Ageing: Public Services and Demographic Change Committee Report
Baroness Greengross Excerpts(10 years, 6 months ago)
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Baroness Greengross (CB)
My Lords, I begin by thanking and congratulating the noble Lord, Lord Filkin, and the Committee for their excellent report.
I want to point out a few things that I have been thinking while listening to the excellent contributions today. First, we are living in an unprecedented situation—unprecedented in the history of mankind’s existence on this planet, which in the history of the planet is perhaps not very long, but which in our minds is a long time. It is a long time since people died before the age of 25 because they were starving, were attacked by wild animals or caught an infection that they had no possible means of correcting.
We know now that most of us are not as certain as we used to be about what happens when we depart this world, so we want to hang around for as long as possible. For that to happen, we want to be in good enough health to enjoy living and be recognised by other people as part of society—not an add-on to be cared for or looked after, but a real part of the total society in which we live. We have to plan, which is what the committee’s report emphasised, across the board to cope positively and to enable us to celebrate in the appropriate way this incredible change in the longevity that each of us can expect to enjoy—real planning for today’s society, and not, as the noble Lord, Lord Crisp, pointed out, planning the future on the basis of what we did in the past. That would be a bit like planning for a war on the basis of yesterday’s war technology and weapons. If we do not, as the report points out, needs will remain unmet, cost pressures will rise inexorably and the balance of responsibilities between individuals and the Government will not change in the way that is absolutely essential. Again, the report points this out.
We need radical reforms across the board but this will be very difficult to achieve because there are many pressures not to change. The report points to the essential fact that, as the noble Lord, Lord Warner, said, we have to look at everything in the light of what we need to keep as it is and what we must change.
In the world of work, we need employers and government to work together because people cannot save in the way that they need to unless they work for longer. We know people have to save more, so they have to work more. In order to do that, employers need help in creating the kind of workplace in which older people can work. There are some brilliant examples in other countries and there are a few in this country. We have to change.
We have to look at how we pay for the kind of care and pensions that we will need in the future if we are to live decently. The move to support old age must take place. If not, age-related spending is projected to rise from an annual cost of 21.3% of GDP in 2016 to 26.3% of GDP in 2061, which is a rise of £79 billion in today’s money. We must therefore consider at all options. We must look at pensions and benefits, and look again at property values, and consider how we will pay for our needs in old age with an open mind.
The support ratio is projected to fall. The Pensions Bill was a laudable attempt by the Government to begin to get this right, on which I congratulate them, but the support ratio—which, by 2051, will be only 2.9 workers to every person of pensionable age—means that this is even more necessary that we thought previously. To make employment realistically possible for our ageing population, flexible work must improve. However, many other changes are needed in work patterns and employers need to be supported in that.
Our built environment must be designed for the real society of tomorrow—not only in terms of housing, critical as that is, but our parks, our open spaces, our roads, our pavements, our transport. The design for the ageing of our population will benefit all of us but it must be taken into consideration. On education, we must look more closely at mixed-age learning centres and open up to the new technology and what it can do.
This is not a party issue or an issue only for the Government, employers, unions and the voluntary sector; this is a whole-society challenge. Major works are going on, in which I am grateful I can play a part, and I wish to mention two or three. The King’s Fund has set up a commission looking at the future of health and social care, of which I am delighted to be a part; the Institute of Chartered Accountants in England and Wales is looking at a strategy for the ageing society; Business in the Community is looking at responsible business practice going forward; and the current and future work of the ILC is part of the Commission on Ageing and the Voluntary Sector. These organisations are trying to address these issues so that we can truly celebrate the ageing of our society in the future. It is a triumph. We must therefore ensure that both our older and our younger future populations together create a society where age does not mean stigmatising labels, but rather that we are all valued for what we are, what we do and what we contribute, so that we can forget about the number of birthdays we have celebrated.
Care Bill [HL]
Baroness Greengross Excerpts(10 years, 6 months ago)
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Lord Warner (Lab)
My Lords, as the self-appointed keeper to this House of the Dilnot tablets, I support Amendments 55 and 56, spoken to so ably by my two noble friends. Turning to Amendment 55, in framing our recommendations in our report, it was never our intention to impose a new set of rigidities in place of the old set of rigidities. It is important that the new system retains as much flexibility as possible. It is worth thinking about what lies behind much of the argumentation in our report and the new architecture that that report proposes. It is all about people, in as fair, orderly and manageable a way as possible, making contributions from their own resources to the rising costs of adult social care as we cope with, live with and adapt to an ageing population. Given the messiness of the present arrangements for top-ups, it would be perverse not to create the maximum flexibility for people to top up, particularly where these top-ups relate to their ability to stay in a home where they and their family have been very comfortable with the arrangements. Preventing such top-ups would be a truly perverse way of implementing the Dilnot architecture. We need a more flexible way of coping with this. Therefore I support my noble friend Lord Lipsey’s set of amendments.
On Amendment 56, my noble friend has a very strong point. I say this as someone who spent 10 years wrestling with means tests as a senior civil servant coping with social security. In those 10 years, numerous were the times when we had to cope with unforeseen consequences of what we thought were well designed social policy changes, but which turned out not quite to work when subjected to the scrutiny of the real world across a large population. I congratulate the Government on taking our report and turning it into a largely workable—we have a few doubts, but largely workable—set of arrangements that can be brought into operation quickly. However it would be very optimistic to think that there would be no unforeseen consequences—wrinkles, if I may use the word—which needed to be looked at, in particular in the areas of means-testing and the working of the cap. I emphasise that this is not a job application from the Dilnot commission to make, like Frank Sinatra, another return appearance, but we do need some kind of credible, independent body to take a look at this.
I would just gently remind the noble Earl that, at the end of our report, on page 69, we talked about some of these potential wrinkles, including the potential further changes in and around means-testing, which we did not have time to wrestle with but which we just flagged up for the Government. I will go not into the details but just the headlines. Under “Consistent treatment of housing assets”, we noted the way they are treated differently across the social care means test in terms of domiciliary and residential care—they are not treated on the same basis. There is also the issue of whether the means-test taper actually disincentivises savings and the issue of consistency between the way people in residential and nursing care, where it is not continuing care, have to meet general living costs but do not have to meet them where it is continuing care. We know that there are already some potential anomalies in the way that the new architecture will interact with some of those areas. We flagged that up in the report.
My noble friend has argued for some kind of independent advisory committee. He may not altogether thank me for raising some of these potential further changes but they are issues that have to be wrestled with. The new set of arrangements will throw up their own issues, which will also have to be wrestled with. Some kind of independent advisory committee, looking at the way in which the new scheme has worked and has bedded down, particularly in the area of the means test, would be a valuable contribution. I do not think it is a partisan issue. It would be welcomed across the parties and I hope that the Minister can look a bit more favourably on my noble friend’s amendment.
Baroness Greengross (CB)
My Lords, first, I add my voice in support of Amendment 55, in the name of the noble Lord, Lord Lipsey. We have not fully taken into account the impact that the Bill will have, when it becomes an Act and is brought into being, on the many people who are now in care homes and where the funding of those homes will suddenly become much more public. Everybody will report to the local authority to get on the meter and the extent of people’s self-funding will become better known. There will be a sort of explosion if we do not get this right and do not allow people to make top-ups. What are we going to do: assume that some of these people will be moved from the care home that they are in and where they are, we hope, happy to another care home because there is inflexibility with the top-up system? That would be really cruel and I hope that we can get as much flexibility and remove as many restrictions on people as we can.
Several cases have been brought to my attention of people who are already in a care home running out of money. They, or their relatives, cannot afford the whole amount but want to be able to top up the local authority amount, which, at the moment, nobody is fully aware of. As this is all going to become much more public knowledge, it is important to have as much flexibility as possible. I hope the Minister will have another look at this.
Earl Howe
My Lords, first, I turn to Amendment 55, in the name of the noble Lord, Lord Lipsey, which concerns the circumstances in which people wish to top up their own fees to pay for more expensive accommodation. To begin with, and for the avoidance of any doubt, I will emphasise that I agree that people should be able to choose to spend their own money on more expensive care, provided it is affordable. Like the noble Lord, Lord Lipsey, I want people to be able to choose to live in more expensive accommodation and gain from a cap on care costs, so that they pay part of the cost of care from their own savings and still receive local authority support.
Through the consultation and stakeholder engagement, we are seeking to better understand the impact of relaxing the rules on self-top-ups and to determine what protections may be needed for vulnerable people.
The answer to the question posed by the noble Lord, Lord Hunt, is that consultation will close on 25 October. The Minister of State for Care and Support and departmental officials have, over the past quarter, attended a variety of events covering the care and support sector, local authorities and financial services providers. These have been broadly supportive of the principle that people should be able to contribute towards their care costs from their own assets. Stakeholders have also recognised that people need to make decisions which are financially sustainable for the long term, and that financial information and advice need to play an important role in achieving this. We will be able to provide a more comprehensive overview of the views expressed in our response to the consultation in the new year. I repeat that we are on the noble Lord’s side. Our only concern is to ensure that when we relax the rules, there are sufficient protections, both for the individual and for the local authority.
Amendment 56 concerns review of the operation of the capped-cost system. I am sure we can all agree unhesitatingly that these reforms need to be implemented effectively to deliver the outcomes we are striving for. The capped-cost system will provide peace of mind and protection against catastrophic costs and will target most help at those with the greatest need. I am confident that we can further agree that to deliver these benefits, we need good oversight. Therefore, I am with the noble Lords opposite in spirit. To that end, we will be reviewing and assuring both implementation and funding, and have committed to reviewing the core elements of the capped-costs system within each five-year period. We will also conduct post-legislative scrutiny, as the Government have committed to do across the board for all new Acts. The agreement we have with the Liaison Committee in the other place is that this should be done between three and five years after Royal Assent.
Furthermore, we have established the Joint Implementation and Programme Board with the Local Government Association and the Association of Directors of Adult Social Services. We will use this to work with local government on continuing assurance and improvement of the arrangements. We are confident that, in their totality, these arrangements provide generous opportunity for assurance and review to ensure that the reforms remain true to our vision.
For that reason, I do not believe it would be necessary or desirable to supplement these arrangements with a further review by additional oversight bodies, such as an independent ministerial advisory committee. Such additional oversight would cut across the scrutiny conducted by the Health Select Committee and cross-government planning on spending through spending rounds. I am sure that noble Lords opposite will not be totally satisfied with that, but I hope that they will be sufficiently reassured by the confirmation I have given that we will conduct a proper review of the operation and funding of these reforms through several channels. I hope that they will agree that this amendment is, therefore, unnecessary.
Lord Warner
My Lords, while I welcome Amendment 57, I want to set out the case for the Minister going a good deal further. Amendment 137 follows the discussion in Committee of amendments proposed by the noble Lord, Lord Patel, and myself. We have come back with an alternative amendment, which has also been signed by the noble Baroness, Lady Greengross. We have done this in consultation with voluntary organisations over the summer, and the wording of Amendment 137 reflects those discussions. To summarise, the amendment would enable the Secretary of State, after discussion, to make regulations that did three things: first, allow people to have their preference for place of death recorded by local health and social care services and for that preference to be implemented wherever practicable; secondly, have their care and support needs and those of carers treated as urgent in assessing needs—and we think, reasonably, that Amendment 57 deals with that; and, thirdly, exempt terminally ill patients from adult social care charges.
Since Committee the Government have brought forward Amendment 57 and, as I have said, I think that it meets many of our concerns about urgent assessment at the end of life. It has certainly had the effect of diluting enthusiasm in some parts of the voluntary sector for a more wide-ranging amendment on end-of-life choice, and I slightly backhandedly congratulate the Minister and his civil servants on achieving that. However, I would still like to have another go at trying to convince the Government, and possibly some members of my own Front Bench, that we should be a bit more ambitious.
Around half a million people die each year in England, about two-thirds of them over the age of 75. A century ago most of us would have died in our own homes. Today, most will die in hospital. The latest figures show that in April 2012, about 42% of people died at home or in a care home. This is an improvement from 38% four years previously, but on present trends it will be at least the end of this decade before half of deaths occur in the place of usual residence. These figures of improvement at the national level, however, conceal considerable regional and local variations.
If you live in the south-west, with 48% of deaths occurring in the place of usual residence, you have more choice than those of us living in London, where the percentage drops to 35%. Of course, as a Londoner I think there are many benefits of living in London, but choosing where I die is not likely to be one of them. There is an even wider variation between local authority areas. The great majority of us want to die at home or the place we normally live rather than, I suggest, the hectic and somewhat impersonal environment of an acute hospital ward. Perversely, we end up not only dying not only in the place where we least want to be but also in the most expensive place.
Marie Curie research has shown that a week of palliative care in the community costs about £1,000 a week, whereas a week of hospital in-patient specialist palliative care costs virtually £3,000 a week. The National End of Life Care Programme shows an estimated potential net saving of £958 per person if you die in the community rather than in hospital. Polling for Macmillan has shown that eight out of 10 health and social care professionals agree that community-based end-of-life care would save money. On top of this, nine out of 10 MPs think their constituents should have the choice to die at home. What is not to like about the first prong of Amendment 137?
I am not trying to dragoon people into dying outside hospital to save money. I want people to have as good and dignified a death as possible, with their friends and families around them. That is more likely to be achieved if they have a right to register their preference for dying at home or their place of normal residence. This would mean fewer people dying in hospital and it would also reduce pressure on A&E departments and acute hospital beds. I suggest that this is a not inconsiderable benefit—as Sir Humphrey would have said—in terms of the cost savings that could arise from allowing people to express their preferences on their right to die at home.
I accept that at this point it may be rushing our fences a bit to pay for exempting terminally-ill patients from local authority care charges. We need some detailed costings and possibly—I suspect the Minister will say this—we need to wait to hear what comes out of the pilot schemes in this area. However, we would also welcome having more information from the Minister on the progress being made in those pilots.
Accepting the first part of Amendment 137 would lay down a clear marker that Parliament wants government to move in the direction that most people want: which is the right to choose to die at home or their place of normal residence wherever practicable. This amendment gives the Government plenty of time to consult on all the detailed arrangements. It does not require those regulations to be made by any particular time and it gives the Government a lot of freedom about what the nature of those regulations might be. We should not miss the chance of this Bill being before Parliament to move in this area and put this change on the statute book. I hope the Minister will respond favourably and be prepared to entertain at Third Reading an amendment of the kind set out in the first prong of Amendment 137. I would certainly be happy—as I am sure my colleagues would—to discuss this further with him.
Baroness Greengross (CB)
I support the comments made by the noble Lord, Lord Warner, about this amendment. We know that the things people say they dread as their final days approach are loss of dignity and loss of respect, and we hear far too much about poor care at the end of life. Very often, it is poor care because people are not in the place they would like to be. We also know that the number of carers identified and signposted by the NHS to the enhanced support is not widely known. We know that much more needs to be done to draw together all the various approaches—I am involved in one of those approaches at the moment, looking with a group of experts at how to improve end-of-life care with doctors, professionals in end-of-life care and lawyers who deal with patients’ wishes. There is still a lot be looked at and brought together, and this Bill gives us a good chance of getting this right, or at least much nearer to being right than it is at the moment.
As the noble Lord, Lord Warner, mentioned, the coalition of charities has also suggested that end-of-life care should be free at the point of delivery. I know that this requires much more consideration—the noble Lord talked about that. I want to concentrate on hoping that this will be considered and that services to dying people and possible loss of dignity and respect will get a far higher profile as things that need urgent attention. Terminally ill people should have their preferred place of death recorded by local health and social care services. That preference needs to be implemented wherever it is practical. People must have their care and support needs and those of their carers treated as urgent by the local authority responsible for assessing those needs.
For people who are dying, every day is precious. They cannot wait while the bureaucratic wheels grind slowly along, and not always in their favour. I support the amendment tabled by the noble Lord, Lord Warner.
Lord Patel (CB)
My Lords, I spoke about this issue when we debated the gracious Speech, at Second Reading and in Committee, when I supported the amendment put forward by the noble Lord, Lord Warner, and today I support Amendment 137. Every time we have debated this, the Minister has been sympathetic to the idea of providing free social care to those who are dying. When I think about this amendment, I think of a patient who has just been told of a diagnosis of terminal cancer, that their life will now last a few months at the most, and that medicine cannot offer much more than perhaps palliative care or treatment of some kind. Once the patient and the family have recovered from the shock, their immediate thoughts are, “Can I cope with my life—which will now be very short—at home, and what support can I get?”.
Currently, the means test for free social care can represent a barrier for those who wish to die at home. It makes it unaffordable for some, but it also means that the person may be passed between the local authority and the NHS while the two systems decide who is eligible for care and whether it should be free or means-tested. Government Amendment 57 is a demonstration of the Minister’s clear intention. He wishes to see this happen, and I thank him for moving this amendment, but it does not go far enough to achieve what I think he, too, wishes to achieve.
The second subsection in the new clause proposed by Amendment 137 is addressed, at least in part, by government Amendment 57. However, Amendment 57 does not introduce any new duties for local authorities. It highlights the existing ability of local authorities to regard the care and support needs of people at the end of life as urgent. In contrast, Amendment 137 allows the Government to introduce secondary legislation to require local authorities to regard the assessment of needs at the end of life as urgent. If the intention of the government amendment is to do that, is it clear enough? The final part of Amendment 137 relates to free social care at the end of life. Research suggests that the introduction of free social care at the end of life has broad-based support. I believe this will help to prevent expensive, unnecessary hospital admissions, prevent burdensome financial assessment during a difficult time and is an important part of giving people genuine choice at the end of life.
Baroness Greengross
“Appealing decisions taken by the local authority
(1) The local authority must have in place a procedure, which includes a review element that is independent of the local authority, by which adults or carers can appeal a decision made by the local authority about—
(a) whether an adult or carer’s needs meet eligibility criteria under section 13,(b) whether to charge for meeting needs under section 14,(c) the result of a financial assessment under section 17,(d) the content of a care and support plan or support plan under section 25,(e) the amount of a personal budget made under section 26 or independent personal budget made under section 28,(f) the payment of an “additional cost” under section 30.(2) Regulations may make further provision about any aspect of the appeals procedure mentioned in subsection (1).
(3) Wherever a decision has been made of a type referred to in subsection (1), the local authority must make the adult or carer aware of their right to appeal the decision and how to request details of the appeals procedure. Details of the procedure must be made available on request.”
Baroness Greengross
My Lords, I shall also speak to Amendment 124. Amendment 76 seeks to ensure that a clear process is in place by which adults and carers can challenge decisions that have been made about their care by local authorities, and to ensure that they are made aware of their right to challenge such decisions. I am grateful to Which? for supplying me with background information on this important issue.
Under the new care and support system, there are many decisions that local authorities will take that will affect an adult’s or a carer’s access to services and what they will be required to pay towards care. These decisions can fundamentally affect families’ quality of life and financial circumstances, as we have learnt. It is right that these decisions are subject to proper scrutiny in cases where families feel that they have been made unfairly, and that those receiving care and their carers are aware of their right to challenge decisions.
Baroness Greengross
My Lords, I thank all the noble Lords and noble Baronesses who have supported these amendments. I am encouraged that the issue is being taken so seriously by the noble Earl. In a way it is a shame that the timing of the consultation is as it is, and that we will not get it through until December. I have always been worried about certain aspects of NHS complaints procedures, when the body that looks at those procedures is the NHS itself. I have felt for many years that that is unfortunate. I am very pleased that the Minister has agreed to look again seriously at all this. We need to protect these extremely vulnerable people from not getting the best level of service that they can because of a decision that could be to the detriment of their care, which could leave them feeling that their situation is hopeless and that there is nothing they can do.
I therefore thank the noble Earl. I am pleased that he is prepared to look at all this again and I hope that we can have some discussions on the outcome. This was a probing set of amendments—I did not intend to do anything other than probe—but I thank him and hope for better news about this or for more detailed decision-making in the near future. In the mean time, I beg leave to withdraw the amendment.
Baroness Greengross
“Power of access for confidential interviewAdult safeguarding access order
(1) An authorised officer may apply to a court for an order (an “adult safeguarding access order”) in relation to a person living in any premises within a local authority’s area.
(2) The purposes of an adult safeguarding access order are—
(a) to enable the authorised officer and any other person accompanying the officer to speak in private with a person suspected of being an adult at risk of abuse or neglect,(b) to enable the authorised officer to assess the mental capacity of a person suspected of being an adult at risk of abuse,(c) to enable the authorised officer to ascertain whether that person is making decisions freely, and(d) to enable the authorised officer properly to assess whether the person is an adult at risk of abuse or neglect and to make a decision as required by section 41(2) on what, if any, action should be taken.(3) When an adult safeguarding access order is in force the authorised officer, a constable and any other specified person accompanying the officer in accordance with the order, may enter the premises specified in the order for the purposes set out in subsection (2).
(4) The court may make an adult safeguarding access order if satisfied that—
(a) the authorised officer has reasonable cause to suspect that a person is an adult who is experiencing or at risk of abuse or neglect,(b) it is necessary for the authorised officer to gain access to the person in order to make whatever enquiries thought necessary and to make a decision as required by section 41(2) on what, if any, action should be taken,(c) exercising the power of access conferred by the order will not result in the person being at greater risk of abuse or neglect.(5) An adult safeguarding access order must—
(a) specify the premises to which it relates,(b) provide that the authorised officer may be accompanied by a constable,(c) specify the period for which the order is to be in force.(6) Other conditions may be attached to an adult safeguarding access order, for example—
(a) specifying restrictions on the time that the power of access conferred by the order may be exercised,(b) providing for the authorised officer to be accompanied by another specified person,(c) requiring notice of the order to be given to the occupier of the premises and to the person suspected of being an adult at risk of abuse.(7) A constable accompanying the authorised officer may use reasonable force if necessary in order to fulfil the purposes of an adult safeguarding access order set out in subsection (2).
(8) On entering the premises in accordance with an adult safeguarding access order, the authorised officer must—
(a) state the object of the visit,(b) produce evidence of the authorisation to enter the premises, and(c) provide an explanation to the occupier of the premises of how to complain about how the power of access has been exercised.(9) In this section “an authorised officer” means a person authorised by a local authority for the purposes of this section, but regulations may set restrictions on the persons or categories of persons who may be authorised.”
Baroness Greengross
My Lords, I am sorry to be popping up and down. This amendment and the others are about elder abuse. I have been involved in the issue of elder abuse for very many years—it is something that I am very familiar with. It is an issue which we have not, as yet, focused on nearly enough in this country. We have recently learnt, from data from the Health & Social Care Information Centre and Age UK, that there has been a “disturbing” rise in the number of reports of possible abuse of vulnerable elderly people in England. Unfortunately, the majority of this abuse is, as we know, by people who are close to the person—that is, family, carers and friends living in the same household, because the majority of abuse happens in people’s homes.
We have seen a 4% rise in the number of cases of alleged abuse referred for investigation in the past year. I urge the Government to do more to protect vulnerable adults. It is a serious issue and, in my view, the danger might unwittingly be increased as a result of some of the positive things that we are doing; for example, personal care planning, which gives people the opportunity to give money to relatives and to use the money for care which has not been planned in the way it used to be. There are many more doors for abuse opening than there used to be, so we have to prevent abuse even more effectively than we did in the past.
In response to the situation, the BBC has reported a Department of Health spokesman as saying:
“No-one should suffer abuse or neglect in a place they are meant to feel safe in, whether this is in their own home or in a care setting”.
Nobody is going to argue about that, but we must put this principle into practice and seek out abuse rather than passively wait for victims to appear. Sadly, some of those victims will never appear. We know why: people are not going to report their son or daughter who is hitting them, being violent or stealing their money because this might make them appear a bad mother or bring the family into disrepute. There are all sorts of reasons why very few people complain.
I am aware that new measures are being considered to make directors of care homes and hospitals personally and criminally accountable for failures in care if they allow neglect or abuse to take place. However, this will not really help people who are being abused in their own homes.
Figures from the Health & Social Care Information Centre have shown that the number of cases referred for investigation by councils in England rose from 108,000 in 2011-12 to 112,000 in 2012-13. While 45% of these cases took place in a care home, 38% of the alleged abuse took place in the older person’s own home. Physical abuse and neglect were the most common types of abuse reported. In 6% of cases the abuser was the older person’s partner; in 16% it was another family member; and in 37% it was a social care worker. Three-fifths of the referrals were for vulnerable adults—those described in the report as people who may be in need of community care services because they are elderly or suffer mental illness, disability or another ailment and are aged 65 or older.
I endorse the expressed views of Age UK and Action on Elder Abuse in that any abuse of older people is unacceptable. We need a zero-tolerance approach to any abuse, whether through neglect, financial manipulation or physical or mental cruelty. My greatest fear is that there are still many cases that are not reported. This amendment would assist the authorities in gaining access to such victims where their abusers may naturally be the very individuals preventing legitimate access.
In my first proposed new clause, I seek to support Action on Elder Abuse in its claim that there are situations where victims of abuse are imprisoned in their homes by a perpetrator who subsequently denies access to adult safeguarding staff. In such circumstances there are no current legal means by which access can be achieved. There is need, therefore, for a power of access for confidential interview, but to occur only where the reasonable suspicion of a social worker or another practitioner is tested by application to a court, which would consider whether to authorise such access. This is available in the Scottish Act and it is proposed in the Welsh Bill through application to a justice of the peace.
Earl Howe
I will gladly look into that point. I am sure that it is possible to do that but, as the noble Baroness, Lady Barker, said, many provisions on the statute book are designed to protect individuals from abuse in one form or another and make criminal offences of those actions. Nothing has changed as regards those criminal provisions. If they need to be underlined, however, and if there is scope for misunderstanding what the Government are doing here, then I take the noble Lord’s point, and will gladly reflect and come back to him on that.
Amendments 80 and 82 emphasise the need for involvement of social work-qualified staff in boards and reviews. In Schedule 2 we make it clear that chairs and members of boards must have the “required skills and experience”. It would be impracticable to put into primary legislation every possible type of expertise and professional knowledge that might be needed. We must allow boards the flexibility to appoint members as they see fit. We will, however, ensure that the importance of social work is recognised in guidance, which will also cover the importance of ensuring appropriately qualified oversight of safeguarding adults reviews.
Government Amendment 81 responds to an amendment tabled in Committee by the noble Lord, Lord Rix, and the noble Baroness, Lady Hollins. On reflection, I see merit in placing a duty on safeguarding adults boards to publish an annual report. This amendment will increase the transparency and accountability of boards.
Finally, Amendment 81A, tabled by the noble Lord, Lord Rix, requires that safeguarding adults boards provide their annual reports to the Secretary of State. With a duty on boards to publish their annual report, we can be assured that they will be publicly available. We would expect the local Healthwatch and health and well-being boards to monitor the safeguarding adults board’s progress and report to the Secretary of State if there are particular matters of concern. To require the board formally to submit a report to the Secretary of State would, if nothing else, undermine the primacy of local accountability, which is at the heart of our approach to safeguarding. I hope that, on reflection, the noble Lord will agree with me.
I hope that I have convinced your Lordships that we have done all that we properly can to provide the right legislative framework for safeguarding and, in consequence, that noble Lords will feel able not to move their amendments.
Baroness Greengross
My Lords, I have to say that I am extremely disappointed that the noble Earl cannot in some way meet the requirements that I put forward in my amendments. Unfortunately, the number of older people who suffer abuse is growing all the time. The sort of personal plans for care that we now want to introduce for everyone just make such abuse a greater risk than it was before. We know that an awful lot of older people are shoved in a room, the door is closed, they get their meal and no one does anything else. Over a long period, those people’s conditions can get worse and worse. When and if they are eventually discovered, it is too late to do anything to help them.
The sort of care that we want to provide for people might be damaged by a refusal to look at this issue in greater detail. I am really disappointed. I understand the noble Earl’s views but disagree with them. I thank all noble Lords who supported what I have said and I assure my noble friend Lady Meacher that I was not intending to persecute carers. My intention related to people who, I am afraid, inflict real harm and hurt on some of the most vulnerable people in our society. I have worked on this issue for years; that is why we set up Action on Elder Abuse, the only specialist agency to look at this. Its view is strong and has not changed. We must have some sort of protection for these very vulnerable people. I hope that one day we can get this matter looked at again and I hope that the Minister will consider it in the future. In the mean time, I withdraw my amendment.
Earl Howe
Before the noble Baroness makes a final decision, I hope that I have been clear that I have reflected on her amendment. I cannot give her false hope that I will reflect further between now and Third Reading; so if she wishes to test the opinion of the House, she should do so now.
Baroness Greengross
I am hesitating only because of time and I know that a lot of people have gone home. I thank the noble Earl for his advice and, on that basis, I seek to test the opinion of the House.
Care Bill [HL]
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Baroness Greengross
Baroness Greengross (CB)
My Lords, I shall speak to Amendment 18 in this group as well. I have already expressed my support for the Bill, which will make a huge difference to the lives of users of social care services and their families. However, a little more can be done to reform the Bill in the areas of information and advice, and also complaints and redress. I welcome the fact that the Government have recognised this issue and that the Minister has tabled amendments on their behalf. This shows that the Government accept the need for proactive engagement around information and advice, the importance of understanding when and how people access information, and the need for a focus on identifying those who would most benefit from it. These issues reflect exactly the thrust of my amendments except that, unlike the Government’s, mine relate to all information and advice about care and support, not just financial information and advice.
While I welcome the emphasis on proper access to financial advice, it seems a bit inconsistent not to apply this proactive approach to all forms of information and advice about care. For example, even when considering financial options, it is difficult to disentangle these from information that is needed about other aspects of care such as the choice of providers. It might even apply to housing, which was addressed in the debate on the amendment of the noble Lord, Lord Best.
At a time when local authority budgets are under increasing pressure, it is all the more important that people needing social care services are supported to efficiently access all existing sources of support fairly, equitably and transparently, and that local authorities are held to account for the decisions they make about distributing resources. Consumers have to feel that they are in control of their own care, understand what support they can expect and have the ability to speak up when they are treated unfairly. My amendments are designed to further these aims and I am grateful to Which? for assisting me in validating the consumer detriment aspects of this argument.
First, in Amendment 13 to Clause 4(1), as well as the local authority having the duty to,
“establish and maintain a service for providing people in its area with”—
care and support information, I would like to see the local authority having a supporting obligation to “facilitate access to” that service. Secondly, my Amendment 18 to Clause 4(4) would expand the local authority’s duty of information and advice provision beyond those to whom it is being provided to also include those,
“who would benefit from receiving it”.
Baroness Greengross
My Lords, I start by thanking the Minister for his very detailed response to these amendments. I am encouraged by what he said. I was, in my remarks, trying to broaden this issue so that integration is about the information and advice that people need and is not always restricted to financial advice and information. It is much broader. Obviously, the proof of the pudding in this is going to lie in what actually happens, and whether we get the sort of integrated approach to this that we hope underlies the philosophy of the whole Bill.
I am sorry that this provision cannot be in the Bill, but I am less worried about that than the eventual result of these measures. The slight muddling around the word “independence” will come out when we consider the next group of amendments and discuss the difference between regulated and independent. The two can be muddled, with regard to “independent” and “regulated”, when thinking of lots of different models for financial products, for example, and “independent” from the local authority. That all needs to be very clear in the minds of those who seek advice and those who are giving advice to very frail and vulnerable people to whom this needs to be clear, broad and helpful, and as well meaning as I know the Minister has in mind for it to be. I beg leave to withdraw my amendment.
Lord Sharkey (LD)
My Lords, I will speak to the first part of this amendment, but before I do so I will register my strong support for the remarks made by the noble Lord, Lord Lipsey, a moment ago, especially with regard to the provision of independent and regulated financial advice.
I think it is common ground that the Dilnot reforms will fail unless the public understand what they are and what their implications are. I think it is also common ground that there need to be vigorous communication campaigns to make sure people do in fact know about and understand the implications of the reforms. Where there seems to be a difference between the Minister and those who supported a similar amendment to this in Committee is over who should be directly responsible for ensuring that these campaigns take place and that they have an effective form, and over how their effectiveness is assessed.
The amendment before us gives the Secretary of State a duty to ensure through national public awareness campaigns that there is a high level of public awareness and understanding of the terms and implications of the cap on the cost of care. In his reply to a similar amendment in Committee, the Minister simply noted that the Bill as it stands places a duty on local authorities to provide information and advice, including on the cap system. In later correspondence, for which I am very grateful to the Minister, he expanded on the point. He noted that, first, the funding reforms create a shared interest on the part of local authorities, government and the financial services industry to make sure that people are aware of the reforms and have access to the right information and advice at the right time so that they can plan and be prepared to meet their care and support needs. Secondly, the Government want to act in partnership with these key stakeholders to get this right, building on the effective relationships already established. Thirdly, the Government are seeking views in a consultation on the design and technical implementation of the funding reforms, which includes addressing the best way to proceed to raise awareness of these reforms nationally and locally.
The Minister’s remarks make it clear that there are lots of interested parties in this communications endeavour, but they entirely overlook the question of leadership. A campaign as vital as this needs leadership. I maintain that that leadership can come only from the Secretary of State. Local authorities, almost by definition, cannot easily lead in any national sense. As for the financial services industry, it is convinced that the information campaigns need clear, well defined leadership, and is quite clear that it cannot come from that industry. Who would believe facts on the reforms presented by somebody trying to sell you something? In fact, the ABI has told me that it believes that the public information initiative should be led by the Government. That is what part 1 of this amendment would do—give the Secretary of State leadership and responsibility.
The other areas where the Minister may differ about a communications campaign are how high to set the bar and how to explicitly make it plain that it is not just the terms of the reform that have to be understood but the implications of the terms of the reform. It is not much good being aware of the facts if you cannot work out what the facts mean for you. However, the difference over how high to set the bar for a communication campaign is critical. As the noble Lord, Lord Hunt, pointed out a moment ago, the Bill states only that local authorities must establish and maintain a service for providing information and advice. The Bill does not set any measure for whether anyone actually receives or understands this information and advice. It does not set targets of any kind.
You can easily see a situation in which local authorities can, at least technically, fulfil a duty to provide advice and information without providing much of it, or knowing how many people are reached by it and how many of those reached understand it and the implications it has for them. That would be an entirely unsatisfactory outcome and certainly not what the Government intend. We need to make sure this does not happen and that is what part 1 of the amendment would do. It calls for,
“a high level of public awareness and understanding of the terms and implications of the cap on the cost of care”.
At Second Reading, the Minister said:
“The Government will adopt a strategic approach to maximising the public’s understanding of the new care and support system”.—[Official Report, 21/5/13; col. 827.]
The key word is “maximising”. The amendment gives written substance to the idea of maximisation.
The first part of the amendment contains a paragraph which would require the Secretary of State to publish annually a report on the levels of awareness and understanding of the reforms,
“including the results of a representative poll of adults”.
When we discussed this requirement in Committee and subsequently, the Minister felt that reviews of understanding and awareness would naturally follow in the normal course of things, and I am sure that is the case. However, the special nature of these reforms and the need to be able accurately to measure progress in informing people and keeping them informed calls for a more definite and more regular assessment. The Minister also felt that the kind of annual survey we proposed might be very expensive. I have had extensive experience of these surveys in business over the past 20 years and I can reassure the Minister immediately that the kind of annual survey this amendment proposes would have an essentially trivial cost. That is why, for the sake of clarity, the amendment makes reference to a “representative poll of adults”. This kind of survey would, in fact, cost very little, would be very easy to administer and would be exceptionally quick in delivering results.
I will close by saying that I strongly believe a large-scale national information and advice campaign is necessary for the success of our reforms. I believe that any such campaign must have appropriate targets and that we should see on a regular basis how these targets are being met. I believe that any such campaign must have clear leadership, and that direct responsibility for that leadership should be the duty of the Secretary of State, as the amendment proposes. I very much hope that the Minister will be able to agree with at least some of it.
Baroness Greengross
My Lords, I fully endorse what my two esteemed colleagues said regarding the need for appropriate financial advice. I am still of the opinion that people should be referred to regulated advisers, who are best placed to advise them on the full range of solutions open to them. However, to avoid repetition, I will briefly concentrate on the paragraph in Amendment 20 dealing with other areas of concern about which we have already talked in some depth, such as housing. People with specific medical conditions and complex needs are reliant on suitable housing provision. We should also not forget the needs of their carers in this regard. The local authority will need to engage with agencies and organisations such as the CABs and Age UK in an integrated way. This should be part of providing a relevant local advice and information envelope.
Plainly, there is no point in getting appropriate financial advice if, through no fault of the adviser, faithfully following that advice cannot be guaranteed to lead to good care outcomes. Those outcomes may be consequent upon ensuring that things such as the suitability of the individual’s housing and accommodation are included in any wider fact-finding conducted by the local authority alongside any care or financial assessments it performs. That housing suitability will probably depend on the complexity of the care package that the individual’s needs disclose. Those needs will probably derive directly from the specific set of conditions and symptoms that the individual faces.
No one would expect a local authority to be familiar with every possible combination of health and social circumstances that an individual may face, which is why close working alongside local agencies and organisations such as the CABs and Age UK in assuring the existence of a complete, competent advice and information envelope is so important. Indeed, it is my firm view that the quality of that integrated approach to care management may well be the key determinant on which successful outcomes depend. I urge the Minister to adopt our amendment, as we believe that it would go a long way to ensure more effective and efficient outcomes for both the service user and the taxpayer.
Care Bill [HL]
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Baroness Masham of Ilton (CB)
My Lords, I support Amendment 22 but am concerned about Amendment 25. Is it wise to mention 30 minutes? I declare an interest as president of a spinal injuries association. Some of our members have broken their necks and are paralysed from their neck down. To get a paralysed person up, to do an evacuation of their bowels and to wash and dress them, using a hoist, might take at least three hours. Surely it is better to stress the individual’s needs rather than to set in stone half an hour. Providers of care may use that as a marker.
A visit taking 15 minutes, as has recently been in the headlines, is totally ridiculous. Having the choice of whether a carer takes someone to the lavatory or gives them a drink is unacceptable. If stress is put on the carer who cannot do the job in that time, they will leave and not do the job at all. The person needing care is left in a dangerous position if adequate care is not given. The amendments need to be flexible and aimed at an individual’s personal needs. I hope very much that the Minister will look at this and will do something to make it acceptable.
Baroness Greengross (CB)
My Lords, I was the lead commissioner at the Equality and Human Rights Commission during a big inquiry looking at home care for older, frail people. We found that half of the people receiving such care were satisfied with it. Half were not. Mostly, the complaints were about breaches of their human rights. This is a terrible indictment of our care system: to be able to say that because of the care that is regularly given to people, their human rights are breached is absolutely unacceptable.
We know that the number of 15-minute care visits, as Leonard Cheshire Disability discovered this week, is going up: 60% of local authorities commission them and the number has risen by 17% in the past five years. I do not want to delay colleagues in the House for very long; it is just that you cannot do the sorts of jobs that the majority of people need in 15 minutes. Of course, one needs flexibility: to give somebody a dose of medicine does not take very long, but to really care for someone, which involves all the tasks that the noble Baroness, Lady Meacher, mentioned so lucidly and clearly, takes much longer. We need some way in the Bill of making absolutely sure that this cannot continue. It is absolutely disgraceful that we have to have this conversation at all.
Baroness Greengross
“( ) ensuring that consideration of the early and co-ordinated assessment of an adult who may have care and support needs, following discharge from hospital or other acute care setting, is initiated upon admission to that acute care setting.”
Baroness Greengross
My Lords, this amendment concerns discharge plans for people in hospital. I shall start by saying that, in response to my Amendment 87ZA tabled in Committee on this issue, the Minister was understandably reluctant to specify the particular circumstances in which the high-level aims of the general duty to co-operate, as set out in Clause 6(5), should apply. He felt that there should not be an exhaustive list of circumstances, such as discharge plan management, in which the power should be used, and said that he expected authorities and their relevant partners to co-operate when an individual was discharged from acute care under this clause. He asserted that Schedule 3 to the Bill sets out clear steps to ensure the safe discharge of a patient from an acute care setting, and that an assessment for care and support should be made before the patient is discharged, not afterwards. Clause 12(1)(b) already allows for regulations to specify other matters to which the local authority must have regard in carrying out an assessment. Given that this involves setting out procedural detail and related matters, he felt it more appropriate to set out such detail in regulations rather than in the Bill.
While I agree with much of that, my main point regarding the importance of discharge being included as part of admission planning into an acute care setting may have been misunderstood. The subject of discharge should be considered as part of the admission process, long before the actual discharge is instigated. That is the important point here, and I remain firm in my belief that it should be included in the Bill. The most important thing is the idea that discharge planning should be part of the admission process. We have all heard a large number of stories of people who have been discharged inappropriately because everything is decided too late in the day and no one is ready for the discharge. I personally could talk about two or three relatives aged 80 to 90 who have been dumped out of hospital in the middle of the night. Such instances are horrific, but I am afraid that they will continue unless we get this right.
Clause 12 is not relevant here because it refers to a need for a care assessment as being an essential part of the discharge process from an acute setting into either supported home care or longer-term residential care. I want to ensure that it will be facilitated by eventual discharge being part of the admission assessment, which is a very different process that is gone through at a different time by different clinical staff. Including such a duty in Clause 6 would ensure that this happens, so that the eventual discharge stands more of a chance of being successful. The Royal College of Nursing has expressed the view that:
“We are currently seeing far too many people trapped in a ‘revolving door’ between community and hospital services”.
Ensuring a suitable discharge founded on appropriate admission from acute care would, in my view, go a long way to reducing this terrible waste of resources and its associated human misery. I beg to move.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Baroness, Lady Greengross, for allowing this debate. This is an important question and I agree that ensuring that an assessment is made around the time of the admission of a patient to a hospital or other acute care setting would help the process of the appropriate discharge of that person when the time comes for them to leave. One has to say that the context in which we are debating this is one in which the health and social care system is under extreme strain. The Minister will know that the accident and emergency performance, and the issue of the four-hour target, is proving to be problematic for a number of trusts, including my own, in September and October. Clearly, if the health service is having difficulties in September or October, in pretty clement weather, it does leave one with some foreboding about what is going to happen later on in the winter.
The Government have injected a certain amount of resource into the system—I think it is £250 million—which is labelled on the tin “to A&E departments”. The Minister will know that the money has not gone to A&E departments; it has tended to go to the clinical commissioning groups. While limited amounts have gone to A&E departments, in the main, this has been dealt with through urgent care boards. My understanding is that in a lot of areas they still have not decided how to spend the resources. This is partly because CCGs seem to be slow to make hard decisions, and partly because some are not spending the money because they say that they have not received it yet. The problem is this: if by the middle of October you still have not spent or committed yourself to those additional resources, it could take another three months. If, for instance, it was a series of care packages or it was extra resource for employing more nurses, it could take an awfully long time from the decision to spend the money to it actually being in place, and then for the money to be spent.
I am really using this as an opportunity to say to the noble Earl, Lord Howe, that there is a real issue at the local level of actually getting all the partners together and to agree the actions that need to be taken to ensure that we do not get the kind of discharge problems that we are seeing.
What is the cause of the issue of A&E performance? There has been some debate about whether it is partly due to the lack of accessibility and primary care. No doubt, there are serious issues involved which would suggest that that is a problem. However, the noble Earl may have seen some work undertaken by Matthew Cooke, who used to be the adviser to the Government on urgent care and was a consultant in my own trust at Heart of England. His work would suggest that the problem is discharge; that there is simply not the capacity in the community or among personal social services departments to provide the support that is required. However much the Government want to beat up A&E departments, unless we can sort out the capacity in the community, these problems will continue.
The noble Baroness’s amendment is really trying to get to the heart of this. She is saying that it is a real problem—not just for older and more vulnerable patients, but it is probably more directed at those patients—if the first time you start to worry about discharge procedures is when they have spent quite a few days in hospital. First, it takes a long time for the system to intervene; and secondly, it may mean that the patient stays in hospital too long. We know all the problems of institutionalisation, when people have greater difficulty in going back to their own home or into low-level community provision as opposed to having to go into care homes.
The noble Earl, Lord Howe, will no doubt say that this is not the stuff of legislation. However, because of the seriousness of the current problems in our health and social care system, it would send a very powerful signal to people working at local level about the absolute importance of starting discharge planning almost as soon as a person comes into A&E, and of the need to have an integrated approach. It would also give a signal to local authorities. At the moment there is a real problem because local authorities often play around with discharges by saying that they are not convinced that a person is ready for discharge. That is simply trying to ration expenditures. A signal to local authorities that that is also unacceptable would be very helpful.
I am glad that the noble Baroness raised this problem. It is a very important issue. I hope that the noble Earl may be able to help us with it.
Baroness Greengross
My Lords, I thank the noble Earl for his reassurance. The noble Baroness, Lady Barker, and I worked together for many years and she is desperate as I am to get this right because it has never yet been achieved. The stories are horrific about poor hospital discharges that have not been adequately planned from the time of somebody’s admission into an acute hospital. We really have to get this right now if we are to be in any way a civilised society.
I thank the noble Earl because he obviously has the same commitment as do many other noble Lords to whom I am very grateful for supporting this amendment. If the regulations are firm enough and closely followed, perhaps this time we will get it right. I hope so, and thank the noble Earl very much for his attention and interest in this matter, which is of very great importance to many of us. I also thank all noble Lords who have supported me.
Care Bill [HL]
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Baroness Bakewell
My Lords, I endorse and support the amendment in the name of my noble friend Lord Warner. We have been watching a very impressive Bill go through this stage. If it is not funded properly, the political and social fallout in terms of the disappointment of an entire generation will be catastrophic. That generation will simply lose the trust that it puts in our capacity to legislate for the needs of society. That is what is at risk and why we need this review of the funding. I have not been a part of the debate so far and I will simply speak to one particular aspect of it, the postcode lottery.
Last week, the Office for National Statistics issued figures for life expectancy which show clearly the disparity between the north and the south. The lowest life expectancy for men is in Blackpool; for women, it is in Manchester. The highest life expectancy is in Dorset. That is not at all surprising. Dorset has the highest number of care homes in the country and has pioneered an outstanding care policy throughout the county based on early intervention and the reabling of people who fall ill. The county has found that this saves money and lives, and citizens are living longer because of it. It is exemplary.
It is not the same in the north of England. I was at a conference recently of the Local Government Association and I was constantly made aware of the pressures that councils in the north are under to trim their funding. Various statistics exist, but it is clear that the budgets of local authorities have fallen considerably. As was debated at the conference, the result is that the eligibility criteria are being squeezed across the north. It made me realise that councils in the north find it laughable that the cap of £72,000 for care should have any meaning for the citizens who live there. The outlook in the north is totally different from that in the more prosperous south. It is not as clear-cut as that, but I am generalising because it is important to grasp how fundamental the difference is. What I want to ask the noble Earl is this: does the funding under the Bill adequately address the increased disparity of care across the country?
Baroness Greengross
My Lords, I support the amendment of the noble Lord, Lord Warner. I partly echo what the noble Baroness, Lady Pitkeathley, said, because I think that the Bill is one of the best that we have seen in a long time. It really could meet our hopes and aspirations, but I am so worried about funding. We know that the funding seems quite generous, but the noble Lord, Lord Warner, did not mention that when he or Sir Andrew Dilnot talk about bringing these proposals into reality, if we set them against the costs of the NHS more widely, a minute part of the costs need to be covered to make the social care provisions real and thus take away the purely crisis intervention that we can see is on its way, as well as a complete lack of preventative care. That is what we hope for. I hope that the noble Earl will think again about the amendment so that we can keep the costing and funding of this under consideration on a regular basis.
Baroness Campbell of Surbiton
My Lords, briefly, I support the amendment of the noble Lord, Lord Warner. I will be brief, as I do not have a second voice. I draw the noble Earl's attention to the fact that, two years ago, the Joint Committee on Human Rights held an inquiry into Article 13 of the UN Convention on the Rights of Disabled People. Article 13 covers the right to independent living. At the time, we were given considerable evidence that disabled people’s right to independent living was beginning to be severely thwarted by the funding situation in this country. We heard very worrying evidence of disabled people losing their independence in our society—the independence that, over 20 years, they had developed. They were working and having families, and being part of society.
Care Bill [HL]
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Baroness Greengross
My Lords, I shall speak to several amendments in this group. I strongly welcome the clauses in the Care Bill that relate to adult safeguarding. It is right that the abuse of vulnerable adults should be placed on a statutory footing, alongside domestic abuse and child abuse. However, these clauses primarily address a minimum safeguarding infrastructure, and in the main seek to meet the requirements of professionals. My proposed amendments focus on the needs of victims.
The prevalence study into elder abuse, funded in part by the Department of Health and published in 2007, indicated that at least 500,000 older people experience abuse at home; abuse that is, sadly, often perpetrated by family members and others whom the victim should be able to trust. Research by the charity Action on Elder Abuse—I declare an interest as one of its founders—indicates that fewer than 10% of the victims come to the attention of adult safeguarding systems. We clearly must do better than that. However, we must also recognise that there are more victims than just the older person. No matter what the circumstances, when someone's mother or father or sister or brother is abused or neglected, it is not unusual for relatives to blame themselves—to feel that somehow they should have known or should have done something. Even when they could not have done so, there are many more victims of elder abuse than just the older person. We know that many victims of elder abuse are elderly people who are attacked by their son or daughter, perhaps because of a long history of domestic violence. However, they are very reluctant to call the attention of the police or anyone to those crimes because they see themselves as having failed as parents.
The amendments go to the heart of what is most cruel about elder abuse. Too many older people are locked away in back rooms, imprisoned by those who choose to exploit them, and unable to seek assistance. Theirs is a silent scream that we must hear, and to which we must respond. We cannot allow abusers the right to deny access to their victims. We must ensure that we do everything possible to find and support the 90% of older victims who currently are unsupported, and we must encourage agencies to work together, as the noble Baroness, Lady Hollins, has said, to report their concerns about possible victims. We must also ensure that those who ill treat or neglect vulnerable people are held to account, because victims and their families deserve to know that elder abuse will not be tolerated and that abusers will be held to account.
Amendment 92ZFC deals with the need for a power of access for confidential interview, to occur only when the reasonable suspicion of a social worker or other practitioner is tested by application to a court, which would consider whether or not to authorise such access. As we have heard, such access is available under the Scottish Act and is proposed in the Welsh Bill through application to a justice of the peace.
Amendment 92ZFD relates to safeguarding adults at risk of abuse and neglect and introduces a duty to report adults at risk of abuse. There is currently no duty on agencies to notify a local authority if they believe an adult may be at risk of abuse. A local authority cannot be expected to identify all abuse by itself. It has to rely on the good will of others to make referrals. There is a need to underline the responsibility of all agencies to report if they have a reasonable belief that an adult is at risk.
As we have heard, the Welsh Bill proposes:
“If a relevant partner of a local authority has reasonable cause to suspect that a person is an adult at risk and appears to be within the authority’s area, it must inform the local authority of that fact”.
A relevant partner is proposed to be the police, another local authority, the probation service, a local health board, an NHS trust, Ministers, or anyone else that regulations may specify.
Amendment 92ZFE is proposed because there is currently no specific offence to protect adults with capacity who are the subject of neglect or abuse but who are not covered by the Mental Health Act or the Mental Capacity Act. The view is that, in such circumstances, they can be covered by the inherent jurisdiction of the courts only, which is time-consuming, costly and not widely used in such circumstances. The Law Commission report noted the gap in the law relating to protecting adults at risk who were being ill treated or neglected but who were not subject to the powers of the Mental Health Act or the Mental Capacity Act. Police officers had suggested that prosecutions were being dropped in practice because doctors could not confirm, or had not documented, that a person lacked capacity.
Additionally, the extent of abuse and neglect uncovered in hospitals and care homes has caused anxiety and outrage throughout the UK. Current systems and law have been insufficient to deter abuse, and too often the few perpetrators who reach the courts have sentences that the public consider far too lenient.
Amendments 92ZFF and 92ZJ are about safeguarding adults at risk of abuse and neglect. I welcome the proposals in the Bill to put safeguarding adults boards on a statutory footing. However, along with the College of Social Work, I believe that the Bill should ensure that social workers are appointed to supervise safeguarding inquiries because they alone have the theoretical, legal and policy knowledge to undertake complex, politically charged and sensitive pieces of safeguarding investigative work that may require co-operation and co-ordination with other professionals and organisations.
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Baroness Hollins
My Lords, I would have added my name to this amendment because it is excellent and necessary. I, too, hope that the noble Earl will see the sense of it. Certainly, people’s fears that the Government would propose to set the national eligibility threshold too high have been confirmed. Rather than celebrating the achievements of councils that have been able to provide highly valued, innovative and low-cost services to people with low and moderate needs, we are instead to fall in line with the majority of local authorities, with the false hope of avoiding financial strain. Failing to provide services to people with moderate care needs is, at best, a missed opportunity to encourage preventive care and significantly improve the quality of life for a highly disadvantaged group of people. At worst, we are leaving a considerable proportion of people with a lifelong disability to fend for themselves.
Case reports of those recently excluded from receiving support are extremely troubling. We have heard some examples already today with some people losing all daycare provision and facing an isolated life at home. Other case reports demonstrate the importance of lower levels of support. I want briefly to give the example of Frances, a middle-aged woman with a mild to moderate learning disability who has always struggled to understand and manage bills. Since receiving a few hours support a week she has finally had relief from receiving constant threats and eviction notices. How long will her support survive before she is declared ineligible? Clearly the resources of the state are limited but they need to be used wisely, and I believe that our care system must encourage and incentivise local authorities to provide lower intensity interventions that can make a difference to the quality of life for many people.
On the face of it, opting for a moderate national eligibility threshold may sound as if it would require considerable additional funding, but providing these services to a group who by definition are often highly vulnerable and disadvantaged could result in great savings by avoiding more costly acute care later. I hope that the Government will rethink this amendment.
Baroness Greengross
There are vast numbers of older people—for whom this Bill is designed, in terms of quantity—who we know want to stay in their own homes in their community. Early intervention can make that possible. If we delay, the alternative is crisis-driven. It leads to many older people going into expensive care homes where they do not want to be and from which they do not emerge again or into hospitals, adding to the problems we know about with frail elderly people. I very much hope the noble Earl will reconsider and enable people with moderate needs to have access to services.
Lord Warner
My Lords, I hesitate to intervene in the debate on Amendment 88Q but I feel under some obligation to share with the Committee some of the thinking of the Dilnot commission where we went into this issue and set out our views in our report. I declare my interest as a member of that commission. I suspect that what I am going to say may be thought of more advantageously by the Minister than by those who tabled the amendment; however, it is important that we consider these factors.
First, we made it very clear in the report that,
“we believe that those who develop a care and support need during their working life should be assessed in broadly the same way as an older person”.
We tried to create an architecture that was reasonably consistent between the needs of those of working age and older citizens. Secondly, when we were asked to undertake this assignment we were asked to consider the feasibility of introducing this and the affordability of the changes. We wrestled with this quite a lot in our deliberations but we concluded in recommendation 6 of the report:
“In the short term, we think it is reasonable for a minimum eligibility threshold to be set nationally at ‘substantial’ under the current system”.
Our concern in doing that was not just that we were mealy-mouthed stooges of the Treasury but the overwhelming amount of evidence given to us about underfunding of the adult social care system over a long period. We considered that and said in the report that it was seriously underfunded and that funding had failed to keep pace with demographic changes in people of working age and those who were not. We thought that the deficit had to be made good but that that was a matter for the Government of the day and would need cross-party consensus if improved funding for social care was to be maintained.
Baroness Greengross
My Lords, I support the noble Lord, Lord Sharkey. A similar amendment in my name is not as strong as his amendment. I think that his would do the job that needs to be done remarkably well and I hope that it will be agreed by the Minister.
Lord Lipsey
My Lords, I will speak to the amendments in this group standing in my name but, before I do so, I should like to offer the strongest possible support for the noble Lord, Lord Sharkey, and particularly for the words that he said at the beginning about the information task that we face here. This is not just a question of advising individuals when they go to their councils, although that is important and we have had a debate on that. It is a question of making the whole of our society aware of what is going on against a background of very great ignorance and misinformation. It is crucial that something is done on a real scale to turn that around and that the best communication skills are used in doing so. We have to move from the language that we use in this Chamber as aficionados or geeks studying the detail of the Bill to the general public out there, and that is a hell of a task.
As I said, I will speak to my Amendments 90D, 92ZZB, 92ZZC and 104ZC. Amendments 90D and 92ZZC relate to a topic that we touched on in the debate on the previous amendment—namely, the costs and administrative difficulties for local authorities of introducing the cap in the scheme. The Local Government Association has expanded on the numerics in the briefings for this debate, as has London Councils. I think that the local authorities have a slight tendency to underplay what is going on for fear that the Government will take the whole thing away from them, and they want to be shown as “can do” rather than “can’t do”. When you get into the detail, and look below the politicians in local government at the fine detail of those who have to implement it, you find that it is quite difficult.
The Government have in principle accepted the burdens doctrine, namely that if they make local government do something they will pay for it. They have provided around £335 million to pay for that. None of this extra money is coming now, by the way. The contributions will not start until 2016. Bad though the administrative mess may be, if local government does nothing to prepare for this scheme until 2016 it will certainly fail. Already it is doubtful whether the burdens scheme is really being met. Many of the costings put forward are fingers in the air stuff. The detail has yet to be grappled with. Details crucial to costing the implementation of the scheme, such as the eligibility requirements, are only emerging bit by bit. We do not even know what the government money is supposed to cover. Does it fund in full the cost of additional self-assessments, when the self-funders and people who will potentially benefit from Dilnot queue up for assessments? I really do not think that we know the detail of duties around advice and information, on which we spoke earlier, or on the funding for setting up new deferred payment schemes.
My change is designed to write into the Bill what is in effect the burdens doctrine. Whatever the cost, the Government must pick it up. It is not as if local authorities have got large chunks of money in their pocket at the moment to reach in and pay for all this stuff. They do not. They cannot afford basic care services at the moment, so this is a huge task. There is a huge task, too, in training the local authority workforce to do assessment and implementation on this scale, and indeed in creating the workforce.
These facts lead me to believe—and I am very glad that my noble friend Lord Warner, with whom I agree on nearly everything, agrees—that it was a terrible mistake to bring forward the start of the scheme from 2017 to 2016. We know why it happened, do we not? The Government found that they had a few spare quid in their pocket, and wanted to be able to tell the electorate that Dilnot was nigh, and so without proper consideration of any kind they brought the date forward. It was a U-turn, and my amendment U-turns on the U-turn to get back to the right place where they were to begin with, namely that the scheme will come in in 2017. This would give it a good chance to work.
I turn now to my other amendments in this group. I hope that we might finally get an actual concession from the Minister, instead of words of great sincerity and great sympathy and not much change. My other amendments in this group refer to the setting up of a ministerial advisory group on the cap and the means test. They insist that this group should be consulted in the planned five-year review of how all of this is working. This is not a criticism of the Department of Health. I have been impressed by how effective officials have been in grasping this scheme, particularly as for most of the time that Dilnot was under consideration they probably thought that it was never going to happen. They are a first-class team, but I do not think that they possess a monopoly on wisdom, and indeed they do not think so, either. The Minister just referred to the working parties with the financial services sectors that have been set up to give advice. I applaud that.
I think that there are complexities in all of this that even the most literate advisers have barely grasped. I will come to some of them, for example when we come to the detail of the proposals on the means test. It would be helpful if Ministers had to hand a helpful advisory group comprising academic experts, local authority representatives, representatives of the financial sector and someone from Dilnot. Maybe the noble Lord, Lord Warner, would like to volunteer. A group of that kind would not second-guess Ministers on every detail, but would offer its general advice on how things are progressing and how they may be set right if there are departures from the course on the way forward.
Care Bill [HL]
Baroness Greengross Excerpts(10 years, 9 months ago)
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Baroness Greengross
where there is a person authorised to do so under the Mental Capacity Act 2005 or otherwise in a position to do so on the adult’s behalf, but that person nonetheless asks the authority to meet the adult’s needs.”
Baroness Greengross
My Lords, I have a number of amendments in this group: Amendment 92ZZCA in Clause 18, Amendment 92ZZLA in Clause 26, Amendment 92ZZQA in Clause 28, Amendments 92ZZR and 92ZZRA in Clause 30 and Amendment 92ZZRB in Clause 31. I will try to be brief.
These amendments follow on from the discussion relating to the amendments tabled by the noble Lord, Lord Lipsey. The first amendment is about the duty to meet needs. We know that carers are often old people themselves. They have often cared for a long time for somebody with dementia or something similar before that adult meets the eligibility threshold for care. In my view and that of the Alzheimer’s Society, those carers should have the right to ask the local authority to arrange that person’s care because it is important that an individual who is in a position to arrange care and support has the right to ask the local authority to do so even when the adult is self-funding. Enabling a carer who would otherwise be required to arrange care to request that the local authority meet that need would help to reduce the strain that that carer is under. Being able to ask the local authority to arrange care would also enable the adult to take advantage of the better rates for care that the local authority can command through block booking and other means. It would be unacceptable if adults who do not have capacity but who have deputies or other representatives were forced to pay higher costs than other people.
Amendments 99ZZLA and 99ZZQA are about the usual rate of independent personal budgets. Clause 26 refers to the calculation of a personal budget that will enable eligible needs identified by the assessment to be met. The budget needs to be sufficient to enable this to happen. Clause 26 treats this as being the cost to the local authority of meeting that person’s needs, whereas a person receiving their direct payment as a cash payment would not necessarily be able to purchase care at the same amount since care homes, as we know, routinely charge self-payers more than they charge local authorities. Legislation has to be clear that local authorities have a duty to meet eligible needs, and personal budgets must therefore be, after application of the local authority’s normal means-testing system, sufficient to purchase that level of care at its local actual cost and not at a tariff rate based on the bulk purchasing power of the local authority.
Clause 28 refers to calculating the independent personal budget, which is, confusingly, different from the personal budget referred to in Clause 26. The independent personal budget is used to calculate the amount that an individual can spend on his or her care that will count towards the expenditure cap. Clause 28, therefore, refers always to expenditure by the individual, so it should be the true cost available to the individual of meeting their assessed needs, rather than the cost to the local authority. Once again, there is a difference.
The amendment to Clause 26 also has an impact on Clause 30. This clause replaces the current choice of accommodation directions which enable a person to choose a different residential care home from that provided by the local authority and to top up the payments if their preferred accommodation is more expensive than the local authority’s usual cost. The Minister has confirmed that this is possible. However, the current system is widely abused with local authorities often requiring top-ups even when there are no places available at the so-called usual cost and the person has chosen the only available accommodation that meets their needs.
Clause 30 does not refer to the usual cost but, instead, defines “more expensive” as being more than the value of the person’s individual budget. If the personal budget is defined in Clause 26 by how much the local authority says it will pay to meet the person’s needs, the system is open to the same abuses as the choice of accommodation directions. However, if Clause 26 requires that the personal budget should be sufficient for the person to purchase services which will meet their needs, this ensures that the rate that the local authority will pay for care is directly related to actual market conditions.
Amendment 92ZZR is about the review of independent personal budgets in Clause 28. People should be able to refuse an assessment as long as they understand the implications of that refusal. However, this clause does not offer adequate protection to people who lack capacity. As it stands, the clause puts people with a deteriorating condition, such as dementia, at risk of falling through the gaps. The proposed new clause stipulates that Clause 28 does not apply when an adult lacks capacity to refuse the assessment. It would stop vulnerable individuals from falling through those gaps as local authorities would be required to carry out a needs assessment and continue to maintain their care account.
Amendments 92ZZRA and 92ZZRB are about the choice of a care home. I declare an interest as chair of the All-Party Group on Dementia and the Alzheimer’s Society shares my concern about this. There is potential that the Bill will not provide the same right to choose a care home as currently exists. Individuals currently have a right to exercise genuine choice over where they live. If an individual has a preference for a particular care home, the local authority should arrange accommodation in that home subject to the following conditions being met: that the home that is chosen is suitable to meet the individual’s needs and as assessed; that it does not cost more than the local authority would usually expect to pay to arrange accommodation for someone with those assessed needs; and that it is available and the provider is willing to enter into a contract on the local authority’s terms.
An individual may wish to move to a home that is more than the local authority’s usual cost, even though there is a home that meets their needs and it is within the local authority’s usual cost. In these circumstances the individual or another person can make arrangements to make a top-up payment, as the Minister has said. The Bill states that regulations “may” provide that the local authority must arrange for the provision of the preferred accommodation. This should be amended to “must” rather than “may” to ensure that the right to choice continues. In addition, the Bill currently says that regulations may provide that where an adult expresses a preference for a particular home, the local authority should act on it. The risk is that this excludes an adult’s representative from choosing a home. Holders of lasting powers of attorney relating to welfare are examples of representatives who should be able to express a preference, and that preference should be acted on by the local authority. I beg to move.
Earl Howe
I am very grateful to my noble friend and I think I had better reflect further in the light of those comments.
I completely agree with the noble Lord, Lord Dubs, in relation to Amendments 92ZZH and 92ZZJ, that a modern, comprehensive care and support system should be able swiftly and effectively to respond to changing patterns of need. But the issue of fluctuating or emergency needs and anticipated review dates should be left to the local authority and the adult to discuss and agree when going through the care and support planning process. Again, we will consider these matters when producing statutory guidance with partners.
I turn to Amendment 92ZZK in the name of my noble friend Lady Browning. As I have indicated previously, the transition of children to adult care and links between this Bill and the Children and Families Bill merit further consideration and will be discussed at a later date. But I share my noble friend’s expectation. Where an adult has an education health and care plan, their care and support needs assessment and plan should be integrated with it. Both the guidance supporting the Care Bill and the SEN code of practice will set out how we expect this to work.
I turn to Amendments 92ZZLA and 92ZZQA in the name of the noble Baroness, Lady Greengross. The Bill is intentionally very clear that the personal budget and independent personal budget must be the cost to the local authority of meeting the adult’s needs, not an arbitrary or hypothetical figure. I can reassure the noble Baroness that the local authority may not set the personal budget to an amount which is less than it would cost the authority to meet the adult’s needs. The personal budget or independent personal budget must reflect the cost to the local authority of meeting the adult’s needs, not the cost to the individual of doing so himself or herself. Otherwise, this would create an unfair advantage for those with more means who are able to pay more for their care and would therefore reach the cap quicker.
I turn now to Amendments 92ZZMA and 92ZZQB, spoken to by the noble Baroness, Lady Wheeler. Enabling adults to request a review of either the care and support plan or the independent personal budget without a determination of reasonableness may leave the process open to abuse and create frivolous reviews costing the local authority time and money. For example, it would not be reasonable to request a review when a review has recently been conducted and needs have not changed. If an adult request is considered unreasonable, then the adult should be informed of the grounds for the local authority’s decision. We will cover this further in guidance.
On Amendment 92ZZR, we wholeheartedly agree with the noble Baroness, Lady Greengross, that if an adult lacks capacity the local authority must carry out the assessment if it believes that this would be in the adult’s best interests. We have addressed this in government Amendment 92ZZQC. This puts beyond doubt that the provisions of Clause 11 should apply to any refusal of a needs assessment by an adult with an independent personal budget. As a result, where an adult lacks capacity or is at risk of abuse or neglect, the local authority must carry out the assessment if it believes it to be in the adult’s best interests.
On Amendment 92ZZRA, I can reassure the noble Baroness that it is the Government’s intention to make regulations on choice of accommodation in residential care.
I turn to Amendments 92ZZRAA and 92ZZRAB, spoken to by the noble Baroness, Lady Wheeler. It is important that people should, as far as reasonably possible, be able to choose the accommodation they live in. People may wish to move into a care home in a new area—for example, to be close to relatives—and they should be able to do this even if this is in another local authority area. I can reassure the Committee that we intend to make regulations that enable people to exercise choice of accommodation both within and outside their current local authority. However, we do not believe that it would be appropriate to require local authorities to find and arrange care in another local authority area. While some might choose to do so, others might lack the local knowledge effectively to undertake this task. The requirement may also potentially have significant costs and could reduce the funds available to support those with the greatest needs.
I turn to Amendment 92ZZRB of the noble Baroness, Lady Greengross. Our approach in the Bill is simple. It allows any “person” nominated by the adult to receive a direct payment on their behalf, provided of course that the conditions specified in the Bill are met. In legal terms, a “person” means anyone with legal personality. Therefore, Clause 31 already allows the local authority to pay the direct payment to a person of a type specified by the adult. This includes user trusts set up as companies and organisations set up as companies.
On Amendment 92ZZS, I understand my noble friend Lord Sharkey’s concerns, and I hope I can reassure him that the local authority cannot fulfil its duties under the Bill unless it tells the adult what he or she needs to know in order to make a decision and reach agreement about whether or not to take a direct payment. Further, the Bill contains a regulation-making power at Clause 33(2)(f) to set out cases or circumstances in which the local authority must review the direct payment to ensure that it is being used and managed appropriately.
I turn now to Amendment 92ZZSA of the noble Baroness, Lady Campbell, to which the noble Baroness, Lady Wilkins, spoke. There may be only a limited set of circumstances in which a direct payment would not be appropriate, such as where needs can be met only through local authority-provided care and support. It is not our intention to for this to be used to limit access to direct payments. However, it is important that this provision remains in order to ensure that the adult’s needs are met via the most appropriate method.
Finally, I turn to Amendment 92ZZSB, spoken to by the noble Baroness, Lady Wheeler. It has always been our policy that, as long as used legally, there should be no restrictions on the type of services purchased with a direct payment, provided it accords with the care and support plan. Indeed, this reflects current guidance. Clause 25 requires the care plan to detail the needs to be met by the direct payment and, under Clause 31, a direct payment must be an appropriate way to meet those needs. There is no need to state in the Bill the type of providers from which people can purchase care and support.
The noble Baroness asked me what kind of client feedback there will be in the planning process. I am sure that she will agree that deciding the way that care needs are to be met is at the heart of a person-centred care and support planning process. These decisions should be agreed between the local authority and the person after considering the range of options and the person’s own wishes and goals.
We have made a number of changes to the draft Bill to address some of the concerns that we heard—that the balance of the care and support planning process was not adequately weighted towards the wishes of the adult. The process must also include involvement with the carer or any other nominated person, so that all people who can contribute have the opportunity to do so. It will in some circumstances not be possible to reach agreement between the local authority and the service user on the care and support plan, much as that is the aim. In those cases, the local authority will have to act to ensure that the person’s needs are met and that any risks to their safety are prevented. I hope that I have reassured the Committee that the care and support planning process is robust, and that the noble Baroness will feel able to withdraw her amendment.
Baroness Greengross
My Lords, I thank all noble Lords who have raised issues and amendments in this discussion, which has been extremely interesting. I also thank the Minister for his response, which was very positive in all but one or two areas, where I am still not absolutely certain that we are clear on the different levels of payments in care homes. However, I shall come back to the House on Report or speak to the noble Earl later. Again, I thank everybody, and particularly the Minister for his very positive responses. I beg leave to withdraw the amendment.
Care Bill [HL]
Baroness Greengross Excerpts(10 years, 9 months ago)
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Baroness Greengross
My Lords, I rise to speak to my Amendments 87ZA and 104A. I thank the noble Baroness, Lady Wheeler, for what she said and I heartily agree with her.
We read far too often about frail older people blocking beds in hospital wards and, apparently unintentionally, making the health service very difficult to function properly. However, they are there due to inadequate planning. These two amendments are intended to try to ensure that the discharge process is started when somebody goes into hospital—that is, right at the beginning of their stay in hospital.
We all have experience of very poor practice. My personal experience is of a 94 year-old who was admitted to a London hospital as an emergency and therefore arrived in pyjamas and with bare feet. He was returned home in pyjamas and with bare feet in the late evening in winter. He had to cross a grassy patch, go into his block of flats and up a flight of stairs in that condition in order to reach his home. There was no planned process to look after him. That sort of thing is totally unacceptable. The aim of this Bill is to stop that sort of practice and to make sure that it does not happen in the future. I think that all your Lordships feel the same about this: we have to get it right. As I said, I feel that the discharge plan should be initiated when someone is admitted to hospital and it should be used as the template for the discharge, when it occurs.
I declare an interest as chairing the All-Party Parliamentary Group on Dementia. We know from one of the inquiries that we have carried out that most frail older people who go into hospital have comorbidity—that is, they have more than one condition. If they have gone into hospital for a fractured femur to be fixed or for some other physical condition to be dealt with, they will stay in hospital for much longer if they also have, for example, dementia. They stay in hospital longer partly for the same reason: that no plan has emerged to look after them when they come out. It is very bad for them to be in hospital and it is bad for all the other patients as well, for obvious reasons. We need to ensure that the local authority and relevant partners know about the special conditions of a patient to get the planning right. We need to ensure that special care and support needs are taken into account long before they leave hospital. That is the reason for those two amendments, which I very much hope that the noble Earl will accept as part of good practice.
Lord Rix
My Lords, I wish to speak to Amendment 87ZB, so wholeheartedly supported by the noble Baroness, Lady Wheeler. It would add providers of relevant services to the list of relevant partners of the local authority. The amendment lays the foundation for a number of amendments which I have tabled in the safeguarding section of the Bill, which will be taken later. There has been widespread concern that the mechanisms and procedures in place to safeguard adults at risk of abuse or neglect are totally inadequate.
Time after time, we have witnessed how processes have failed or safeguarding has not been taken seriously, which has led to serious consequences for people with a learning disability. For example, there is the death of Francesca Hardwick and her mother Fiona Pilkington, the murder of Steven Hoskin, and more recently, the abuse scandal at Winterbourne View. There have been a number of prominent cases where the provider has failed to co-operate in providing information on adults at risk or where cases have occurred such as that reported in the aftermath of Winterbourne, where the provider declined to share information for the serious case review and there was no requirement on it to do so.
The amendment is therefore intended to add providers as relevant partners, so that they are in the frame for further amendments to the safeguarding part of the Bill in Clauses 41 to 46. When we talk about providers, I am referring to those who are providing a service which has been commissioned from a person's care plan, such as care and support or education services. Although I appreciate that regulations will set out other relevant partners, we feel that providers should be named explicitly in the Bill. This will emphasise the importance of the provider of services being subject to the duty to co-operate and will bolster the safeguarding process accordingly. I look forward to hearing the Minister’s thoughts on the matter.
Baroness Meacher
My Lords, Amendment 82B has the effect of requiring local authorities not only to provide information about the system of care and support, how to access it and so forth, but also to take action to facilitate access to that information; that is, to try to make sure that people know it is available. My remarks also apply to Amendment 86C, to which I have added my name, which requires that the local authority must produce or arrange for the production of packs of information relevant to the needs of individuals with specific medical conditions and ensure that these packs are provided to individuals following the diagnosis of a specific condition—not waiting until much later on, when they probably need social care or other intervention.
First, I apologise to the Minister and to your Lordships that I was unable to be here for earlier sittings of the Committee. I have been out of the country a lot on other Lords’ business and just have not been able to participate. I also must thank the Alzheimer’s Society for its help with these amendments.
I join other noble Lords who have welcomed the Bill, which has an emphasis on the provision of care and support for people who need it. I was impressed by the quote at the top of the Department of Health Factsheet No. 1, which states:
“Information, information, information; without it, how can people be truly at the heart of decisions? Information should be available to all regardless of how their care is paid for. There are some things that should be universal; information is one”.
That is from a Department of Health document; perhaps other noble Lords have quoted it before me, in which case I apologise. The point is that if people are unaware that information and advice are available, they are unlikely to look for them. We can assume that if these amendments are not accepted by the Government, there will be considerable underuse of information services and, of course, that the people who will lose out will, as always, be the most vulnerable—those who most need that information.
The Alzheimer’s Society tells me that it frequently hears of the difficulties people face when struggling through the complexities of the health and social care system for the very first time. Too often, people with dementia and their carers report that they did not have access to the information and advice they needed because they simply did not know it was available. We all know that feeling: if only we had known that it was available, we would have looked for it, whatever it was. Sadly, people often come across services by chance and far too late.
If a person in the early stages of Alzheimer’s is aware of a memory clinic, for example, which can either provide help itself or refer the client on to organisations such as the Alzheimer’s Society well before they need social care, the client can make adjustments to help them continue living as normally as possible and for as long as possible in their own homes. These are simple things like putting a note on the front door that says, “Are your keys in your pocket?”, and suchlike. With guidance, carers can gradually increase the home adjustments as they notice the need for them and thus defer the need for the involvement of social services and ultimately residential care.
Noble Lords will know the point that I am coming to. We all know that resources are incredibly tight. The point is that timely information and making people aware that it exists is very cost-effective. If you manage to keep people in their homes much longer, and if you manage to help them avoid social services intervention, all this will save taxpayers’ money. We can expect that a small spend on a proactive approach to information provision will save the taxpayers a great deal of money over time. I beg to move.
Baroness Greengross
My Lords, I support Amendment 82B in the name of the noble Baroness, Lady Meacher, to which my name is also listed. At the same time I speak to Amendments 83, 83A, 84, and 85. I think that Amendment 86C is in the next grouping; I hope that I am right.
On Amendment 82B, we know that many people, as well as their carers, say that they did not have access to the necessary information and advice—and that they did not even know that it was available. They have had to seek out the information themselves. We are talking about people who are vulnerable and often at crisis point. It is the worst time for either frail people or their carers to have to find out where to go and how to find the advice they need. I would add that, in my long time working in this field with older people, I once had a telephone call from a Minister in the department whose mother needed care and who was asking me to help because this Minister had no idea where to go to get the information and advice. It is not just people who do not know their way round the right office—it is all of us at certain times. We just do not have the knowledge of where to go.
If we require local authorities to adopt a proactive approach to information provision, perhaps it will ensure not only that people have the right information at the right time but that the information is in a format that is accessible. This will help people to get the right care and support in place and give them the confidence they need in very difficult situations.
On Amendments 83, 83A, 84 and 85, I was very pleased to see that, in Clause 4, the Government have incorporated a key element of the Joint Committee’s report into the Bill, namely that it is part of a local authority’s duty to establish and maintain the service for providing people in its area with information and advice. We must make sure that advice relating to care and support includes information about access to regulated independent financial advice.
The Bill will also oblige local authorities to offer deferred payment agreements which will involve local authorities in taking an interest-bearing charge on the property of an individual against the cost of care fees which, as we know, will be repaid after the individual’s death. As has been said, however, individuals offered these products may be highly vulnerable. They expect the same authority to assess fairly both their eligibility for care and their ability to fund it, as well as providing appropriate advice and information about a financial product which the local authority itself is offering to pay for that care.
In a way this is in competition to FCA-regulated financial products, so, obviously, there is a potential conflict of interest here. This conflict is exacerbated if the care for which the loan is made is directly provided by the local authority and if the level of charges and interest are also determined by the local authority. It is therefore very important that people are directed towards regulated financial advice as part of the decision-making process. This amendment seeks to do that through regulated, accredited financial advisers such as the people who are members of SOLLA, the Society of Later Life Advisers. Only in that way can the development of safe and secure financial products be facilitated.
Lord Mackay of Clashfern
My Lords, I have spent most of my life as an advocate, so I have to say how important advocacy is. I want to say a few words in relation to the point made by the noble Baroness, Lady Gale, about continuing NHS care. The point is important in that Clause 22, as the boundary between health and social care, is vital.
I would have thought—I may be wrong and obviously the noble Baroness will correct me—that it ought to be the general practitioner who advises a patient as to whether they need continuing NHS care. During our deliberations in the Joint Committee there was quite a lot of discussion about the question of continuing NHS care, and it is obvious that there is some conflict of interest. The local authority providing the care may wish to have it provided by the NHS since that would be free and not its responsibility, so the boundary between the NHS and local authorities is particularly relevant in this connection.
At the moment, I do not see how it can be for the patient to claim continuing NHS care. The GP should be able to say to the patient that they need it and that should be sufficient for it to be provided. The likelihood is that a patient would have great difficulty in assessing for himself or herself whether continuing healthcare was needed, so it must be a matter for professional advice. I think that the advice that we are talking about in this context is advice about local authority services, not about the services that the NHS can provide. However, as I say, the boundary between the two is vitally important. I hope that the point made so eloquently by the noble Baroness, Lady Gale, arising from her own inquiry, will be looked at with a considerable degree of care.
Baroness Greengross
My Lords, I hope that noble Lords will forgive me, but I forgot to speak to one of the amendments that is relevant to this group; that is, Amendment 86C. It is about people with dementia who have had a diagnosis. I know that the noble Earl will share the Prime Minister’s view and those of all of us who have looked at the number of people who receive a diagnosis of dementia. We now want to ensure that many more are diagnosed, and diagnosed early.
However, there are many reports that people diagnosed with dementia and their carers feel terribly abandoned after they have had the diagnosis. The Bill’s emphasis on access to prevention services and information and advice for people, particularly if their needs have not yet reached the threshold of eligibility for social care, is welcome. But there are no specific prompts to ensure that people receive the information they need at the time when it is most useful. The risk is that, although local authorities have set up information and advice services, the information does not reach people at the right time. A post-diagnosis information pack tailored to specific long-term conditions should be given to every individual who is diagnosed with one of those conditions. It would provide access to tailored information about the support that is available to them, and it would enable them to cope with the challenges of living with a long-term condition. The pack would provide information on the likely impacts of dementia and contain core information on national and local services. I think that this would be an important aspect of providing the right information and advice at the right time.
Lord Beecham
My Lords, this Bill has the potential to do for social care what Beveridge did for the welfare state and Bevan did for the health service. It is potentially the most significant development in, for example, residential care since the workhouses were replaced by a more civilised form of residential accommodation.
The noble Baroness, Lady Barker, anticipated precisely the point I was going to make, which is that this is not just a matter for local authorities. My principal reservation about these amendments, if I have one, is that it looks as though the entire burden of information and advice is to be placed on local authorities whereas of course, as the noble Baroness rightly said, there are other potential partners who clearly need to be involved. I scribbled on the grid that is helpfully provided by those who support the Front Bench on this side the words “in collaboration with”, and then I thought of a number of potential partners. Of course the health service is one of them, but in addition I would suggest that the Court of Protection needs to be involved. It has a supervisory and supportive responsibility for a particular group of people and, with the development of lasting powers of attorney and so on, their deputies as well. I have to say—I have said it before and I will say it again—that I am not convinced that the Court of Protection is doing a terrific job in this area, but that is another reason why it should be looked at as a potential partner.
There may be other partners. For example, in the case of younger people perhaps with a learning or other disability, there are roles for those involved in further education, the Department for Work and Pensions and the Department for Business, Innovation and Skills. Those bodies might look at their role in terms of what is available by way of education, training and so on. It seems to me that a range of organisations should be involved, certainly as a whole, but more particularly in the provision of information and advice.
On these Benches we support most of the amendments that have been moved and spoken to this afternoon, with the qualification that, where relevant and necessary, a reference to collaboration should be included. For example, in Amendment 82B, the first amendment moved by the noble Baroness, Lady Greengross, one would want to see “in collaboration with” appropriate partners.
We support the amendments, notably moved by my noble friend Lord Lipsey, around the provision of independent financial advice. That seems very important. I have a slight reservation about Amendment 86D, which is about payment of,
“the reasonable costs of a first consultation with an independent financial adviser”,
to be paid for “by the local authority”. If I am ever in need of this kind of advice, I would be able to afford that relatively easily. Given the pressure on budgets, is a universal application of that principle necessary or desirable? That, however, is a detail, that might be looked at later. Given the scale of the potential involvement and the potential conflict of interest referred to by several noble Lords, the independence and proper status of such financial advice are important considerations.
With regard to the amendment in the name of the noble Lord, Lord Sharkey, I will perhaps anticipate the Minister by quibbling over the word “demonstrably”. Frankly, I am not sure that that takes us very far. As the noble Lord admitted, what is demonstrable to some is not necessarily demonstrable to others. I do not think that that part of his amendment is particularly cogent, although I agree with the rest of it.
I have more serious doubt about the amendment of the noble Baroness, Lady Browning. Amendment 86H requires that the information and advice be provided by “social work-qualified staff”. It could be, but I am not sure that it should be a requirement that it should be, given the pressure on the service in dealing with casework as it is. I do not think that the skills of social workers are always consistent with the role of giving information and advice in the sense that is intended by the amendment.
Care Bill [HL]
Baroness Greengross Excerpts(10 years, 9 months ago)
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Lord Hunt of Kings Heath
My Lords, as this is my first intervention, I refer noble Lords to my interests as president elect of GSI, chair of an NHS foundation trust and a consultant and trainer with Cumberlege Connections.
I have three amendments in this group. Amendment 86J seeks to delete “high quality services” and instead insert,
““services appropriate to their needs as identified in the needs assessment and carer’s assessment”.
The problem with the draft as it currently stands is that it is very vague and entirely subjective depending on who is defining “high quality services”. Perhaps the noble Earl can clarify how the Government think it ought to be defined. Otherwise, there is a risk of uncertainty and inconsistency which, certainly when it comes to eligibility criteria, the Bill is designed to eradicate.
My second Amendment 86K would ensure that those in receipt of care and those involved in providing care are involved in shaping the market, as required under Clause 5. I have received a number of submissions about the market-making role of local authorities, and I was concerned to receive a submission from the Association of Directors of Adult Social Services, which said that while the intention of Clause 5 in promoting quality and diversity within the market is laudable, ADASS was of the view that the proposed duty placed on local authorities is wholly unrealistic. It points to a large number of providers that have no relationship or contact with local authorities, and says that combined with increased personalisation and limited leverage through the regulation framework, the ability of local authorities alone to influence diversity and quality of service is restricted.
I was very disappointed with that response, and rather taken aback by it. I hope that the noble Earl will share my view that in fact local authorities ought to be able to influence not only the market but the quality of care provided by private providers to a very great extent. Would the Minister accept that, to be effective, local authorities need to have a strong engagement both with users of services and carers, and with those who are providing services, too? That is why I tabled the amendment.
I listened with great interest to the noble Baroness, Lady Emerton, and I very much agree with her about the need to ensure quality in provision of service. That brings me to my own substantive Amendment 86P, which is very much concerned with the conditions under which care workers are employed in the main by the private sector. This is a hugely important issue. Clearly, we have a growing number of disabled and older people who need care and support. The people working in the care sector are vital. We need quality people who are highly trained and who can give the right commitment to the vulnerable people they are asked to care for. Clause 5 is important because what we see is a very fragmented industry delivering care that in many cases is of questionable quality and employing insecure, low paid, unregulated staff. Amendment 86P is concerned with the importance of fostering a sustainable workforce to encourage the acquisition of skills and decent working conditions that support the continuity and quality of care.
I was shocked to see a parliamentary Answer from the Minister’s honourable friend Mr Lamb recently, showing that more than 300,000 people working in the care sector are employed on zero-hours contracts. The point that I wish to make is this: how can people who do not have the security of knowing what they will earn pass on a sense of security to the people whom they care for? The rise in zero-hours contracts is bad for service users, many of whom are, of course, extremely vulnerable. There is another issue. People who are being cared for want to see the same person to have a continuity of care relationship. We know that that is severely hindered by those wretched zero-hours contracts. I believe that secure employment would allow staff to concentrate on caring rather than worrying about whether they are earning enough money for themselves and their families to live on.
I ought to declare an interest as a member of UNISON, which produced an excellent report, Time to Care, which undertook a survey in 2012 of care home workers. It showed that 80% of those who responded had to rush work or leave a client early to go to another call on what is called call cramming— in other words, too many calls for a care worker to undertake—and 56% received between the national minimum wage and £8 an hour. The majority did not receive set wages. Not surprisingly, turnover is high, while wages and conditions are poor.
Here is a shocking statistic. Nearly 57.8% are not paid for travelling time between visits. This morning I met a carer in Southwark who works roughly 20 hours on a zero-hours contract. She reckons that, because of the travelling time, she actually works for 27 hours, but is paid for only 20. The problem is that there is a race to the bottom because local authorities are, in my view, neglecting their responsibilities for ensuring that, when they place contracts, they are with good quality organisations. The companies who are exploiting their workers in this way are winning contracts at the expense of companies who treat their employees wisely. No wonder, therefore, that 36.7% of respondents are often allocated different clients on a daily basis, so that there is no chance of any relationship being developed.
There are many other statistics. The scandal of the 15-minute visit is well known. Indeed, the UK Homecare Association survey shows that three-quarters of all trips to old people have to be completed in less than half an hour and one in 10 is limited to no more than 15 minutes.
In Committee last week, I discussed with the Minister whether the CQC could be persuaded—or indeed, I hope, instructed—by your Lordships, to prioritise the regulation and inspection of local authorities in their commissioning duties. We have heard a lot about the CQC’s past failures and future hopes. It is clear that the focus is going to be on the NHS. I do not disagree with that, but when you think of the thousands of vulnerable people dependent on care workers, I wonder if the priority is right. If I were in the CQC’s shoes, I would focus on the care sector and particularly on local authorities and their own responsibilities. That is probably the best way to get into this issue.
We could have a debate about the regulation of social care workers. We could debate mandatory training and the noble Baroness, Lady Emerton, has tabled an amendment which would very much focus on that. I hope the Minister will recognise that we have a problem here. If we are to see this legislation enacted in the way that we all hope it will be, I am convinced that we have to look at the way that workers in the care sector are employed and do everything we can to prevent the abuse that we are seeing with these zero-hours contracts.
Baroness Greengross
My Lords, I rise to speak to the amendments in my name—Amendments 86L, 86M, 86N and 86Q. These amendments are all about quality of care. We know what happens at the moment. There is the opposite of a monopoly in that there are lots of sellers, but largely one buyer of care. Many care homes know this. The local authority is in a very strong position and will tell the care home managers—in the private or voluntary sectors—that they will take 20 beds and negotiate a price which is very low. That means that the care home cannot provide a decent quality of care at that unrealistic price. This has been talked about and written about by Laing and Buisson and various other bodies. It is a known fact among those who follow very closely what goes on, but at the moment it is not really known to the public.
Baroness Greengross
My Lords, I have mentioned to the noble Earl another aspect of this which I think needs to be taken into account. Not only will this funding by some people of other people—or the “secret tax”, as I call it—become better known but there will be a strong incentive for self-funders to dispose of their assets so that the local authority pays the local authority rate for them, even if they pay in more on top of that. Therefore, I think that the Government need to take into account the huge extra cost on local authorities which we have not thought about so far. If self-funders were to go to a financial adviser and ask for advice, I imagine that many financial advisers would say, “Dispose of some of your assets and at least the local authority will pay that rate for you”.
Earl Howe
But for somebody with assets who is looking to be taken care of in a residential home the incentive to dispose of their personal assets is surely going to be a great deal less than it is at the moment. I would have thought that that incentive was much greater now than it will be in the future, when we hope that there will be financial products on the market to enable people to insure up to the level of the cap. Therefore, I am not sure that I completely understand the force of the point that the noble Baroness is making. Obviously there will be some incentive for people to dispose of their assets but I suggest that it will be less than she has stated.
To move on to the noble Baroness’s Amendment 86M, there will be a dispute between a local authority and a provider as to the prices proposed or other matters. Occasionally, disputes may become intractable. Therefore, I completely understand why the noble Baroness proposes through her amendment to, in effect, require a new independent adjudicator to arbitrate in any unresolvable disputes. However, it is our view that any disputes arising as part of a contractual negotiation must be resolved through that process. Appointing or establishing a new independent adjudicator would be likely to add unnecessary cost and bureaucracy to the process of commissioning. We also believe that it will be likely to increase disputes by providing a means of challenge which would soon become a standard process.