cheryl, for allowing me to do so. I hope it opens the door to looking more broadly at the impact of health and social care services on one another, and on patients and their carers.
I am most grateful to the Clerk for his advice in Westminster Hall today. I am very glad that we were able to have the debate.
Question put and agreed to.
That this House has considered the effect of social care provision on the NHS.