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NHS and Social Care: Winter Service Delivery

Volume 788: debated on Thursday 25 January 2018

Motion to Take Note

Moved by

That this House takes note of the impact on front-line social care of Her Majesty’s Government’s NHS plans and the delivery of services over the winter period.

My Lords, the most appropriate place to start this debate is with the WhatsApp open letter of 12 January to the Prime Minister from the heads of 68 accident and emergency departments in England. Its signatories included St Thomas’s in London, Heartlands in Birmingham, Addenbrooke’s in Cambridge, the Royal Liverpool, and Frimley Park, where Mrs May issued her new year apology for cancelling 55,000 non-elective surgical operations. With figures showing over 300,000 patients waiting more than four hours in A&E, a record half a million-plus emergency admissions, and 75,000 patients waiting more than 30 minutes in the back of an ambulance, these front-line doctors wrote about the hundreds of patients a day, some of whom were dying prematurely, being treated on corridors and about patients sleeping in clinics turned into stopgap wards.

One of the main purposes of the messaging was to swap practical tips about how to become “corridor specialists” as hospitals become overwhelmed with patients. This speciality includes the Red Cross delivering tea and blankets and sitting with patients waiting on their own. I can think of nothing worse than, for example, being a sick, elderly patient on a trolley without a carer or friend to stay with them, speak up for them or make sure they are being looked after. For the A&E doctors, their reality was that the Government’s winter plans,

“have failed to deliver anywhere near what was needed”.

Their key demand was more hospital beds and an urgent boost to social care. The president of the Royal College of Emergency Medicine warned:

“Our emergency departments are not just under pressure, but in a state of emergency”.

All this, of course, has a huge knock-on effect on social care while arising from the Government’s failure to fund and provide the everyday healthcare and community support, for millions of people who need it, which could stop many of them turning up at A&E and occupying hospital beds in the first place.

We know that the Minister’s response will be his repeated mantra about the extra £337 million the Government made available to trusts this winter and the £1 billion extra in social care funding allocated in the 2017 March Budget. Of course extra funds are welcome but, first, trusts were not told about their allocations until a few days before Christmas, so effective on-the-ground advanced planning was severely hindered as they had no idea of what money there was to spend. Secondly, the Government’s instruction was for half of the £337 million to be spent on servicing trust debts, not on emergency planning. Thirdly, such debts will be further increased by the cancellation of 55,000 non-elective surgical operations. Finally, as all the health think tanks, specialists and everyone involved in the provision and delivery of NHS and social care services have attested, the extra funding was simply nowhere near enough even to begin to redress the huge cuts that have been made in NHS funding and local government funding of social care over the past eight years.

The Government need to acknowledge and own up to the scale of the crisis. The Minister knows that the Budget did not provide extra funding for social care in the short term or address the predicted funding gap of £2.3 billion by 2020. Specifically on A&E care, can the Minister tell the House how the Government will assess the actual impact that providing additional funding in November and December had in dealing with the worst winter crisis the NHS has faced in decades?

On social care, as the very comprehensive Lords Library brief for today points out, we talk of adult social care mainly in terms of the needs of older people, but it also includes care and support provided to physically disabled people, people with learning disabilities, people with mental health problems, drug and alcohol misusers and the carers involved in caring for them. That is the scale of the demand and the need that has to be addressed. I will focus today on carers and older people.

I am a carer, as many noble Lords will know. Emergency care, hospital admission and then discharge is a make-or-break time for carers and their families. Many people become carers for the first time when this happens, as I did. It heaps pressure on families and, despite all the guidelines, most discharges take place with little notice, particularly when there is a national directive to free beds to make way for winter. If you speak to carers, particularly if discharge takes place when the patient is medically unfit or without the proper facilities and care available at home, they will tell you that this is one of the most traumatic times for them.

The number of carers is increasing every day. It is now estimated at 6.8 million, an increase of 1 million over the past 15 years. As Carers UK has stressed, families are caring more, not less, as some would have it. On top of this, we see in the press that carers have been asked by one trust to collect their elderly from hospital to help with the discharge process and ease the winter crisis. Is this really where society wants to head?

For carers, frequent GP and hospital visits, providing and arranging transport and so on are a routine part of looking after partners or relatives with disabilities or co-morbidities or of caring for frail and elderly people. Cancelled operations mean desperately trying to reinstate the cancellations in domiciliary care support made for the hospital stay and, of course, dealing with huge upset and disappointment.

There is the added winter threat of norovirus or flu and the impact this will have on carer and cared for or on both together. Where there is a carer involved in A&E corridor waits, they will be there with their loved ones, doing their best to care for them in very difficult circumstances and sharing their anxiety and concern. Acknowledging the vital role carers play as partners in the health and social care system has to be backed up by providing the resources that are needed to undertake the caring role.

Can the Minister update the House on the call to action that the Government have promised in place of the national carers strategy refresh that carers were expecting two years ago? It was due in the new year and we are nearly at the end of January. Can he tell us when it is to be published and ensure that it provides the support and resources that carers need?

As Labour has emphasised, the winter crisis has consequences not only for those in urgent need, but for everyone using the NHS. The panic cancellations of elective operations and outpatients clinics in the face of hospitals running at full capacity will have a major impact on the many older people who rely on NHS services to stay well and on their carers. As Age UK has stressed, waiting for a hip or cataract operation or having an appointment postponed will leave many people experiencing pain, discomfort and anxiety. It will result in a need for more support in the home or from primary care and could even accelerate people’s need for urgent and emergency care.

The noble Baroness, Lady Campbell, wanted to participate in this debate today, but had a previous commitment. She asked me to raise the key issue of the impact that the winter crisis has on people with acute, long-term conditions and disabilities, such as muscular dystrophy, cystic fibrosis or acute asthma, who, if they go down with flu or chest infections, need emergency care in specialised respiratory units. The availability of these beds is increasingly under pressure because hospitals are unable to discharge severely disabled people occupying those beds back into the community if they require more social care support than they had before. She faced this very perilous situation three years ago when her local specialist unit was full to the brim for many days and a suitable, high-dependency placement could not be found, and she lives in fear of that every winter. Will the Minister undertake to write to her on the urgent measures and steps that will be taken to ensure that people with acute and long-term disabilities receive the integrated and joined-up care they need?

Planning for winter means planning across health and social care. As NHS Providers said last year:

“Too often winter pressures has just been about acute hospital capacity. Last winter showed that ambulance, community and mental health capacity are just as important, as is primary and social care capacity”.

Social care’s extra £1 billion pounds last year was designed to reduce delayed transfers of care and free beds, but only 28% of trusts managed to secure any commitment from hard-pressed local authorities to spend the money on delayed transfers. Most would have simply been unable to meet that commitment.

Over last winter the lack of capacity to deal with expected demand across the whole system was clear: 64% of trusts lacked ambulance capacity; 71% lacked acute capacity; 76% lacked community capacity; 80% lacked mental health capacity; 91% lacked social care capacity; and 92% lacked primary care. Can the Minister explain why the Government’s winter crisis plan for this year did not take account of all these factors? Was this really the effective planning the Government insist went on? Will the lessons be learned for this year’s promised winter crisis ministerial review?

On delayed transfers we know that the NHS needs to get its act together. More than 58% of delayed transfers in November 2017 were attributable to the NHS, mainly through patients having to wait for further NHS non-acute care; 34% of delayed transfers were due to social care. What was the main reason? It was patients awaiting a care package in their own home. Financial penalties on local authorities or instructions to trusts to use the limited extra funding to reduce their debts do not address the crisis in either sector. As the Local Government Association puts it, delayed transfers,

“are a symptom, not the cause, of the pressures on the NHS and in many cases the solutions will lie in investment in prevention, primary care, community services and hospital avoidance schemes ... There cannot be a sustainable NHS without a sustainable adult social care system”.

We know that as a result of the cuts to local government, the availability of adult social care packages has fallen so dramatically that 90% of councils are now able to respond only to people with critical and substantial needs. At least 400,000 fewer people are getting publicly funded help. Age UK’s estimate is that there are now 1.2 million people with unmet needs for help with essential daily support, such as bathing, toileting, taking medicine, cooking, shopping and other everyday tasks.

All this makes it vital that the Government’s Green Paper this summer does not deal just with a cap in care costs or any disastrous proposal for a care cap floor, unless, of course, Jeremy Hunt throws in the towel and recognises that the Dilnot proposals that we all spent two years working on are actually the best chance we have for bringing fairness and some equity into the health and social care system in the near future. The Green Paper must also address how we can achieve the fundamental integration between health and social care that is needed to meet the scale of the current crisis and the rising demand and to provide the care and support that people should be getting.

The Government have tried very hard to make the change of Jeremy Hunt’s title to Secretary of State for Health and Social Care sound like a fresh and important sign of action and purpose. I must say that I am one of those who thought he was supposed to have that role anyway. However, if it means that the Green Paper will be health and social care-led—rather than led by the Cabinet Office—and that Jeremy Hunt will take leadership responsibility instead of, as is his frequent habit, blaming the health and social care crisis on everybody else, then that is at least a start. His recent recognition of the need for a 10-year strategy is also a step in the right direction.

Can the Minister confirm that the Green Paper is still scheduled for the summer? Can he be any more specific about its aims, scope and publication date? What work will be done alongside the Green Paper to produce a national integrated staff recruitment, training and development strategy for health and social care? Currently, Health Education England provides the NHS staff strategy and Skills for Care deals with social care staff. Is this not a key issue that needs to be addressed to ensure integrated working? Will the chronic low pay problems, particularly in social care, that are one of the root causes of staff shortages and low morale be tackled? How will health and social care budgets be joined up?

I am grateful that this debate has attracted so many experts among noble Lords, and I am very much looking forward to it. I close by paying tribute, on behalf of us all, to the extraordinary efforts and work of our NHS and social care staff, particularly over this Christmas and new year and this winter.

My Lords, I have lost count of how many debates on these and related topics I have taken part in during 20 years in your Lordships’ House, but that does not make me any less enthusiastic about taking part in this one or make me offer any fewer congratulations to my noble friend on securing it when both the topics and the timing are of the utmost importance.

I might shock your Lordships today if I stand here and say that there is no winter crisis in the NHS and that there are no problems in the NHS. But in one sense, many would say that is right. The cancelled operations, the ambulances queuing, patients dying in corridors and all the rest are actually a crisis of social care, not of the health service. Health service budgets may be ring-fenced, but social care has lost about £6 billion from its total spend, and a 50% rise in the number of people especially elderly people, stuck in hospital is because there is nowhere for them to go in the community. Nearly 1,000 care homes have closed and 30,000 care home places have been lost because the providers can no longer afford to operate on the money they receive from the state, especially in areas where there are fewer wealthier self-funders, who cross-subsidise the places which are paid for by the state. By the way, this is another scandal waiting to happen, as it is in effect a stealth tax.

The last time that I spoke on social care I said that I was beginning to see a bit of light at the end of this long, dark tunnel, as there seemed to be some kind of consensus, at last, about the fact that this issue had to be tackled, even if there is no consensus as to how. Since then, we have seen the Secretary of State for Health add social care to his title, which I acknowledge is a step forward, even though there has been no change in how the budget works, with the purse strings for social care still apparently held at the DCLG. The result is the chaos we have seen all too frequently.

I am sure the Minister will tell the House about areas where pooled budgets are working well. I applaud those, but let us not forget that the reason we are seeing the growth of things like accountable care strategies and strategic partnerships is that local people are having to find ways to work around the fragmented system that was set up with the disastrous reforms of the Health and Social Care Act 2012, under which nobody knows who is in charge and decision-making is complex and fragmented.

Of course, what anyone who has been in A&E this winter will tell you are tales not only of chaos and pressure but of the hard work and commitment of dedicated staff doing their best against the odds. Another lot of people doing their best against the odds are the carers, already mentioned by my noble friend—who brings such valuable experience of her own as a carer to your Lordships’ House.

We must never forget the contribution of carers to social care, which is worth £132 billion every year, but neither must we forget the cost to the carers themselves. Three-quarters of carers report that their own health—physical or mental, and mostly both—is adversely affected by their caring responsibilities, while the financial strain of caring is well documented: not just the immediate costs of extra heating, transport and specialist food but the loss of future income because of lost earnings and lost pension provision. We should also remember that many people in the health and care workforce, struggling as they are to cope at present, are also juggling that work with their caring responsibilities. How are they supposed to make arrangements when they are given no notice of hospital discharges and given no choice at all about providing care for a loved one?

However, not involving carers is short-sighted and makes neither economic nor moral sense. That is why the failure to produce the long-promised carers’ strategy has been a great disappointment and disillusionment to the carer population—two years, we have waited for it. Of course the Minister will say their needs are to be included in the Green Paper on social care, but, as my noble friend asked, where is the action plan that was promised as a stop-gap? What will it cover? How will it be implemented? When may we expect to see it? We need urgent answers, and I hope today we are not going to be fobbed off with, “It will appear in due course”, which seems to be the Government’s answer to everything at present.

The Secretary of State is now in charge of the promised Green Paper and we simply must hope that he will find a way to rectify the decades of debate followed by inaction that we have had on social care. Heaven knows, debate has not been lacking: royal commissions, Wanless, Barker, Dilnot—your Lordships will be familiar with them all. But they have been followed by indecision upon indecision about how we are to tackle the complete unpredictability of the cost of care for families. It is literally a lottery where some of us pray we will die of cancer, and therefore get our care funded by the NHS, and not of Alzheimer’s, when we or our families will have to bear the burden. The only fair solution is to pool the risk between as great a number of people as possible so that everyone loses something but no one loses everything.

Of course, how social care is to be funded in future is a political decision, and surely if this winter has shown us anything, it is that such decisions cannot be put off and kicked into the long grass as successive Governments have done for 30 years. Is a consensus emerging, for example about a hypothecated tax? The chair of the Health Select Committee believes that national insurance could be extended to those over retiring age. Could some of us better-off pensioners—I include many in your Lordships’ House in that—forgo our £200 Christmas bonus and our free prescriptions? I know there are anxieties in all parties on this topic. My own party worries about the charges of a “death tax” that were made about our proposals in 2010, and no doubt the Government are still bruised by accusations about a “dementia tax” made at the time of the last election. But with the numbers of people over 85 set to double by 2039, there is no more pressing problem that our nation faces—even Brexit, although that will bring its own problems.

The snowdrops are out, the weather is milder and the winter crisis may be receding, but the respite is only temporary. Let us not have this self-same debate next January. We need political courage and leadership, and now is the time to show it.

My Lords, I thank the noble Baroness, Lady Wheeler, for the opportunity, as the noble Baroness, Lady Pitkeathley, just said, to return again to this subject. I will not make a long speech as I would like to leave as much time as possible for the debate that will follow. On behalf of my colleagues on these Benches, I wish the noble Baroness, Lady Jowell, all the very best and ask her colleagues to convey that to her.

The noble Baroness, Lady Pitkeathley, is right: we have been back to this ground so many times. In preparing for this debate, I thought back to many of the debates that we have had in the past. The origins of the problem we are looking at go back to the National Health Service and Community Care Act 1990. In that Act, for the very first time, welcome things happened: we began to break down procedures within the NHS and to cost and quantify them. But the problem was that we made them into individual units of activity, and to this day, within the NHS, the systems that join up those individual units are failing. They fail completely when they have to be matched up with the social care system, which is completely different.

Those problems were identified and partially addressed in 2003 with the Community Care (Delayed Discharges etc.) Act, when the then Minister, the noble Lord, Lord Hunt of Kings Heath, was sitting there trying to answer questions from very talented opposition spokespeople such as me. We asked him a question that he never could answer, which was why the then Government thought that the answer to the problems in the NHS was to fine social services departments. I never understood that. We still have, within the whole system of discharge, a system of penalties.

Perhaps I can answer the noble Baroness. Surely the point is that both local government and the NHS were being properly funded at that point. Therefore it was entirely appropriate to have a system to encourage local authorities to do the right thing.

The issue that I think the Government were trying to solve was one for which we have never had any evidence: that of local authorities trying to game the system. It is correct that the overall amount of funding has gone down, but we have not had evidence of people gaming the system.

We have never had a system, or even part of a system, that incentivises GPs and those in charge of social care to prepare for winter pressures, invest in programmes that will see older people through the increased incidence of illness that we know happens in winter, and avoid unnecessary admissions to A&E. What has changed in that time is that we now have better data and better information systems, but in many ways we are still failing to take all that and improve those systems. At the moment we still have ambulance services being rated on completely different systems across the country so we cannot generate data.

The Government have done some things that are very welcome. Everyone agrees that the primary care streaming system, into which they put £100 million, is a worthwhile initiative. Unfortunately, the initial evidence is that it is failing simply because it takes people from another part of the system—GPs—and locates them in hospital. What are the Government going to do to properly monitor that system in its entirety as part of an overall approach to winter pressures, to see whether it is worth more investment or whether it simply takes resources from other parts of the system?

On the question of beds, we have a national system of monitoring general and acute beds and ways of measuring the overall occupancy rate. We do not have a method of assessing the number of beds in relation to need. For example, we can open up a load more beds, as the NHS always does at times of crisis, but if there are no more staff to look after the people in those beds then we are not really addressing the need. We need to refine the measurement of this so that we have a metric along the lines of “nurses per bed per day”. That is the point at which things become really bad. I remember talking to a nurse about a patient—actually my mother—and being told that she was far too good to be in hospital and would be going home. She died two days later, which was not a surprise to any of us. I say that because it is not an uncommon experience for patients.

We have been through this time and again. The one thing that we have failed to do is incentivise GPs to work with community organisations from the summer onwards to predict the people in their area who are going to be most at risk and to put in place very low-level, simple and low-cost packages of care for them that can be there very quickly when they are discharged. The biggest cause of delayed discharge is not the absence of social care but the absence of community nurses and NHS staff available to work in the community to ensure that we do not send people home only to see them return unnecessarily into acute care.

My Lords, we may or may not be experiencing one of those periodic crises that beset the NHS and the social care sector every 10 years or so, and by the time we know for certain it will be too late to do anything about it. Indeed, even if the Government announced another £1 billion of spending today, the lead times are such that it would not have any impact until well into the next financial year. However, if there is not a crisis this year, it will happen next year or the year after that.

The coalition Government were right to try to secure efficiency improvements out of the NHS and social care sectors, but the squeeze has gone on for too long. Although the Chancellor announced more money in his recent Budget, it was more a temporary sticking plaster than a permanent solution to NHS finance problems. The NHS will come under further pressure in the years ahead as the demographic pressures long predicted by the independent OBR and others begin to materialise. Those spending pressures are compounded by the so-called triple lock, which means that pensions and health spending are accounting for an ever-increasing proportion of public spending. It is no longer realistic to cut spending on prisons, the police and defence; they too are under heavy pressure. So something has to give.

The NHS is the last great socialist institution, free at the point of use and based on the principle of command and control. Its founders were wrong when they predicted that better healthcare would reduce demand. The fact is that demand is infinite. We now know that demand increases as society becomes more prosperous so healthcare, under the NHS model, will always be rationed. Governments are inevitably reluctant to admit this but it is a fact, and it may be no bad thing. The NHS is certainly a lot cheaper than the US private system, which is beset by waste caused by supplier-induced demand.

Such is the British people’s attachment to the NHS that I do not think it is realistic to change its founding principles. Of course the NHS could be better managed. For example, we need to find better ways of managing demand. Far too much money is wasted on patients who fail to turn up for appointments. We also need to solve the age-old disconnect between the NHS and social care. I welcome recent government efforts to address this, although there is still more to do, but better management and reform is not going to be enough. If we are to avoid future winter crises, we need to address the funding side of the equation.

Despite the Treasury’s excellent presentation in this year’s Budget, the Chancellor’s proposals effectively financed extra spending on the NHS through higher borrowing. That is not the right approach. The current pressures are structural and on revenue spending. Good stewardship should ensure that structural spending is financed out of higher taxes. It would run against the orthodoxy that I imbibed over 30 years at Her Majesty’s Treasury but I propose a hypothecated tax that would be set at the beginning of each Parliament, informed by independent projections by the Office for Budgetary Responsibility. A new NHS and social care tax would be introduced to fund these additional pressures. It would be based on national insurance contributions, which, incidentally, already include a little-known NHS allocation. Unlike national insurance contributions, the tax would be paid by those above retirement age as well as those below it, and it should be charged on savings, rental and pensions income as well. The fact is that young people are already bearing too much of the burden of funding the elderly. It is time that the old folk put something back. We need greater solidarity across the generations.

This new NHS tax would be separately itemised on people’s pay slips and could be spent only on the NHS and social care. In my view, taxpayers would be more prepared to pay higher taxes if they knew where the additional money that they raised was being spent. A 2% tax, paid by young and old alike on incomes above the lower earnings limit of national insurance, would raise well in excess of £10 billion a year. I hope the Government will give it serious consideration.

My Lords, as ever, much of what I might have wished to say has already been said so I will not repeat it. I will try to keep my contribution brief.

In one sense, the current situation in health and social care, which, as we have heard, has been widely reported and analysed by the media, is nothing new. Admittedly, the number of patients with flu this year, especially elderly ones, has not helped. Last year, though, in its document entitled Winter Warning, NHS Providers commented that, “NHS performance last winter”—that is, 2016-17—

“showed unacceptable levels of patient risk as growing demand outstripped NHS capacity”.

Every winter has brought its own challenges, and short-term problems and pressures are not necessarily indicators of long-term difficulties. At the same time, though, as we all know, and as was pointed out by the noble Lord, Lord Macpherson of Earl’s Court, an increasingly large and elderly population with multiple morbidities has been steadily putting a huge strain on both the NHS and social care in this country.

The delivery of services is not an issue only over the winter period: it is a constant headache, not least in accident and emergency departments across the country, but also in care homes and private homes that are struggling to cope. As the noble Baroness, Lady Wheeler, pointed out, in a recent survey, no less than 91% of trusts reported a lack of social care capacity as winter approached, despite the promise made in the March 2017 Budget of an extra £1 billion for social care in 2017-18.

This emphasises the need for two things to happen, one of them short term, the other long term. The short-term need should be relatively straightforward to meet. It involves not only planning for next winter now but making sure that the necessary funding is released well before the winter actually arrives. As the noble Baroness, Lady Wheeler, reminded us, in the Budget on 22 November 2017 the Chancellor of the Exchequer committed £337 million to address winter pressures. That was very welcome but it came about four months too late. Health and social care providers are clear that any extra funding to help with the demands of the winter period needs to be committed by the end of July at the latest to enable effective planning.

The longer-term need is rather less simple but even more important. This is the need to tackle the thorny issue, alluded to several times, of the long-term sustainability of both the NHS and social care. I had the privilege of sitting on the ad hoc Select Committee of your Lordships’ House chaired by the noble Lord, Lord Patel, which produced a report on this exact topic last year. Unfortunately, the report came out just before the general election, which means that we are still awaiting a response from the Government and proper debate on its many recommendations.

Those recommendations relate directly to the subject under discussion this afternoon. Recurring winter pressures cannot be separated from the pressing need to address the ongoing issues around sustainability, including personal responsibility, increasing integration—we welcome the new Department of Health and Social Care—workforce planning, a model for funding and, above all, a non-party-political group, rather like the OBR, to advise the Government of the day about long-term requirements.

I greatly look forward to that debate in the hope that it may help to mitigate the need for ongoing debates such as this.

My Lords, I declare my interests as a vice-president and former chairman of the Local Government Association.

Health and social care are vital services that support our nation. Social care helps to reduce pressures on the NHS, by both supporting people to be discharged from hospital and helping to prevent them needing hospital treatment in the first place. It is an essential public service that helps working-age disabled adults, older people and their carers, as well as promoting well-being and independence.

The money the Government have brought forward for both the NHS and social care is welcome, particularly during the winter, when there are increased demand on services but, as we have heard, the timing of such allocations needs to be more realistic to be really helpful. It is also encouraging, as mentioned by the noble Baroness, Lady Pitkeathley, that the Government have included “social care” in the Secretary of State’s job title and appointed a Minister in the department with responsibility for the service. This shows that health and social care should now be afforded the same level of political importance across government.

A great deal of the public debate this winter has focused on problems associated with the delayed transfer of care, particularly as the pressure increased on NHS beds and staffing. Local authorities remain committed to supporting people as they are discharged from hospital. It is positive that councils have reduced delayed transfers of care attributable to social care by 20% since July 2017, which was when the Government first introduced the target. As the noble Baroness, Lady Wheeler, said in her opening remarks, citing the LGA, delayed transfer of care is a symptom, not the cause, of the pressures on the NHS. In many cases, the solutions are additional investment in prevention, primary care, community services and initiatives that keep people out of hospital.

It is crucial that, in the important debate on how we make sure our NHS is funded, we do not lose sight of social care. We cannot have a sustainable health service without sustainable, and sustainably funded, social care. The LGA estimates that social care faces a £2.3 billion funding gap by 2020. According to the LGA, the financial situation is making it increasingly challenging for local authorities to fulfil their legal duties under the Care Act. The message from local government and the wider care and support sector is that the situation is now critical and we need political agreement nationally and locally on the solutions. That is why it is important that we have a national debate about how we ensure high-quality, sustainable health and care services in future. With this in mind, I welcome the Government’s commitment to bring forward a Green Paper on social care by the summer.

In my closing remarks, I ask the Minister whether, further to suggestions being made by Members in the other place and by the noble Lord, Lord Macpherson, today, the Government are considering hypothecated tax for the NHS. If they are, will the option be consulted on in the Green Paper as the Government look at the funding model for social care? Our health and social care services are essential to the nation’s well-being. These services look after people when they need it most, care for them and help them live healthy lives. We need to work hard across this House, in the other place and with national and local government to find political agreement on how to ensure that we can continue to provide a high level of care for generations to come.

My Lords, I begin by thanking my noble friend for initiating this important debate. She exactly the right person to do so, bearing in mind her trade union background—as an official of a union which happens to be mine, serving public employees including various union members in the health and social care sectors. I also thoroughly enjoyed hearing the contribution of my noble friend Lady Pitkeathley, a real champion for carers, as was reflected in her speech. I have another reason to be grateful to her: together with the late Lord Alf Morris, she ably steered through this House my Private Member’s Bill, enabling it to become the Carers and Disabled Persons Act 2000. The limit on the speeches in this important debate is so restrictive that I can make merely a few points, with apologies to Carers UK, Age UK and others who have taken the trouble to give me material for my contribution.

I have long since advocated the merger of health and social care within one department. After all, they are one of another. It is clearly a step in the right direction, and I must say that some credit must go to the Secretary of State for standing up to the Prime Minister, who wanted to sack him. He has shown some muscle by standing his ground. We now know that he has the opportunity to flex those muscles with his new title embracing social care. But he must now ensure that cash follows this important step forward. If not it will be seen as just a gesture—merely a change in name with little substance.

Now we all await the long-overdue Green Paper, which should be followed quite quickly by a White Paper and an Act of Parliament, reflecting the true purpose of the 1947 Act. In truth, there is no clear definition of social care for it is so diverse—from cradle to grave, and taking in the current plight of our children who rank in the lower leagues of Europe and beyond. While Scotland and Wales face similar funding strains, they are coping rather better than England, having introduced measures such as banning smoking in playgrounds in Wales and developing stronger mental health schemes for children in Scotland. Child poverty is at its highest level in the UK since 2010, and measures need to be taken to ensure that the health of our children is not being put at risk.

At the other end of Mr Hunt’s responsibilities is tackling the plight of the elderly in our society. The care system in the country is close to breaking point, and it is estimated by Age UK that there has been a real-terms public spending cut of some £160 million to older people’s social care in the last five years. It goes on to point out that 1.2 million people aged 65 and over are in need of care and support, which represents an 18% increase on last year alone. It means that one in nine are living below the poverty line, which is a disgrace in one of the richest countries in the world.

I cannot conclude my remarks without stating something said by my former GP and vice-president of the BMA, Dr Kailash Chand. He points out that the Government’s health plans are based on the reverse of NHS principles; instead, the greater your care needs, the more you pay. In the case of social care, which is beset with multiple providers, there is less state provision and more privatisation. That is also my view. Mr Hunt now has a golden opportunity to prove his critics wrong, and I hope he can do that. He has the perfect occasion to do so when eventually the Green Paper arrives. So, Secretary of State, this is your chance to shine.

My Lords, I draw attention to my interests as a local councillor in the borough of Kirklees, and as a vice-president of the Local Government Association.

The stark facts are that in the last winter period, there were an estimated 34,300 excess winter deaths in England and Wales. That is a shockingly high figure and one on which I hope we will seriously reflect. Last October, a joint university research team found that of these excess winter deaths, around 8,000 a year may be caused by “deadly” levels of so-called bed blocking. NHS England regularly reports on delayed transfers, and the latest report cites a number of reasons for them: insufficient capacity in intermediate bed-based so-called step-down care; social care assessments and agreement with families for transfer to residential care; and delays in providing home care support for those who can continue to live in their own homes.

Leaving older people in hospital when they are able to go home has a very high impact on the individual, their family and other patients, as well as additional costs to the NHS, obviously. However, it is hardly surprising that these delays occur with such devastating consequences. Professional bodies and local government have been making it clear for many years that the funding of adult social care is at crisis point. As we have heard, the LGA estimates that there is a £2.3 billion per year shortfall in the funding necessary for adult social care. This figure is confirmed by work done by the King’s Fund. The result is that local authorities have been steadily reducing care costs and defining ever higher eligibility criteria. So across England, spending per adult resident on social care fell by 11% between 2009 and 2016—that is according to the Government’s own figures.

Ten per cent of councils have cut their spending on social care by 25%. Think about what that means to vulnerable older people who need social care in those areas. Councils serving more deprived areas have had to make even deeper cuts to social care budgets, despite clear evidence of efforts to protect social care spending. The more deprived an area, the higher reliance on government revenue support grant, hence the larger the cut in the spending power of these councils, as the Government, year on year, cut the revenue support grant to fund them. Local authorities have had to respond to much reduced budgets by putting pressure on the costs of local authority-funded residential care and home care. The result is not surprising: care homes cross-subsidise by higher payments from self-funders. That is a scandal waiting to hit the headlines.

Rationing has resulted in the number receiving care falling by 25% between 2009 and 2014—and I am sure that that has risen in the couple of years since then. Consequently, older people are struggling for longer on their own and the tendency is for this to escalate into more acute episodes requiring acute care in hospital. It is quite obvious that a significant part of the solution is for the Government to provide adequate funding for adult social care.

The Government’s response to this crisis of funding has been woeful. A much-publicised £2 billion has been added to the social care budget, but that is over three years—in other words, a mere £600 million a year in the face of a need for £2.3 billion a year. The additional £1 billion provision in the 2017 Budget has come with very long strings attached. A lot of it has gone not to adult social care budgets but to the better care fund, which is about collaboration between the NHS and social care services. The Government have decided, in the face of this funding crisis, to put the burden of social care costs on to what they have previously described as “hard-pressed council tax payers”.

Councils are able to charge a 3% social care precept for two years, but council tax is a regressive tax system that takes no account of ability to pay. Furthermore, a council tax rise of 1% raises very different amounts according to the rateable values in the council district. So 1% in my own borough of Kirklees raises £1.6 million, and a 3% rise barely covers inflation. The consequence is that Kirklees Council will, reluctantly, further reduce expenditure on adult social care this year.

The Government have enhanced funding for the NHS and social care through the better care fund but, in my experience, the NHS and local authorities have, quite rightly, used this fund to develop more collaborative approaches, which do not impinge on the immediate crisis. Does the Minister accept that adult social care funding needs to be substantially increased year on year to meet the shortfall predicted by 2020? I look forward to him providing some positive hope in the promised Green Paper of the Government’s willingness to accept the crisis for what it is: a consequence of inadequate funding.

My Lords, I draw attention to my interests as outlined in the register. I thank the noble Baroness, Lady Wheeler, for securing the debate on this important topic and for her excellent speech which, together with that of the noble Baroness, Lady Pitkeathley, and others, covered some areas which I will now not repeat. This topic should be of concern to all parties in this House, given the public’s expectation of access to high-quality provision, not only of healthcare but of social care.

Some 40 or 45 years ago, when I was at school, I read in a series of papers about the scandal in mental hospitals. It really encouraged me to go into mental health nursing and improve the lot of people who now no longer suffer in that way in institutional care. However, in the Times last week, there was the headline:

“A million lonely pensioners left to starve in their homes”.

A group of MPs from across all parties have talked about this. We are beginning to create what we had in institutional mental hospitals 40 years ago in people’s own homes, where they are even more isolated and alone than those who were in the system that I worked to change.

In all four countries in our United Kingdom, patients are waiting in ambulances or on trolleys in A&E prior to the full assessment of their conditions. One reason is that our acute hospitals are full, with bed occupancy rates of higher than 90%—completely different to the international recommendation that 80% to 85% is a safe way to practise. We know, as others have already outlined, that this is frequently because patients who are deemed fit enough for discharge are not fit enough to go home without significant levels of social support and care.

Rural England reported earlier today that, in Cornwall, there are on some days 60 people in hospital who are ready to go home, but part of the problem is that it is difficult to recruit home carers. Is that a surprise, when these carers are on less than £9 an hour and are not paid to travel, particularly in rural areas? At least when I was a district nurse I was paid for my travelling time. Patients are therefore held in ambulances, although with excellent paramedic care and support. Yesterday, South Western Ambulance Service NHS Foundation Trust told me that this costs about £66 an hour for individual ambulances and the clinical crew. Let us compare that to the £9 an hour for carers—if we could just turn the system around, could we not improve for the same amount of money? We know that people wait for long periods for discharge from hospital, which costs a minimum of £450 a day. We need a coherent total systems approach to health and social care. How can we do this? Well, is it not time for the Department of Health and Social Care to reimagine community services, as the recent King’s Fund report suggests?

As a short-term measure, we could set up some pilot sites, with acute trusts given the funds and authority to purchase and maybe even provide community support, including residential and nursing homes, for the first six weeks after discharge. Indeed, we could set up success measures to see whether we can reduce social isolation, enhance older people’s nutrition and thereby reduce admissions.

We need not only to remember that the current situation is affecting social care but to think about the perception of those whose planned operations have been postponed. These elective operations involve both young and older people, perhaps waiting for a simple hernia repair or orthopaedic operation. How do they feel about our NHS? Surely they would rather have innovative solutions than stay with the status quo. The issue of intergenerational fairness and a potential hypothecated tax was raised by the noble Lord, Lord Macpherson. We will turn the next generation off the health service unless we can provide the care they need as well as the care for their grandparents.

What plans are there to consider more innovative pooling of health and social care budgets, to provide the best seamless care for our people, and to reduce the stress caused not only to patients but to NHS and social care staff in our hospitals and community teams who—believe it or not—want only to provide high-quality services to those they serve? These are the questions that our staff want answered and we need to answer to encourage recruitment and retention in our vital services. I have given some of the simplest costs in financial terms that the public would understand, so surely a reorganisation with a community focus for older people’s care may enable better services for the same cost. This of course also includes suitable housing for frail elderly people and, possibly, NHS nursing homes.

Finally, does the Minister agree with a summary in a paper on economics from the BMJ last year, which concluded that spending constraints, especially for personal social care, were associated with a substantial mortality gap? The paper suggested that spending should be targeted on improving care delivery in care homes and people’s homes, and on maintaining or increasing nursing numbers.

My Lords, I remind the House that I am a family carer, retired psychiatrist and a past president of the British Medical Association, whose work I will refer to during my speech. There has been a lot of talk and publicity about the pressures on what are termed acute services. We have all seen the television images of trolleys and the problems in accident and emergency and so on; they make headlines and they are provoking debate—and I welcome today’s debate. One solution will indeed be a focus on the problem of delayed transfers of care back to the community. Without taking attention away from these important areas, I want to highlight similar concerns within mental health services, which seem to me to be as acute in nature as those described in general hospitals—although, in truth, they are not just confined to winter.

The British Medical Association’s bed occupancy report highlighted particular problems with high bed occupancy and delayed discharge in mental health settings. It identified the main reasons for delayed discharge as being a lack of suitable community services or facilities to support patients at home and a lack of available beds within local community or specialist facilities. Of particular relevance, given the ongoing review into the Mental Health Act, the BMA report noted an association between the reduction in mental health beds and the increase in the number of patients admitted following detention under the Mental Health Act, with the balance shifting towards a more acutely ill in-patient population. It seems sometimes that people have to be sectioned to get a service, even if perhaps that might not otherwise have happened.

In December 2017, the mental health charity Mind published its survey of over 1,000 people discharged from mental healthcare facilities and reported that patients found planning for their discharge was rushed and unsatisfactory, and that around half of patients experienced inadequate planning and support with housing and finances before discharge. If I had more time, I would give noble Lords some examples. Given these issues, it is surprising that the framework in the care Act for addressing delayed transfers of care seems to overlook patients with mental health conditions. One of the mechanisms to promote integration and co-operation between the social care sector and the NHS is the system of local authorities reimbursing the NHS for a delay in transferring care. This system is viewed as an incentive to improve joint working between health and social care. However, the provisions do not apply to mental health care, which is explicitly excluded from this framework. In fact, I understand that the only way a mental health patient may benefit from this framework is if they are unfortunate enough also to develop a physical illness that requires treatment under an acute medical consultant, but of course, ensuring adequate care planning for someone with a significant long-term social care need who also has an acute medical condition requires additional time and skill.

By no means do I think that fining local authorities is the sole mechanism for integrating social care and the NHS. The issue is rather more complex than such a blunt measure could resolve. However, that it is excluded from this framework suggests something about the way mental illness is prioritised compared with physical illness. If increased integration and co-operation between the health service and social care is what is needed for physical illness, why is it not also prioritised for mental illness? If the reimbursement provisions in the care Act are felt to drive integration and co-operation for those with physical illness, why not apply it to mental illness also?

While my amendment to the Health and Social Care Act 2012, on parity of esteem, may have helped to raise concerns and awareness of mental illness and parity of service provision, and outcomes are now regularly raised as critical goals in a modern health and social care system, this debate highlights yet another area where it is partly missing. Although I am very grateful to the noble Baroness who initiated the debate for referring to these issues, what worries me when we hear talk of winter pressures, black alerts in hospitals and crisis management is that it is in this environment that those with the most complex health and social care difficulties can be overlooked. Whether we expected such problems in advance or not, this is not an environment where we can deliver the best care for the most vulnerable people. Care services for vulnerable adults need to be part of a long-standing sustainable system. We cannot rush their discharge just because it happens to be winter. In fact, it is at this time when we should be most careful about discharge planning. Do we have more social workers, community mental health workers, community care placements and district nurses during the winter season in order to pick up the work from the overstretched general hospitals, or do we just settle for less robust discharges? If the latter, then clearly, those with complex mental and physical needs will suffer most—the very people who often find it hardest to make their voice heard.

A sustainable health and social care service cannot run at two different speeds: one for summer and one for winter. Careful, considered, joined-up care is needed all year round. This care does not suddenly appear when a winter crisis is identified.

My Lords, I welcome this debate. Thankfully, much of what I wanted to say has been said by the noble Lord, Lord Macpherson of Earl’s Court. I wish that more Treasury mandarins like him retired, came here and became progressive. We would welcome that.

However, at the bottom of this crisis, which is not new but occurs perennially, is the fact that we have undertaxed ourselves and refused to raise the resources necessary to enable a civilised society to look after itself. We have not taken on board the seriously high cost of living longer. Our pension systems have been wrecked by that because, when we started them, we thought that people generally lived about 10 years beyond retirement. However, if people live 30 years beyond retirement, the pension system is wrecked. I agree with the noble Lord, Lord Macpherson—indeed, I do so because I proposed this measure—that there should be a hypothecated tax system and national insurance contribution, as he said, with much stiffer taxation for self-employment, which I think is a species of fraud practised upon the tax system. Indeed, in the Budget before last, the Chancellor tried to tackle that problem but he was shot down in no uncertain terms. We have to stop believing that tax cuts are great, borrowing is bad and that somehow in between we can finance a welfare state. Therefore, we should definitely have a hypothecated tax.

We should also tackle the financing of local councils. We have a tax, the council tax, which is, of course, regressive. But worse than that, it is frozen at old levels of house prices. We proudly proclaim how much house prices have gone up but for many years we have not taxed the capital gains that home owners have made. It is time that we tackled that question. Some noble Lords will remember that it was when we had to revalue properties in the light of the rise in prices way back in the Thatcher Administration that the entire fiasco of poll tax happened because of the timidity of that Government in revaluing property. Again and again, Governments have not revalued property and therefore council finances have suffered. It makes no sense whatever. We need a serious revaluation of private properties. You may keep the council tax rate the same, just move the bands up. A lot of people would move up the bands: that is the reality. If people pay the appropriate tax, they will receive good social care in return, so they would not lose anything. As I say, we need a hypothecated tax and we need a revaluation of council tax.

Something was revealed to me last week in a report of the National Audit Office on the PFI and all those things. The Carillion disaster has coincided with some early nights so I read that. When PFIs were proposed, it was quite clear that it was a piece of imaginative accounting and the Government could borrow off the balance sheets and pretend that they were being fiscally responsible but at the same time hiving off a huge debt. The important point is that that borrowing was very fruitful for the NHS. We need that kind of borrowing to expand hospital capacity and the health and social care infrastructure. Whether you do that kind of borrowing under a PFI or openly is a question we can go into. But given that currently the rates of borrowing are very low, now would be a chance—perhaps the last chance very soon—to borrow a lot of money dedicated to improving the health and social care sector. We cannot go on complaining about winter deaths and not pretend that it is the lack of resources which is causing this problem. So we need more taxation. I was sacked twice from the shadow Front Bench for proposing more taxation, and that was in the Labour Party before new Labour. I do not want to get anyone sacked but I think it is still worth saying that we are an undertaxed nation and we are paying the price for that.

My Lords, I declare my interest as president of the Local Government Association.

“Our NHS … is in crisis and the adult social care system is on the brink of collapse”.

These are not my words but the opening line of the report of the ad hoc committee The Long-term Sustainability of the NHS and Adult Social Care. Chaired by the noble Lord, Lord Patel, it was published in April of last year, and as we heard earlier, we have still to see a response from the Government. It would be good to hear from the Minister when that response will be received. The recent headlines have focused on the intense pressure on the NHS. Today’s debate provides a welcome focus on the less visible but no less important issue of social care, and I am very grateful to the noble Baroness, Lady Wheeler, for organising it.

My first and most important point is that we do not simply have a winter crisis. We have a crisis of funding in the NHS and social care, which has been brought into sharp relief by the additional pressures of winter. I have no doubt that every effort has been made nationally and locally to prepare for winter. There are certainly some excellent individual examples of local services taking action to minimise hospital admissions and delayed discharges. But the issue here is systemic and not seasonal. Without action to address the fundamental issue of funding, no amount of work locally, excellent though it is, will stop the problem from getting worse. In the meantime—this is a crucial point—we are putting intolerable pressure on the system and the people who work in it.

A lot has been said recently about the shortfall in NHS funding. I will simply quote what the very well-respected chief executive of the King’s Fund, Chris Ham, said in a blog he shared with me at the time of the Budget last year:

“In the 40 or more years I have worked with and for the NHS, I can’t remember a time when the government of the day has been so unwilling to act on credible evidence of service and funding pressures”.

Put simply, the Government are in denial of the scale of the problems. But, as the LGA put it so well in its brief for today’s debate, there cannot be a sustainable NHS without a sustainable adult social care system, and, in my view, the current position is not sustainable. Give or take a bit, social care—adults and children—takes up about half of local government funding. Since 2010, local government spending power has been reduced by around a third. The brunt of this reduction has been borne by staffing reductions and cuts in universal services such as highways maintenance and libraries. Children’s care pressures have, if anything, increased in that period. So it does not take a great mathematician to see that however hard local government tries to avoid reductions in adult social care—and I know from personal experience that it does—cuts will be inevitable. The extra money and the increased flexibility on council tax are welcome but, as others have said, they are nowhere near enough. Crucially, the LGA has said that by 2020 there will be a £5.8 billion funding gap in local government as a whole, of which, as we heard, £1 billion is to do with social care, and we have another £1.3 billion of pressure on the provider sector.

Many people have said that this problem can be solved by simply bringing the funding streams together. By giving control to one Minister, the newly named Secretary of State for Health and Social Care, local government can somehow be “brought into line” on delivery. I urge extreme caution on this. First, the squeeze on local government is across all aspects of its funding. People want to see clean streets and maintained roads too. You cannot simply deal with social care in isolation from the rest of local government finance. Secondly, because of the increased retention of business rates, most if not all local authority income will come from locally generated and retained income sources. It will not be in the gift of any government department to give control over that. So bringing together health and care is a good thing, which results in better and more joined-up services. But it will not solve the funding gap.

Money is not always the answer. But in this case it is inevitable and essential that it is provided. We need an immediate cash injection to stabilise the system, but we also need a royal or cross-party commission to look at the longer term. We must engage in a debate with the public on what kind of health and care system they want, how much it will cost, and how we should pay for it. Like the noble Lord, Lord Macpherson, my view is that it should be a hypothecated tax on both income and wealth. But let the commission decide on the options. We might then, with that commission, be able to address the urgent questions set out in the Select Committee’s excellent report.

My Lords, I too welcome this timely debate, which has been initiated by my noble friend. I declare an interest as yet another vice-president of the LGA—that makes three of us so far, and our president has spoken. I am also leader of Wigan Council and chairman of the Greater Manchester Health and Social Care Partnership, so I can see these issues from both sides—although whichever way you look at them, it is not a pretty sight.

Reading in the press about the daily problems in A&E, it is tempting to talk about a winter crisis, as many noble Lords have done, but like the noble Lord, Lord Kerslake, I think that this is not a winter crisis but symptomatic of the general crisis in health and social care. Fundamentally, it is caused by the ageing population—which should come as good news in your Lordships’ House: we can live longer—but obviously that puts pressure on both the health and social care sectors. We have not commensurately increased money for the health service to reflect the increased pressure that comes with an ageing population, and in social care, as we have heard, there has also been a reduction. Although noble Lords have concentrated on the revenue side, it is also true of the capital side. To refer to one example, Watford General Hospital was built and designed to take 45,000 to 50,000 admissions per year. It currently deals with 90,000. Is it remarkable, then, that it has had to use corridors and other places to deal with admissions?

Workforce issues are key in the NHS. Although we know that the NHS suffers shortages generally, it is particularly true in A&E, which is not the most popular area for people to go into. It has been said that we are 2,000 consultants short in A&E, and of course the numbers in nursing are going down too. As we saw in the report last week, the numbers leaving the nursing profession outweigh the numbers going in. Although that is caused by a great number of factors which I will not go into, it puts severe pressure on those who remain. Finally, there is a lack of integration between health and social care.

Now that the Secretary of State has acquired an additional title he will discover that funding is the most fundamental issue he faces in social care. Colleagues have talked about the quantum of money. That is important but we should also remember to ask who will pay for social care. The Tory party made a bit of a mess of it in the last general election when it tried to talk about how much individuals should contribute to social care. The Tory party is very unclear on that point. In the short term, the Government have tried to put more of the burden of paying for social care on to local taxpayers: instead of putting up general taxation, they have put up local taxation. The noble Baroness, Lady Pinnock, mentioned one aspect of the regressive nature of council tax. I could spend all of my allotted time here or longer talking about reforming council tax—a subject referred to by my noble friend Lord Desai. It is something that I have long advocated.

The other issue is that the council tax situation between local authorities is unfair. For example, many northern authorities like mine have more properties in the lower tax bands than do other places. Therefore, a 1% increase in council tax gains six times as much in Richmond and five times as much in Windsor and Maidenhead as it does in my authority. We might say, “Well, we’re all giving 1%”, but that 1% raises very different amounts of money, and that cannot be justified.

Although health and social care needs more money, the fundamental problems are such that we cannot just put more money in. We need to change the NHS from being an ill-health service, which, on the whole, it does pretty well, to a proper health service. I wonder whether anyone has read the recent report on children’s dental health. We are spending money on repairing and replacing children’s teeth instead of simply getting them to clean their teeth. Yesterday’s Times reported on lifestyles which are likely to cause long-term problems. People will be four or more times likely to develop chronic conditions by the time they get to 65, and that will mean more pressure on the NHS. Unless we put more effort and energy into prevention and early intervention, the extra demand will eventually overwhelm not just the NHS but government overall.

I do not want to end on too desperate a note—there are reasons to be cheerful. In my authority, the use of transformation funds from Greater Manchester will make a difference. We are working to keep lots of vulnerable people in care homes. We have a 180-bed care home which we think has saved 36 people from going to A&E. We are also working with GPs, many of whom have to deal with what are really non-medical issues, such as housing problems, fuel poverty and loneliness. Those are issues where GPs try to provide medicines but those are not the answer. We need to turn the system around. That is a real challenge and we need real leadership to do it. I hope that the Secretary of State is up for it.

My Lords, I too congratulate the noble Baroness, Lady Wheeler, on securing this debate and on her elegant demolition of the Government’s winter planning. I also welcome the conversion of the noble Lord, Lord Macpherson, to hypothecated tax—having left the Treasury—as well as his rather telling analysis.

Each night the BBC brings us the latest bulletin on what is happening in our hospital, GP and ambulance services up and down the land. Sick patients wait on trolleys and in cubby-holes for a doctor to see them; ambulances queue to discharge their patients and then cannot leave because they cannot get their trolley back; cancer patients wait longer and some probably die sooner; and surgery waits lengthen as more operations are cancelled. Welcome to Britain’s 21st century NHS, often said by Ministers to be the best in the world. What the Government have achieved, I suggest, is to make Hugh Pym a household name.

This winter’s crisis has highlighted how dysfunctional our health and care system has become and how difficult it is for staff to work in it. Committed doctors, nurses and a multitude of other staff are being driven to exhaustion and burn-out. Their good will and professional commitment are being taken for granted and will not last—they are rapidly evaporating. We are now well past the point where the promise of a Boris £5 billion bung in a glorious post-Brexit future will encourage the staff to stay. What people working in the NHS and social care want to see is a credible and funded plan for fixing a broken NHS business model, and rebuilding and aligning the social care system effectively with the NHS.

The Government remind me a bit of Blackadder waiting for Baldrick to come up with a cunning plan. Even when they were given a respectable route map by your Lordships’ Select Committee last April, they did not seem to know what do with it. Ten months later we still await a response. The 2011 Dilnot proposals for capping individual liability for care costs was legislated for and then abandoned. Social care reform has been kicked into the long grass following the election campaign fiasco. We now have yet another review, which almost certainly will delay any substantial reform until the early 2020s. Sadly, I think that this Government are so preoccupied with Brexit that they lack the bandwidth to get to grips with the complex and difficult problem of making our NHS and social care system fit for purpose for 21st century needs.

Yet the narrative on social care is appalling. There has been a 25% to 30% real-terms funding cut since 2010, and that is only starting to be reversed this year. The shortfall from these cumulative cuts will never be made up. The absence of further funding in the Autumn Budget and the local government finance settlement means that a further funding gap of £2.3 billion is now emerging. Those are not my calculations; that is according to the Conservative-led LGA.

Hundreds of thousands fewer people now get publicly funded social care than in 2010, and the numbers are continuing to rise. Furthermore, thousands of care beds have simply disappeared from view. In this situation, why should we be surprised that so many older people now turn up in A&E and hospital beds? The Government were warned repeatedly that this would happen, and now it has. It is inevitable that many local authorities simply will not be able to reach the Government’s totally unrealistic and “undeliverable”—not mine but the Conservative LGA’s word—expectations on delayed transfers of care from hospital. The Government seem reluctant to face up to what we have all known for some time—that a sustainable NHS requires a sustainable social care system.

If the Government want to avoid continuing NHS crises, they must start spending more money now on social care than they are currently planning to do. They must do this for the next three years or so while they work out a longer-term funding plan. That means probably allocating a further £5 billion to £6 billion over the next three financial years. In order to be a bit constructive, as a short-term expedient I suggest that the Minister and his colleagues start quickly to think about reducing hospital bed-blocking by funding more transfers of NHS patients to step-down care in nursing and residential care homes as part of NHS continuing care, instead of waiting for the unavailable care packages.

Finally, I want to say a few words about NHS sustainability, and this is where I share the views of the noble Lord, Lord Macpherson. No Government can have a sustainable NHS that meets the population’s needs without a plan for handling the unrelenting rising demand that has an unaffordable funding tab of a 4% increase a year. This Government have no such plan and, as far as I can see, nor do the Opposition. This Government have demonstrated that you cannot achieve NHS sustainability with funding increases of a little over l% in real terms a year for the best part of a decade and with no investment strategy for changing the wrong business model to meet demand. Unless we change faster the way that we deliver health and social care, we will be setting up the NHS and its staff to fail. We also have to ensure that when we give the NHS more money, sufficient of it is ring-fenced for investment and that it does not go towards propping up the present system.

My Lords, I too am grateful to the noble Baroness, Lady Wheeler, for initiating this debate and to everyone who has participated in producing a set of solutions which, if they were brought together, would solve the problem. I feel sorry for the Minister, who has had little support from any quarter today for his problem.

Everyone knows that much more money is needed. There is a 2% gap that needs to be filled and one way or another we have to find measures—basically through taxation—to meet that need. We also need to look for other ways in which funds can be raised in which we might involve the wider public so that, in turn, we get a greater recognition—to pick up the point of the right reverend Prelate the Bishop of Carlisle—that there has to be more responsibility for the NHS across a broader front. It is not only an issue of the Government providing the money but of how we care for ourselves and each other, of how families care—or do not care—for the elderly, and of how families pay for the elderly or refuse to do so because they want to keep the house for themselves in due course. When these issues are raised, there is a row and people run for cover because they are far too difficult to address.

As the noble Lord, Lord Smith, said, I hope we can spend some time addressing the winter problems, but we see these problems all year round. I bore the House to death when I go on about alcohol and A&E and the costs involved. When the Minister took his job, he said that he was going to stamp down on drunkenness in A&Es. I would like to see some evidence of that because the papers were full of such issues over the Christmas period.

Substantial numbers of people go to hospitals and A&E when they should not be there. I am probably the only Peer here today who was in an A&E department on Christmas day, when we had a family incident. I was there at 10 o’clock through until three o’clock in the morning before the family member was moved into an acute assessment ward and kept in for five days. We were not overrun, to my surprise, by the number of people I had anticipated being in A&E. However, given the relatively small number of patients there, we were, to a degree, overrun by the number of friends and relatives who went along with them. There were four or five people with each patient, creating noise on mobiles, causing confusion and making it much more difficult to manage the A&E. Some simple things need to be addressed. Why do we need so many people going into A&E when it causes a delay in patients being dealt with?

Similarly, when we got to the ward there was very little management and it was difficult to determine who was in charge. People were coming in, shouting and screaming down their mobile phones, and patients were surrounded by four, five or six people spending three, four or five hours in there. If people wanted to make a complaint about it, there was nobody around who was able to address the issue and slow it down. Hospitals used to be about patients, peace, calm, serenity and recovery. During that week, I was in that hospital every day—my Christmas was lost—and my experience, in many respects, was that I was in a place of riot and chaos. It should not be like that in a hospital. It would cost very little money to put this right, but it needs addressing. I know it is a minor issue compared with what we have debated today.

I return to the topic of alcohol. Cheap booze is a source of many of the problems within A&E—not only at Christmas but throughout the year, from Thursday evenings through to Sunday—and that has to be addressed. It is amazing that the Chancellor is struggling to find money for the NHS and yet, on the other hand, he is freezing the regulator in terms of increasing the cost of alcohol duties. He is making alcohol cheaper on the one hand and on the other is struggling to find the cash to keep people well. We now have more people drinking less but certain categories of people drinking more. More people are now going into hospital with less alcohol being drunk, and the price of alcohol, in the main, is going down rather than up. Fairly simple action could be taken on that by adjusting taxes. This would put it right and we would have a good response all the way round. We should apply it across the board—for example, with sugar and a range of other issues. We should look at the polluters who cause the problem to see whether they could make a greater contribution.

At the end of the day, much of this comes back to public health campaigning and how we look after ourselves and each other. Regrettably, the amount of money which has been spent on public health has been cut over recent years. We need to review that and start looking at ways in which we can help people to look after themselves better in the future, live longer and lead better and happier lives than they are doing at the moment. That requires bold decisions, frankness and honesty, which, regrettably, so far the Government have not been prepared to engage in.

My Lords, this has been an interesting debate. There are many experts and much experience in this House. There is also a great deal of passion and it is not surprising that there is a lot of agreement.

I start by thanking all care workers who, on low wages and often with little thanks, do a splendid job, day in and day out, whether in a hospital, residential or nursing home, or in a domiciliary setting. There are 1.4 million people employed in social care roles, caring for more than 1 million adults. The winter period is often challenging. Certainly in the rural area where I live, these people have to cope with bad weather, dark morning starts and dark evening finishes, and, invariably, with clients who are less well.

The other unsung heroes in the world of care are the carers. I echo the call of the noble Baronesses, Lady Pitkeathley and Lady Wheeler, for the carer strategy and the action plan, long promised and long overdue. These carers are selfless family members or friends, who often work without help, payment or support, rarely getting respite.

The carer’s allowance, for those who take it—a lot of people are not even aware that there is an allowance that carers can take—is £3,260.40 a year. The winter bit is that there is a £10 Christmas bonus. I wonder: do we value our carers? Your Lordships will know, because the noble Baroness, Lady Pitkeathley, reminds us on a regular basis, that were this huge army of carers to be paid just the living wage, it would cost the Exchequer much the same as the annual national health and social care budget. That is their value, but what are they worth?

Recent research shows that more than half of us believe that we do not know a single family member or friend who cares, while as many as three in five believe that they do not know any work colleagues who help look after a loved one. In reality, one in 10 people in the UK are carers and one in nine people in the workforce are juggling their paid job with unpaid caring. I remind the House that the Care Act calls for carers’ needs to be assessed alongside the needs of those they support. Could the Minister tell the House when the most recent report on this was published? Is this being met right across local authorities? When would he expect the next one, so we can measure improvement?

The solution to many problems is more money. More money can mean more staff and new preventive ideas. It could ease the way for primary care and community care to work more coherently with local social services. I acknowledge that more money has been made available to the care and health systems over the winter period. The better care fund increased social care funds by £4.4 billion over three years, as well as the adult social care support grant of £240 million in 2017-18. But work needs to be done in many parts of the country to improve existing systems—to look into data sharing between health and care as a matter of urgency, for example.

Before I address delayed transfers of care, I will talk about the reduction in social care support. Social care budgets have seen an estimated loss of more than £6 billion since 2010. Between 2010-11 and 2014-15, spending on social care fell by 7% even as demands increased over the same period. The social care precept allowed local authorities to raise council tax by up to 2%, and in December 2016 this was raised to 3%, but, as my noble friend Lady Pinnock and the noble Lord, Lord Smith of Leigh, explained, this tax is inherently regressive in its structure. Local councils in poorer areas are not able to levy an effective council tax as easily to meet social care demands.

Cuts to local authority funding, rationing and a reduction in the level at which support is available have reduced the number of care packages. This will invariably increase the likelihood that someone will become frail and so, when falling ill, will need hospitalisation. If care packages can enable someone to look after themselves, they often avoid going into hospital. Ironically, often self-funders fail to pay for as much support as they need. They can find themselves less able to self-manage and find themselves admitted.

There are financial and physical costs of the delayed transfers of care. The estimated annual cost to the NHS is around £820 million each year and the loss of 1.15 million hospital days in acute treatment—up 31% compared with 2013. There are physical costs. Each additional day in hospital is a higher risk of infection and rate of readmission. The amount of strength lost per day in hospital—I am talking about muscle strength of an elderly person—is up to 5%. Delayed transfers of care seem to hurt twofold: once on the bed shortage, but again on muscle loss. If elderly patients lose up to 5% of their muscle mass daily and constitute the majority of patients under delayed transfers of care, the NHS could indirectly be contributing to a number of falls and hip fractures in the long run.

A lot of delays are attributable to the NHS, with 58.3% of all delays in November, compared with 34% to social care, and 7.6% jointly, with social care’s share slightly falling over the last year. The noble Baroness, Lady Watkins of Tavistock, spoke about the primary reason for social care delays—35.4%—being due to patients awaiting the care package in their own home. Will the Minister explain why there is not enough capacity in the system? Could this be due to a fall in private investors who no longer see this as a good investment? What is the solution? We all know that local authorities have responsibility for market shaping, but what if the market does not wish to be shaped? Where do we find ourselves then?

I shall put in a plug for the local community hospital. Those in my own backyard in Cornwall, having been saved from cuts in 1996 in advance of the 1997 general election—I remember Frank Dobson coming down and waving his magic wand—are now coming into their own as a safe place to transfer patients to when they no longer need medical care but do need nursing and rehab. Additionally, they are a resource for the GP, who can admit a patient for as short a time as a few days to see them over a crisis, rather than have them go into the local acute hospital.

Integration of health and social care is the holy grail of care. We watch with interest devo-Manc, where there is a commitment to integration of health and care, and Cornwall, where there is a move to make the CCG a department of the council. We should also note that Torbay has been working for years like this, now under the auspices of the Torbay and South Devon NHS trust, which states that it provides acute health services, community health services and adult social care. It is not rocket science; others have done it.

I was surprised, and then on reflection pleased, that the Department of Health was to be renamed the Department of Health and Social Care, despite the fact that the Secretary of State has always had responsibility for social care albeit with the support of a Care Minister. However, I am disappointed that, since Mrs May became Prime Minister, the Care Minister has not been a Minister of State—what message does that send us? That particular Minister of State historically has also looked after mental health. Those are two areas where you need somebody with a bit of oomph in the department.

In the first week in January, an article in the Financial Times written by Sarah Wollaston, was headlined:

“Only political courage can save Britain’s health service—It will take a cross-party approach and a willingness to put public interest first”.

Along with others, we on these Benches eagerly await the Green Paper on social care funding and ask the Minister what other topics will be in it. Will it become a portmanteau paper?

But do the Government have the willingness? My honourable friend Norman Lamb visited the Prime Minister along with Liz Kendall and Sarah Wollaston to ask for her support in this cross-party look at the issue. They also asked her to consider raising income tax by a penny in the pound, which would raise £6 billion, which is the gap between where we are and where we need to be financially. Indications suggest that the public would warm to the idea. They see the system creaking and feel it is the least they could do. Those of us on these Benches agree.

My Lords, it is a great pleasure to respond to my noble friend’s debate. As my noble friend Lord Smith mentioned oral health in the north-west, I remind the House that I am president of the British Fluoridation Society, which of course is the answer, at a stroke, to the dreadful oral health issues among children in Greater Manchester and the north-west generally.

My noble friend Lady Wheeler made a persuasive speech about the pressures that the NHS is under and the relationship between that and front-line social care. The latest figures on performance graphically illustrate this: in 2017, 16.5% of patients spent more than four hours waiting for treatment compared to 5.6% in 2012. On delayed transfers of care, there were 1.97 million delayed days in the first 11 months of 2017 compared to 1.26 million in the equivalent 11 months of 2012. The 18-week referral-to-treatment target for consultant-led treatment has not been met since March 2016. The 62 days from referral to treatment target for cancer has been met for only one month since April 2014. The number of cancelled operations is going up, as are ambulance response times—the new target of seven minutes for life-threatening calls was not met in its first month of operation. Occupancy levels in hospitals have become a hugely difficult issue. On 2 January this year, 57 of 137 trusts had bed occupancy above 98%. That means not just pressure but almost certainly unsafe practices in those situations. The Secretary of State, who has made quite a lot of noise about safety, needs to take stock of his own responsibility for the fact that there are now some very critical situations in the NHS where undoubtedly patients are vulnerable.

If the Government were at least open about this, we could have a proper debate, but, as the noble Lord, Lord Kerslake, said in quoting Chris Ham—who knows a thing or two and goes back quite some way—it is the Government’s denial about the scale of the problems faced that makes it so difficult to debate with them and have any meaningful discussion about the way forward. I think all noble Lords agree with my noble friend Lady Pitkeathley that the NHS crisis is also a crisis of social care. The information we received from the Association of Directors of Adult Social Services, saying that 90% of councils are able to respond only to people with critical and substantial needs, is telling, because we know it means that we are storing up even more trouble for the future because we are not intervening at a stage where we could help people. The report that we saw from Age UK and the chair of the Malnutrition Task Force said that only 29,000 people now receive meals on wheels, down from 155,000 a decade ago. No wonder it is said that 1 million older people are starving in their own homes. That is the scale of the problem that we face.

The noble Baroness, Lady Wheeler, in talking about the experience of carers, really brought this home to us. As she said, emergency care and hospital admission and then discharge is a make or break time for carers and their families. People like her become carers for the first time when this happens. Despite all the guidelines and good practice, most discharges take place with very little notice, particularly when there is such pressure to free up beds to make way for patients who are waiting in A&E, on trolleys or, indeed, in the ambulance, waiting to be seen in A&E.

My noble friends Lady Pitkeathley and Lord Pendry talked about the impact of carers and the problems they face for their health. I hope the Minister will respond to this question: if we cannot produce a carers’ strategy, can we at least have an interim action plan? Let us not just hide behind a Green Paper, which, frankly, I do not think we will see for many a month, if at all. I suspect the problem is that the Treasury will not agree to any proposal that is not along the lines of that which Mrs May proposed during the last election, which caused such concern.

Capacity is a major issue. The pressure is increasing but NHS capacity is reducing. Could the Minister explain why that is happening? I should also like him to reflect on STPs. There was a time when all the answers to all the problems were to be in the sustainability and transformation plans, which then became programmes. We do not hear so much from Ministers about STPs now, but the health service is trundling on because no one has told it to stop work on them. We debated here a few months ago the west London STP, which is a remarkable document. Because financial balance by 2021 is the imperative, it is essentially taking a great deal of capacity out of west London and then saying that through heroic demand management, which we have never seen before, everything will be all right. Most STPs repeat this because, basically, they have been told by the regulators that they have to come up with a plan that meets financial balance. I do not think Ministers believe in them anymore, but they used to believe in them; they used to say that they were the answer to the problem—but everyone out there knows that they are pieces of fantasy, which will never be delivered. I pray in aid the National Audit Office report, which came out in January and said:

“Local transformation of care is being hampered by a lack of resources and ongoing pressure to make increasingly tighter finances balance each year”.

So they are reducing capacity, but not producing any investment to develop other services, which would then help to reduce demand on acute care. So there is no hope whatever of achieving anything that these STPs say they will do.

We then come briefly to the new role of the Secretary of State. Will the Minister explain what that new role is? He knows that his department has been responsible for social care for decades; he also knows that the Department of Health negotiates the adult social care vote, albeit that then goes through DCLG. So what is changing? Is the Department of Health now to have the money for social care and is that then to be ring-fenced as an allocation to local authorities? If not, has there been any change at all in the Secretary of State’s responsibilities? I think we ought to know.

I accept, and my noble friend Lord Smith and the noble Lord, Lord Kerslake, explained, that it is not simply a matter of having integrated health and social care budgets. First, you have to deal with the gap between free-at-the-point-of-use NHS spend and means-tested social care spend. Until you deal with that, integration is very hard to deliver at local level. Secondly, you cannot look at social care budgets without looking at the overall spend and discretion of local authorities. Adult social care is probably the biggest discretionary spend they have: if you start to intrude on what they can do, it is very difficult to see how local authorities have the flexibility at the moment to be able to manage the rest of the local authority responsibilities. This is not at all easy.

The noble Lord, Lord Macpherson, spoke very articulately about the pressures on government finance in general. He said we could do with better management and I agree: the system needs to be reformed. I also agree with my noble friend Lord Brooke about the way hospitals are run. The hypothecated tax, informed by the OBR and based on national insurance contributions, seems to be a runner. His point about retired people having to pay national insurance was very well made. I have just been re-reading, or glancing at, the book by the noble Lord, Lord Willetts, about intergenerational fairness. Reflecting on my noble friend Lord Desai’s willingness to increase taxes, which I agree with, it is very difficult to say to younger people, “We are going to increase your taxes to be spent largely on a service that provides for older people”, when you have the current benefits for older people. This is a controversial statement to make from this Dispatch Box, but inevitably this has to be confronted. I am hoping to join my noble friend in being sacked at this point.

I come back to the report by the noble Lord, Lord Patel. It is a very good report, published on 5 April 2017. “How long, O Lord, how long” before we get a response from the Government?

My Lords, I begin by congratulating the noble Baroness, Lady Wheeler, on securing this debate and bringing very welcome attention to the interaction between the NHS and social care systems. I am of course speaking on behalf of the newly minted Department of Health and Social Care and I promise that a focus on service integration is one that the Secretary of State and I, as well as Caroline Dinenage—who is Minister of State for Care, just to clarify that question—welcome and embrace. That is not, as we have discussed today, solely to deal with the winter pressures the NHS and social care systems face, but in order to provide a truly world-class health and social care system. Before answering the question that the noble Lord, Lord Hunt, asked about social care policy, this means that the department, through the Secretary of State and the Minister of State, are driving the reform process through the Green Paper, which was previously under the control of the Cabinet Office.

I congratulate all noble Lords on their contributions. I fear that there is sometimes a tendency in these debates—rightly, because we all want to solve problems—to focus on negatives. It was good to hear from the noble Lord, Lord Brooke, and I hope that the family member concerned is in good health now and having a positive experience of their care, even though the situation he describes is rather alarming; it is certainly something I shall look into. We know that the vast majority of care being delivered is of a high quality and of course, that is because of the wonderful health and care staff to whom we all owe so much.

I start where the noble Lord, Lord Desai, started—in the less controversial part of his speech—by recognising that many of our challenges stem from the fact that people are living longer, which of course is very welcome. It is a global phenomenon: worldwide, the population aged 60 or over is growing faster than all younger age groups. In developed countries the proportion of the population aged 65 and over is expected to rise by 10% over the next 40 years. What that means in England is that by 2026 the population aged 75 and over is projected to rise by 1.5 million, from 4.5 million to 6 million, and by 2041 to have nearly doubled to 8.3 million.

Funding social care and health services is of course a challenge that all developed countries face. One issue, as we have said, is longevity; the other is the likelihood of multiple health conditions. An arresting fact is that by 2025, the number of older people living with a disability could increase by 25%, while the number of people with dementia will increase by 50% over the next 10 years. That is one reason why the solutions we come up with in the social care system need to deal with some of the arbitrary distinctions in the way that older people with different conditions get dealt with by the current set-up.

As noble Lords have pointed out, that inevitably means that we must change the way we provide services. The traditional model of healthcare was reactive, set up to deal with infectious diseases. Now, we are dealing with long-term, complex conditions that incorporate not just physical illness, but mental illness, as the noble Baroness, Lady Hollins, pointed out. Equally, the traditional model of social care relies on admissions to care homes, whereas we know that people increasingly want that care to be delivered in their own home. That in itself brings challenges, as the noble Baroness, Lady Watkins, said regarding loneliness and that horrifying statistic of older people suffering malnutrition in the home. These traditional models need to change. They are expensive and tend toward silo working. We need to move to a system in which care is individually tailored to people’s needs.

I will come on to talk about winter, but I want to address the situation regarding social care funding, which has been the topic of so many noble Lords’ speeches today. We know and admit that local authority budgets have faced pressures in recent years. They account for about a quarter of public spending and they had to play their part in dealing with the historic deficit inherited by the coalition Government in 2010. That meant that social care funding was inevitably impacted during the last Parliament, but with the deficit under control, we have turned a corner. There were two Budgets last year. In the March Budget, the Government announced that councils in England would receive an additional £2 billion for social care over the next three years. I understand noble Lords saying that is not enough, but it is important to recognise that that, combined with other measures, gives councils access to over £9 billion over three years in dedicated funding for social care. That gives local authorities the ability to increase spending on adult social care in real terms to support and sustain a more diverse care market. As noble Lords have pointed out, that is incredibly important. The 2014 Care Act places obligations on local authorities and this extra funding is designed to enable them to meet those standards. The funding will also inevitably help to ease pressure on the NHS, including—as many noble Lords have pointed out—by supporting more people to be discharged from hospital as soon as they are ready. That is always important for patient welfare and safety, but never more so than at this time of year.

Winter is always challenging for the NHS in all four countries of the United Kingdom—not just this year, but in other years too. That is of course because cold weather and an increase in flu and other viruses place additional demands on the service. This year, preparations began earlier than ever before. I quote Sir Bruce Keogh, NHS England’s national medical director, who said:

“I think it’s the one that we’re best prepared for. Historically we begin preparing in July/August. This year we started preparing last winter.”

I was pleased to hear the noble Lord, Lord Kerslake, recognise that that preparation—as called for by the right reverend Prelate the Bishop of Carlisle—had taken place. Of course, that means we need to start preparing for next winter now; and indeed, we are.

Ahead of winter, NHS England and NHS Improvement also asked international experts from five leading countries to review how well prepared the NHS was for winter. They complimented the NHS on its state of readiness. In practical terms, they meant that just before Christmas—on Christmas Eve—bed occupancy had been reduced to 84%, helping to free up capacity to deal with the increased demand on services seen following the new year. Similarly, as my noble friend Lady Eaton pointed out, the 20% reduction delivered by local authorities has freed up over 1,400 beds a day.

I should also take this opportunity to reiterate the apology made by the Prime Minister for the cancelling of elective care. It was a difficult but planned-for decision to deal with extra demand as it arose. I should also emphasise that it did not include urgent treatments or treatments related to cancer.

Noble Lords will I hope know, as we have discussed it before, that there has been an unprecedented system-wide push on flu vaccination, including an expansion of the winter GP and national pharmacy programme. For the first time, workers in care homes have been able to access the vaccine free of charge. This has meant over 1 million extra people have been vaccinated, with the highest ever uptake among healthcare workers at 59.3%.

We know that doing things efficiently is one approach but we also know that more money is necessary. The Budget provided an extra £337 million-worth of funding for winter. The noble Baroness, Lady Wheeler, challenged me on whether that money came too late. It is important to point out that at least half that money went to fund plans that were already in place. It is simply not the case that it could be implemented only once it had arrived. I should also point out in response to, the noble Baronesses, Lady Wheeler and Lady Barker, and others that, NHS England will at Easter be reviewing the impact of all the funding and the measures it took to deal with winter. The consequence of that funding is to have helped the NHS to open over 1,300 beds in December. That is on track to rise to 2,700 in February; the latest data shows 3,000 additional beds have been made available since the end of November.

However, I recognise that the preparations and investment have not fully been able to mitigate the enormous pressures on services, including ambulance services, and that in some cases this has led to unacceptable care being delivered. In particular, the rate of flu in hospitals is higher than the peaks reached in the previous seven seasons. The latest data in December showed that emergency admissions had risen by 4.5% compared to last year, so services are extremely busy. Despite that, the NHS treated 55,328 patients every day in A&E within four hours in December—over 1,200 more every day compared to the previous December. Let me use this opportunity to pay tribute again to the incredible work that our NHS workers do in emergency departments across the country.

As the noble Baroness, Lady Barker, reminded us, there have been many well-meaning actions by successive Governments over the years intending to improve our health services, but they have sometimes got in the way of delivering a truly joined-up system. I believe we all know and agree that the only sustainable solution to short and long-term pressures on the NHS is the integration of health and care services. That is the goal set out in NHS England’s five-year forward view, which this Government endorse. Integration is already happening on the ground. Now in its third year, the better care fund is a mandatory, national programme for integrating health and social care, which joins up services so that they are designed around people’s needs and enabling them to manage their own well-being, and to live as independently as possible. By mandating the pooling of funds, the better care fund has helped to join up health and care services, and to incentivise local areas to work together, with increasing amounts of funds used within this process.

The challenge now, which all noble Lords alluded to, is that we need to take that model and spread it into all corners of the health and care system, taking advantage wherever possible of the huge potential of technology to transform the way that care is delivered. The noble Baronesses, Lady Watkins and Lady Jolly, made suggestions about particular pilots and the use of community hospitals for integration. Schemes such as the vanguards scheme and new models of care are doing that, but I shall certainly take away their ideas and write to them to see whether we could do more to hasten that integration.

We all acknowledge that the health and care systems have to work collectively to transform themselves for the future, both in the interests of patient care and to put the system on a financially sustainable footing. The key process for delivering that is through the sustainability and transformation programme. The noble Lord, Lord Hunt, asked whether we were still as committed as we were before to that programme. I can promise him that we are and that it is now evolving into the creation of accountable care systems, which bring every actor in the local area’s health and care system together to deliver the kind of care that we want to see. That was backed by significant capital funding in the Budget.

The first group of designated accountable care systems have agreed to deliver their fast-track improvements as set out in the next steps on the five-year forward view, including taking the strain off A&E, investing in general practice to make it easier to get a GP appointment, and improving access to high-quality cancer and mental health services.

We know that the burden of care cannot simply continue to fall on hospitals. We need to move care into the home and the community. It was instructive to hear from the noble Lord, Lord Smith of Leigh, about how Wigan, as part of devo-Manc, is taking the lead in that initiative. Service integration needs to be underpinned by a joined-up workforce, as many noble Lords have said. That is why it is welcome to see the draft workforce plan launched by Health Education England. It includes the social care workforce, recognising the interdependencies between the two workforces. Many noble Lords, including the noble Baronesses, Lady Watkins and Lady Barker, asked about total staffing numbers. It is a topic we talk about a lot in this House, and I hope they will welcome the increase in training places for doctors and nurses. I should point out to the noble Lord, Lord Smith, that it also includes increased training places for emergency doctors.

I turn to the social care Green Paper. I use this opportunity to reiterate the Government’s commitment to publish a Green Paper by the summer of this year setting out their proposals for the reform of social care. It will be broad in scope and will look at the full range of issues relating to older people’s social care. To answer the noble Lord, Lord Pendry, it is intended to lead to a lasting solution. In developing the Green Paper, it is right that we take the time needed to debate the many complex issues, listen to the perspectives of experts and care users and try to build consensus, which has too often eluded us, so that the reforms can succeed. I look forward to engaging with all noble Lords in that process to take advantage of the golden opportunity to achieve lasting reform, as the noble Lord, Lord Pendry, said. The Green Paper will include action on carers. Many noble Lords asked about that. There will also be a carers action plan. I am not able to give a date on that, but I will write to all noble Lords when I am able to do so.

As well as reforming care, we also understand that the NHS needs to change. The Secretary of State for Health and Social Care said that,

“as we come to the end of the five year forward view, we need to seek consensus on the next stage for the NHS. We will need significantly more funding in the years ahead, and we need to build a national consensus on … that funding”.—[Official Report, Commons, 10/1/18; col. 346.]

The Secretary of State’s view is that we should try to do that for a 10-year period and not a five-year period. He is clear that he is open to all discussions with colleagues about the best ways to do that. I know that he is making that case in government, but we are clear that NHS spending will continue to rise to meet the demographic challenges that we face.

The noble Lord, Lord Macpherson, provided some interesting and well-considered ideas, which were backed up by the noble Lord, Lord Desai, and others, about how things could change. We can and must speculate about different ways of raising revenue for various spending priorities. Of course, taxation is a matter for the Chancellor and the Treasury, but the last Budget shows that when we have been given the opportunity to increase funding for the NHS, we have done so. Indeed, the proportion of public spending taken by the NHS has been increasing over time.

Building a sustainable health and care system will require some big and urgent decisions, but getting this right promises a better service, where people understand their responsibilities, can prepare for the future and know that they will receive care of a high standard that will help them maintain their independence and well-being. We need to create a consensus, by whatever means, in this country behind a plan for change. That has eluded too many Governments in recent years. I hope that, when the chance comes, all noble Lords will make available their expertise and wisdom so that we can deliver a health and social care system that is truly fit for the future.

My Lords, I thank noble Lords for their thoughtful and wide-ranging contributions. I am not going to deal with them in detail because we want to move on to the next debate. I hope the Minister will write to noble Lords in response to the questions he has not been able to deal with and that he will draw the attention of the Secretary of State for Health and Social Care to everything that has been said today.

Motion agreed.

Sitting suspended.