Health and Social Care Bill

Baroness Greengross Excerpts

Monday 19th December 2011 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, I speak to the amendment to which I have added my name in relation to children, but also speak to a raft of other amendments related to allied healthcare professions. Last week we had a debate about the need for the voice of children in the Bill to be strengthened. On reflecting on this and the debate that we had over other vulnerable groups, it struck me quite forcefully that children are the only group who do not have an independent voice en masse. In all other vulnerable groups, there will be a spectrum of people, some of whom can be outspoken and some who can be advocates for others, even among groups such as those with dementia, the very elderly and those who have come here to this country as asylum seekers. However, children under the age of 16 are completely dependent for consent and for other issues on those who have a legal parental role to act on their behalf and to consider their best interests.

We discussed last week the fragmented society in which some children are now brought up, and the difficulties that individual children face. We also discussed the need for health and social care services to reflect the needs of children. I urge the Minister, in looking at these amendments and those we debated before, to consider very carefully where our society will be heading if we do not strengthen the voice of children on the face of the Bill.

Amendment 330A, to which the noble Lord, Lord Low, has put his name and, I believe, will be speaking, will try to secure a change so that this Bill parallels the change in the Education Act.

I will now address my remarks to the need for representation and consultation of allied healthcare professionals, and in so doing declare my interest as president of the Chartered Society of Physiotherapy. Physiotherapists are the largest part of the allied health professions’ workforce. The Bill needs to state that allied health professions as a group are consulted, because there is, sadly, great ignorance in medicine and nursing as to the full range of professional services that allied healthcare professionals can contribute. They contribute right across the range; innovative models of service provision now being developed are able to free up medical and nursing time and decrease the number of interventions needed, particularly on aspects such as orthopaedic surgery, where physiotherapists are running clinics and are able to intervene and completely obviate the need for some patients to progress to surgery.

Allied health professionals by and large, and physiotherapists in particular, are focused on re-enablement; on keeping people healthy; working with the parts of them that are healthy and helping them cope with the parts that are not; on preventing absence from work and avoiding unnecessary hospital admissions and unnecessary interventions. We are already hearing of delayed discharges from hospital. The Health Service Journal of 27 October this year had a piece on this. Patients are having to wait for care packages, including physiotherapy services, that could enable them to be cared for in their own homes. Without the allied healthcare professional voice being involved at senior-level commissioning, acute services will not be joined up in the community, and that leads to fragmented care for patients and poorer health outcomes. Care in the community setting is viewed as key to the Government’s efficiency savings in relation to hospital admissions. Allied healthcare professionals enable patients to take control of their own care and resume living in their own homes, empowering them and easing the burden on front-line services. There are a whole group of amendments in my name which list allied healthcare professionals. I hope that the Government will look favourably on these.

[Baroness Greengross]

My Lords, my Amendment 332A follows well from the previous two speakers. It would ensure that integrated working in health and social care delivery—particularly the latter, which we know from many noble Lords who have spoken, including the noble Lord, Lord Warner, is often very much the junior partner in these discussions—is given an explicit place on the face of the Bill, rather than simply being relegated to regulations and guidelines. In his report on Fairer Care Funding, Andrew Dilnot commented that when someone has a care or support need, they do not really know which part of the range of state funding is going to provide the services that they need. This particularly applies to people with multiple needs and co-morbidities, which is often the majority. We know that there are many different services delivered at national and local level—for example, the NHS, the adult social care system, social security benefits, public health services and housing services. They can all be critical in meeting people’s needs. The problem is that all these elements overlap and interact, sometimes positively but sometimes rather negatively. Dilnot noted forcefully that when services that are shaped around people work well together, outcomes are better; when they do not, people experience very disjointed services and their experiences are poor.

We need a care system that is more consistent, with less variability, and one in which people feel that services are working for them, not against them. In this context, I welcome the Department of Health’s commitment to breaking down the barriers between health and social care to improve the outcomes and experience of users. Having a National Health Service that is free at the point of need, but a shared-responsibility system of social care, means that difficult decisions will continue to be made if this carries on. For example, in response to the Nicholson challenge, how will clinical commissioning groups ensure that the focus stays on the patient and on integration of services and not on contracting and other arrangements? Do we know what type of support managers need to make integrated services a reality? How can staff be encouraged to work collaboratively? Through this process, how can the correct values and ethos concerning the dignity and respect of patients, which we all believe in, be developed and maintained within and across organisations? There are many examples of where the consequences of having different care streams can seem extremely unfair to people. But when streams have been integrated or a more co-ordinated approach is taken, there is evidence of improved outcomes, high-quality services and better value for money, as well as the fostering of innovation. In my view, the powers proposed in Clause 192 for the health and well-being boards to support integrated working should be extended to encourage explicit joint commissioning.

In support for innovation in Part 5, greater regard should be given to the role that service and technology solutions, for example, can have in breaking down traditional boundaries and in encouraging better integration of health and social care services. All generations, including older people, are having their lives transformed by the dramatic changes that we daily witness in communications technology, yet in the UK the adoption of telehealth into health and social care, particularly in prevention and intervention, has sometimes been much slower than in many countries in the industrialised world. In other parts of the world, we have clear evidence of the key role that these systems play in the prevention of ill health, in self-management, in the provision of improved outcomes and in dependence for service users and efficiency savings for the taxpayer. As part of the overall redesign of care, this represents a vital element in the shift towards more preventive care, reducing the imbalance between hospital and primary care spend and making better use of scarce clinical resources. Better integration should facilitate such innovations and would go a long way to making health and social care more self-directed and giving a boost to the personalisation agenda. Integration deserves to be more than a footnote in this Bill. It could be the cornerstone of better quality, value for money and patient-centred care.

[Baroness Jolly]

I have put my name to Amendments 328B and 330ZAA. I send the apologies of the noble Baroness, Lady Tyler, who is not well. She had hoped to be able to speak to these instead of me. First, I should like to make a few general points about health and well-being boards. It should go without saying that the Liberal Democrats really welcome local democracy in health and the far greater involvement of local authorities than is the case at the moment, as well as the use of scrutiny committees. We are somewhat saddened that in the legislation there is only one elected decision-maker on a health and well-being board. I understand the Government’s unwillingness to prescribe, but they have not quite got the balance right. There may be as many elected councillors as other voting stakeholders, with maybe a casting vote given to the chair. That feels much more like localism in action than what we currently have.

Linked with that is the role of district councils, which is not mentioned terribly clearly. Here I have another apology, because I know that the noble Lord, Lord Greaves, had hoped to speak on this point. What we are losing in his eloquence we are probably making up for in brevity, but I still feel as strongly as I am sure he will. I can almost feel him behind me now, as I speak, but he is not well and is not able to be with us.

Where are district councils in this framework? I know that a lot of local authorities have now become unitary, but there are really key parts of England where strong county councils are well underpinned by district councils. They need to be there, because they provide planning, housing, leisure and environmental health—all these things that have to be well woven into the fabric of this Bill and the delivery of services. They are also part of the solution for the big public health issues. Three examples come to mind without even having to think very hard. Wearing their leisure hat, obesity is a very big issue. Some people prescribe exercise for obesity. On housing, in my neck of the woods, with the warm, wet westerlies, housing gets damp very easily. That brings with it chronic heart and lung problems, particularly if you cannot afford to heat. District councils also play a key role in housing on mental health issues. They are often providers for county councils and PCTs and I know that they would hope for a similar relationship with clinical commissioning groups, when things become established. They should be at the table of the health and well-being boards. I appreciate that you cannot have every district council having one representative. In Kent, where there are 16, or in Devon, where there are eight, you cannot bring those in, but there needs to be some arrangement for working together to ensure that district councils should be there.

Health and Social Care Bill

Baroness Greengross Excerpts

Tuesday 13th December 2011 Lords Chamber

[Lord Owen]

My Lords, I gave notice that I would raise this matter under whether the clause should stand part of the Bill but it is easier and more convenient to do it on this occasion. It is extremely important that this amendment is given serious study by the Government. I hope that either they will produce their own amendment or that the noble Lord, Lord Clement-Jones, will push this on Report to a vote.

Not to have such a provision is ridiculous, particularly in view of what we heard earlier from the noble Lord, Lord Newton, about how long it is taking to conduct mergers between trust hospitals in other areas. It is an ingenious way of doing it. I was trying to work out a way in which it could be done and rather failed. The wording that the noble Lord has come up with is very sensible and I hope that the Government will give it a fair wind. It is all part of the policy of trying to curb this uninhibited competition in every aspect of this Bill.

[Baroness Greengross]

My Lords, I was recently privileged to be the lead commissioner for the Equality and Human Rights Commission on an inquiry, looking at the human rights of older people in their own homes in need of care and support. This inquiry was a very large one with a lot of evidence, involving 500,000 people in total in this country. We found that half of the people were very happy with the care they received. The other half—250,000 people—were rightly not happy with what had happened. There were awful instances of people being abandoned for 10 or 12 hours, having no social interaction or opportunity to talk or chat. They were left without care for many hours. These are very bad instances of poor care and I really believe that had the staff of the 250,000 people been trained properly in what the tool of human rights can achieve—and if their managers had understood that—a whole lot of these instances of very poor care would not have taken place.

My amendment is designed to ensure some clarity on the application of the Human Rights Act to domiciliary care services commissioned from private and third-sector organisations. This amendment would clarify that providing these services is a public function within the meaning of Section 6(3)(b) of the Human Rights Act 1998. It would bring domiciliary care in line with residential care; similarly, this amendment would confirm that health care services commissioned from private and third-sector organisations fall within the scope of the Human Rights Act. It would clarify the extent of the public sector equality duty because the definition of public function under the Human Rights Act also determines the definition of public function under Section 150(5) of the Equality Act 2010 for the purposes of the public sector equality duty. My amendment also uses wording which is consistent with Schedule 1 to the Health and Social Care Act 2008.

In 2008, Parliament introduced amendments to the Health and Social Care Bill—now the Act—to overturn previous case law and ensure that private and third-sector care homes were defined as carrying out a public function. We were delighted that that applied and that they therefore came under the scope of the Human Rights Act. This received cross-party support and was the result of a long campaign by the EHRC and also the Joint Committee on Human Rights. The campaign aimed to ensure that organisations receiving public money were subject to proper regulation.

We also know that a similar problem is likely to be the case in healthcare if the care is commissioned by the health service to private or third-sector organisations. It is very important to make this clear because the fact that private and third-sector providers operate at the moment outside the scope of the Human Rights Act undermines, or threatens to undermine, the pioneering work of the Department of Health itself in promoting its Dignity in Care campaign. Further, the Health Service Ombudsman has recently documented 10 investigations into NHS care. All of that demonstrates that we need clarity in order to get this right and make sure that people are protected. We must be certain that people are not subjected to breaches of human rights which no one can do much about in the present situation.

I have cut short what I was going to say because it is late, but I do want to say that support for this amendment will clarify beyond doubt the fact that a person commissioned to provide home-based social care or healthcare is, in providing that sort of service, performing a public function within the meaning of the Human Rights Act and the Equality Act. I hope that the Minister will find it possible to support the amendment.

[Lord Low of Dalston]

My Lords, I have added my name to Amendment 295G, to which my noble friend Lady Greengross has just spoken, and I strongly support it. As she made clear, it would put an extremely important point beyond doubt. I want briefly to underline three key points.

First, it would remove a major ambiguity about the scope of human rights legislation in relation to health and social care, and with it persisting doubt about the rights of those in receipt of health and social care services. Despite the then Government’s intention that responsibility under the Human Rights Act should follow the outsourcing of state functions, it was generally understood—this was confirmed in the case of YL against Birmingham City Council—that the Human Rights Act covered only residential care provided by local authorities. Private and voluntary organisations that provided care home services under a contract with a local authority were not considered to be performing public functions under the Human Rights Act because there was only a contractual relationship between the parties, and so were not covered. This loophole, as my noble friend Lady Greengross has explained, was closed by Section 145 of the Health and Social Care Act 2008, but only for residential care services. It did not apply to contracted-out social care services provided in people’s homes. The purpose of the amendment is therefore to clarify that the Human Rights Act extends to services provided in people’s homes when provided under contract to a public authority and would remove all ambiguity as to whether the Human Rights Act applies to such services when commissioned from private and voluntary organisations.

As my noble friend has explained, a similar issue arises in relation to health services, especially given the significant increase in the commissioning of NHS services from private and voluntary providers envisaged by the present Bill. Amendment 295G would also place beyond doubt that private and voluntary providers of healthcare services fall within the scope of the Human Rights Act and the public sector equality duty, putting them on a similar footing to providers of residential social care. The amendment would therefore make it clear that those who receive publicly funded health and home care services provided by the private and voluntary sector are guaranteed the same levels of protection and rights to redress as those who receive services provided directly by the state, placing them on the same statutory footing as those who receive residential care services commissioned from the private and voluntary sector.

This is not just a matter of academic importance—the removal of a minor technical anomaly. Quite apart from the fact that it puts beyond doubt that a significant swathe of health and social care provision is within the scope of the Human Rights Act, local authority provision of home care services has been on a downward trend for the past couple of decades, with the result that the state now directly provides only 16 per cent of publicly funded services. This means that 84 per cent of such services are provided by the private and voluntary sector. This figure was less than 5 per cent in 1993. Indeed, the proportion of care delivered by the private and voluntary sector has gone up from 56 per cent to 84 per cent in the last 10 years. This means that the possibility that people in receipt of health and social care services may be deprived of the protection of the Human Rights Act has moved from being an issue at the margins of the field of health and social care to being one of central—indeed, dominating—importance.

Health and Social Care Bill

Baroness Greengross Excerpts

Wednesday 7th December 2011 Lords Chamber

[Lord Warner]

I shall briefly respond to that. We should never forget that the lion's share of the money that goes on state-funded adult social care comes from central government and is passed through local authorities to be spent on that group through the commissioning of various domiciliary, residential and even nursing home care. Although what I have crafted is a duty on the Secretary of State, a lot of this comes back to where the balance is struck between the NHS and adult social care in terms of priority and funding in Richmond House. They are all under the same departmental expenditure limit at department level.

The sense I had as a Minister was that it is a bit like the Army: you have to put a musician in the canteen. A former director of social services is kept well away from social care in Richmond House. I saw a reluctance in the NHS culture in Richmond House—which, thankfully, has changed with the arrival of David Behan —to fight for social care at the time of expenditure reviews. That is a real and serious issue. The big guns of the acute sector are alive and well in Richmond House when the expenditure review comes around. My noble friend Lord Hunt is nodding—I think enthusiastically, given his current job as chairman of a foundation trust. This is a real issue. We need a bit more balance in the statutory duty on the Secretary of State in order to align the money going into social care vis-à-vis the NHS.

There is a perfectly good point to be made at the local level. You want to see priority being given to adult social care at the local level, and you want to see openness on the part of local government—which, if I am honest, has not always been there—in working across the boundaries with people in primary care and in the NHS. That is absolutely an issue. However, if in local government you have only enough money to deal with people with substantial or critical needs, then your ability to help people with moderate needs and stop them getting worse will be restricted by the amount of resources available. It will then be extremely difficult to work across that boundary. We know that many local authorities have reprioritised their services, taking money away from other services and putting it into adult social care, but a very clear finding from the Dilnot commission was that the adult social care pot is simply not big enough. It is no good for us to keep uttering that there is a need for integration if there is not enough money at the local level for adult social care to work across the boundaries.

[Baroness Greengross]

My Lords, I strongly support the amendment and the remarks of the noble Lord, Lord Warner, and the other noble Lords who have spoken. Over the past 50 years we have seen a huge rise in longevity. In this century and at the end of the last century, that rise in longevity has been largely due to medical success in taming many acute and terrible diseases that once we could hardly even talk about. Now, many cancers can be lived with for a long time. However, the big and difficult condition to be dealt with now is dementia. This is a long-term illness and it is terminal in various forms, yet the care for people with dementia is funded largely through social care. This, in itself, is an enormous anomaly. One in four patients in hospital who are elderly and a huge number of people in the community have dementia, but that illness is treated as being due for social care, not NHS care, although the borders do blend to some extent.

We need to celebrate that huge medical success but we cannot do so if we go on as we are with the funding of, and attitude towards, social care, which remains very much as the Cinderella between the NHS and the community. Many people now say that this differential means that in reality we should close 20 per cent of acute hospital beds and transfer those patients to a different sort of care—perhaps hospitals transformed into community hospitals. It is not a case of killing them off; they should be transformed into care centres where people with these long-term conditions can be properly treated. We really must work towards that and accept the truth of it. If we do that, there will be an obvious need to integrate health and social care quite differently from the way that we have done it in the past. What is needed is not a transfer of resources but integration. We must get this right.

I have recently been involved in the EHRC’s inquiry into the care of older people in the community. We found that while a quarter of a million people are happy with the social care they receive in their homes, another quarter of a million are not—and understandably so because some of the ways in which they are looked after are, frankly, appalling. This is partly because of the huge diversity and differential in the allocation of resources, as well as the status and training of staff in dealing with the most difficult issues and problems. I am not going to go through everything I learnt from that inquiry. The report has been published, and I hope it will be helpful to many people in policy-making and in practice.

If we get this right and we keep people in the community for longer, we will save an enormous amount of money. At the moment, adult social services directors have no choice but to give money to the people in the most acute need, which means that the social care needs of all these other people are therefore not being met. If I were one of those directors and I had to choose where my money was going to go, that is what I would do. That needs to change because of the necessity of resource integration. We must find a way to intervene earlier, for dementia for example, with drugs, early diagnosis, and treatment in the community. People will then be able to live in the community for much longer and many will die in the community. An enormous amount of money will be saved. Care for people with dementia, in particular, in hospital is really unsuitable. It is bad for them and it is extremely bad for other patients. It really must change.

One reason that community care goes wrong is annual budgeting. If, like local authorities, one has to have an annual budget, one can do no preventive work. At least a four-year cycle is needed. It is like starting a business, investing in it, and expecting the return within a year—it cannot be done. One must wait a few years for the return. However, local authorities cannot wait because they lose their central government grants; we need to change that. The well-being boards need to be given the resources to integrate care properly so we can get rid of this imbalance.

Further, the Dilnot recommendations—and I congratulate the noble Lord, Lord Warner, on the distinguished role he played in this—are the first realistic proposals which bring together all sectors—public, private and voluntary—to get it right, with what seems to be a political consensus. This is such an opportunity, and we really cannot afford to lose it. Older people will suffer the most. There is still an enormous amount of discrimination. The social care we offer to younger disabled adults and to people with physical or learning disabilities is totally different; the attitude, and the range of resources and skills available to younger adults are quite different. This is direct and really damaging discrimination. The only way to change this is by integrating resources through the well-being boards. We need to make Dilnot a reality so that in the longer term all of us know enough to save for our pensions and our care. This amendment is essential if we are to get some action now. I support it very strongly.

Hospitals and Care Homes: Hydration

Baroness Greengross Excerpts

Monday 7th November 2011 Lords Chamber

Asked By

[Baroness Greengross]

To ask Her Majesty’s Government whether they have plans to implement a hydration policy in hospitals and care homes.

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

My Lords, all providers of regulated activities, including hospitals and care homes, are required by law to have policies in place that protect people from the risks of dehydration. The Care Quality Commission can take action if these requirements are not being met. It is for health and social care providers to develop local hydration policies. There are a number of best practice resources available to help providers to do this.

[Baroness Greengross]

My Lords, evidence has clearly demonstrated that adequate, and indeed good, hydration can lead to fewer falls, through less dizziness, less constipation, less renal and urinary tract problems, and can bring a host of other benefits, particularly among elderly people in hospitals and care homes. Could Her Majesty’s Government introduce firm guidelines on this for all key providers of care, whether in NHS hospitals or in care homes?

[Earl Howe]

My Lords, I think that mandating a blanket approach to hydration from the centre, as it were, will not have the effect that we want, which is to deliver the person-centred improvements that we all want to see. Having said that, I know that there have been some important developments. As I have just said, providers are now required by law to have policies in place that protect people in hospital, and the regulatory body charged with overseeing compliance—the CQC—has been equipped with tough powers of enforcement. My right honourable friend the Secretary of State instigated a whole succession of unannounced inspections of NHS trusts, and there are further ones on the way. We are also looking at changing the NHS constitution in relation to the issue of whistleblowing. So a lot is going on, but there is a limit to what central government can do. It is in the end up to staff and managers on the ground.

Health and Social Care Bill

Baroness Greengross Excerpts

Monday 7th November 2011 Lords Chamber

[Lord Patel]

My Lords, I support these amendments and I have my name on two of them. I particularly associate myself with the comments that the noble Baroness, Lady Williams of Crosby, made on the need to address the issues within public health to reduce inequalities.

We must all be very encouraged to see the recommendations of the Health Committee in its report of 2 November on public health. One of the recommendations says:

“We do not understand why the Secretary of State’s new statutory duty to reduce health inequalities under the Bill appears to apply only to the exercise of his functions in relation to the health service. We recommend that the Bill be amended to make it clear that the Secretary of State’s duty to reduce health inequalities applies in the exercise of all his functions, including those applying to public health”.

The noble Baroness, Lady Williams, already referred to the inequalities in health that occur because of lifestyle-related diseases. In previous discussions we have noted that 40 per cent of acute admissions are related to lifestyle-related diseases. It must be right that the statutory duty of the Secretary of State includes functions relating to public health.

[Baroness Greengross]

My Lords, I will speak to Amendment 33 in my name. I am pleased to follow the noble Baroness, Lady Williams, and the noble Lord, Lord Turnberg, because a lot of my work is concerned with the sort of inequalities they have spoken about. The noble Lord, Lord Turnberg, mentioned Professor Sir Michael Marmot. I have been privileged to chair the advisory group for the longitudinal study on ageing that he established. I have done that since it started. It demonstrates so clearly the terrible, almost life-or-death sentences that health inequalities impose on different groups in terms of their life expectancy. This is really something that is quite impossible for us to continue.

My other role as the lead commissioner on age at the Equality and Human Rights Commission means that I hope very much that we can, if we amend this Bill, achieve more positive healthcare outcomes. The Bill, in order to achieve that, must be explicit that improvements have to be achieved across the whole population, not just some parts of it. We know that one group whose needs are currently very often underprioritised and underrecognised is older people, particularly within the NHS. Sadly, ageism persists in clinical practice—very often older people lag behind other groups in terms of better healthcare outcomes. I am very concerned that unless a clear obligation to demonstrate that improvement is being achieved across the whole population, the specific needs of older people will continue to lag behind those of other groups or sometimes to be ignored and similar existing health inequalities may even be maintained and strengthened.

My amendment would define the Secretary of State’s duties to reduce health inequalities against three different criteria: the definitions of equality contained in the Equality Act 2010; different parts of England; and different socio-economic strata. In any subsequent reporting of progress towards reducing health inequalities, the Secretary of State would have to demonstrate consistency in the progress made against the three criteria.

My amendment would clarify the Secretary of State’s duties in relation to reducing health inequalities. I am afraid that without this in the Bill health service improvement may not reach everyone. There may be a failure to improve services for specific groups such as those mentioned within the list of protected characteristics. Clause 3 currently requires the Secretary of State to have regard to the need to reduce inequalities between the people of England with,

“respect to the benefits that they can obtain from the health service”.

The amendment to this clause would ensure that access to health services and improving health outcomes were an intrinsic part of the Secretary of State’s duties. Without guaranteeing improvement in access to services, there is a risk that there could be high levels of variation in the kinds of services the NHS provides across the country.

I have listed the equality characteristics detailed in the Equality Act 2010 which is not necessarily Members of your Lordships’ House. Too often it has been the case that health inequalities exist in part because people belong to one of the groups listed here and there is actual discrimination against a patient. In relation to specific treatments, patients are treated differently not purely on the basis of clinical decisions but on the basis of one of the protected characteristics, particularly age. For example, despite improvements in cancer outcomes, a 2007 study of breast cancer patients in Manchester found that older women are less likely than younger women to receive “standard” management for breast cancer and less likely even after accounting for differences in general health and co-morbidity to have surgery for operable breast cancer.

My amendment will ensure that the Secretary of State’s duties are clear and specific and that people across England can be sure their access to healthcare and the quality of the healthcare they need will be assured regardless of who is providing the service. The areas where the Secretary of State can demonstrate improvement in reducing inequalities should be balanced and fair in their focus. The risk otherwise is that commissioners will be incentivised to invest their efforts in improving health outcomes for those groups where they believe they can make the easiest and quickest gains and some groups, including older people, risk being shunted to the sidelines. This must not happen.

[Baroness Murphy]

My Lords, I have a great deal of sympathy with those who want to beef up this duty on the Secretary of State. I want to ask the Minister to explain why the public health function was left out—it is very specific about NHS responsibilities. I suspect the answer is that public health is in relation to other departments of state. He is shaking his head so perhaps that is not the answer. Working in the NHS one cannot but be aware of these profound inequalities. Within the first week of going as chairman to the east London health authority, three facts hit me in the face. First, in Hackney, people had only a 25 per cent chance of referral for a hip replacement as per the norm for England. Secondly, in Newham, mortality rates for bowel cancer after treatment were 30 per cent worse than elsewhere. It clearly emerged that there was a failure of referral to access, for, particularly, certain of the ethnic communities. Thirdly, on a visit to the community podiatry service, every patient was white in an area where the population was 25 per cent black and minority ethnic. Simply, no one had ever asked them the relevant question. Addressing inequality seems to be profoundly difficult on the ground: you must have the information and the wit to discover whether there is a problem of access, referral or discrimination and treatment, or whether there are underlying features of the illness that make inequalities difficult to address.

Health: Healthcare Assistants

Baroness Greengross Excerpts

Monday 24th October 2011 Lords Chamber

[Earl Howe]

I can agree in part with what the noble Lord says. I do not agree that the training of nurses is skewed against what one might call the traditional caring activities that we associate with nursing, because my understanding is that the division is around 50:50 between the academic and practical elements of the training. We recognise the important contribution of nurses, not just in the new roles that they have taken on but in the fundamental aspects of care. They have the reach and relationships to improve outcomes and experiences for patients. We are doing our best to support them by various means.

[Baroness Greengross]

My Lords—

[Baroness Thornton]

My Lords, I often take my lead from the noble Baroness, Lady Masham. In an article in the Times today she said that a voluntary register was no cure. This, taken with the confusion created by, I am afraid, the noble Earl’s remarks about struck-off nurses, underlines the point at issue. I ask the Minister: is it really satisfactory that there is a chance that no one would know that a nurse was a struck-off nurse? Is it satisfactory that thousands of nursing care assistants are taking blood and carrying out procedures, but patients cannot know whether they are on a register and properly regulated? That is the problem. The noble Earl needs to think about the kind of juggernaut that is heading towards him on this one.

Health: Mental Health Strategy

Baroness Greengross Excerpts

Monday 14th February 2011 Lords Chamber

[Baroness Greengross]

My Lords, I join in congratulating my noble friend Lady Murphy on securing this important debate. The strategy is most welcome. It has a lot to commend it, especially the pledge to combat the stigma and discrimination that is still faced by so many people affected by mental illness.

In its opening lines, the strategy, one of whose key areas for action is to identify mental health problems and intervene early across all age groups, tells us that good mental health and resilience—I emphasise that word—are fundamental to our physical health, our relationships, our education, our training and work, and to achieving our potential. The use of “resilience” here and the rhetoric that follows it so early on in the strategy are interesting. They inform us that the main focus of the strategy is the very worthwhile desire to get people of all ages with mental health issues into work and to keep them there—an endeavour that deserves our full support. This might prove particularly hard in the difficult economic circumstances that we face. As chair of the All-Party Parliamentary Group on Corporate Responsibility, I heartily endorse anything that facilitates a better understanding of the contribution that people with mental health issues want to, and can, make to our economic recovery, and the critical role that employers can play in bringing that to pass.

One of the key examples that our group recently highlighted has been the Business in the Community campaign, Business Action for Working Well. Mental and emotional well-being is an important focus of that campaign. I can do no better than to quote Alex Gourlay, the chief executive of the health and beauty division of Alliance Boots and chairman of the BITC campaign, when he said,

“Employers need to take urgent action to promote the mental and physical health of their employees if they are to ensure the competitiveness of their companies in difficult, as well as prosperous, economic times”.

A small charity in south London is one such example. It trains people, some with severe physical as well as mental health conditions, to achieve NVQ qualifications or credits towards NVQ qualifications in IT, office skills and sometimes in horticulture, working in the nearby hospital grounds.

The key to the project’s success and to the achievements of the students is the sort of flexible working that they can cope with, so that fluctuating conditions can be accommodated by giving people certain agreed tasks to complete in a specific time, say one month, and not by measuring their achievements by the usual outcome measurements that we use. That enables their resilience to their conditions to be maximised. The sense of achievement of many of the people who gain an NVQ or part of one is quite remarkable. It can transform their sense of self-worth and, through that, their future.

In welcoming the strategy, I have some concerns that the section entitled,

“Improving outcomes for older people with mental health problems”,

majors on depression in older people, which is very welcome, but sadly gives dementia scant treatment. The document states that improving the quality of care for people with dementia and their carers is a major priority for the Government and that the Government are committed to more rapid improvement in dementia care through the local delivery of quality outcomes and local accountability for achieving them. As chair of the All-Party Parliamentary Group on Dementia, I would say that this is very welcome, but the strategy goes on to report that for every 10,000 people over the age of 65, 500 have dementia, as if in some way this were a low figure and not too troubling. We know that the reality is very different.

Research shows that more people fear being diagnosed with dementia above anything else, including cancer or even death itself. One million people in this country will suffer some form of dementia within two decades, and one in three people of 65 and over will die with it, yet 12 times as much is spent each year on cancer research, and six times as many scientists are working on how to treat tumours. Currently, as many as two-thirds of people who develop dementia are never diagnosed, while the best treatments can only help to reduce symptoms and cannot prevent the degenerative disease progressing. In Annexe A of the strategy an action within objective 4 is to,

“Implement the recommendations of Quality Outcomes for People with Dementia: Building on the work of the National Dementia Strategy”.

We know that in development of a dementia quality standard, the condition seems something of an afterthought in the strategy.

I also have a concern that the strategy might inadvertently imply that some people with mental health issues were unsuited to the world of full-time employment and are therefore, in a sense, second-class citizens.

The wording of the strategy tends to focus on contribution. I feel that that is too associated with condemning older people—those over working age, including those with early-stage dementia—to being in an unstoppable decline into residential care and to never being expected to be resilient or even interested in contributing to society, whereas we know that many people with early-stage dementia could remain engaged, independent and supported at home, making a significant contribution to their communities, perhaps supporting others who are in full-time employment.

My last point is that dementia is still not always treated as a health issue, but rather as a social ill that is funded, especially in the community, mainly through social care rather than as a health condition. Despite the fact that dementia confers a life expectancy of only five to six years, it remains the poor relation to cancer and heart disease in research funding, because it is not seen primarily as a health issue. We must change that, and I hope that the strategy will, because only by changing it can the ambitious challenge of the strategy to mainstream mental health in England be fully and effectively taken up by both commissioners and providers in health and social care.

NHS: Front-line and Specialised Services

Baroness Greengross Excerpts

Thursday 13th January 2011 Lords Chamber

[Baroness Greengross]

My Lords, as chair of the All-Party Group on Dementia, I have a particular interest in dementia care. In my brief remarks, I wish to highlight the potential impact of the changes to those services.

People with dementia are major beneficiaries of effective joined-up working between health and social care. Can the Minister assure me that any changes in the current coterminosity of boundaries for commissioning health and social care will be appropriately managed for people with dementia?

One in three people over the age of 65 will die with dementia, and so for many it will be a terminal disease. Why, therefore, is dementia treated, rather than as a health issue like cancer, more as a social ill? In other words, it is more likely to get funding through social care. Thus many dementia patients are obliged to self-fund their care. Is something going to be done to remedy that?

With the implementation of the national dementia strategy we have witnessed the increasing knowledge and ability of many NHS managers in commissioning for dementia, which is absolutely essential. However, the number of people with these particular skills remains relatively small and it is a concern that the pace of structural change has the potential to undermine this progress. Can the Minister assure me that the valuable dementia commissioning expertise which has been developing recently will be retained in the system?

Lastly, GPs will in future play an increasingly important role in commissioning services for people with dementia. However, I am concerned that many GPs have too little awareness or knowledge of dementia. For example, when surveyed, only 31 per cent of GPs believed that they had received sufficient basic and post-qualification training to diagnose and manage dementia and only 47 per cent of GPs said that they had sufficient training in dementia management. Only one-third of people receive a formal diagnosis of dementia. What will be done to ensure that GPs are fully capable of discharging their new commissioning responsibilities with regard to this absolutely urgent situation? I hope that the noble Earl can respond.

Health: Osteoporosis

Baroness Greengross Excerpts

Tuesday 19th October 2010 Lords Chamber

[Baroness Howe of Idlicote]

My Lords—

[Baroness Greengross]

My Lords—

[Lord Strathclyde]

My Lords, it is difficult for the House to decide between the noble Baronesses, both of whom I am sure noble Lords would like to hear. Perhaps if one takes priority over the other, we might get both in. I am asking for one of them to give way.

[Baroness Greengross]

My Lords, it is well known that if an elderly or frail person living at home has a fall which results in a hip fracture is monitored, a great deal of future pain, distress and huge expense to the NHS can be avoided. Does the Minister agree that installing a fracture liaison service in every health area would reduce this serious situation and that the Government ought to make public that aim?

[Earl Howe]

The noble Baroness is correct: fracture services have produced some positive results where they have been used in various parts of the country. I can best answer her question in two brief ways. While decisions about the provision of particular services are best taken locally, it will be the outcomes framework, which I have mentioned, and the incentives that go with it, that will determine the extent to which the NHS locally responds to needs related to this area. Funding for the NHS is protected and will increase above inflation every year of this Parliament. In this difficult climate, that demonstrates the Government’s determination to provide the best outcomes from services, including falls and fractures services.

Disabled People: Dementia

Baroness Greengross Excerpts

Monday 11th October 2010 Lords Chamber

[Earl Howe]

My Lords, the right reverend Prelate rightly calls attention to the needs of those with aural disability. The Government’s plans for audiology are in gestation at the moment. Unfortunately, it is too early for me to tell him, but I shall aim to write him a letter at the earliest opportunity.

[Baroness Greengross]

My Lords, in declaring an interest as chair of the All-Party Parliamentary Group on Dementia, I ask the Minister what plans the Government have to reduce the inappropriate length of stay in hospital of many patients with dementia and other impairments. As that would result in quite a lot of savings, I ask the Government to reinvest those savings in community services.

[Earl Howe]

My Lords, the noble Baroness is right. The national dementia strategy quite rightly recognises the need to improve the quality of care for people with dementia in hospital and that is identified in the new implementation plan as one of the key priorities for action. Of course, the main priority has to be to avoid admitting dementia patients to hospital in the first place, if possible. We should admit them only when it is strictly necessary and we should discharge them at the earliest opportunity. We have set priority areas for all hospitals to take urgent action, including appointing a senior member of staff to improve the quality of care for people with dementia and to look after the training of staff in hospitals.