That the Virtual Proceedings do consider the short- and long-term impact of Her Majesty’s Government’s approach to the COVID-19 pandemic on the provision and delivery of social and domiciliary care for disabled and vulnerable adults and children, and the case for ensuring the sustainability of social care services.
The Motion was considered in a Virtual Proceeding via video call.
My Lords, I will start today’s important debate in the way I know noble Lords from across the House will want me to: by recording our deep sadness and regret for the loss of the now 19,609 people across the UK who are known to have died from this terrible disease in hospitals, care homes and their own homes. We know that the true figure, due to delays in recording and reporting, is likely to be considerably higher. Our sympathy and thoughts are with their families, friends and the people who will have cared for them: relatives, NHS and social and community care staff. As a dedicated care manager in a small Nottinghamshire home, where deaths to suspected Covid-19 had reached a total of nine residents—a third of the people under her care—put it, she thought of them as “family”. “It’s just soul destroying,” she said, adding:
“We have deaths normally, but they are good deaths with their family around them.”
As the weeks go on, Parliament will rightly focus on the continuing fight across health and social care to halt the spread of the disease and on the care of patients and staff currently suffering from it. Staff across these services have been putting their lives on the line, and sadly we see reports that over 100 have now died as a result of this dedication. Our thoughts are also with their families, friends and colleagues, and of course we are for ever grateful to all our NHS and social care staff, who are working tirelessly to help us deal with the crisis.
Today’s debate is the time to take a hard look at the short and long-term impact of Covid-19 on social care. It is vital to continue to step up the pressure on the Government to deliver on what have too often, sadly, been woefully inadequate and seriously belated promises and actions on social care. We also need to take stock and identify what the current social care response to this pandemic tells us about how a similar crisis must be handled in the future, and how, in the years to come, social care is organised, funded, delivered and staffed, and properly mainstreamed into our health and care system.
My Lords, the Coronavirus Act 2020 has relaxed the duties and responsibilities of local authorities to provide care and support to a revised minimum level which would solely meet a person’s needs measured according to their human rights—a very low bar indeed in this context. In the immediate short term, local authorities have other priorities. Even in better times, it is a struggle to fund social care and it is vital that we do not lose the hard-won legal support structure ensuring that correct social care is assessed and delivered to the neediest in society. Will the Government undertake to repeal the social care provisions of the Act and reinstate the pre-existing law and regulations at the earliest opportunity?
The Government have announced £1.6 billion of additional aid to local authorities to support social care. The delivery of this money to hard-pressed providers has not been smooth, and I urge the Government to press local authorities to use this money as required by the Government. Without this financial support, many providers will fail, leading to an intense crisis in domiciliary support and in homes. Will the Government apply the greatest possible pressure on local authorities to pass the additional funding on to providers of social care? Will they consider ring-fencing some of this money?
Turning to specific cases, many hard-pressed families have family members who require significant support. The strain on the mental health of family members acting as carers frequently results in provision for respite from their duties for a few nights at specified intervals. The requirements of social isolation and quarantine mean that they no longer receive the respite needed to survive. They are now locked into a cycle of support without any break and with no additional provision forthcoming to help them in any way. In the current emergency, will the Government encourage both local government and social care provision under the NHS to look carefully at the needs of the often forgotten and unsung family carers who are already saving the Government millions in care costs?
First, I declare my interests in the register, including as a vice-president of the RNIB and of the Alzheimer’s Society. I am addressing noble Lords today from my experience of four years chairing the social services committee of the City of Sheffield and as shadow Secretary of State for Health in the 1990s. I want to address the future rather than the present, since I know that other noble Lords will do that. I endorse everything that my noble friend Lady Wheeler and the noble Lord, Lord Astor, said and called for this afternoon.
When the noble Baroness, Lady Grey-Thompson, spoke on 24 March, she did so from the heart in relation to the immediate situation facing people with disabilities. I want to look at what will happen in the months ahead if we do not get the exit strategy right. We are all aware that social services have been massively underfunded for very many years. The pressures and demands on the service have been way beyond what could actually be met by local authorities and private providers. That is why it is really important that when we come out of the worst of the lockdown, we have the continuing resource to be able to sustain both domiciliary and residential care. It is really important that we also sustain the volunteers who have made themselves available, both the 750,000 nationally and those with mutual aid at community level. I hope that, with data protection in mind, we might be able to keep a register and keep them involved for the future. I hope that the Government will consider that.
The real issue that I want to address this afternoon is: what happens if the lockdown continues for a substantial period? Some people have started to talk, sometimes irresponsibly in my view, about a gradual release of the isolation taking months rather than weeks. That release is crucial for mental health and for people with disabilities, but also crucial to avoid ending up with more people needing support in the years ahead because they have deteriorated over the period of the lockdown. I therefore hope that the Government will consider setting up a separate body from SAGE, which will give advice on the way in which the dragon that we are slaying in relation to the pandemic will not be replaced by an equal beast—to use a metaphor on St George’s Day—that will lead to substantial additional pressures on the system in years to come, as people who were not feeling aged, isolated or full of distress and anxiety find that they now are. In other words, let us not, with the best intentions of today, make a major problem for tomorrow.
I thank the noble Baroness, Lady Wheeler, for securing this important debate. As the terrible and ever-rising death toll in care homes has so visibly shown, the social care sector, so long underfunded and neglected by politicians and policymakers, finds itself at the front line of this cruel pandemic. The severity of the challenge faced in care homes and other community settings is impossible to overstate. In short, care homes providing personal and close contact care need urgent access to reliable and ongoing supplies of protective equipment to protect residents and staff, rapid and accessible testing, and far greater support, with funding and equipment on an equal footing with the NHS.
If this pandemic has proved one thing, it is that health and social care are inextricably linked and cannot be treated differently. The National Care Forum has called on the Government to form a ring of steel around care homes, but what is it like at the moment? I have spent the past couple of days talking to various social care leaders running front-line social care services. It has been a humbling experience to hear what is going on.
Their stark messages include: how the rhetoric from government is hard to hear when the reality is so different; the confusing, contradictory and constantly changing nature of guidance issued by government and other bodies; the daily struggle to secure protective equipment, with government supplies sometimes being diverted to NHS facilities and homes having to source their own supplies at extortionate prices; staff shortages running at 25% alongside existing high vacancy levels that require the hiring of agency staff, which raises the risk of transmission; a serious shortage of nurses in homes and great difficulty recruiting, as nurses are deployed into the acute sector; testing arrangements which show little understanding of how the sector works, with care workers who have no car being asked to drive to centres many miles away, at times that do not fit with their shift patterns; patients being sent from hospitals into care homes without testing; much-needed financial resources from government not reaching the front line; GPs no longer coming into care homes to verify deaths, leaving such tasks to some of the lowest-paid staff; and care workers left feeling insecure and anxious when left in charge of clinical details.
My Lords, I draw attention to my interests in the register, in that I am a vice-president of the LGA. The Care and Support Alliance has reported thousands of people getting in touch with its members over this very issue. The questions I raised at Second Reading of the Coronavirus Bill are still valid and I will be writing to the Minister, because of our three-minute time limit today. To help proceedings, I have nine questions.
There is still a lack of adequate PPE for disabled people and their carers. One young disabled woman reported that she was verbally abused for not having adequate PPE available, even though it is difficult to obtain. Another young woman struggling with PA support was told that she should just go and live in a care home. My first question is: now that care home deaths are being reported, are HMG changing their strategy for this sector? A really serious danger is that some disabled people may be forced to move back to their families, which could be toxic or abusive, because that could appear safer than a care home.
Secondly, for transparency, will HMG report deaths in the community so that the true overall death figure is accurate; if not, why not?
Thirdly, HMG said that the delivery target was 100,000 coronavirus tests a day by the end of April. Is this on target and how many more need to be done? Was this a logistics aim or a medical aim? Will the Minister confirm that disabled people will not be excluded from testing?
Fourthly, will HMG review the carer’s allowance? Unpaid carers are also in a precarious position.
Fifthly, will HMG urgently review the guidance on direct payments? It is confusing and families are at breaking point trying to manage working from home.
However, my biggest concern is that, as I understand it, eight areas have switched on the Care Act easements. I can find the names of six: Sunderland, Middlesbrough, Warwickshire, Staffordshire, Birmingham and Solihull. So, sixthly, as a matter of urgency, can the Minister confirm that these six are correct? It was reported in the Law Society Gazette this morning—but has now been removed—that the other two are Croydon and Hertfordshire, although Hertfordshire has said that it has not triggered easement. This is very confusing for everybody. Can the Minister confirm which areas have triggered easement?
My Lords, I congratulate my noble friend on calling this vital debate at a very difficult time in our history and I thank her for all the work that she has done on this issue. I declare an interest as chair of the National Housing Federation, the trade body that represents not-for-profit housing associations in England.
The spread of this virus is indiscriminate, but its impact on our society’s most vulnerable people is pernicious. I pay tribute to all those who, despite the risks to themselves and their families, are still faithfully working to help those in their care. Many of us have reason to be grateful to them and their families for their sacrifice.
Like many, I have found the number of fatalities in care homes alarming and distressing. Earlier this month, reported deaths from Covid-19 in care homes quadrupled in the space of a week, and we know that this is not the full picture. We need a clear plan in place to reverse this trend.
Some 50,000 care home spaces in England are provided by not-for-profit providers, such as housing associations. They also provide 76% of all supported specialist and sheltered housing schemes for older people, people with disabilities and people with mental health needs. They support people in homelessness, hostels and domestic abuse refuges. All of these are vital components in our social care system beyond those services regulated by the CQC. All of these care settings are currently grappling with the enormous challenges that this virus brings. We should not let them be forgotten or neglected.
Accessing PPE is a significant ongoing challenge for all these workers who have daily contact with those people who are being shielded. While we quite rightly prioritise NHS staff, it must be extended to others most at risk. I welcome recent government guidance on testing in the community. I know that housing associations hope that it will stimulate greater availability of tests for their front-line staff. Those working with our older and more vulnerable population need to know that going to work will not put their safety and residents’ safety at risk. We owe it to people working in care settings to value and publicise their work and to put it on a financially secure footing, now and in the future.
I join other noble Lords in commending and thanking the care sector for all it does for those in its care, in care homes and in the community. I am happy to echo the opening remarks of the noble Baroness, Lady Wheeler, and thank her for instigating this debate.
The majority of care providers are private organisations, not-for-profit organisations or charities. Their income has remained pretty well constant throughout this crisis, but their costs have soared—for replacement care workers from agencies or banks to cover staff illness, and, as we heard at Questions, the new unanticipated costs of PPE. Can the Minister confirm that no provider of care will be allowed to fail in this crisis due to lack of funding to cover these and other costs?
My comments will largely be about people with learning disabilities and others who have found themselves with “DNR” on their records. We are fortunate to live in a country where life is universally valued. For the last month or so, we have seen this play out on the news, as we witness daily the efforts of our NHS and care workers struggling to save those who are in their care. Their compassion brings us to tears, and to our doorsteps on a Thursday evening. Old, young, fit or frail—it matters not. But this Covid-19 crisis has seen parents of autistic adult children receive letters from their GP practices suggesting that these children should have a “do not resuscitate” or DNR label added to their notes.
I applaud the Care Quality Commission for its condemnation of GPs across the country for categorising people who receive care in community settings as not requiring resuscitation should they fall ill with coronavirus. Let us be clear: a DNR is a clinical decision that, in perfect circumstances, involves the doctor, patient and family. NICE recommends that clinicians use the clinical frailty scale when considering patients for intensive care. It is designed to prioritise those most likely to recover from the virus, but it is not suitable for use with people who have learning disabilities, nor for people with other kinds of disabilities or conditions that affect their ability to do things independently.
1:40 pm
Baroness Masham of Ilton (CB)
My Lords, I thank the noble Baroness, Lady Wheeler, for securing this debate. That so many people are speaking shows how important this extraordinary virus is.
I have had many disabled people contact me. One was the wife of a man who has multiple neurological problems. His conditions, because he has several, were not on the high-risk list. He was told that he should work, even though he is vulnerable. Her Royal Highness the Princess Royal is patron of the Spinal Injuries Association and I am its president. Princess Anne has written a personal encouraging letter. I shall quote one sentence: “I want to let you know that you are not forgotten.”
We do not understand why people with spinal injuries, who can be very vulnerable, are no longer on the most vulnerable list. One tetraplegic died because he was denied ventilation. Many disabled people live in their own homes and have live-in carers. With Brexit and then coronavirus, it has become very difficult to get helpers. Will the Government recognise this predicament and relax immigration rules for people coming from Europe, as they make very good carers? This is not only for people living in their own homes, it is for hospitals and care homes. We really are at risk.
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We know that there is widespread frustration and dismay in the social care sector that once again it has been a plan-B afterthought. The Government’s social care plan was finally published last week, five weeks after the plan for the NHS. From the outset, Labour has made it clear that we want the Government to succeed in dealing with this huge crisis and we have pledged to work constructively with them. But we have also made it clear that we will challenge where there are mistakes that can be put right and where we think something is not happening that needs to, and we will closely scrutinise the decisions made. It was in that spirit of constructive engagement that we fully co-operated with the Covid-19 Bill before the Recess, and in which we want today’s debate to be framed.
In the same vein, we have repeatedly called for urgent action on the supply and delivery of personal protection equipment and for the testing of all NHS and social care staff for the virus, and we have proposed ways that will help to turn the situation round. Last weekend’s Public Health England announcement, changing guidelines on the need for full-length protective gowns for doctors and nurses treating Covid-19 patients because supplies were due to run out, has just added to the despair felt by staff in the NHS and social care over not having the essential equipment that they need to keep patients and themselves safe. Being told to reuse equipment, or not to waste it, and the stop-start big announcements of targets or shipments on their way just decreases morale still further and makes the situation even worse.
On care homes and domiciliary services, even the most ardent of cheerleaders for the Government, such as the Daily Telegraph and the Daily Mail, have recognised and been highly critical of the chaos surrounding testing and PPE. Key charities—the Alzheimer’s Society, Marie Curie, Care England and Age UK—have talked about the “devastation” in the care system, with the lack of testing and PPE meaning that staff are putting their lives at risk while also carrying the virus to vulnerable groups.
On 16 April, ADAS—the Association of Directors of Adult Social Services—summed up the PPE situation as “shambolic”, with early PPE drops in the care sector “paltry” and more recent deliveries “haphazard”, with “confusion and additional workload” resulting from the mixed messages and poor communications between the two key government departments: local government and health. We know that care home managers have been desperately driving miles around trying to buy masks, gloves, gowns and other vital PPE to try to halt the spread of the disease in care homes, with many staff making their own masks or having to use the same masks and other items all day. All this involves huge extra costs for care homes. The care provider MHA, for example, had to purchase 200,000 masks at five times the usual cost.
Full PPE is just as important to staff in care homes nursing residents with suspected Covid-19 as it is in hospital and NHS care settings. It is also vital if families are to be allowed into care homes to be with their very ill or dying loved ones. The recent change in government guidance on this is very welcome, but it can happen only if homes have full PPE, testing and other important procedures in place to protect staff, residents and their relatives. Can the Minister now provide an exact date by which all those working in social care will have the continual, adequate supply of PPE of the required standard so that they can do their jobs in safety?
From the outset, care homes have underlined that patients should be transferred from hospital only after they have been Covid-19 tested, but this essential requirement was not in the original guidance and has not been followed in many areas. Can the Minister confirm that new guidance will be issued on this very basic requirement, with accompanying levels of PPE? Will care homes and care home providers be refunded the full and crippling extra costs for PPE, including covering the spiralling prices which the shortages have led to? We know that residential care is in a precarious financial state, with many homes facing closure, and that the UK Homecare Association fears that financial pressures resulting from Covid-19 could force a significant number of the UK’s 8,000 home care providers to close within weeks.
On funding, the Government have rightly said that the NHS will get whatever resources it needs to deal with the Covid-19 pandemic. Can the Minister categorically state that this also applies to social care? This means covering the extra costs not just of PPE but of staffing in care homes and home care to pay for increased staff, staff sickness and vacancies, and other care costs.
On testing, Labour has strongly stressed the urgent need for testing of patients and staff in care homes, and for a clear and detailed plan on how this is to be actioned and achieved. Not testing new or returning residents, for example, risks contaminating care homes where elderly and vulnerable people are supposed to be “shielded”—a policy described by care home providers as
“importing death into care homes.”
New testing for all residents with symptoms and for all those being transferred into homes has been announced. Can the Minister tell the House how and where those who have tested positive will be effectively isolated? Will extra resources be provided to care homes for this? Since the lockdown began, care homes have sealed themselves off, banning visitors and introducing social distancing for staff and residents, but caring for Covid-19 residents is staff-intensive, requiring barrier nursing of residents in single rooms.
In home care, which is widely acknowledged to be the most fragile part of the social care system, Covid-19 presents a particular challenge for care workers who visit multiple clients a day, every day, in their homes. Routine testing and access to PPE are essential. With no centralised record of the numbers of people needing support, there are fears that people might be left without care or even dying alone at home without care. What action have the Government taken to prevent this happening?
A detailed plan is also needed for how and when the Government will test all the 1.4 million front-line social care staff, to include domiciliary home care staff and staff working as personal assistants, who are doing a vital job of looking after disabled and mentally ill people in their homes, through direct payments. Only 505 social care staff have so far been tested. How will this number be escalated to meet the needs? Can testing centres cope with the proposed volume of testing? What plans are there for providing testing arrangements locally for staff who cannot drive or do not have time to drive the often very long distances involved? What will the criteria be for social care staff being eligible if, for example, they do not have symptoms but have been in contact with someone who has tested positive for Covid-19?
Under the emergency Covid-19 Bill, there was deep consternation and fear across the House that the temporary suspension of rights under the Care Act 2014 on care and carer assessments, eligibility and care packages would result in care standards being lowered or even ended, putting disabled and vulnerable adults and children at risk.
As a carer of a 75 year-old stroke recover, I know how much carers depend on vital social care support in the home and the community and many carers have spoken to me about their concerns. Can the Minister tell the House what national monitoring arrangements and oversight mechanisms have been put in place to keep this situation under close review? Does he have any national data on the number of councils that have had to revise existing care packages and arrangements in the light of Covid-19?
For the future, Labour’s new leader, Sir Keir Starmer, this weekend called for a new settlement for social care: an ambition for society that puts dignity and respect at the heart of how we care for the most vulnerable, and how we properly reward our key health and social care workers and repay the debt we owe to all those who have sacrificed so much during the Covid-19 crisis.
We must learn from the current crisis about how social care should be valued, resourced and delivered in the future. Under Covid-19, the broken care system is at least getting some of the long-overdue attention it needs and deserves. Surely the public cannot be in any doubt any longer about how essential it is. Treating social care needs as secondary to NHS needs has almost become a default system for the sector. As so often in the past, the current crisis sees yet again stakeholders, staff and charities warning the Government that older people’s lives are not worthless and that care home staff are not second-class carers. This is the reality of how the sector has had to struggle for recognition and funding.
I hope the Minister will reassure the House that the Government now recognise that we must have proper planning for pandemics on the scale of Covid-19, a system that goes across health and social care, for the future. Clear responsibilities must be given to the key NHS, social care and public health lead agencies and, as used to happen in the past, sufficient stockpiles of protection and testing equipment must be regularly monitored and updated. We have now seen all too well that this is not money wasted, to be first in line for austerity cuts or dumping in favour of no-deal Brexit planning. Integrated data across health and social care which accurately reflects what is happening on the ground is a key requirement for any future plan.
Secondly, we have to address the overall health and social care structure. The commissioning, duplication and bureaucracy of the Lansley NHS structure, the fragmented multi-provider structure of residential, home and community care and the precarious method of funding have to be addressed if we are ever to have fully integrated care. As we have learned from this pandemic, public health provision and planning needs to be across health and social care.
Thirdly, local authorities must be properly resourced for the social care duties they undertake under the Care Act. We know that £7.7 billion has been cut from council budgets since 2010. Of the £2.9 billion welcome extra funding for councils for Covid-19, only 10% of the initial £1.6 billion was allocated to social care. The additional money, however welcome, allocated to a desperately underfunded service which was in crisis before the pandemic, barely touches the cash crisis that social care faces.
Fourthly, we must treat staff with the respect that they deserve as the professionals they are. Home and domiciliary care pay rates do not match those of NHS staff, who themselves do not receive the pay which reflects the vital work they do. Some 1.4 million people work in the social care sector. Care workers are often employed by agencies on zero-hours contracts. It is hardly surprising that, even before the Covid-19 outbreak, there were 122,000 care worker vacancies and that annual staff turnover is 30%. More than one-third of care home staff are currently believed to be off work or self-isolating.
Finally, future social care planning has to include basic personal care support in people’s homes for those in need, including the 1.4 million older people that Age UK has identified who need help with washing, dressing and going to the toilet that they currently do not get. This is why Labour strongly supports a national care service and we know that the Lords Economic Affairs Committee rightly supports this, too.
I am so grateful that so many noble Lords are contributing today, covering many issues that I just have not had time to cover. In conclusion, the coronavirus pandemic has brought the deep crisis in social care to the fore. We no longer live in a society where social care can be delivered on a shoestring budget, under a system routinely starved of funding that relies on periodic cash boosts to prop it up and save it from total collapse, and in which care workers are overworked, undervalued and underpaid. In other words, we cannot just applaud the front-line workers every Thursday and then go back to business as usual. I beg to move.
Based on these conversations, I ask the Minister: why are care homes having to pay VAT on protective equipment when the NHS does not, and what urgent steps will the Government take to put them on an equal footing? What measures are they taking to ensure that some registered nurses in the newly returning workforce are deployed to care homes, which desperately need them? When will the newly established volunteer scheme be used to help care homes? Finally, when will the Government’s visa exemptions for NHS nurses be extended to those working in the social care sector?
When this terrible tragedy subsides, a long-overdue and fundamental reform of social care must be a top priority. A national health and social care system means just that: a fully integrated service, properly funded and run on an equal basis so that we are no longer, as one social care professional put it to me, simply an afterthought at the back of the queue.
Seventhly, can he explain how these areas have apparently reached crisis point, such that they cannot carry out their duties to disabled people, but nowhere else has? Or are there more than eight?
Eighthly, how are disabled people expected to get advice if they do not know what law their local area is applying?
Finally, ninthly, does the Minister accept that HMG should publish regularly the full list of areas that have switched on Care Act easements and, if they are not prepared to do so, can he explain why not?
The statistics on the effects of the virus on those in care homes must be a wake-up call to take action on the questions about our social care system that have dogged our country for so long. Housing associations are already mobilising for this. A root-and-branch review of how we provide care to the most vulnerable in society has never been more critical. Will the Minister commit to it now? Without it, we remain as unprepared for any future health crisis as we were for Covid-19.
Whatever the circumstances, life or death should not depend on your age, your disability, who provides your care or where you live. Does the Minister agree? Could he please persuade the department to put this message out to all care and health providers? Perhaps we can ensure that it is part of the promised Green Paper.