Health and Adult Social Care Reform

Statement

The following Statement was made in the House of Commons on Monday 6 January.

“A happy new year to you, Mr Speaker, and to everyone across the House. With your permission, I will give an update on health and adult social care reform.

I start by paying tribute to the NHS and social care staff who worked throughout the Christmas break, including by staffing our hospitals, ambulance services, care homes and call centres on Christmas Day and throughout the new year. From visiting hospitals and residential care homes in the south-west of England, Essex, London, South Yorkshire and the north-west over the past two weeks, I know the extent of the pressures they are dealing with. They are going above and beyond to keep the NHS standing, to provide people with the social care they need and to give patients and care users the best care they possibly can against the most challenging backdrop.

We have seen more than three times as many patients hospitalised with flu this winter compared with last year, in a service with no slack left to give. Since coming into office, the Government have been doing everything we can to prepare the NHS for winter, including by ending the resident doctors’ strikes. This is the first winter in three years when staff are on the front line, not the picket line. The Chancellor made an additional £1.8 billion available in-year to fill the black hole left by the previous Government, and we introduced the new respiratory syncytial virus vaccine to protect more than 1.2 million people against the virus.

But I am not going to pretend for a second that the experience of patients this winter is acceptable. The Government have been honest about the state of the NHS since the election, and we will continue to be. The NHS is broken but not beaten. It will take time to fix, but it can be done. That is why the Chancellor made an additional £1.8 billion available in-year to fill the black hole left by the previous Government and to enable us to deliver on our first steps to cut NHS waiting times. That is why we are undertaking fundamental reform, and it is why we are acting on social care.

These are the honest facts. The social care system in this country is failing, leaving hundreds of thousands of disabled and elderly people without the care they need. The failure of social care is piling enormous pressures on the NHS. In November, more than 12,400 hospital patients a day were well enough to leave but had to stay overnight because they were not able to be discharged. We have an ageing society: by 2050, there will be 4 million more people aged 65 and over in England. If we do nothing, social care costs are expected to double over two decades.

Of course, there is plenty of blame to go around. In 2009, when Andy Burnham established cross-party talks on social care, the Conservatives pulled out and leaked details of the talks to attack Labour. In 2017, it was Labour who torpedoed Theresa May’s proposals. In 2022, the right honourable Member for Richmond and Northallerton (Rishi Sunak) as Chancellor delayed Boris Johnson’s cap on care costs, and then defunded them as Prime Minister. There has not been a shortage of good ideas in the past 15 years, but a lack of good politics. It is time all of us across the House do things differently.

I have written to my opposite numbers and the leaders of all UK-wide parties represented in the House to invite them to help break out of the cycle of political failure. I hope all of us across the House will put aside our ideological and partisan differences, and work together on this, to finally find a way through to a long-term plan that can build the broad consensus we need.

We do not need to agree on everything, but in April we will launch an independent commission on building a national care service. I am delighted that it will be headed by one of our country’s leading social reformers, and Whitehall’s greatest doer, Baroness Louise Casey. The noble Baroness, Lady Casey, has served Labour, Conservative and Liberal Democrat Governments. She is a trusted, independent figure, who will take views from all parties and, crucially, the public as she seeks to build a cross-party and national consensus on the future of social care. She will get things done. Her first report will be published next year, making a series of recommendations that can be implemented straight away throughout this Parliament, and her final report will come later in this Parliament.

In the meantime, we are stabilising the social care system today. We have legislated for the first ever fair pay agreement for social care, to tackle the workforce crisis—the 131,000 vacancies we see today. In the Budget, the Chancellor provided the biggest increase in carer’s allowance since the 1970s, worth £2,300 a year to family carers, and an extra £3.7 billion for local authorities.

On Friday, I visited the home of Keith and Elaine in Carlisle. I saw at first hand how extended doorways and the installation of accessible kitchen and bathroom facilities have changed their lives, thanks to the disabled facilities grant, allowing them to live with renewed dignity, independence and happiness. That is why I announced last week the immediate release of £86 million through the disabled facilities grant, to provide an extra 7,800 home adaptations before April, changing the lives of thousands more disabled people for the better, just as Keith and Elaine have experienced.

We are not hanging around on reform either. We are introducing new standards to help people who use care, their families and providers to choose the most effective new technology as it comes on the market. We are joining up care and medical records so that NHS and care staff have the full picture they need to provide the best possible care. We are training care workers to perform more health interventions to help people stay well and at home. A lot done, a huge amount more to do and, if this House gets this right, the best is yet to come.

I turn to the elective reform plan the Prime Minister has launched today. The Government inherited NHS waiting lists at 7.6 million. The NHS standard, that patients should wait no longer than 18 weeks for treatment, has not been met for a decade. Millions of patients are forced to put their lives on hold while they wait. In his investigation, Lord Darzi listed the causes of this crisis: the undoing of new Labour’s reforms, the disastrous top-down reorganisation, and slashing GPs and community health services, all of which have led to a dramatic drop in hospital productivity. Lord Darzi has diagnosed the condition; now this Labour Government are prescribing the cure.

In November, the Prime Minister set out the Government’s plan for change—a plan to dig this country out of the hole it was left in and an act of resistance against the status quo of managed decline. It committed to cutting maximum waiting times from 18 months today to 18 weeks by the end of this Parliament. Today, we are setting out how we will hit that ambitious target, so that once again the NHS is there for us when we need it. This will demand faster improvement than even the last Labour Government achieved. That means doing things differently. It had to be a plan for investment and reform. Investment and reform are what Labour promised before the election. Investment and reform are what we are delivering. Our elective reform plan will cut waste and inefficiency, ramp up the number of appointments, scans and operations that the NHS performs, and give NHS patients greater choice, control and convenience.

Any patient using the NHS can see the waste and inefficiency in the service when they use it. Staff feel it holding them back every day. When the Government announced significant investment in the Budget, I said that it would come with reform, so that every pound was well spent, and here it is. Resources will be diverted from hospitals to GPs, to get hundreds of thousands more patients cared for faster in the community. Patients will have the choice of whether they want or need follow- up appointments, saving a million pointless appointments a year. GPs will be able to refer patients directly for tests and scans, cutting out the middleman and speeding up diagnoses for patients across a wide range of conditions. For years, restaurants have been texting customers reminders of their bookings, giving them the chance to cancel or rearrange, to cut down on no-shows. The NHS will learn from the hospitality sector, do the same for patients, and cut around a million missed appointments every year as a result.

In opposition, we said that investment in new and more productive ways of working would make a significant dent in waiting times. Today, we are announcing 17 new and expanded surgical hubs to run like Formula 1 pitstops and bust through the backlog. Community diagnostic centres will open at evenings and weekends so that patients do not have to take a time off work for their appointment and can get diagnosed faster. We are rewarding trusts that cut waiting times fastest with extra capital investment as an incentive, and we are publishing a new agreement with the independent sector—the first of its kind for 25 years—to cut waiting times.

Over the past 14 years, a two-tier healthcare system emerged in this country. People who can afford it are increasingly going private to skip the queue, while those who cannot are left behind. Working people are going into debt, and others are running fundraisers to pay to get an operation. Those stories belong in pre-war Britain. They should shame the Conservative Party. I am determined to end two-tier healthcare in this country, so that whether you are the richest or poorest person in Britain, you get timely, quality treatment, free at the point of use. This new agreement will see more NHS patients able to choose to be treated in a private hospital where there is capacity, paid for by the state. More capacity will be available for people in working-class areas of the country, and for women stuck on gynaecology waiting lists. Where we can treat working people faster, we will, and we make no apology for doing so.

Working-class patients in this country deserve the same choice, control and convenience as the wealthy expect—indeed, as we all expect from other apps and services that we use every day, but not the NHS. That is why we are also modernising the NHS app to put patients in the driving seat for their own care. If customers can choose when their Deliveroo meal will arrive, and be kept informed until it is dropped off, why should patients not be afforded the same service by the NHS? With this plan, they will be. Patients will be able to manage their appointments, book tests and scans, view results as soon as they are ready, and choose where they will be treated. We will cut down on letters that arrive in the post after an appointment and give power back to the patient.

In the past six months, we have ended the resident doctors’ strike and invested billions more in our health service, with the biggest investment in hospices and end-of-life care for a generation. We are delivering investment and reform in general practice to fix the front door to the NHS and bring back the family doctor, and we have started to get NHS waiting lists falling. This plan for investment and reform will press down harder on the accelerator and will change our NHS and the experience of millions of patients. It will put the NHS on the road to recovery, and I commend this Statement to the House”.

15:21:00

My Lords, I begin by echoing the comments made by my right honourable friend the shadow Secretary of State in the other place in support of all those who worked in the NHS and social care sectors over the Christmas period. They sacrificed their time, which could have been spent with their friends and families, to care for those most in need. On the NHS app, we support the digitisation of health and care to modernise the NHS, and support digital patient records to allow joined-up health and social care to deliver better outcomes for patients and to inform patients. However, the NHS app already sends appointments and updates on treatment to some patients, while some GP surgeries prefer patients to use their own website, not the app. I would be grateful if the Minister could expand on how the updated app will differ and offer up further information to your Lordships’ House. Also, where your GP cannot see you, is the plan to allow all patients to book an appointment with another GP without having to deregister from their current practice and reregister with another practice? Will that be allowed with the updated app? One of the problems was always where there were GPs who could not see their patients but other GPs in the same area had spaces on their lists. In the Statement, the Secretary of State said: “We are rewarding trusts that cut waiting times fastest”, and the carrot of “extra capital investment” is used as an incentive. This appears to make sense, but noble Lords will know that I have always been interested in potential unintended consequences. If the Government reward trusts with extra investment if they cut waiting times fastest, what will happen to those trusts that are not able to cut their lists as quickly? Will they see reduced investment, and will that simply lead to them continuing to perform poorly? What is the solution? Will hit squads—in the best possible terms—be sent in to turn them around? What other plans are there to tackle underperforming trusts which do not qualify for these extra incentives? How do the Government and NHS intend to avoid perverse incentives such as trusts prioritising certain patients over others—not necessarily based on medical needs—to cut waiting times to win this extra cash? How do we avoid that? On social care, I appreciate the candour of the Statement in acknowledging that Governments of all colours, for decades, have not really dealt with this problem of long-term social care. As my right honourable friend the shadow Secretary of State said in the other place, we will work with the Government and the commission. However, I will put a few observations to the Minister. For decades, successive Governments have known about the ageing population, and Governments of all colours have commissioned report after report, which mostly gathered dust on the shelf. Although I have the greatest respect for the noble Baroness, Lady Casey, given that most commentators on social care agree that everything to be written about funding social care has already been written, I am curious to know what the Government expect to achieve by initiating yet another commission. A solution was proposed in the Health and Care Act 2022. Noble Lords welcomed that we finally had a solution but disagreed on some of the details. But we had a solution to which the Treasury agreed. I remember the Opposition criticising the Government not for introducing the social care cap but for not doing it earlier, and they also suggested a number of tweaks. The incoming Government could have tweaked the numbers to address the concerns that they expressed at the time, and they could have grasped the nettle, but I am afraid that the announcement looks like yet another Government kicking the can down the road. So will the Minister write to noble Lords with the terms for the commission led by the noble Baroness, Lady Casey? This time, will the Department of Health and Social Care continue to work with the Treasury to ensure that whatever solution is finally proposed, even if it is likely not to be a new solution, has the agreement of the Department of Health and Social Care, other government departments and the Treasury? If not, it will simply find itself kicking the can down the road yet again when it comes to 2028. My final point is on how to cut the backlog. These Benches welcome the Government continuing the policy of the last Government in opening new surgical hubs and community diagnostic centres at weekends and evenings. But, when we were in government, we found a potential workforce issue in opening community diagnostic centres at weekends and evenings. Of course, there are only so many staff who can be employed to keep these services open for longer, so have the Government made an assessment of how many staff they envisage will be available to keep these centres open for longer hours? What is the plan? Will it be a redeployment of existing staff, will existing staff be asked to work longer hours and overtime, or will they recruit new staff?

My Lords, we on these Benches welcome the Statement and can see some positives in the way forward, but we have some reservations about timescales and unintended consequences in the implementation that I would like to explore with the Minister. On social care, we have already called for cross-party talks, as many noble Lords will know. Social care is in crisis and at a tipping point, and it is an unbearable pressure for many families. But we cannot understand why the review will take until 2028 and full implementation will probably not happen until 2029-30. It is a bit like calling the fire service when your house is on fire and asking it to attend once it is out. So what specific components of this review that are not already in the public domain have the Government already determined will take until 2028 to be dealt with? Will the review tackle all forms of social care, including continuing care and young people’s services? The NHS elective reform plan marks a significant initiative for reducing waiting times and enhancing patient access to elective care. The plan introduces some welcome measures, but many are not new, such as the expansion of the diagnostic and surgical hubs, increased utilisation of digital platforms such as the NHS app and a commitment to meeting the 18-week referral to treatment standard by the end of this Parliament. Although these proposals are commendable, I have been of the view for many years that elective and emergency care need to be provided in different, and probably separate, ways. Several critical concerns warrant attention to ensure the plan’s success and sustainability. A primary concern is that the plan focuses predominantly on elective care, potentially overlooking the broader health and social care ecosystem. The Nuffield Trust emphasises that, for the plan to be sustainable, there need to be concurrent reforms in social care, significant investment in community services and attention paid to the determinants of ill health, such as housing and education. The focus on throughput measures will mean that it will be focused purely on those. What outcome measures will be put in place, not just for the quantity and speed of care but for the clinical outcomes for patients? The emphasis on meeting elective care targets should not overshadow other clinical priorities. It is critical to ensure that resources allocated to elective procedures do not detract from urgent and complex care needs. Indeed, the financial model set out in the plan on tariffs will create incentives to focus on elective cases when budgets are stretched. What measures will be put in place so that the expanded diagnostic and surgical hubs, along with the extra reported 3.5 million procedures in the independent sector, will avoid pulling staff away from urgent care and complicated patient needs? This must be based on a fully costed workforce plan, so when will that be presented? The plan has been announced with little firm detail on funding, especially considering that the £3 billion ring-fenced for cutting waiting times this financial year will not be available from April. Will this ring-fenced scheme be reintroduced? While we welcome the thrust of this plan, there will be some unintended consequences, and we really need to see a detailed implementation plan to ensure that elective care does not overshadow emergency care and those seeking social care.

I thank both Front Benches for their welcomes, in varying degrees and to varying aspects, for the two plans: one to deal with social care into the very far future—something that I would want to emphasise—and the other on electives. I, too, pay tribute to NHS and social care staff, not just for the work that they did through Christmas and the new year but for the work they do and the commitment they show in some very difficult circumstances all year round. That is exactly why we have come to your Lordships’ House and the other place with this Statement. To start with social care, the noble Lord, Lord Kamall, talked about the agreement that was around in respect of the social care cap, but that really dealt with only one aspect of social care; what we seek to do is something that actually has not happened before, which is a very comprehensive and long-lasting approach that will transcend politics and last, no matter who the Government are, and that is perhaps what has been lacking. Certainly, I would agree that there has been no shortage of ideas in the past 15 years—some good and some, as I am sure some people would say, less good—but what there has been a lack in is a different way of doing things and a different approach, and that is what the independent review led by the noble Baroness, Lady Casey, will seek to provide. I am glad that both opposition parties have accepted the challenge or invitation from the Secretary of State to participate in a cross-party solution, and I am most grateful to party leaders and spokespersons for that. I want to put on record that the noble Baroness, Lady Casey, is regarded as Whitehall’s number one doer; she is a leading social reformer, and she has served Governments of all political stripes, which equips her very well to talk about building a national care service. I understand the concerns raised about the amount of time that is being taken. The noble Lord, Lord Scriven, referred to that. Perhaps I can reassure your Lordships’ House that the first report will be published next year, with recommendations that can be implemented as soon as possible. The final report will be later in the Parliament. I should also say that we have not actually waited. It is important to say that there are a number of things happening right now, because I do not want your Lordships’ House to believe that everything is waiting for the conclusion of the report. I shall run through some of them because I think they are helpful in terms of social care. Legislation has happened for the first ever fair-pay agreement, which will tackle the 131,000 vacancies that social care is currently carrying and is a real problem in providing service. On the budget, I was very glad that your Lordships’ House welcomed the biggest increase in carer’s allowance since the 1970s. There has been an extra £3.7 billion for local authorities and, last week, the immediate release of £86 million for the disabled facilities grant, which will enable some 7,800 home adaptations before April. There has been a whole range of reforms, including the current introduction of new standards. The noble Lord, Lord Kamall, asked about digitisation. Joining together medical and care records is so important. I know from the report of the House of Lords committee chaired by my noble friend Lady Pitkeathley that the most concerning aspect for those who care for those who need that support is that they constantly have to say what is wrong and what the issues are. Always having to repeat things was the number one issue that that report identified. We are also training care workers to perform more health interventions. I would say that there has been a lot done but that there is an awful lot more to do, which is why I am very glad about this approach. I do not regard this, by the way, as kicking the can down the road; I regard this as realistic for the situation that we are now in. I must emphasise that we really want a cross-government approach that will outlast any Government, no matter who they are, into the future. On electives, the noble Lord, Lord Scriven, asked about measuring outcomes and ensuring that, in meeting one target, other matters are not overlooked. He makes an extremely fair point, and we will, as part of the ongoing work, look at how we measure and how we avoid the unintended consequences that both noble Lords have referred to. I am grateful for the reminder on that point. It is important, and noble Lords will have heard it said by the Secretary of State, that we take the best to the rest—I think that is crucial. There is some excellent work that goes on across the country, but it is not universal or serving everybody. On reducing waiting times, the noble Lord, Lord Scriven, used the word ecosystem, which I would absolutely share. For example, the failure of social care currently puts enormous pressure on the NHS. It is an ecosystem, and not always a positive one, I might add. If we go back to November, some 12,400 people every day were well enough to leave hospital but could not do so because it was not possible to discharge them. That is a failure of social care very much linked to the NHS, but we also have an ageing society. By 2050, we will have 4 million more people aged 65 and over than we have now and if we do nothing, for example, on social care, the costs will double over the next two decades. Neither exists in isolation. Social care and the NHS come together. I say to the noble Lord, Lord Kamall, that this is absolutely a cross-government problem which will require a cross-government solution. Of course, it will be very much part of the 10-year plan and part of our three immediate pillars of change, which are sickness to prevention, hospital to community and analogue to digital. This is about major reform, not kicking the can down the road on social care and the NHS. I know the noble Lord was not suggesting that of the NHS. On workforce, we are currently making plans which are different from those of the last Government, so we must carefully look at not just numbers but the range of skills and professions needed. This reform requires change. It is not about standing still. The noble Lord, Lord Kamall, asked how we will keep centres open for more hours. It was one of our manifesto commitments, and we have held many discussions with workforce representatives to seek a wide range of solutions. One proposal, which has been extremely well received, is to offer to pay people overtime to do the work. We are already reducing waiting lists through this. We all know that the current working hours of the NHS do not reflect the reality of people’s lives. This is a really big opportunity to make a major change and grasp the many nettles. I wish all of it could happen immediately—particularly on social care, as we know that it has taken a long time and many have failed along the way—but it will take time. However, we have the plan and a commitment to support, guide and resource not just the NHS that we need now, but that we will need in the many years ahead.

15:41:00

My Lords, the Statement is most welcome, not least the attention given to social care services. I congratulate the Minister and the Government on striking that proper balance between health and social care. The issues are hugely challenging, very expensive and important for the whole of society, especially if the National Health Service is to survive and prosper, for reasons that the Minister has touched on. The issues in social care range from recognition of the very important contribution of unpaid carers to the fact that a large number of local authorities face financial problems which place their future in a degree of jeopardy. The commission to be chaired by the noble Baroness, Lady Casey, will tackle these and many other issues, but we have to get through the immediate situation. Can the Minister assure the House that, in taking the social care agenda forward, from today these matters will be kept in sharp focus and handled with great vigour and determination?

I am pleased to give that assurance and thank the noble Lord for his welcome for these measures. As I mentioned earlier in response to opposition Front-Benchers, we have not waited. In the last six months, we have made a number of immediate changes. He mentioned carers, and it is worth emphasising that, as I said, the increase in carer’s allowance is the largest since the 1970s. It will mean roughly an extra £2,300 a year for family carers. That is extremely significant. This House rightly presses me on the need to recognise carers, in particular unpaid carers, which we have done. The whole range of measures I described earlier will show our direction. I look forward to the noble Baroness, Lady Casey, publishing her first report next year. Those recommendations will also be there straightaway. We are doing this on all timescales.

My Lords, it is indeed gratifying, as the Minister has mentioned, that many of the health proposals take into account the report of the Committee of your Lordships’ House on integrated care, which I had the privilege of chairing. I am going to take it for granted that the issue of unpaid carers will be the focus of the commission’s report, since the whole edifice of social care depends on unpaid carers. Does the Minister agree that social care and health care work best when you cannot see the join between them? Therefore, are we able to look at employing people across both disciplines—and indeed across the voluntary sector as well, which provides many of these workers—in order that the focus can be on the patient or the user, and not on the institution?

As the House knows, my noble friend is a great campaigner on this issue. I can certainly assure her that the review will include exploring the needs of the 4.7 million unpaid carers who effectively hold the adult social care system together. On the point about the care workforce, we are already improving career pathways by expanding the national career structure, including new role categories. The suggestions my noble friend makes about a seamless service are quite right. We are a long way from that, but I hope we will be able to get to it, and the workforce will be key in that.

My Lords, may I tell the Minister that the Statement is not an accurate representation of what happened in 2009-10? More importantly, it is now over 13 years since Andrew Dilnot produced his report, and there have been many promises to implement it that have not been kept. There should be no further delay. The Minister should acknowledge that if there is further delay in implementing a social care cap on costs, many thousands more people will face the catastrophic loss of their life savings and earnings as a consequence of meeting those costs. Until we implement the cap on social care costs, we will not know whether it will deliver a market in providing insurance against long-term care costs, which in itself would make a significant contribution towards meeting some of the costs of social care in the future.

I understand the wish of many, myself included, for more urgent action. However, the reality is that acting in haste will not solve the problem, not least because of the depth of the difficulties we are looking at. The noble Lord is right that many promises have been made—a number by his own Government—but not fulfilled regarding what should happen on the cap. I reiterate the point I made earlier: while I appreciate that there are Members of your Lordships’ House who believe that Dilnot is the answer, it deals with just one aspect, and that is not what we need. As my noble friend just said, we need a comprehensive look at creating a more joined-up service that will work around people, rather than focusing on institutions or one particular problem.

My Lords, I am grateful to His Majesty’s Government for trying to get cross-party agreement on this really important issue; it is important that it does not get lost in party politics. It is good to hear about the improvements to the NHS app, which is working quite well in some areas already. However, some people are digitally excluded, and there is a lack of connectivity in rural areas. How are we going to ensure that these groups are not excluded as we go forward with this important work?

The right reverend Prelate is correct to mention—I have raised it myself—not just the digital exclusion of individuals but connectivity. It is one of the reasons that we will approach this in a cross-government fashion. However, on our move from analogue to digital—the noble Lord, Lord Kamall, rightly mentioned the capacity of the NHS—our view is that it can do so much more than it is doing currently. The Secretary of State said in the other place that restaurants, for example, have been texting customers for many years, have they not? They remind customers about their booking and give them a chance to cancel or change it. That is the kind of connectivity and service that we need from the NHS. I assure the right reverend Prelate that, where people are unable to use whatever the digital solution might be, they will be able to deal with it person-to-person or on paper. We will be flexible enough and actively seek out those who are not, as he described, immediately connected.

My Lords, the Darzi review estimated the impact of delayed discharges at some 13% of total hospital beds. Given this, can the Minister say how confident she is that the immediate steps to improve the rate of discharge from hospital into social care, which she has already outlined, will happen? How quickly will that happen and over what timescale, and what accountability measures will be established at both national and local levels to ensure that those delayed discharges start to come down, and quickly?

The independent review by the noble Baroness, Lady Casey—in addition, as I mentioned, to producing recommendations that can be implemented straight away next year—is focusing on completing its final report later in this Parliament, so we are looking at the longer term. I cannot give an exact timetable, although I am hopeful that we will be able to update your Lordships’ House with further information, as the noble Baroness quite rightly asked. The matter of discharge requires there being suitable facilities in the community, but we are not in that place, so this will take some time. But I am very hopeful that all of the measures here, and the measures we have taken already, take us further to that point. We will continue to strive on the matter of discharge, because it is a problem not only for the NHS but for patients and their carers and for social care. We are carrying, as we know, a lot of vacancies and a social care system that is creaking at the seams: we must be honest about that.

My Lords, I welcome the Statement and many of the proposals in it. We have learned from past experience that all reforms to, and any proposal to change things in, the NHS—and, for that matter, social care, but more so with the NHS—lead to increased bureaucracy but not the benefits that we thought they might deliver. One of the waiting list initiatives is that GPs will have a consultation with hospital staff to try to reduce waiting times and avoid unnecessary duplication. There is some financial incentive attached to that, but it certainly will increase bureaucracy. What modelling has been done to find out whether it will work, whether it will increase bureaucracy and by how much it will increase costs?

I am grateful to the noble Lord for welcoming many of the measures in this announcement. He referred to the £20 fee that will be paid to GPs to call the consultant where necessary. I understand the concern about increasing bureaucracy, but all these reforms are intended to work the other way. We will very closely monitor them and have very carefully considered them with all those who will be dealing with them. I am actually more than hopeful, because the intention is that allowing the GP, for example, to get further advice, and making sure that people are being seen in the right place, will save money. It will mean that people are not taking up a referral place and that they will be referred for the necessary tests, scans, et cetera without the middle bit, which is a very backward-facing way of dealing with things. We will continue to monitor that to ensure that we are reducing what is currently wasted clinical time, while also preventing unnecessary out-patient appointments. The monitoring should show all of that and I will be very happy to update the House on that. The fee is to ensure that it can happen and is an incentive to do so. Of course, the greatest prize is an increased and speedier service for patients.

My Lords, it is pleasing to welcome the proposals from the Government. It is also very pleasing to hear of the immediate things that can be done for social care, because we should not be waiting for the final report. There are some more suggestions that we could make that do not require any money—that should be music to the Minister’s ear. We do not need more money to reduce the bureaucracy that people in the community are required to go through to gain admission to a care home. It is horrendous. They have a means test and a needs test serially, which can be very bureaucratic and time-consuming, and there are waiting lists. We must reduce that bureaucracy. The second thing, which the Minister has already referred to, is the value that we place on care home workers. It is good to hear that they will get a rise in their money and that ideas will be put about on their careers, but, unless they have a recognised national qualification and registration of that qualification, career prospects will be limited. We must do more for them to allow them to see themselves in a career that could go on to nursing in the NHS. We must do more in that field if we are to retain these enormously valuable people.

My noble friend, as always, makes very practical observations. I totally agree with the point about bureaucracy in terms of care homes. I have experienced that as I have power of attorney for an elderly friend, and I constantly wonder: if I am struggling with it, what would it be like for somebody who perhaps is not as used as I am to dealing with forms, organisations and, indeed, bureaucracy? It is extremely troubling. Yes, that will be part of what we will be looking at to improve social care—and also the discharge ability that we were talking about earlier. Valuing care workers, professionalising the service and recognising them are all key. I agree that it should be a natural move from being a care worker into a clinical setting, but we also need to recruit people to be care workers, retain them and upskill them, which is so important.

My Lords, on the vexed subject of delayed discharge of very elderly patients who have been admitted from care homes, quite often with ailments such as flu, medicine management, wound-dressing management, et cetera, surely the key is to ensure that many of these patients are not admitted in the first place. This follows on from the last question about the training of care workers. Is there an argument for enhancing their training so they become better carers in terms of dealing with these problems? Can the Minister say something about what I know has been tried in a number of care homes: having intermediate NHS beds in care homes?

Both the points that the noble Lord makes are very welcome and shine a light on the need to be more flexible in the range of services and care provided. It should not be just an either/or. People have intermediate stages. Some of the issues about discharge are about having a position in the middle, which is more about rehabilitation, and having the things in place to allow people perhaps to return home or to some other setting. There is also the point about having a range of settings. Currently, the offer is perhaps too restrictive, although not in all places, as there are some excellent examples. We must be much more creative in the kind of offer that is available and in the training of care workers, not just for the service that they offer to patients, which is important, but for their professionalisation and their morale in their jobs.

My Lords, why is there no mention of mental health in the Statement? What happened to parity, I wonder? For example, 12,400 hospital patients a day are well enough to be discharged. I presume that this does not include the 1,500 or so autistic people and people with learning disabilities who are waiting to be discharged from psychiatric hospitals but for whom there is no social care? Community diagnostic centres are mentioned but there is nothing about the need for 24-hour community drop-in centres for citizens who have mental health problems. Social care costs for elderly people may be expected to double, but what about the increasing costs of care for disabled adults of working age?

The noble Baroness makes very real and important points. Some of the points in the Statement cover mental and physical health but, if I might be honest about the situation, this is only one of the things that we are putting forward. As I said at the beginning of this Statement, how I wish that we could deal with everything immediately. It is not possible. This is just the first stage in the journey that we are on. I hope that the noble Baroness is reassured by the direction that we are taking, the commitments and the work that we have already done on mental health. The Committee stage of the Mental Health Bill next week will also be a very significant step forward. I absolutely accept that there is so much more to do, and we will be getting through that.