Health and Care Bill

Debate between Baroness Greengross and Baroness Finlay of Llandaff

Lords Hansard - Part 1 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Greengross (CB)]

My Lords, I will speak to Amendments 133, 139 and 161 in my name, and to Amendments 143 and 144 in the name of the noble Baroness, Lady Finlay, to which I have added my name.

Amendments 133, 139 and 161 are intended to clarify the role that continuing healthcare—CHC—will play, along with other commissioned services. The Continuing Healthcare Alliance has raised concerns about the provision of NHS continuing healthcare. The package of care is there to support people with ongoing and substantial needs in England. Examples of conditions for which someone may qualify for CHC include Parkinson’s, motor neurone disease and dementia, but there are many others as well.

Amendments 143 and 144 would strengthen the power of NHS England to give directions to integrated care boards. They would help to ensure national consistency of CHC services, which, sadly, is not always the case at present. When the Bill was debated in the other place, the Minister, Edward Argar, responded to a similar amendment as follows:

“It is right that clinical commissioning groups, as they are currently called, are held accountable for NHS continuing healthcare within their local health and social care economy. That will also be the case with the national move to integrated care boards, where the board will discharge those duties and be accountable for NHS continuing healthcare as part of its NHS commissioning responsibilities.”—[Official Report, Commons, Health and Care Bill Committee, 28/10/21; col. 825.]


Given this earlier response, I believe that it is the intention of the Government to improve the national delivery of continuing healthcare and to ensure more consistent delivery throughout England. The intention of this group of amendments is to clarify that in the Bill, so I commend Amendments 133, 139 and 161.

[Baroness Finlay of Llandaff (CB)]

My Lords, I added my name to Amendments 133, 139 and 161, which were so ably introduced by the noble Baroness, Lady Greengross, and others. I also have Amendments 143 and 144 in my name. All the amendments aim to tackle the accountability gap: the inconsistency of provision of continuing healthcare across different parts of England.

The noble Baroness, Lady Greengross, alluded to some diseases, but this goes much wider. There are people with spinal injuries and long-term multiple sclerosis and there are people who have had strokes. They all need ongoing long-term healthcare at a high level—way above the level that can be provided by social care.

The problem is that the accountability gap exists and there is inconsistency in the quality of provision, with eligibility criteria being interpreted differently in different areas. Amendments 143 and 144 aim to strengthen the powers of NHS England in the Bill to give direction to integrated care boards, with the particular aim of closing this accountability gap. Within the existing system, NHS England is responsible for holding clinical commissioning groups accountable for their discharge of continuing healthcare and functions.

In the reformed system proposed by the Bill, NHS England will hold these boards accountable in a similar way, but I question whether it has adequate authority both in the current system and the proposed system and whether the levers available to it to act meaningfully are adequate. While the intention prior to the Lansley reforms was to give NHS England powers to intervene to create meaningful change in practice, the powers were restricted to high-level interventions where there was a failure of governance at the highest level, rather than interventions where a CCG was failing to implement good practice or to adhere to national policy.

The 2018 report by the Public Accounts Committee in the other place supported these concerns and stated:

“NHS England is not adequately carrying out its responsibility to ensure CCGs are complying with the legal requirement to provide continuing healthcare to those that are eligible.”


There are limited accountability mechanisms and there is inadequate data collection at present. These amendments seek clarification and would drive long-overdue improvements in the quality and, importantly, the consistency of the way that continuing healthcare decisions are made and the process is administered, with the aim of improving outcomes and reducing the strain of applying for continuing healthcare for people who live with complex health needs and for their loved ones, in particular their family and carers.

Financial Guidance and Claims Bill [HL]

Debate between Baroness Greengross and Baroness Finlay of Llandaff

Committee: 2nd sitting (Hansard - continued): House of Lords
Wednesday 6th September 2017 Lords Chamber

[Baroness Greengross (CB)]

My Lords, we all know that because of the profound changes since pension freedoms were introduced, retirement income decisions have become much more complex. From the age of 55 there are a greater number of options for using the pension pot, including taking the pension as cash, keeping the fund invested or purchasing an annuity. Accordingly, I welcome the broad drafting in this Bill of the objectives and functions of the single financial guidance body and, in particular, the recognition of provision of advice as well as guidance, and the continuation of the vital role played by the Money Advice Service in support of the financial capability strategy.

Financial decision-making is complex and retirees must consider their long-term, not just their short-term, retirement income needs. The SFGB needs to encourage this by ensuring that consumers understand the full range of options available, including the potential role of any housing wealth. Consideration of the potential role of housing wealth is already included in the pensions advice allowance, which allows people to withdraw £500 tax-free from their pension pots on up to three occasions, to pay for financial advice on their retirement. I welcome that inclusion and think it should be extended.

This means that pension income and the value of housing equity are considered alongside one another. Because some people will feel unable to afford, or be unwilling to pay for, such advice, it is crucial that free impartial guidance is available through the SFGB. The Equity Release Council’s White Paper, Equity Release Rebooted, estimates that over-55s in England possess about £1.8 trillion in housing wealth, and that is expected to double to £3.6 trillion by 2036. Meanwhile, the average value of a defined contribution pension in 2012-14 was £30,300. Research by the Equity Release Council estimates that while the average 55 to 64 year-old should have a pension pot of £123,000, they may only have an average of £30,200, indicating that a likely future need for supplementary retirement income is there, such as from housing wealth.

I would want not to push people into equity release but to look holistically at their assets. In one important area affecting retirement assets, the FCA’s prediction means that approximately 2.6 million interest-only mortgages will reach maturity over the next 30 years, with estimates that 48% of borrowers may not have enough money to fully repay their loan. It is not surprising that statistics from the council’s spring 2017 market report indicated that the use of property wealth to fund lifestyle and health in old age is growing rapidly, and is likely to continue to grow in the coming years.

In 2013, Demos estimated that the over-60s were holding unmortgaged housing wealth of £1.23 trillion; that figure would be significantly higher now. The Aviva Real Retirement Report suggested in 2016 that 46% of homeowners aged over 45— approximately 6 million households—see property as a key part of their retirement income planning, increasing to 58% among 45 to 54-year-olds. This is borne out by the Equity Release Council seeing a year-on-year equity release lending growth of £342 million. The average amount lent under an equity release policy during the second half of 2016 was very high, at £92,376 for lump-sum plans and £54,584 through drawdown plans, with an additional £37,751 reserved for future use.

I share the view of Age UK and many commentators that a saver withdrawing their pension pot should receive guidance, including on housing wealth, by default. But since that is the subject of a later amendment, I shall not discuss it any further here. In summary, as part of this wider landscape of helping people to preserve their lifestyles and well-being in retirement, a consideration of the important role of housing wealth should be an explicit part of the advice envelope proffered by the new body. I hope that that might be acceptable. I beg to move.

[Baroness Finlay of Llandaff (CB)]

I support this amendment from my noble friend Lady Greengross because, as she has outlined, a lot of people have the majority of their wealth tied up in their property. The current equity release schemes are much more flexible than they used to be and contain a variety of safeguards. The Equity Release Council’s statement of principle, by which all the council members must abide, mandates that all equity release customers must receive independent financial advice. Can the Minister clarify whether all equity release schemes will fall under the FCA? I understand that currently it is only those from members who are part of the Equity Release Council, which means that we will potentially have twin-track standards going on for the customer.

The requirement for a solicitor to sign off the arrangement becomes particularly important when we look at the issues around mental capacity and coercion. When I was at the Equity Release Council’s annual meeting, I was quite shocked to hear from one person there who had been negotiating equity release with a client. She had a suspicion that something did not quite seem right and decided to visit the client without the client’s son present, at which point the client said, “I don’t really want to do this at all. My son’s pushing me to do it”. She had the sense to say, “That’s very simple. I am refusing the equity release, and I will write to you”, and she tore up the forms there and then.

Health and Social Care Bill

Debate between Baroness Greengross and Baroness Finlay of Llandaff

Monday 19th December 2011 Lords Chamber

[Baroness Finlay of Llandaff]

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

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

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

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

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

[Baroness Greengross]

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

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

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