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NHS Winter Pressures

Volume 826: debated on Tuesday 10 January 2023


The following Statement was made in the House of Commons on Monday 9 January.

“Mr Speaker, I wish to take this first opportunity to update the House on the severe pressures faced by the NHS since the House last met. I and the Government regret that the experience for some patients and staff in emergency care has not been acceptable in recent weeks. I am sure that the whole House will join me in thanking staff in the NHS and social care who have worked tirelessly throughout this intense period, including clinicians in this House who have worked on wards over Christmas. They include my honourable friend the Member for Lewes, the Minister for Mental Health, and the honourable Member for Tooting, the shadow Minister for Mental Health.

There is no question but that it has been an extraordinarily difficult time for everyone in health and care. Flu has made this winter particularly tough: first, because we are facing the worst flu season for 10 years—the number of people in hospital with flu this time last year was 50; this year, it is over 5,100. Secondly, it came early and quickly, increasing sevenfold between November and December. It also came when GPs and primary and community care were at their most constrained. When flu affects the population, it affects the workforce too, leading to staff sickness absence that constrains supply just as it also increases demand.

These flu pressures came on top of Covid. Over 9,000 people are in hospitals with Covid, while exceptional levels of scarlet fever activity and an increase in strep A have created further pressure on A&E. All that comes on top of a historically high starting point. We did not have a quiet summer, with significant levels of Covid, and delayed discharges were more than double what they were during the pandemic. I put that in context for the House: in June 2020, there were just 6,000 cases per day of delayed discharge—patients medically fit and ready to leave hospital—whereas throughout last year the figure was between 12,000 and 13,000 per day. The scale, speed and timing of our flu season have combined with ongoing high levels of Covid admissions in hospital and the pandemic legacy of high delayed discharge to put real strain on front-line services.

Since the NHS began preparing for this winter, there was a recognition that this year had the potential to be the hardest ever. That is why there was a specific focus on vaccination. There were 9 million flu shots and 17 million autumn Covid boosters. We extended eligibility more widely than in the past, to cover the over-50s, and became the first place in the world to have the bivalent Covid vaccine, which tackles both the omicron and the original Covid strain.

NHS England also put in place plans for the equivalent of 7,000 additional beds, including the introduction of virtual wards of a sort that one can see at Watford General Hospital. That innovation is still at an early stage of development, but has the potential to be significant in reducing pressure on bed occupancy in hospitals; in Watford alone, it has saved the equivalent of an extra hospital ward of patients. In addition, our plan for patients put £500 million specifically into delayed discharge, with a further £600 million next year and £1 billion the year after. Although the funds are already starting to make a difference, efforts have taken time to ramp up operationally with local authorities and the local NHS.

In addition, our 42 integrated care boards, recognising how bed occupancy in hospitals and social care are connected, will fully integrate health and care in the years to come. But likewise, they are at an early stage of maturity, with ICBs having become fully operationalised only in July 2022, less than six months ago.

Our plans involving the integration of hospital care and social care, additional funding for discharge, increased step-down capacity, the equivalent of 7,000 additional hospital beds and a vaccination programme at scale have provided the groundwork for the government response, but it is clear we need to do more right now in light of the level of flu and Covid rates and given that hospital occupancy remains far too high and emergency departments are too congested. Recognising that, we launched the elective recovery taskforce on 7 December, and in the coming weeks, we will publish our urgent and emergency care recovery plans. NHS England and the Department of Health and Social Care have been working intensively over Christmas on these plans, which were reviewed with health and care leaders at an NHS recovery forum in Downing Street on Saturday.

The recovery falls into three main areas of work: first, steps to support the system now, given the immediate pressures we face this winter; secondly, steps to support a whole-of-system response this year to give better resilience during the summer and autumn—as we have seen with the heatwave this summer and with the levels of Covid, pressure is now sustained throughout the year, not just, as in the past, during autumn and winter—and, thirdly, our work alongside those two areas on prevention, on maximising the step change potential of proven technologies, such as virtual wards, and on the wider adoption of innovations such as operational control centres and machine reading software to treat more conditions in the community, away from someone reaching an emergency department in the first place.

Let me first set out the measures I can announce today to provide support to the NHS and local authorities now. First, we will block-book beds in residential homes to enable some 2,500 people to be released from hospitals when they are medically fit to be discharged. When that is combined with the ramping up of the £500 million discharge funding, which will unblock an estimated 1,000 to 2,000 delayed discharge cases, capacity on wards will be freed up, which will in turn enable patients admitted by emergency departments to move to wards, which in turn unblocks ambulance delays. It is important, however, that we learn from the deployment of a similar approach during the pandemic by ensuring that the right wraparound care is provided for patients released to residential care. I have asked NHS England to particularly focus on that, so that it is the shortest possible stay on patients’ journey home and into domiciliary care, and indeed it is in the NHS’s own interests for those stays to be as short as possible. Taken together, this is a £200 million investment over the next three months.

Next, our A&Es are also under particular strain. From my visits across the country I have seen and heard how they often need more space to enable same- day emergency care and short stays post emergency care. Our second investment is in more physical capacity in and around emergency departments. By using modular units, this capacity will be available in weeks, not months, and our £50 million investment will focus on modular support this year. We will apply funding from next year’s allocation to significantly expand the programme ahead of the summer. We are giving trusts discretion on how best to use these units to decompress their emergency departments. It might be for spaces for short stays post A&E care, where there is no need for a patient to go to a ward for further observation, or for discharge lounges that previously have not been able to take patients in a bed—many of those are often simply chairs—or for additional capacity alongside the emergency department at the front end of the hospital.

The third action we are taking to support the system right now is to free up front-line staff from being diverted by Care Quality Commission inspections over the coming weeks, and the CQC has agreed to reduce inspections and to focus on high-risk providers in other settings, such as mental health. Those are the actions we are taking that will have an immediate effect.

I turn to the measures we are taking now that will give greater resilience into the summer and next winter. We now have 42 NHS system control centres in operation across England, staffed 24 hours a day, seven days a week, tracking patients on their journey through hospitals, helping us to identify blockages earlier and getting flow through the system. Where we have implemented these systems, such as the one I saw in operation in Maidstone, they have had a clear impact. We will therefore allocate funding in next year’s settlement to apply these systems more widely.

Similarly, we have also seen how the use of artificial intelligence and data can demonstrably reduce demand and release patients sooner. NHS England has been tasked with clarifying and simplifying the procurement landscape, taking on board best international practice, so that a small number of scalable interventions are taken forward where international experience shows they can deliver meaningful benefits to patients.

Next, we will capitalise on the incredible potential of virtual wards. Last week at Watford General Hospital, I saw how patients who would have been in hospital beds were treated at home through a combination of technology and wraparound care. Patients released sooner are often much happier, knowing that they are receiving clinical supervision and always have the safety net of being able to quickly return to hospital should their condition deteriorate. There is scope to expand these measures to many more conditions and many more hospitals in the months ahead.

We are also opening up more routes for NHS patients to get free treatment in the independent sector and offering even greater patient choice. The elective recovery taskforce is helping us to find spare operating theatres, hospital beds and out-patient capacity.

We must also take steps in primary care. We are clear that our community pharmacists can support many more things to ease pressure on general practice. From the end of March, community pharmacists will take referrals from urgent and emergency care settings; later this year, they will also start offering oral contraception services. But I want to do even more, as they do in Scotland, and work with community pharmacists to tackle barriers to offering more services, including how to better use digital services. The primary care recovery plan will set out a range of additional services that pharmacists can deliver.

Finally, notwithstanding very severe pressures, we know that to break the cycle of the NHS repeatedly coming under severe pressure, the best way to reduce the numbers coming through our front doors is to address problems away from the emergency department. On Friday, we signed a memorandum of understanding with BioNTech—a global leader in mRNA technology —to bring vaccine research to this country, which will give as many as 10,000 UK patients early access to trials for personalised cancer therapies by 2030. This builds on the 10-year partnership we struck with Moderna in December to also invest in mRNA research and development in the UK and build state-of-the-art vaccine manufacturing here.

We are also reviewing our wider care for frail, elderly patients in care homes long before they ever get to A&E or our hospitals. Take the brilliant work being done in Tees Valley, where community teams are being used to help with falls to prevent unnecessary ambulance trips to hospitals. We have looked at what more support we can offer elderly patients further upstream. With an ageing population, and many more people with more than one condition, it is clear that we have to treat patients earlier in the community and go beyond individual specialties to better reflect patients with multiple conditions to give the right support to people where they are, which is often at home or in residential homes.

Today’s announcement provides a further £250 million of funding, which recognises the spike in flu on top of Covid admissions and high delayed discharge numbers from the pandemic. The funding will provide immediate support to reduce hospital bed occupancy and decompress A&E pressures, and, in turn, unlock much-needed ambulance handovers. This funding builds on the £500 million announced in the Autumn Statement specifically for discharge, which is ramping up, and the additional funding for next year.

All this work ultimately builds on the much-needed greater integration of health and social care through the 42 integrated care boards, which we will strengthen through the Hewitt review, and through a step change in capability, including operational control centres.

This immediate and near-term action sits in parallel with our wider life science investment, such as the deals with BioNTech and Moderna, and underscores our commitment to recognising the immediate pressures on the NHS and investing in the science that will shift the dial on earlier, upstream treatment at scale, particularly for the frail elderly, long before a patient reaches an emergency department. This is a comprehensive package of measures, and I commend this Statement to the House.”

My Lords, from this Statement one might conclude that the NHS is facing challenges but that, overall, things are moving in the right direction. This could not be further from the truth and does not reflect how dire the situation has become. It is clear that the Government have failed to grasp what everyone else has managed to: that there is a deeply urgent crisis in health and social care, where irrevocable damage is being done to people’s lives.

While on the one hand the Government are bringing in legislation that will mean that NHS staff can be sacked for exercising their right to strike, on the other they are refusing to conduct meaningful pay negotiations that could end the strikes in the health service. Indeed, they only thought to convene an NHS recovery forum this week, when we are already half way through the winter.

It is increasingly becoming clear that the sporadic pots of money proposed as sticking plasters for various pinch points are not being deployed quickly enough. For instance, the £500 million emergency adult social care discharge fund was announced in September, but some half of it still has not yet reached the front line. The NHS has now said that it is too late to make a difference to the winter crisis. Has the Minister identified what is stopping the funding coming through? What plans are in place to deal with this so that funding can promptly get to where it is needed? It is no good making announcements and then not following through.

Nor is it easy enough to work out whether funding is new or recycled money. I hope the Minister will be able to clarify this now and in the future. The nature of this Government’s approach to funding health and care—half a billion pounds here one week, another few million there—gives the impression of knee-jerk reactions rather than strategic policy-making. In fact, the approach is so last minute that, after making the announcements in yesterday’s Statement, an extra £50 million was suddenly found and a further press release was issued.

Yet we know that prevention is better than cure in every sense. A GP appointment costs the taxpayer much less than a desperate patient turning up at A&E. Is the Minister content with this eternal hole plugging? What plans are there to move towards a more holistic and sensible long-term approach, including plans to fix primary care so that patients can see the GP they want in the manner they choose? What plans are there to recruit the care workers needed to care for patients once they have been discharged from hospitals, and to pay them fairly so that we do not lose them to other employers? As ever, where is the comprehensive and detailed workforce plan to train the doctors, nurses and health professionals that the NHS so desperately needs?

Underlying this has been an abject failure to make the social care system sustainable. Half a million people are waiting for social care assessments. They clearly are at major risk of having to be admitted to hospital as a result. How will the Minister work to prevent this, especially when care workers are leaving in droves to work in retail and other sectors? Is there a government target for when the number of people waiting for assessments, often in pain and discomfort, might finally start to come down?

The Statement cites Covid, flu, strep A, scarlet fever, and even CQC inspections as reasons why the NHS is under such strain. Is this not surely passing the buck, when other countries face similar challenges and yet are not gripped by such chronic crises every single winter?

In the context of an ageing population where demand on the system will only increase, is the Minister willing to assure your Lordships’ House that a sustainable social care solution will finally be produced before the next winter hits? The NHS Confederation has responded to yesterday’s Statement by referencing the obvious contained in the Government’s words on the need for

“the right wraparound care for those being discharged from hospital”.

The NHS Confederation also says that

“after a decade of austerity neither the social care sector nor the government are in any position to ensure it.”

Does the Minister agree with that analysis: that it is the choices of this Government over the past 12 years that have had a direct and devastating impact on the current delays? It is this fundamental that the Statement has failed to address.

My Lords, we welcome the fact that the Government are making a Statement, as it is abundantly clear to everyone that we have a crisis on our hands, and we on these Benches have been calling for this to be recognised as a national major incident. In that context, will the Minister clarify the status of the NHS recovery forum that was announced with great fanfare last week? Was it a one-off, or will it be meeting regularly and taking ownership of this crisis? If it is not the NHS recovery forum, what group within government will be taking us through the rest of the winter? This requires daily, serious leadership at the highest levels in government.

I have three questions on the specific measures outlined in the Statement. First, the Government have told us about the block-booking of care home beds, which should provide some immediate relief for hospitals, but they are much less clear on how they plan to increase domiciliary care so that people who can and should be in their own homes do not get stuck in care homes unnecessarily. The last thing we want to do is to move people out of one inappropriate care setting into another one, and domiciliary care remains the key to providing the best care for the vast majority of people who need neither hospital nor permanent care home residency. Can the Minister offer us any assurances on what the Government intend to do about domiciliary care provision?

Secondly, the Statement referred to the new NHS system control centres that will be in each integrated care board area, and which are a welcome development. There is published information about the data that will go into these new centres, but no information about what the centres themselves will make available to the public. Does the Minister agree that it would be helpful for people to know much more about the pressures on the NHS in their local area through these NHS system control centres publishing regular updates with as much information as they can provide to help patients make informed choices, with full knowledge of where the blockages are in the system?

Finally, the Statement referred to the use of artificial intelligence systems to help release patients sooner and track their progress through hospitals. There have been recent press reports about Welsh hospitals using tools developed by a British company called Faculty AI to improve patient discharges. Can the Minister add any insights into how these and similar technologies are going to be tested and deployed in England? I know that nothing is a silver bullet, but the reports suggest that they could make a significant difference to discharging people more efficiently and quickly. If that is so, we do not need to wait to deploy these technologies, and should be getting on with it.

My Lords, I thank noble Lords for their comments. As I mentioned in answering the previous Question, this is a reflection, from our part, of trying to understand the situation. We did some plans in October and looked at demand and supply, and that led us to make the announcements about the 7,000 extra beds and the £500 million adult social care discharge fund. It was clear to us that the bed occupancy issue was going to be at those danger points, and that was the plan.

Then, of course, as with any plan, you amend and review it all the time. Over the last few weeks of December, with the onset of flu beforehand, it became clear that we had higher levels of bed occupancy than we had planned for at that time because we had 7,000 or so extra beds taken up by flu while, at the same time, still requiring higher levels of Covid care than planned. It became clear from all this that the bed occupancy levels were still too high to be comfortable. This was causing the knock-on impact on the flow across the whole system, backing right up into the A&E wait times. That is why, very responsibly, we looked at the latest data, planned, and realised that we needed to do more. That was very much the components of the plan.

In answer to the point from the noble Baroness, Lady Merron, some of those short-term measures were about bringing in extra adult social care funding packages and, candidly, looking within every area of our budgets at what we really needed to spend over the rest of the year and at what we could prioritise. We managed to make some in-year savings through reducing headcount, particularly in admin and central areas, and then looked to redeploy that to make sure it was going to the front line.

As well as that, we looked at things such as the expandable modular space. This goes back to the flight control systems, which I would recommend to anyone. It is well worth a visit to Maidstone, where you will see what we plan for the longer term and what we are looking to do across the system in time for next winter. It became very clear there that, because it has the data, it can manage demand and supply. It sees the incoming from the ambulances; it sees the bed situation; it sees those people who are getting close to be ready for discharge. It is working with clinicians to say, “Actually, we’ve got some incoming and we need to free up that space. Let’s get the social care places ready. Let’s have transport ready and clean the bed quickly.” It is absolutely those micro-improvements and the Team Sky cycling-type approach that address it. AI comes in very much as part of that; you can speed up the flow all the time. It is not silver bullet stuff, but it is about looking at those micro-improvements as you go through it. That is very much the background to all this.

Dom care is an important aspect of that as well. I went through the stats with the team today, which said that of the 13,000 people ready for discharge, probably only 3% should require social care in the long term, and the other 97% should be in a home environment. Some of them might need a few weeks, which is where those care packages come in, and a lot of them need dom care, but 97% of them should not be in care going forward. That is why we need to focus these things towards that. That is the thinking behind this.

The modular space is an important component of this. Look at Maidstone again; it has looked very carefully at the patient flows and at where you can have same-day emergency care and get people out again so that they never have to go into a hospital. But you need extra space to do that. We have made this available so that the hospitals can decide where they most need that expandable space—whether it is pre-A&E, when they are finished in A&E and waiting in a decent space for a bed to come free, or step-down or discharge areas. It is about providing that flexibility and putting it in place quickly for them all.

What we were trying to do here was show flexibility and be fleet of foot to be able to course correct as time goes on; to put our hands up and notice when things were difficult and more challenging because bed occupancy was higher than expected—as I say, due to flu, Covid and other factors—and put in the measures to address them. That is exactly what we are doing in the short term.

In the longer term, next year—not that many people would say that nine or 10 months away is the longer term—we need to make sure that adult social care has further funding, as the House has heard me say many times. There will be a substantial increase next year, up to £1.7 billion, and a substantial increase the year after, of up to 20%. With flight control systems, expandable modular care and the rollout of virtual wards, we have a number of things that, on their own, are not a silver bullet, but, by putting them all together, you will start to get the changes and improvements that we expect to see. I say unashamedly that, if there are other facilities in the independent sector that we can make use of, be it making more use of pharmacies or expanding virtual wards, then we should do so.

I am sure there will be more questions as we go on in this debate, but I hope your Lordships can see that we have tried to respond to the challenges through a range of measures that we believe will make a difference. At the same time, we must be open to the need to do more; we will need to add more things and course correct as time goes on.

The Minister may not agree, but the NHS is in crisis. He may say that the situation is “challenging”, but it could not be more challenging. Although infection rates related to Covid, flu and other infections may have exacerbated the situation, the genesis of the crisis is not of today’s making. It has been in the making for years. It is related to lack of capacity. Does he agree that the emergency measures now being put in place are not likely to work? If they are not likely to work, what is plan B? Importantly, what is the long-term plan to ensure that this does not continue into the spring, summer or next winter?

I absolutely think these measures will improve the situation; I would not be putting them forward if I did not believe that. At the same time, just as we put out plans in October and are amending them now, I will continue to amend our plans. I think that is a flexible, responsible approach: you have a plan, you adapt that plan, you invest and you continue to improve. That is what we will continue to see and do; we will see those improvements go through this year and into the next.

My Lords, my noble friend the Minister mentioned pharmacies in his response, which clearly demonstrated a complete lack of understanding of the crisis that is going on in the independent pharmacy sector. They are closing at an alarming rate, yet they are the front line of the NHS, with record numbers of people coming to see them for free medical advice because they cannot get in to see their GP. There is a very serious crisis in the independent pharmacy sector, which is vital for healthcare. I have had many meetings, I have had letters, and I have got a campaign going in the media. It is clear from the responses that the department does not have a clue about the extent of the crisis and the closure of these independent pharmacies. Something needs to be done before they all close.

I wholeheartedly agree with my noble friend that the pharmacies are the front line. We realise that they have been underutilised in the past. Actually, the plan of using them more for patients will put more funding their way, which I hope will support them, just as allocating Covid vaccinations to many pharmacies provided support. I hope my noble friend will see that this plan should add to the viability of a number of pharmacies by putting more business their way. They are a crucial part of the front line.

My Lords, this focus on the number of hospital beds may be at the wrong end. It is much more fruitful to think about why staff are so dissatisfied and unhappy that they wish to leave and do so in droves. We have to do more to improve the morale of the nursing and medical professions and, in particular, those who work in the community—the care workers. We are losing them in great numbers; they are not coping. The reason is partly their pay, and we must pay them a reasonable rate, but it is also that they are completely disillusioned as people do not take them seriously. They do not have a professional qualification or a proper training programme. They do not have the possibility of career progression. We must do more to encourage them and ensure that they have a satisfactory career. If we do, we could possibly get more patients out of those beds that were building up, and perhaps help reduce the queues of ambulances.

I agree that we need a whole-system approach. Workforce is a key part of that, including the adult social care workforce. Again, as all noble Lords did, I welcome the advent of the agreement to do a workforce plan, which needs to take all these factors into account. We need to make sure that it is an attractive place to work, and that people see it as a career progression—and that it is modular so that you can start in social care and, if you want to, progress into other parts of the health service.

My Lords, I declare my interest as a vice-president of the LGA and vice-chair of the All-Party Group on Adult Social Care. Nearly three years ago, the Government created Nightingale hospitals, which were much vaunted and had millions spent on them. Virtually all of them were useless because there was no staffing available for them at short notice. I listened to the question from the noble Baroness, Lady Merron, about the short, medium and long-term workforce plan. We are now in emergency time: there are 160,000 social care vacancies and 40,000 nursing vacancies, which includes those in social care. How is this unblocking of beds going to be staffed and by when?

Obviously, prior to this, we were in touch with the adult social care sector to make sure that there was that capacity within the system for it. We have been assured that the capacity exists, but we wholeheartedly agree that we need to recruit the staff to fill those vacancies, which is why we have taken measures to recruit internationally as well as in the domestic recruitment programme. Those are all key components of the longer-term plan to solve this issue.

My Lords, I remind noble Lords of my declared interest as chairman of the King’s Fund. The Statement made yesterday in the other place refers to a primary care recovery plan. It is well recognised that the hospital system is not sustainable if primary care cannot discharge its important gatekeeper function. Is the Minister able to confirm that, as part of that plan, there will be a radical review of options that might be adopted to ensure that primary care can deliver its important function?

Yes, this is very much the focus of my colleague Minister O’Brien. I think it is understood that as many as half of the people who turn to up to A&E could have been looked after by the primary care system, so a lot of the pressures caused are as a result of that. It is absolutely a whole-system problem; many of the issues at the front end are about the GPs and at the back end they are about adult social care, which is why we need to address the whole system.

My Lords, last month, I had the dubious privilege of staying at one of the Minister’s hospitals. I was struck by the sclerotic way in which decisions were taken. It seems that the whole premium is on safety rather than looking after the patient. I would ask that the department looks into the way in which decisions are made, because I found far too often that a decision was made on the basis of what was safest. The multidisciplinary team, as it was called, was basically there to deflect anyone who wanted to do anything very adventurous. Will the Minister start looking, maybe in selected hospitals, at ways in which the decision-making and care process can be speeded up and made less sclerotic?

I have seen very good examples of where that works. You have clinicians in the room with the data—the management and bed information. They make decisions according to the flow and number of people who they see are going to need a bed from the ambulances and the A&E situation, and the number who are ready to release. You have clinicians united with the information to make good decisions. Those are the best. The idea with the longer-term plan is to make sure those “best” have the tools in terms of the flight control system and have management processes in place so that they can adopt and follow best practice. It is key to what we are looking to make sure we have in place in time for next year, as the noble Baroness, Lady Merron, mentioned.

My Lords, the Minister replied to my Written Question on 5 January about commercial companies promoting strep A tests. The Answer said that these are “not currently recommended” by NICE

“for individuals aged five years old and over … with a sore throat”

and that UKHSA is conducting a

“bedside review of existing antigen-based lateral flow devices”


“identify the tests that are most likely to perform well”.

Given that, can the Minister explain why I have a number of emails from DAM Health headed “Concerned about strep A? Order your home test kit today. Only £12.99 per test kit. Quick and reliable results within minutes”? Can the Minister truly put his hand on his heart and say there is sufficient regulation and oversight of private testing companies, and indeed the broader private health sector? Is it not profiteering from the crisis in the NHS, potentially damaging the NHS and putting more pressure on NHS services?

First, I declare an interest in this space. As many noble Lords will know, I set up a Covid testing company which never did any business towards the Government; I am very pleased to say that it served only the private sector. I am disposing of it as part of my obligations as a Minister. As the question relates to testing, I am quite keen to put that on the record.

Secondly, I would say “absolutely”. Dare I say it, but the reason my company was so successful is that we set the very highest standards according to the regulators. That is why we were able to win the crème de la crème—the Formula 1s and Wimbledons of the world. I cannot speak for other companies which may not be taking that high level of support, but there is absolutely a role for the regulator to make sure that only effective tests are marketed and those which are not effective should not.

My Lords, I wonder whether the Minister—I hate to say this—will recognise that, too often, it feels that the Government have no institutional memory, have no ability to learn from what has happened in the past and keep trying to reinvent the wheel while the wheels are spinning away long before they get anywhere near. The King’s Fund recently published a report on how the last Labour Government brought down waiting lists. That report shows that you do not just have to shout about it; you have to put in place all the different steps, including the right financial flow.

From all that has been said today, it is clear that the right flow is to encourage more people into social care work and encourage and enable them to do more serious, high-level work like urine testing. The Government have not even begun to think about this. Until financial support for the whole flow and the financial incentives to change the things the Government need to change are there, and that is understood by Ministers, we will not get it. It is not enough to say, “We’re putting another £15 million or £50 million into this, that or the other”, without making sure that you know how it is going to be spent and that people are going to be there to deliver it.

I have said before in this Chamber —and I will say it again—that we should be learning all lessons. I like to think that, three months into my role, I am learning some of those lessons. The noble Baroness will see that we have taken some backwards steps on the use of the independent sector, which, again, was pioneered 15 or 20 years ago, but hopefully we will move forward again. I unashamedly say that we can learn from those things. I have spoken to some colleagues from the noble Baroness’s side of the House, and will continue to, because I will adopt anything that works, and I agree that payment by results is one of those things. We can speak after these questions; my door is definitely open on those matters.

My Lords, I have the privilege to chair the NHS national community nursing plan clinical reference group. We meet on a regular basis and look at how community nurses can keep people out of hospital and get people home from hospital. We have heard very little about that today. Can I have five or 10 minutes with the Minister at some stage to bring him up to speed on the work that is going on?

As with my answer to the previous question, I look forward to that meeting and learning everything we can. I will repeat the statistics on that subject that struck me most: of those 13,000 people who are fit to be discharged, we think that only 3% need to be in social care in the long term; 97% could be at home, which is the best and most cost-effective place for them. We need to ensure that the support is in place to ensure that that option exists.

My Lords, I declare my interests as a nurse and as a new appointment to the NHS England board as a non-executive director. There are two things missing from this discussion. First, there has been no reference to people waiting for mental health support. How can we ensure that people in mental health crisis are moved rapidly out of busy A&Es to be supported in quieter environments? There is a very good example across the road, at St Thomas’ Hospital, which is helping the A&E. Secondly, it is high time that we seriously consider giving full-time contracts to care workers in domiciliary services, because, as soon as somebody goes into hospital, the care worker’s hours are cut and, although they know that individual, they very rarely get reallocated to them when they are transferred back out of hospital. The lack of continuity of care often results in readmission, so what will the Minister do to ensure that, in the way that the noble Lord, Lord Turnberg, just outlined, we improve the lot of those particular care workers?

First, I welcome the noble Baroness to the NHS England board, with high expectation of the value that she will add to it. I am very interested to understand her point further; I will speak to Minister Whately about that and respond to the noble Baroness in writing. Where people have knowledge of a patient at home, they can add that to their care when they come back out again.

My Lords, one of the lessons we learned, sometimes very painfully, during the earlier stages of the pandemic was the importance of working with, and often through, local government to tackle some of these issues. The same is true now. Would my noble friend explain how the NHS will use discharge funding and purchase social care provision? Will integrated care boards do that locally with local government, which has been managing social care purchasing for decades?

I thank my noble friend. The best ICBs that I have seen have the local authority as part of their board and their decision-making on a day in, day out basis. One of the best control systems that I saw in an ICB actually had the local authority social care people in the room making the decisions with them, so they are a key element in all of this. On purchasing and funding, they are very much a strong player.

The Government have spent 13 years cutting the number of beds and they are now reversing that and starting to increase it, which is welcome. The other thing that they have done is to constrain pay in the NHS and social care. They have an opportunity to do something about that. Why are they not taking the opportunity to boost pay in both those sectors to address some of the problems that we face?

I welcome what I hope, over the past few days, has been better mood music—let me put it that way—in this space. I hope from the different things that we see that we will get closer towards a landing zone where we can reach agreement going forward. We know from both sides that neither side wants to be in this dispute. My hope very much is that constructively—with good will on both sides, which we are seeing—we will find a way forward.