Care Bill [HL]

Baroness Greengross Excerpts

Wednesday 3rd July 2013 Lords Chamber

Overall, we wish CQC well. I am concerned about the pressure being put on it to come up with a new system before it has time duly to consider it. I hope the noble Earl will agree to an amendment around pilots.

[Baroness Greengross]

My Lords, I shall speak to Amendments 76ZZA and 76ZAA in my name. I thank the noble Lord, Lord Hunt, for the support he expressed earlier. On Amendment 76ZZA, we know that one of the major problems identified in the Francis report was the inadequate handling of complaints and concerns. This issue has not been addressed in the Care Bill. My amendment would enable the Care Quality Commission to introduce more rigorous complaint systems across all care settings. I hope the Minister will consider this because it is very important to get this right now. This is about the way in which a registered service provider or a local authority will handle complaints and concerns, and it is very important.

Amendment 76ZAA is about continence care. I declare an interest as chair of the all-party parliamentary group on this subject. It is hardly spoken about, but it is terribly important; people just do not recognise how many people have some problem with continence. The NHS services should have continence care as an essential indicator of service quality. It therefore needs to be established as an essential indicator of high-quality services across the NHS and care settings within the periodic assessments of care standards undertaken by the CQC.

A number of recent assessments have demonstrated that continence care is still a low priority across NHS settings, with poor treatment resulting in escalated and more costly care needs and poorer patient outcomes. This is in spite of the fact that good bladder and bowel control are fundamental to people’s dignity and independence and that NICE has published a wealth of best practice recommendations to effectively assess and treat the condition. The Francis report included an entire chapter outlining the scale of failures in continence care. Given the expected rise in prevalence of incontinence and the impact that poor care can have on patients and the NHS, continence care must be seen as a key indicator of high-quality provision across care settings. An explicit requirement within the Care Bill for the CQC to assess providers for the quality of their continence care would directly respond to the failings in this field which the Francis report identified—the stated purpose behind Part 2 of the Bill. That would encourage providers actively to address how they manage incontinence by assessing their local protocols and policies about the condition, taking steps to improve awareness among staff about incontinence and undertaking internal audits in order continuously to improve care standards.

[Lord Sutherland of Houndwood]

My Lords, I wish to register my support for the proposals in some of these amendments. The integration of services should always be highlighted. We have a long way to go and, since we are not providing an integrated budget, every encouragement short of that should be given, so I support the amendments that propose this.

The amendments and stand-part question in the name of the noble Lord, Lord Hunt, have to do with the standing of the CQC. CQC has been through a very rough patch, and to some extent, responsibility lies as much here as elsewhere. I remember the debates a number of years ago, when we changed the structure of the regulation that should be provided in this area three or four times within four or five years and always handed the ball on to a new organisation that we thought would solve all the problems. We failed consistently to answer the question: what are the signs that the new organisation will succeed in all the tasks being given to it? We now see that there have been difficulties. Moving with a degree of caution has a great deal to commend it, and I look forward to the Minister’s response to the questions raised by the noble Lord, Lord Hunt.

The rhetoric around the comments of politicians, those in health regulation and the press continually refers to Ofsted and Ofsted-style inspections. I declare an interest, in that I had something to do with founding Ofsted and the type of inspections that in due course developed. Ofsted is a rather a different beast, and these comparisons do not help. For example, the chief inspector is independent of the control of the department, which seems not to be the case in the plans for the future. That means that the relationships with the Minister and Secretary of State will have to be very carefully managed. I am not sure that sufficient thought has been given to that. That is part of the case for asking whether Clause 80 should stand part of the Bill.

The other pressures being put on CQC have to do with financial assessment. These are additional responsibilities for which CQC is hardly prepared. There is a need for specialist staff and specialist abilities to decide whether companies providing care at all levels have the ability to continue sustainably to do that—but that does not, as we have seen in other forms of financial regulation, come easily to regulatory bodies. This has to be looked at very carefully, along with the pace at which change is introduced into the practices of CQC, which is under, we hope and expect, good new management.

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[Baroness Tyler of Enfield]

My Lords, I add my support to Amendment 78ZA, to which my name is also attached. The noble Lord, Lord Bichard, has already spoken very eloquently of the reasons behind the amendment. Dignity and respect are absolutely fundamental pillars of well-being, which is why I would like to see these words spelt out in the Bill. Well-being is unattainable without dignity and respect as central components. In saying this, I am conscious that the public’s opinion on this matter is one of pessimism and distrust of the current social care system. In a recent survey, only 26% of the public felt confident that older people receiving social care are being treated with dignity. If the public do not trust their loved ones in the hands of the social care sector, what hope is there that well-being is being promoted?

We have recently seen and heard of shocking failures in the care of older people in both the health and social care sectors. These very harrowing examples serve to illustrate the importance of enshrining dignity and respect as a critical part of well-being in order to try to change the culture among care workers in the health and care sectors, to ensure the transformation of services that this Bill is intended to bring about and to have the sort of compassionate care that we all like to see. Dignity will also be very important when it comes to secondary legislation and specifically to the eligibility criteria. It is vital that these criteria have regard to the well-being principle. I am happy to be corrected about this if I am mistaken, but the draft feels very health-and-safety-oriented and does not mention dignity at all.

I would have liked to add my name to Amendment 79 about including well-being as part of the Secretary of State’s duty, the reasons for which have already been set out very clearly. The very wide-ranging definition of well-being, set out in The Care Bill Explained, makes it absolutely clear that for the well-being principle to be made a reality it would need to be the joint responsibility of a wide range of partner agencies, nationally and locally. Government action on key issues such as welfare, transport and housing are likely to have a very distinct impact on well-being at an individual level.

We rightly hear a lot about the importance of joining up health, social care and wider services: horizontal integration, if you like. For any system to work as it is intended and to be fully aligned it must be, as I said at Second Reading, vertically integrated as well to make sure that everyone, from the Secretary of State downwards, has the same objectives and is pulling in the same direction.

[Baroness Greengross]

My Lords, I support Amendment 78ZA. Six years of serving on the Equality and Human Rights Commission taught me that if we embedded dignity and respect into the training of staff we would avoid many of the tragedies we have read about. This applies, right across the board, to staff in health, social care and housing. It is essential that we take dignity and respect as very serious elements of the training of all staff who come into contact with frail and vulnerable people.

[Earl Howe]

My Lords, the well-being principle in Clause 1 was devised on the basis of the Law Commission’s report on adult social care which this part implements. The report recommended that the new statute should set out a single, overarching principle that adult care and support must promote or contribute to the well-being of the individual. Not least in the light of our debate at Second Reading, I can therefore understand the noble Lords’ intention in tabling Amendments 78 and 79. It is to ensure that any functions that the Secretary of State exercises under this part take into consideration how such provisions will impact upon people’s well-being. I can give the Committee what I hope will be a welcome reassurance on that issue and, in the process, a rather better and fuller answer than I gave at Second Reading.

It is already the case that the Secretary of State must have regard to the general duty of local authorities to promote an individual’s well-being when making guidance or issuing regulations. This is because, when making regulations or issuing guidance, the Secretary of State must consider how local authorities can fulfil their statutory obligations. He cannot ignore those obligations and I believe this addresses the central concern of the noble Lord, Lord Hunt, and others who have spoken to the amendment. The question is whether the Bill should go further. The Government do not believe that it is appropriate to apply the well-being principle directly to the Secretary of State. The well-being principle is intended to apply at a very real, individual level. It has been designed to frame the relationship that exists between the local authority and the individual adult, in effect setting out how it is expected the local authority will behave when making a decision, or doing anything else, in relation to a person needing care and support or to a carer. The Secretary of State does not act at this individual level, and I am still reluctant to make any amendment which might be seen to detract from this important legal reform.

Having said that, I have listened with care to the strength of feeling in this debate, not least to the point made by the noble Baroness, Lady Pitkeathley, about the Secretary of State’s duty to have regard to the NHS constitution and whether there was something comparable that we could devise in this context. That is an interesting comparison and, while I am not yet convinced that it is fully comparable, I am happy to take the points that have been made away with me and give this matter further thought before the next stage of the Bill.

Amendment 78A seeks to bring in to the well-being principle the idea of spiritual well-being and I listened with care to my noble friend Lady Barker who spoke to this amendment. The Government believe that the clause, as it is already drafted, takes such a factor into consideration. Clause 1(2) sets out that well-being means an individual’s well-being in relation to emotional well-being. The Government believe that emotional well-being incorporates the concept of spiritual well-being.

I turn to Amendment 78B, which proposes that local authorities must take into consideration an individual’s beliefs, values and past practices. While we share my noble friend’s intention in this regard, we believe that the clause as it stands already incorporates the idea that people’s beliefs and values should be taken into account when a local authority has regard to an individual’s views, wishes and feelings.

The second part of the amendment would be to ensure that “past practices” were also taken in account. I reassure my noble friend that we will be setting out in guidance the importance of taking into consideration, when planning a person’s care, their views and feelings as well as considering any practices in the past that have been important to that individual.

The noble Lord, Lord Bichard, highlights the importance of dignity in care in his Amendment 78ZA, and he spoke about that concept very powerfully. I am pleased to say that the Government agree that this is important, which is why we amended the Bill to make an explicit reference to dignity into the well-being principle, following pre-legislative scrutiny. With respect to the noble Lord, I cannot agree with him that the word has somehow been lost; it is right there on the page.

I turn to Amendments 78E, 87K and 88J, tabled by my noble friend Lord Black of Brentwood. These amendments focus on the very important topic of pets. The Government have considered this issue carefully since the amendment was tabled, and we believe that the Care Bill already allows for the consideration of pets. First, Clause 1, the well-being clause, provides that local authorities, when exercising any function under Part 1 of the Bill, have a duty to promote the well-being of an individual. Well-being is composed of many aspects, including emotional well-being. A pet might be so important to an individual that their emotional well-being would depend in some way on their pet. If that is the case, a local authority will have to take it into consideration.

Furthermore, Clause 1(3)(b) sets out that in exercising any function under Part 1 of the Care Bill a local authority must have regard to an individual’s “views, wishes, and feelings”. This could include how an individual feels about a pet, and their wishes for the pet. Clause 9, which covers the assessment of needs for care and support, also allows scope for pets to be taken into consideration in the assessment process. As Clause 9(4)(a) sets out, a needs assessment must take into consideration a person’s well-being. This could certainly include an individual’s pet, from which they derive a lot of emotional well-being.

I turn to Amendments 78D and 88L. The Government believe that it is more important than ever that care and support services operate in tandem with health services. The Government have committed to breaking down barriers between health, care and support, as well as encouraging co-operation, integration and joined-up working between local partners. The Government believe that the Care Bill already allows for such co-operation to occur, and I shall explain how. First, Clause 1(2)(a) makes it clear that the well-being principle incorporates physical and mental health. Local authorities must therefore already consider a person’s health when exercising any functions under Part 1. Secondly, Clause 3 details how local authorities must exercise their functions under Part 1 with a view to ensuring the integration of care and support with health provision, where they consider that this would promote the well-being of an individual.

Regulations on assessments for care and support are also relevant. As Clause 12(1)(f) sets out, regulations may set out when a local authority must consult someone with expertise before undertaking an assessment. Regulations may also set out conditions around co-operation with the NHS, by specifying the circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare.

The noble Lord, Lord Hunt, expressed the view that the eligibility regulations do not sufficiently promote integration. I note the point that he made and look forward to debating this in perhaps fuller measure when we come to discuss eligibility. However, I ought to point out that the draft regulations published last week are subject to consultation, and I am sure that the discussion will explore the points that he made.

My noble friend Lady Tyler said that the regulations do not mention dignity specifically. I think that they have to be read in context. The well-being principle, including the reference to dignity, applies to the assessment of the adult’s needs and to the local authority’s determination of whether those needs are eligible.

To return to my noble friend Lord Black’s amendment on companion animals, we are clear that there should not be any limitations on the uses of direct payments, which was an issue that he raised, as long as they are used to meet needs for which they are paid and not in a way that is unlawful. The key is that direct payments are used to improve people’s outcomes.

I understand the intentions of noble Lords in tabling these amendments but I hope that they feel reassured that they are not necessary, although I will take back the specific issue that I referred to earlier. In the light of that, I hope that the noble Lord, Lord Hunt of Kings Heath, will feel able to withdraw the amendment.

Care Bill [HL]

Baroness Greengross Excerpts

Wednesday 3rd July 2013 Lords Chamber

Moved by

[Baroness Greengross]

78C: Clause 1, page 2, line 7, after “support” insert “or need for health provision and the importance of reducing needs of either kind that already exist,”

[Baroness Greengross]

My Lords, I will also speak to my Amendments 79C, 79G and 79K.

Amendment 78C is about trying to strengthen the provisions to ensure that we have an integrated approach to care planning. This would happen if we could ensure that local authorities consider how to prevent or delay healthcare needs, as well as care and support needs, when providing or arranging the provision of services, facilities or resources for care. We have talked about this previously but I think that the Bill should require local authorities to have regard to the potential to prevent, delay or reduce health needs as well as care needs when providing or arranging care and support services. This duty would have wider benefits because it would strengthen the requirements on local authorities to prioritise integrated care services in line with Clause 3 of the Bill. It should also improve cost efficiencies for local authority budgets at a time when social care budgets are being squeezed, as we have heard, by reducing the need for more intensive and costly forms of care.

Similarly, Amendment 79K tries to enshrine the duty of prevention. We know, and have heard from other noble Lords, that many people reach a crisis point when the person for whom they are caring is critically ill, or has a fall, or the partner dies, or something else happens. There is a panic and the wrong sort of care or very expensive acute care is provided. If appropriate identification, awareness and assessment of needs could be made before people reach this point, it would be absolutely brilliant at avoiding some of these acute costs of care. Enshrining prevention in the Bill is very important. Accordingly, it is imperative to ensure that the prevention duty focuses on what a local authority must do to prevent deterioration in well-being, to underpin the imperative to prevent, delay and reduce the need for care and support.

In order to make sure that happens, Amendment 80B ensures that local authorities have regard to NICE clinical guidelines and equality standards. This came to me through chairing a committee which produced a report on autism as it now affects a lot of older people. This is a fairly new phenomenon, because fortunately people live longer—not just healthy people, not just sick people, not just frail people, but people who have conditions such as autism. We know that NICE’s remit will be extended—in fact it has been extended since April of this year—to include social care services. It has the potential for a new focus on evidence-based decision-making. For example, the NICE guidelines on adults with autism states that investing in employment support is cost-effective.

This, and similar findings, should be taken into account by local authorities when they are providing services, including preventive services. All of these together would help to provide a range of preventive care. In order to make that happen, I hope we can encourage local authorities to look at more than one-year budgeting, because preventive services need longer than that. Local authorities need to be encouraged to take a longer view. If you are running a business and invest in something, you do not expect a return immediately. If you invest in preventive services, you will not necessarily get a return in one year, you have to give things a longer time span to reap the benefits. That also applies in these cases.

Amendment 87G makes sure that local authorities assess preventable needs and look to reduce these needs as an integral part of their duties in relation to the assessment progress. Briefly, that explains this group of amendments. I beg to move.

[Lord Touhig]

My Lords, I speak in support of Amendments 79K, 80A, 80B and 87G. At the outset, I pay tribute to the noble Baroness, Lady Greengross, who did an excellent job in chairing the commission on ageing and autism. We look forward to the publication of the report very shortly. It was certainly an eye-opener for a great many of us, and the many who thought they knew a lot about support and social care learnt a great deal during that time.

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[Earl Howe]

My Lords, I apologise to my noble friend for intervening before she had a chance to speak. As the Committee will have gathered, I was observing that it is always good when there is an outbreak of consensus across the Chamber, and I think this is a case in point. It is critical that care and support work actively to promote people’s well-being and independence, rather than just waiting for people to reach crisis point. We want a system that promotes independence and reduces dependency as well as supporting those who already need care and support.

Preventing and delaying needs from arising, or reducing them where they exist, is a central part of local authorities’ modern responsibilities for care and support. Adopting preventive approaches can reduce needs in the longer term, saving public money and improving outcomes. There has never before been a clear legal duty that reflects this priority and establishes prevention as part of the core local authority responsibility. Clause 2 fills that gap, requiring local authorities to provide or arrange services to prevent, delay or reduce needs for care and support and carer’s support. This will create a legal basis for a wide range of preventive services that can help people maintain their independence for longer. The noble Lord, Lord Low, mentioned some good examples but they might also include exercise classes, which can help people maintain and increase their mobility, befriending services and hobby clubs, which can reduce loneliness and social isolation, and installing grab rails in a frail person’s home, which can prevent falls, broken bones and unnecessary stays in hospital. However, those are not the only examples. We want local authorities to be truly innovative in the services offered in their area, which is why we have not been prescriptive in the way that local authorities carry out the duties conferred by the clause. I agree with the noble Lord that these things can bring direct financial savings, and I quoted some good examples, I hope, in speaking on an earlier group of amendments.

Amendments 79A and 79K make the point that prevention should be an overarching principle of a local authority’s care and support functions, and that this should be framed in the context of well-being. This is surely right. To that end, Clause 1 sets out that in exercising care and support functions, local authorities must promote an individual’s well-being. This includes, among other things, having regard to preventing, delaying and reducing needs, as expressly stated in Clause 1(3)(c).

The noble Lord, Lord Rix, makes clear in tabling Amendment 79D the need for local authorities to be proactive in preventing, delaying and reducing needs for care and support, but also in safeguarding adults with needs for care and support from abuse or neglect. As he mentioned, Clause 41 does just that by requiring local authorities to ensure that inquiries are made when an adult with needs for care and support is at risk of abuse or neglect. Clause 42 and Schedule 2 create the legal framework for local authorities to establish safeguarding adult boards, which must devise, publish and implement annual strategic plans for adult safeguarding in their area. There will of course be the opportunity to discuss safeguarding in greater detail at a later date.

Amendment 80C, proposed by the noble Lord, Lord Low, raises the issue of prevention as part of the joint strategic needs assessment and joint health and well-being strategy under the Local Government and Public Involvement in Health Act 2007. I listened to him with care and hope that I can reassure him. The existing legislation in relation to these joint assessments and strategies is clear that where any needs can be met by the local authority exercising its functions under the prevention duty in Clause 2, these would be included as part of the joint assessments and strategies.

In Amendments 78C, 79C and 79G, the noble Baroness, Lady Greengross, highlights the importance of preventing, delaying and reducing health needs as well as needs for care and support. Again, I find myself in complete agreement with her and, as I said, I believe that the Bill achieves this laudable aim. This is where the importance of integration and co-operation can clearly be seen, a matter also raised by the noble Lord, Lord Hunt, in Amendment 79B. Clause 3 requires local authorities to promote the integration of care and support with health and health-related provision, including where this would contribute to preventing, delaying and reducing needs.

Clauses 6 and 7 require local authorities and their relevant partners to co-operate in the exercise of their care and support and carer’s support functions. Such co-operation is to be performed for the purposes of, among other things, promoting an individual’s well-being, which in turn includes having regard to the importance of prevention through Clause 1(3). Accordingly, there is a clear duty on local authorities and their relevant partners to co-operate with one another in preventing, delaying and reducing needs for care and support and carer’s support.

These duties, coupled with the return of public health responsibilities to local authorities as a result of the 2012 Act and the new prevention duty, present a unique opportunity for aligning prevention services across health and care and support. That is why local authorities will be required to ensure the co-operation of their director of public health, where relevant to care and support functions.

I turn briefly to Amendments 87F and 87G, tabled by the noble Lord, Lord Low, and the noble Baroness, Lady Greengross. The Government believe that the Care Bill allows for the assessment process fully to take account of prevention. As the well-being principle requires the local authority to have regard to the importance of preventing, reducing or delaying needs for care and support, it must also consider this when conducting an assessment.

Amendment 80A highlights that, to be able to prevent delay and reduce needs for care and support and thus promote independence and well-being, we need to improve the quality and diversity of preventive services, facilities and resources. To achieve this, Clause 5(7) makes explicit provision for local authorities to promote the diversity of services, resources and facilities which can prevent delay or reduce needs for care and support. As the noble Baroness also points out with Amendment 80B, commissioning decisions, including for preventive services, should be made on the best evidence available. In the case of preventive interventions, we know through engagement with the care and support sector that this is not yet as strong as we would like. The Government have committed to developing a library of evidence on prevention. That will enable commissioners to make decisions knowing what is proven to work and what is not. However, to be able to build this evidence base and to find the solutions to the care and support needs of the 21st century, we need to allow room for innovation in developing and testing new models of preventive interventions. Without breaking the mould of traditional care packages, pioneering solutions such as shared lives schemes, which offer an alternative model to home care or residential care using community networks, would not have been able to flourish.

The noble Baroness, Lady Greengross, observed that local authorities need more than a year to plan in terms of the budget cycle. Local authorities already have multiyear financial settlements and that gives them scope to plan services in the longer term The noble Lord, Lord Touhig, returned us to the important subject of autism. He remarked that adults with autism rely on low-level preventive services and he felt that the Bill does not do enough in this area. The reforms to care and support set out in the Bill will benefit people with disabilities, including people with autism. The provisions around prevention, personal budgets and transition between children and adult services are just some examples of new laws which will benefit many people with autism.

As local areas gain a better understanding of autism needs locally and develop autism commissioning plans, we expect them to look more at the cost benefits of more low-level and preventive services, such as befriending services or social skills training. Preventive services can be provided to prevent, delay or reduce needs for care and support, regardless of the level of need involved. I hope that I have reassured noble Lords that prevention is suitably reflected within the Bill and that the noble Baroness, Lady Greengross, will feel able to withdraw the amendment.

[Baroness Greengross]

My Lords, I was very encouraged by the words of the Minister, but I am still rather worried. It was great to hear the points made by the noble Lord, Lord Touhig, who is so knowledgeable about autism. I am also very grateful to the noble Lord, Lord Hunt, for his comments, and to the noble Lord, Lord Low, who made some very apposite points about prevention. If I were a director of adult social services and had very limited funds, I would have to concentrate on the people in the greatest need, and it would be likely that prevention would slip to a lower level of my attention. This is the danger of preventive services not getting the attention that they need. I have yet to be totally convinced that prevention will prevail in the way that the noble Earl suggested. I hope that he is right.

We need a longer timeframe. It is difficult for local authorities to budget in that way, but it is essential if we are to focus on preventive services in the long run. I hope that, as we go through the remaining parts of the Bill, we can be clearer about how to ensure that prevention is at the top of our list. That will apply to eligibility criteria, which we will look at later. In the mean time, I thank all noble Lords who supported what I said and my colleagues for their support. I beg leave to withdraw the amendment.

Amendment 78C withdrawn.

Autism

Baroness Greengross Excerpts

Monday 17th June 2013 Lords Chamber

[Earl Howe]

My Lords, we are indeed currently supporting, along with NHS England, a practical guide for CCGs to support health professionals and others in implementing the adult autism statutory guidance, as well as the NICE guidelines on recognition, referral and diagnosis, and the management of adults on the autism spectrum. This will be published later in the summer through the Joint Commissioning Panel for Mental Health.

[Baroness Greengross]

My Lords, I was recently privileged to chair a commission that looked for the first time at the large numbers of people who grow into old age with autism. I would very much like the noble Earl to assure the House that these people will not be ignored, will also receive diagnosis, and that professionals will be trained to ensure that a preventive support system of care is introduced so that it is not always crisis-driven. Can he tell us that?

[Earl Howe]

I agree with the noble Baroness that the needs of those with autism in older age should not be forgotten. We will meet the National Autistic Society, following the publication next month of its report on autism and ageing, to see how we can support the taking forward of this work, which builds on that done by the autism and ageing commission in this House. We are also looking at the whole issue of the training of health professionals, in particular the core curricula for doctors, nurses and other clinicians.

Care Bill [HL]

Baroness Greengross Excerpts

Monday 10th June 2013 Lords Chamber

Moved by

[Baroness Greengross]

16: After Clause 85, insert the following new Clause—
“Regulation of healthcare and care assistants
(1) HEE shall establish and maintain a register of qualified healthcare assistants and care assistants.
(2) HEE shall, from time to time—
(a) establish the standards of proficiency necessary for admission to the register being the standards it considers necessary for safe and effective practice under the register; and(b) prescribe the requirements to be met as to evidence of good health and good character in order to satisfy HEE that an applicant is capable of safe and effective practice as a healthcare assistant or care assistant.(3) Regulations may prescribe—
(a) access to the register;(b) the process of application to and acceptance on the register;(c) the process of registration and readmission;(d) deemed registration of EEA health care assistants and care assistants;(e) lapse of registration;(f) approved qualifications;(g) EEA qualifications; and(h) fitness to practice under the register.(4) HEE shall, before carrying out duties prescribed in subsections (1) and (2), consult—
(a) the Secretary of State;(b) the Care Quality Commission;(c) such other persons, or other persons of such a description, as may be prescribed; and(d) any other person it considers appropriate.(5) “A healthcare assistant” is an individual who provides personal care for the health service, but who is not—
(a) a carer as defined under this Act;(b) a healthcare worker currently registered with the General Medical Council or Nursing and Midwifery Council; or(c) any other healthcare worker as may be prescribed. (6) A “care assistant” is an individual who provides personal care for the purposes of adult social care, but who is not—
(a) a carer as defined under this Act;(b) a healthcare worker currently registered with the General Medical Council or Nursing and Midwifery Council; or(c) any other healthcare worker as may be prescribed.(7) “Adult social care”—
(a) includes all forms of personal care and other practical assistance for individuals who, by reason of age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs, or any other similar circumstances, are in need of such care or other assistance, but(b) does not include anything provided by an establishment or agency for which Her Majesty’s Chief Inspector of Education, Children’s Services and Skills is the registration authority under section 5 of the Care Standards Act 2000.”

[Baroness Greengross]

My Lords, I bring this amendment before the Committee because, as we all know, there are huge numbers of very frail people, usually older people, often with multiple conditions, in our hospitals and care homes, and indeed in the community now. The numbers are growing. For all sorts of reasons—I think that some of them could be tracked back to the European working time directive—nurses are doing more and more complex tasks in the care that they provide, some of it electronic, that very often removes them from the day-to-day care of some of these very frail people. The same applies in care homes. The care that is provided is very often not provided by qualified nurses but by healthcare assistants or care assistants. There are many of those people who are fantastically caring. They have a natural ability to relate to the patients that they deal with or the residents in care homes. However, a lot of the dreadful cases that we read about in the newspapers take place because unqualified and unregistered care assistants are looking after people without the necessary training and without the necessary standard of care being insisted upon. This is extremely worrying.

We have heard a lot about dehydration or malnutrition and about a lack of dignity and respect. That is terrible, whoever is providing the care, but it is even worse somehow if the care is provided by people who are neither registered nor trained adequately and cannot be blamed for the fact that complex and difficult care situations are thrust upon them and they are landed with residents that they do not know how to care for adequately.

The amendment asks HEE to establish and maintain a register of qualified healthcare assistants and care assistants. If we could get there, we would then begin to have a remedy for some of the awful cases that we read about. We would know that people were fit to practise under the register and that there would likely be fewer cases of what can, unfortunately, amount to abuse.

When this system goes wrong in our country, we often learn that it is due to people who are not trained, qualified or registered being given enormous responsibilities. I would be pleased to know if the Minister agrees with me that this amendment would be of enormous benefit to patients and residents.

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[Earl Howe]

I conclude by saying to the noble Baroness, Lady Greengross, that I hope she takes some encouragement from the work that is in train, and that she agrees with me that it is right to take stock after we see the recommendations flowing from the Cavendish review later in the year. No doubt that can inform our deliberations on Report. I hope that, in the mean time, she will feel able to withdraw the amendment.

[Baroness Greengross]

My Lords, I thank all noble Lords who have spoken for accepting that the principle that I was arguing about is correct and that there is a need for something to be done. I think we all recognise that, too often, people receive rather poor care. It is very hard to pin down what is going on because we do not have the mechanism to do so.

I also thank the noble Baroness, Lady Cumberlege, for saying that the principle of what I said was right. I thank the noble Baroness, Lady Browning, and all noble Lords who have spoken for agreeing that something really needs to be done. In my rather simplistic way of looking at things, I think that training leads to a qualification that will lead to a registration. It is as simple as that. Getting the training right would eventually lead to a professional approach of which people could be more proud and which would give them the self-respect that they need and, in the majority of cases, deserve. That would also give us the knowledge that, when things go wrong, there is a mechanism that will stop them from getting worse.

I also agree with the Minister that the Cavendish review could be the way forward and perhaps this is pre-empting something that we will have to wait a while to achieve. I feel very strongly that this has gone on for far too long; the anxieties are really great and something must be done. I hope I can work with my noble friend Lady Emerton so that somehow we can speed things up a little. In the mean time, I thank the Minister for his comments and beg leave to withdraw the amendment.

Amendment 16 withdrawn.

Care Bill [HL]

Baroness Greengross Excerpts

Tuesday 21st May 2013 Lords Chamber

[Baroness Greengross]

My Lords, I add my name to the list of noble Lords who have expressed the view that the Bill is very welcome indeed. I was privileged to serve on the scrutiny committee considering the Bill. Integrating—or at least having co-operation between—services that are so differently organised at the moment is extremely difficult to succeed in, but essential if we are to get it right. We are talking about an extremely vulnerable group in our society. In fact, there is more than one group. There is a huge number of frail, older people and a very large number of disabled people of all ages. It is not fair or worthy of our society to think that people can shop around for the services that they need. It is impossible, we know that. They must be integrated.

I have a very simplistic view on this. I know that it is difficult to bring a paid-for service and a service that is free at the point of delivery together, but if the money is ring-fenced and put in the hands of either the clinical commissioning group or the health and well-being board, where they are mandated to mix up the money and use it in a co-ordinated way, I cannot understand why that would not work. As I said, that is my simplistic way of looking at this.

Everyone has echoed the fact that we need more money to make this succeed. We do, but Andrew Dilnot and his colleagues demonstrated clearly that the amount of money needed to make this succeed is a minute proportion of what we spend in the National Health Service, primarily on acute services, and that if we integrate those services we can achieve a great deal. We do not always measure the savings that we will make on acute NHS services, as a proportion of NHS costs, by getting this right. Those are not, generally speaking, the right services to deal with the people involved. People often need to go into hospital for short periods but much of what they need can, and much more could, be provided in the community.

I have previously spoken with the noble Earl about the innovation that is necessary, including step-down facilities for people who do not need to be in acute hospitals, like the Scandinavian model of patient hotels. That would not be privatisation, as they would be NHS-funded contracted services which provide private accommodation and family care—opportunities for care rather than healthcare—with access to medical specialists as and when necessary. All sorts of such experimental schemes can be introduced if we mix the money. I think that that is the priority.

We need to get rid of the terrible situation at the moment where people are waiting in their own homes for the care that they need. I know about this because I was the lead commissioner for domiciliary care for older people not very long ago. If people who need services are at home, a care worker comes to you who cannot count the time that it takes to get there but then has to get you up, clean you up, clean up your room, dress you, make you a meal, talk to you and help you eat your meal within 15 minutes. That is, physically and mentally, totally impossible. It is an insult and an impossibility. We cannot go on doing that to vulnerable people, so we must somehow put our resources together and get this right. It is a disgrace at the moment and of course, when it does not work, we need advocacy services. I agree with the noble Lord—forgive me, but I think that it was the noble Lord, Lord Bichard—who was talking about the role of care homes. Another step-down facility can be the care home, if the care home of the future can be more of a local hub.

I would like to see that my mum gets to know the care home provider, goes there for French classes, local history lessons or art—and for the odd weekend if daughter is going away—and that, knowing it, she goes there for a holiday and then moves in. That is not dumping mum; it is mum going to a place that she already knows well. The care homes of the future must be a resource for the local community and linked to all the other services. They must be part of the step-down procedures, from acute hospitals to caring for the sort of vulnerable people who we are talking about.

In the Bill, there is the possibility of making this happen but we must get some things clarified. What are the duties of a local authority in promoting well-being, for example? It is not absolutely clear. We must be certain that there is enough care and support provision in every local area. In terms of well-being, we need to make sure that the Prime Minister’s challenge on dementia, which is due soon, will outline how much progress is being made on making the quality of care as important as the quality of treatment. When we talk about the growing challenge of dementia, it is not always about treatment but about care. The prevalence of dementia makes that essential. The other point that we might bring in is that much of dementia care should come under public health because it is about prevention, well-being, design and preventive care. If we can bring public health professionals, who are now very important at a local level, into this group of providers then we stand a chance of getting this right.

I also support the noble Lord, Lord Bichard, in making the point that end-of-life care is important and that we must make sure that people who are approaching their last days do not have to pay for the care that they need. These definitions of what health and social care are should disappear at that point. We are talking about services to dying people. After all the years that I have worked in the field of aging and with older people I know that the loss of dignity and respect, and going into an inappropriate hospital setting, are what people fear most as their life draws to a close.

I agree with everybody who said that moderate care must be part of the equation. If I was a director of adult social services, I would have to concentrate on those in the greatest need. We are so limited as regards the number of people who can obtain services at all. If we could only include moderate services, we might have a chance of preventive types of care being part of our envisaged service provision.

We must also do something about self-funders subsidising the funders who get their total funding paid for by the local authority. In terms of inflating the cap and the personal care account, although annual wage inflation appears to be the chosen index some sort of acknowledgement must be made of the actual cost of care. I assume that the practice of self-funders paying more than local authority-funded people, often for the same accommodation in a residential or other type of care home—subsidising the latter, in other words—will be clarified or should cease. Otherwise, self-funders are going to reach the cap far in advance of other residents. This is not only unfair but might well be challenged as not being legal, being a form of taxation which is not publicly accountable.

When elderly people who are frail go into hospital, their discharge procedure must be verified and known about as part of the admission process. I think we made this clear in the scrutiny committee. We get these terrible stories now of very frail people being discharged from hospital with no proper plan. We know, because we have heard about this recently, about the horrible wait that people have to leave hospital. We must make sure that advice relating to care and support includes information about how to access relevant independent financial advice. This should bring in the members of SOLLA; the noble Lord who spoke about that was in an authoritative position to do so.

Some new schemes are coming forward from one or two think tanks, including one with which I am associated, which are looking at more affordable savings products that might appeal to people of modest means. I hope that for people not normally able to pay for an insurance scheme, these products would help encourage the insurance companies to come in and provide the sort of long-term schemes that are needed to make this care system work properly. Unfortunately, they really do not exist in this country at the moment, but with the catastrophic costs being taken on board by the state it should be possible before too long to interest the insurance industry in being part of paying for care for older people in the future.

This Bill has been awaited for a very long time. We need to make sure that other things that we have learnt, such as human rights protection, are not left out of the Bill as it proceeds through Parliament. We know that there are some serious problems in ensuring that human rights protection will follow people, however their care is provided. I hope that we can work on that in Committee to make sure that it is clarified and that it is simple to access human rights protection. Whoever the provider of care might be, frail and vulnerable people, who are usually very old, need that protection. We have seen too many instances of human rights being abused and quite dreadfully breached. This Bill is so important, as long as it guarantees that those sorts of abuses will not happen in the future.

UK: Ageing Population

Baroness Greengross Excerpts

Tuesday 19th March 2013 Lords Chamber

[Earl Howe]

My Lords, I can say to my noble friend that I will certainly do that, because this is a very important report. I thank not only the noble Lord, Lord Filkin, but all members of the committee, who worked extremely hard to prepare a very well thought out set of conclusions.

[Baroness Greengross]

My Lords, does the noble Earl agree that social care has been the poor relation for so many years and that we need integration as soon as possible with health and housing? To achieve that, would he commit to the Government mandating integration and earmark sufficient funds so that this care can be a reality as soon as possible for older people with chronic conditions?

[Earl Howe]

My Lords, I very much agree with the noble Baroness. It is our ambition that people should receive high-quality, integrated, person-centred services that deliver the best outcomes to the service user. Making the service as a whole more efficient is the other benefit of integrating service. There is no single definitive model of integration. Some localities are further advanced than others in thinking about new ways of delivering it. We are developing the concept of pioneers to support the rapid dissemination and uptake of lessons learnt across the country, but we want to encourage local experimentation as much as we can to allow local areas to provide integrated care at scale and pace.

Care Services: Elderly People

Baroness Greengross Excerpts

Wednesday 6th March 2013 Grand Committee

[Baroness Greengross]

My Lords, I thank the noble Lord, Lord Turnberg, for so vividly portraying the crisis that is preventing us celebrating, as we should be able to do, the aging of our population. We can all expect to live to a great age. The noble Lord, Lord Roberts, has described very movingly that life is not always so good. Certainly it is not so good with the number of people who need appropriate care. We have an opportunity to get things right now, and we must do.

I was the lead commissioner for the EHRC inquiry into the needs for care and support of people living in their own homes. We found that half the people in this country were satisfied, but that means a huge number were not getting an adequate service, most of them elderly women. We are just about to celebrate International Women’s Day. It is appalling that they are not getting the sort of care and support that they need. We should be able to do something about their isolation, loneliness and the bad situation that they face, particularly with the impending—if it is not already with us—crisis of dementia.

As chair of the All-Party Parliamentary Group on Dementia, I am aware of this issue every day as this group has the highest attendance of MPs and Peers of any all-party group. People are recognising that this is a huge issue and we have to get it right. I would like us to look at how we can prevent things going as wrong as they have done up to now and get this right, with the help of the draft Care and Support Bill that will come to us shortly. We need to look more broadly at alternative ways of meeting the needs of a huge number of people in our population. I hope that the Government will do this. One way of meeting these needs is to look at the Scandinavian model of hospital hotels, which brings in another sector to help provide appropriate care. This happens almost automatically in Scandinavia. I hope that the Minister will agree to look further at that model. I have a group studying ways of implementing it.

We must also prevent people going into unsuitable hospital care, as the noble Baroness, Lady Jolly, clearly pointed out. We should not do anything to stop people with acute needs going into acute hospitals but it would be far better to transform some of them into local hospitals which deal more effectively with people suffering from one form or another of dementia and other chronic conditions. No MP would ever agree to a hospital closure but they might agree to the transformation of a hospital into one more suited to meet the needs of many patients today. Those patients are badly cared for in hospitals that are unsuited to their needs. It is also very unsuitable for patients with other conditions to be on the same ward as patients suffering from some form of dementia, which is usually the case. The latter ought to be able to stay in the community, but to make this work we need more collaborative working and integration between health and social care. The draft Care and Support Bill will facilitate this to some extent but other measures are also necessary.

We have to hope that local authorities will use the flexibility they have—they do have some—to allocate their money in a different way. However, health, social care and housing need to be integrated under the law, where possible, to enable more co-operation to take place. One way of doing this is to provide more preventive care. Local authorities must realise that they can save the NHS a lot of money if they keep people who have multiple needs, but not acute ones, out of acute hospitals. There has to be co-operation in this regard and local authorities must use any flexibility they have. There is not enough money but there is some money which they could use in this respect. Integration is terribly important.

Another important aspect of the draft Bill is that for the first time self-funders will be included as users of services. A fact that is not publicised is that very often when those self-funders have to go into a care home they pay over the odds. The local authority has negotiated a very low rate per patient but the self-funders are charged more than their care costs. We may approve of that “Peter and Paul” situation but it is not publicised and we should not have that sort of secret “tax” in this country. That has to be looked at by the Government who should make clear what is and is not appropriate as regards cross-subsidies. I hope that the Minister will look at that.

In summary, will the Minister look at the savings that can be made to acute NHS budgets through the provision of adequate care? Will he also look at the Scandinavian model and make sure that staff at all levels are trained in human rights, which the EHRC inquiry insisted on, and will he look at cross-subsidies?

Social Care: Funding

Baroness Greengross Excerpts

Monday 21st January 2013 Lords Chamber

[Earl Howe]

My Lords, as the noble Lord is aware, the draft Care and Support Bill is currently going through pre-legislative scrutiny. Our proposals can be amended to support the cap in law and we would include the appropriate provisions when legislation is introduced. I can tell the noble Lord that work is going on drafting such clauses. We have said that we will build national eligibility criteria into the Bill.

[Baroness Greengross]

My Lords, from what we read in the press, it looks as if the Government’s plans might include a cap of £75,000 and that that will not include accommodation costs. As I understand that 85% of people incur lifetime costs below £75,000, would this not skew the outcomes unfairly?

[Earl Howe]

My Lords, we have to speak speculatively and hypothetically because I cannot give the noble Baroness any indication of the level at which the Government will finally propose to set the cap. The level of the cap needs to represent an affordable and sustainable relationship between the state and the individual. We will give due regard to the Dilnot recommendations for the cap while taking into account current economic circumstances. We will set out further details in the coming weeks but I am sure that the point that the noble Baroness effectively makes will be closely borne in mind as we approach decision time.

World Sepsis Declaration

Baroness Greengross Excerpts

Wednesday 19th December 2012 Lords Chamber

Asked by

[Baroness Greengross]

To ask Her Majesty’s Government whether they intend to support the goals of the World Sepsis Declaration; and what action they are taking to improve knowledge and skills regarding sepsis.

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

My Lords, the Government fully recognise the importance of addressing sepsis—a potentially life-threatening condition. We support the overall thrust of the World Sepsis Declaration. We have taken a range of actions to address sepsis, focusing on those interventions directly relevant to England—for example, the training of healthcare professionals in the awareness of sepsis. I commend the Global Sepsis Alliance for its initiative in raising the profile of this serious condition.

[Baroness Greengross]

I thank the noble Earl for that reply. However, given the problem of even adequate recognition of the problem of sepsis, and to ensure that the desired treatment improvements are fully underpinned by quality standards, can he assure the House that the Government are able to identify where sepsis sits within the NHS Outcomes Framework and the QIPP workstreams?

[Earl Howe]

Yes, my Lords. The NHS Outcomes Framework is, as the noble Baroness will know, a high-level document intended to drive improvements in the service generally. A condition such as sepsis would be covered in three separate domains of the framework, depending on which aspect of the condition was being considered—for example, safety, most obviously, or quality, or indeed the patient experience. The patient safety aspects are reiterated under Section 5 of the mandate as well, and under this general direction it will be for clinicians to take responsibility for delivering the clinical outcomes.

Social Care

Baroness Greengross Excerpts

Thursday 29th November 2012 Lords Chamber

[Baroness Greengross]

My Lords, the reason why we are facing this huge crisis in health and social care is the amazing advance that has been made, mostly in medical care, in controlling a lot of acute conditions that used to kill people. Those people are now able to continue to live and we must celebrate that. However, because we have not changed the systems adequately to cope with that advance, we are in crisis. We should not think of it all negatively, but we should be quicker to change and adapt our systems to cope with what has happened.

Integrating the two funding streams of health and social care seems a huge problem. However, if we take advantage of the localism agenda and the fact that funding from Government is coming down to the clinical commissioning groups and the health and well-being boards at a local level, and if that money can be ring-fenced and secured at that level, the CCGs or the boards can mix the funding and solve that crisis by using it in the best way available to meet the needs of this population. It cannot be difficult to achieve that. Maybe the Minister will tell me whether he thinks that that is nonsense or whether it might be possible; I cannot see why it is not.

We need to get other changes into the system very quickly, including the culture change from a clinically driven focus on acute care to a patient-driven focus on long-term conditions. That is all part of the same change. Because it needs to be managed differently, it is a question of managing it at the different levels—national, regional and local. We must bring more to the forefront of these caring changes. The allied domains of care—housing and welfare benefits, the DLA and attendance allowance—are all part of the changes that have to be incorporated into getting this right.

We must also remember that we are not dealing just with elderly people. As the noble Baroness, Lady Campbell, among others, has reminded us, we are dealing with people with disabilities who now, thankfully, live to a greater age. Their care goes across their life, so we need a pan-age mechanism for treating people on an equal basis. At the moment, that does not happen. Younger people who need long-term care get a breadth of care plans that is not available to older people. Therefore, discrimination is often apparent in the system that we have now.

We have to expand the evidence base for early intervention and really understand the benefits of that. The ILC, with which I work, has done a lot to look at saving money through people going into extra-care housing. It has clearly demonstrated that this saves a huge amount of money because people do not go into much more expensive care in a care home or even in hospital until a much later age. I believe that that is a system change that we can achieve. I hope that the Minister will confirm he feels that this is possible.

We know that by speeding up home adaptations and equipment, we can also help people to stay at home for longer. The city of Hull did something that is purely common sense. It realised that no one would ask for a ramp or a plastic lavatory seat unless they needed it because neither is very decorative in one’s home. It decided that, rather than wait for someone to assess the need and then exchange information, which takes several months, before allocating a ramp or a loo seat to anyone, it would just give them to anyone who asked. Hull has saved a huge amount of money and immediately speeded up the process by doing that. Things can be done.

The goals that the Government have indicated that they want to achieve are achievable if sometimes we just use common sense. We are all determined to speed up the process of what we need to do to make life tolerable for a whole lot of people who at the moment are subject to quite a lot of neglect. There have been many illustrations of that in the speeches made by noble Lords today.

The recent Nuffield Trust report on integrated care for patients and populations gave the Government measures that I hope they will adopt—in fact, I think that they already have. I hope that we will get clear, measurable goals to improve the experience of people; that we will be able to enhance these goals by guaranteeing a certain standard of care for patients with complex needs; and that we, and the Government, will recognise that we are talking about people for whom time is very precious. They do not have that much longer to live, so we have to have timetables that are kept to and we have to understand the complex needs of the population that we are seeking to serve. I hope that the Minister, who I know feels very strongly about these issues, in representing the Government can assure us that he will take into consideration those and the many other points that have been raised today.