Residential Care: Cost Cap

Baroness Brinton Excerpts

Thursday 10th December 2015 Lords Chamber

[Baroness Brinton (LD)]

My Lords, I suspect that given the difficulties facing the social care sector at the moment, particularly the residential care sector, much of this debate will focus on viability and financial problems, so I want to start with a comment about quality. Yesterday was the first anniversary of my mother’s death. During most of the preceding 11 years, she was at home, but she was also in respite care and residential care, and the care taken by everybody involved—the social services department, the domiciliary care company, the residential homes, one of which was a very small provider with the other part of a much bigger scheme, the hospitals and the intermediate care—was fantastic. I cannot fault any of the support and care she had from the whole of Dorset and all the people who my family were involved with over that 11-year period. It is worth pointing that out because too often we hear of the problems, and it is right that we focus on making sure that care is of high quality, but if we do so by ignoring care where it is of high quality, we miss out on many people’s experiences.

Dilnot was a very important point in Parliament’s history because the three major parties came together to agree that we needed to move forward together. Social care had for many years been something of a Cinderella issue, but the aspirations of Dilnot were certainly enshrined in some of the Care Act and I am very pleased that the noble Lord, Lord Lansley, wants to mark Paul Burstow’s role as Minister in making sure that much of the detail about the quality of care and the support for carers has been noted.

The problems that much of the sector faces, particularly the residential care sector, are because of the perfect storm that we now face. Much of it is financial but it is not only that. Can the Minister identify where the savings from the non-implementation of the Dilnot report have gone? The noble Lord, Lord Lansley, said that the moment when it could have been funded from other resources has gone. From looking at the spending review and some of the initial statements about next year, I understand that we are talking about probably £700 million being identifiable from that preceding amount. What has happened to it and where has it gone? It is evident that local authorities and the Department of Health are going to face major problems because of the demographics and the pressure of making sure that there are spaces available at levels that the residential system can afford if it does not have extra funding.

The better care fund, which was created by the coalition, was a step in that direction. It was a good one in that it started to change the emphasis from hospital care to residential and community care. However, despite the increase we have heard about, it is back-loaded to 2018 and 2019 and will not help over the next two years. The system is currently in major crisis. The introduction of the national living wage is also going to cause real problems for private providers of residential homes. On the announcement of the national living wage, quoted companies saw a fall in their share value. Major providers have started disposing of large numbers of homes, because they are seriously worried about how they can trade, let alone make a profit. Finally, lenders to that sector have stopped lending, because the business model is bust. If that is the case, everything that the Government are trying to do through the better care fund will be useless. More and more people will be staying in hospital because there will not be the beds for them to go to.

The local authority social care directors estimate that the current local authority shortfall will be £4.3 billion by the end of this Parliament. It is not clear from the spending review that there will be enough to fund the national living wage or demography. We know that cumulative local authority budgets have been cut over recent years, but what is less well known is the result for those authorities with social care responsibility: five years ago 30% of their funding went on social care, while it is now 35% and increasing. As a result, they have had to face tightening eligibility thresholds quite substantially, so that now only those with the most severe need can get any help at all, forcing pressure back on the primary care sector and on hospital trusts.

Members who have been involved in these debates will know that earlier in the year I spoke about one poor pensioner in the north of England who was told quite clearly that one of her legs was social care and one of her legs was her GP. She ended up going back into hospital because the social care element was not able to maintain one of the legs. This resulted in an emergency bed because the primary care would not let the nurse look after the leg with the other problem because it was not its leg. That story is easy to laugh at, but when budgets are so tight and protected, it makes people behave in peculiar ways. We have to find ways around this problem.

I have another concern. Some care providers have been told by their local authorities that they should fund the basics, like sick pay and travel between work for those in the domiciliary sector, from the profits they make from self-funders—and that they should not be expected to carry that burden for either health or local authority-funded patients. This is unbelievably facile. We need to make sure that we understand the cost of funding a residential care place. If our public sector is asked to provide it—which it must be for those in need—the funds must be available.

Of course, the demography is increasing so even without the pressure that we are seeing the situation will undoubtedly get worse. In the last few seconds, therefore, I would like to talk about a parallel. If the pressure that we are seeing in this sector was evident to people on the nightly news in the way that we have seen flooding in the last few weeks, I suspect that the Treasury would act all too quickly in making sure that emergency funds were available.

In closing, I repeat my question to the Minister. At the very least, please can we be assured that the money that should have gone into Dilnot is passed straight through to the sector this year, not just some of it during this Parliament?

Health: Parity of Esteem

Baroness Brinton Excerpts

Tuesday 20th October 2015 Lords Chamber

[Lord Prior of Brampton]

My noble friend makes a very good point: reaching for medication is often not the right way forward. I am not sure how much time in the undergraduate syllabus is reserved for mental health training. However, I know that a considerable amount of time is set aside for it, so that people who decide to become GPs will have had some training in mental health before they qualify. Only last week, I was talking to Clare Gerada, who was the president of the Royal College of General Practitioners. She said that she thought the best combination of all was for a GP to have studied psychiatry as well.

[Baroness Brinton (LD)]

My Lords, it is encouraging to hear the new Government continue the priority that the coalition Government gave to improving mental health access for everyone, and specifically for children. I am also encouraged to hear the Minister talk about waiting time targets. However, surely true parity of esteem will be reached when we have targets for CCGs and, if they miss them due to lack of funding and the appointment targets are missed, that is publicised in the same way as missed A&E targets.

[Lord Prior of Brampton]

That is a very interesting point. We have three principal targets for mental health: two relate to IAPT and the other to access for those who have their first psychotic episode. Clearly, we do not yet have the range of targets for mental health that we have for physical health, although the introduction of those three targets this year is a big step forward. It is important that the targets should be based around outcomes rather than funding.

Social Care and Support: Funding

Baroness Brinton Excerpts

Monday 19th October 2015 Lords Chamber

[Lord Prior of Brampton]

As regards the position of the social care sector, “fragile” is putting it kindly. It is very difficult; there is no point making any bones about that. The increase in the living wage, which is long overdue and very welcome, will add to pressures on the sector. It was made very clear in the Five Year Forward View that the future of the healthcare system is very much tied up with the future of the social care sector. The noble Baroness can be assured that we have brought that to the attention of the Treasury and we are waiting for a favourable result in November.

[Baroness Brinton (LD)]

My Lords, the social care sector is in a perfect storm, with councils having faced a 30% cut in their social care budgets as well as the increase in the national living wage which—much as it is welcomed—it is estimated will cost an extra £1 billion. I ask the Minister once again: will the Government commit to spending the extra £6 billion that they are saving by not implementing Dilnot and ring-fence that money to support the social care sector through this very difficult time?

Social Care

Baroness Brinton Excerpts

Thursday 15th October 2015 Lords Chamber

[Lord Prior of Brampton]

I thank my noble friend for that important observation, with which I agree completely.

[Baroness Brinton (LD)]

My Lords, the better care fund was a good starting point for the integration of health and social care, but the Government deferring the integration of the spending limits in the Dilnot review means, we are told, that there are £6 billion of savings. Will the Government ensure that that saving of £6 billion from not fully implementing the integration of health and social care is put towards the new minimum wage and the new contracts ensuring that staff are paid for travel between appointments?

[Lord Prior of Brampton]

The position on the savings from deferring the introduction of the Dilnot proposals is that they are being taken into account under the spending round and I cannot comment further today.

National Institute for Health and Care Excellence

Baroness Brinton Excerpts

Monday 13th July 2015 Lords Chamber

[Lord Prior of Brampton]

I am not entirely convinced by the argument about regulation when it comes to managing wards. My own observation is that when you have strong leadership from strong ward sisters, ward managers or charge nurses, many of the problems that we identify seem to disappear and there is very high staff morale, low absenteeism and little use of agency staffing. So much comes down to local leadership, and sometimes regulation is used as a scapegoat.

[Baroness Brinton (LD)]

My Lords, given that everyone accepts that the new safer staffing guidelines will require more nurses, what will the Government and Health Education England do to reduce the number of nurses who do not qualify from their training, which is currently running at about 20%?

[Lord Prior of Brampton]

That is a very high figure. It is quite revealing that most of the people drop out in their first placement, and it behoves universities and Health Education England to ensure that they are recruiting new nurses who have done some work in a care home or hospital so that they know what the realities and practicalities of being a nurse are.

NHS: Whistleblowing

Baroness Brinton Excerpts

Tuesday 30th June 2015 Lords Chamber

[Lord Prior of Brampton]

There are a number of organisations that the noble Baroness might wish to contact, but most important is to raise the matter first in the local organisation. All organisations should have their own whistleblowing procedures, and that is the right way to raise concerns. If any individual finds that not to be satisfactory, the right way to proceed is through the Care Quality Commission, which has a dedicated hotline in its service centre in Newcastle.

[Baroness Brinton (LD)]

My Lords, which takes priority: duty of candour or an employee’s contract with their NHS trust where they are gagged?

[Lord Prior of Brampton]

The duty of candour should clearly take precedence. It should be seen in the context of an agenda to improve patient safety in hospitals; if we are not open about our mistakes, we will not learn from them.

NHS: Cancer Drugs Fund

Baroness Brinton Excerpts

Monday 16th March 2015 Lords Chamber

[Earl Howe]

My Lords, the noble Lord is right that there is a particular issue around the appraisal of new cancer drugs. That is why NHS England, the Department of Health, cancer charities, NICE and the Ethical Medicines Industry Group, as well as the ABPI, are working together currently as part of a new working party tasked with finding the best way to get new cancer drugs appraised and commissioned for patients. A number of proposals have been looked at to reach an integrated process between NHS England and NICE which results in clear and final decisions on baseline commissioning of chemotherapy drugs.

[Baroness Brinton (LD)]

My Lords, given the good news that the Minister just gave us about the working group looking at the future of some of these complex drugs, and the whole policy about “No decision about me without me”, would it not be sensible to have patients’ advocates, such as Prostate Cancer UK, able both to present and to appeal the case for a drug? It seems bizarre that this is the one area where there is no input of anybody other than the committee making the decision.

[Earl Howe]

I differ slightly from my noble friend on this point. I think that the key determinant for the reprioritisation process has to be clinical input, and that is indeed what happened. It is necessary to have as objective a process as possible when looking at how to reprioritise a cash-limited fund of this kind.

NHS: Medical Staff

Baroness Brinton Excerpts

Monday 15th December 2014 Lords Chamber

[Earl Howe]

I beg your pardon, my Lords. DfID has a number of programmes designed to support the health economies of developing countries. They have been in place for many years. They can take the form of training, not just of doctors but of all healthcare professionals. I am aware that DfID is extremely supportive of those programmes.

[Baroness Brinton (LD)]

My Lords, 10 years ago there were more Malawian doctors working in England than there were in Malawi and the Royal College of Surgeons, working with CBM UK, a disability charity, set up the College of Surgeons of East, Central and Southern Africa. In that time the number of African-trained surgeons has substantially increased through this joint practice. Are other royal colleges following their example in setting up similar projects?

[Earl Howe]

I am not aware of the answer to that question but I can tell my noble friend that the UK has been moving towards self-sufficiency for a number of years. For example, there was a 27% decrease in the number of registrations of non-European Economic Area nurses from April 2010 to March 2014, continuing a longer-term trend. The number of doctors in the NHS with a primary medical qualification from outside the EEA has remained relatively static over the last four years despite the full-time equivalent number of doctors increasing by more than 5% over the same period. I think we can take heart from those figures, mindful, of course, of the need to adhere to the World Health Organization code of practice.

HIV: Stigma

Baroness Brinton Excerpts

Monday 1st December 2014 Lords Chamber

[Earl Howe]

My noble friend, with his immense knowledge of this subject, is of course absolutely right. The 2011 UN Political Declaration on HIV and AIDS specifically includes a goal to eliminate by 2015 stigma and discrimination against people living with and affected by HIV through the promotion of laws and policies which ensure that human rights and fundamental freedoms are protected. Progress towards universal access cannot be made unless stigma and discrimination are tackled. They are a particular barrier with regard to the criminalisation of gay men and women, transgender people and sex workers. DfID is a constant champion of these groups internationally.

[Baroness Brinton (LD)]

My Lords, Prince Harry’s brave statement today to declare his secret reminds me of mine. A dear friend died of AIDS three decades ago. I cannot speak his name because to this day his family do not know that he had it. The point made by the noble Lord, Lord Fowler, is important, but we have children and young people in this country who are suffering from HIV and AIDS. What education is planned specifically for young people who are at risk, along with their school friends?

[Earl Howe]

My Lords, sex and relationship education plays an important part in exposing young people to the whole subject. Guidelines are available that schools must follow. They include sections on HIV and sexually transmitted diseases generally. As I say, secondary schools must follow those guidelines.

Nursing and Midwifery (Amendment) Order 2014

Baroness Brinton Excerpts

Thursday 27th November 2014 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, the Government have identified improvements that can be made to the legislation within which the Nursing and Midwifery Council operates, to improve public protection and increase public confidence in the Nursing and Midwifery Council. Therefore, the department carried out a UK-wide consultation on proposed changes to the Nursing and Midwifery Order 2001, which is the Nursing and Midwifery Council’s governing legislative framework. The majority of respondents supported these amendments.

The first of the proposed changes is to enable the Nursing and Midwifery Council to appoint case examiners who will be given powers currently exercised by the investigating committee to consider allegations of impairment of fitness to practise, following an initial screening which has considered that an investigation is appropriate. Two case examiners—one lay and one registrant—will consider the allegation, following the procedure set out in amendments to the Nursing and Midwifery Council (Fitness to Practise) Rules, which are being developed in parallel to this order by the Nursing and Midwifery Council.

The case examiners will then agree their decision on whether or not the registrant has a case to answer—this is the same process used by General Medical Council case examiners—and whether the allegation should therefore be considered by the health committee or by the conduct and competence committee. If case examiners fail to agree on whether there is a case to answer, the allegation will be referred to the investigating committee for determination. The introduction of case examiners should lead to the swifter resolution of complaints and thereby improve public protection and the efficiency of the Nursing and Midwifery Council’s fitness to practise processes, as well as reducing the stress to registrants caused by lengthy investigations.

The second change is to introduce a power for the council to review “no case to answer” decisions made at the end of the investigation stage in fitness to practise cases, and to make rules in connection with the carrying out of such a review. This will bring the Nursing and Midwifery Council’s power in line with the General Medical Council’s power.

The third change is to introduce a power to allow the council to delegate this function to the registrar—the chief executive. The amendments to the fitness to practise rules being developed by the NMC will provide that the registrar may review a “no case to answer” decision where new evidence comes to light that has a material impact on the original decision or if it is considered that the decision may be materially flawed, and in both cases that it is in the public interest to review. Save in exceptional circumstances, a review of a “no case to answer” decision cannot be commenced more than one year after the date of that decision.

The fourth change is to revise requirements for the composition of the registration appeal panel by removing the requirements for a Nursing and Midwifery Council member to chair the panel, which is intended to establish a clear separation of duties between the operational and governance functions to avoid suggestions of perceived bias and conflict. Additionally, it will remove the requirement for a registered medical practitioner to be on the panel in cases where the health of the person bringing the appeal is an issue. It is intended that medical advice will be provided by independent medical witnesses and reports to ensure the panel remains detached from that part of the process, and therefore making the process more robust and transparent. This will also ensure more consistency between registration appeals and fitness to practise appeals.

The fifth element is to clarify existing legislation that the Nursing and Midwifery Council’s Health Committee or Conduct and Competence Committee has the power to make a strike-off order in a health or lack of competence case upon a review of a final suspension order or conditions of practice order, provided the registrant has been the subject of such a final order for at least two years. This is not a new power but provides clarification of the existing legislation to protect patients and the public by ensuring that those whose fitness to practise is impaired cannot continue to practise.

The sixth change is to introduce a power for the Nursing and Midwifery Council to disclose to a third party certain information relating to a person’s indemnity arrangements for the purpose of verifying that information for the Nursing and Midwifery Council’s purposes. This will enable the Nursing and Midwifery Council to verify the information it receives to ensure that indemnity arrangements are in place and provide sufficient cover against the liabilities that many be incurred by a practising nurse and practising midwife registrant.

The seventh change is to give the Investigating Committee a new power to also make an interim order after it has referred a case to the Health Committee or to the Conduct and Competence Committee if that committee has not begun its consideration of the case. At present, once the Investigating Committee refers a case, the power to make an interim order rests only with the Conduct and Competence Committee or the Health Committee. This will ensure that if new information is received which suggests that an interim order is necessary for the protection of the public after a case has been referred to another practice committee, but before the committee has started to consider it, the Investigating Committee will have the power to make an interim order.

The introduction of case examiners and the power to review “no case to answer” decisions, made at the end of the investigation stage in fitness to practise cases will bring the Nursing and Midwifery Council in line with the General Medical Council. The implementation of these recommendations requires a Section 60 Health Act 1999 order to amend the legislation governing the Nursing and Midwifery Council. I commend this order to the Committee, and I beg to move.

[Baroness Brinton (LD)]

My Lords, this amendment to the Nursing and Midwifery Order is to be welcomed. A regulatory body has to balance the respected traditions and structures of an informed 150 years of experience with the urgent needs of the current issues that the council faces when there may be rare problems with registered nurses and midwives. Much of what is proposed follows good practice. However, there is one area in which I have some minor queries and I wonder whether my noble friend the Minister can help.

The move away from independent consultants forming an investigation committee to having an in-house employed case examiner raises two minor concerns that are not reflected in the consultation response at paragraph 8.6 of the Explanatory Memorandum. Will the case examiners have extensive training in gathering the evidence that they will have to present to the quasi-judicial relevant committee considering each case? Will the benefits that other investigating groups such as Ofsted and local government inspectors have, given that at least one member of those teams comes in from outside, ensuring that there is always fresh challenge, be lost with this new arrangement?

Secondly, as employees of the council, will their job specification make it absolutely clear that they must conduct their role without fear or favour? It may be obvious when they are dealing with people outside the council but occasionally—very rarely—there may be a case where, for example, a decision not to have an interim suspension might have resulted in further injury or damage, and therefore members of the council themselves and other judgments might be being examined. The case examiners must be truly free to examine the council’s own processes and to feel no pressure from their own managers.

The no case to answer decision and the independent chair of the appeals panel are important and to be welcomed. However, given what I have just said about the case examiners, I find it slightly peculiar to remove the requirement for a registered medical practitioner to be on the panel, because that person in the past has provided that independent voice from the members of the council.

The points that I have raised are minor ones, and I welcome the order. However, I hope that I can have some reassurance on these points relating to the new role of case examiners.