Care Quality Commission: Morecambe Bay Hospitals

Baroness Pitkeathley Excerpts

Thursday 20th June 2013 Lords Chamber

[Earl Howe]

The right reverend Prelate makes an extremely important point. The Government have been very supportive of the concept of hospital chaplains, who play an enormously important role in supporting not just patients but staff. I am concerned because I have heard anecdotally that in some hospitals there are moves to dispense with hospital chaplains. I am in touch with one of his right reverend colleagues about this. Once again, we have a mechanism—if I may call them a mechanism—that could be deployed to good effect in this context.

[Baroness Pitkeathley]

The Government’s support for the current leadership and the newly launched New Start consultation will be welcome to all those of us who know the current people. Can the Minister assure the House that the Government will stand firm in this support when the tabloid press starts calling, as it surely will, for more heads to roll? Will he further assure the House that he believes that the last thing that the CQC needs is more change at the top?

[Earl Howe]

I agree fully with everything that the noble Baroness has said. We have in the CQC the right team to take it forward. They are very clear that there needs to be a complete refresh of the senior team where doubts emerge about the individuals concerned. We are already seeing a complete refresh of the board. I share her worry about the tabloid press and calls for heads to roll. Nevertheless, it is appropriate, in the particular context of Morecambe Bay, for there to be a close look at the role of certain individuals: exactly what they did, what they knew, when they knew it and whether what they did was either wrong morally or against the law.

Care Bill [HL]

Baroness Pitkeathley Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Warner]

My Lords, the purpose of this amendment is to require HEE to give attention to ensuring that, in educating and training staff for the NHS, it also ensures that, as far as possible, staff can work across the health/social care boundary in an integrated way. I welcome the fact that the Government have inserted into Clause 88(1) paragraph (h), which states that Health Education England must have regard to,

“the desirability of promoting the integration of health provision with health-related provision and care and support provision”.

That strengthens the Bill from its draft version, but the Bill should go further, hence my amendment.

I would like to ensure that when separate regulations are made under Clause 85 for particular groups of staff, Health Education England is also required to try to use particular regulations to promote integration in accordance with the Clause 88 provision. For example, if there are to be regulations on community nurses or healthcare assistants, the issue of training them or recognising qualifications or registration, Health Education England should act in a way that facilitates integration of services by enabling those staff to carry their training and qualifications across employment in as wide a range of settings as possible. In short, it is to help secure an integration through portability of training and qualifications provision.

We are very good at mouthing platitudes about integration and swearing undying fealty to that great god, but we are rather less good at removing the blockages to it. One of those blockages can be training and education that prevents staff from working in a range of settings, with qualifications that are not always recognised by a range of employers. We need to do our best when we have the opportunity to remove those blockages and secure more people who are equally at home working in a predominantly health or a predominantly social care setting and can easily move between those settings for the benefit of services users. These staff need to be alert also to the importance of integrating care for individual service users across organisational boundaries. I want to ensure that Health Education England is in no doubt that this approach is important for tomorrow’s workforce. That is what my amendment seeks to achieve.

I recognise that there may be better ways of reflecting my intentions in the Bill than the precise wording of my amendment. However, I think we should go further than the broad duty in Clause 88 and relate it specifically to regulation-making powers for particular groups of staff. I would certainly be happy to discuss other ways of achieving this in the best interest of patients. I beg to move.

[Baroness Pitkeathley]

My Lords, I speak in support of the amendment. It is absolutely vital from the point of view of the patient and the family that the workers with whom they come into contact have an understanding of the whole of their situation. The training and experience of such workers has to encompass that whole situation. For example, a person who is admitted to hospital quite suddenly with a stroke has contact with social care services, finance departments of local authorities, charities of all kinds, reablement services, private care providers, as well as all the health services concerned with the actual condition.

Most people in that situation have none of the hinterland that some of us in the House have. We start with knowledge that, for example, health and social care systems are differently funded and that there is no commonly understood framework for integration. Most people experiencing services do not have that pre-existing knowledge. If such a person is going to have the opportunity for choice, to which we are all committed, it is absolutely vital that the workers with whom they deal have the broadest range of knowledge and experience. People’s experience of health and social care does not come in discrete packages. It is vital that the experience of workers does not come in discrete packages either.

As this is the first day of Carers Week, I will add a further point about carers. The report published today by Carers UK, Prepared to Care?, shows that every day 6,000 people take on a caring responsibility, often without any preparation, information or advice. Therefore, I hope that the Minister will agree that the responsibilities of the workforce across all services should include training and awareness of the needs of carers. The promotion of integration contained in the amendment would also address that issue.

Care Bill [HL]

Baroness Pitkeathley Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Turnberg]

My Lords, I strongly support my noble friend’s amendments, which would ensure that local authorities and, in particular, patients and carers can be represented on the LETBs. I have three amendments in the group. Amendment 38 adds to the list of bodies from whom LETBs need to seek advice—namely, the local university medical and nursing schools. I know it is hardly likely that their advice will not be sought since they are so intimately involved in delivering educational programmes, but in case that message is not clear, we need to have it clarified somewhere in the Bill. I recognise that there has not always been unlimited delight felt by the trusts about the way the universities, particularly the nursing schools, have provided education suiting their products to the trusts’ needs. Nevertheless, it would be clearly wrong to ignore them.

Amendment 41 draws attention to the need to include postgraduate deans in the local education and training boards’ activities. It surprises me, to say the least, that the deans are not mentioned at all in the Bill, despite the fact that they are absolutely crucial to the oversight of education and training. I am sure they will be involved but we must have the comfort of knowing that their crucial role is acknowledged by seeing them clearly mentioned in the Bill.

Amendment 50 makes it a requirement for LETBs to include in their list of bodies from whom they need to take advice, the local universities in their patch. It is not enough to include these bodies in the catch-all phrase of subsection (4)(e),

“such other persons as the LETB considers appropriate”.

The medical schools need to be named in that list.

[Baroness Pitkeathley]

I speak in support of Amendment 51 on the patient and carer voice. I know that there is sometimes resistance to patient and carer representatives on bodies such as this. One often hears professionals say, “They only speak from their own experience”. Yes, they do speak from their own experience—and that is actually the powerful and most informative bit. That is not to say that patients and carers can only speak from their own personal experience; they speak from the wider experience too of other patients and carers with whom they are in contact. That is the most important voice and we should give it a hearing, because very often it is a way of approaching a situation entirely differently from the way in which the professionals would come at it. I am sure that there is a great deal that most professionals, either trained or in the process of being trained, could learn from that.

[Baroness Cumberlege]

My Lords, I wish to say a word about these issues. There is a danger, when we are setting up on the face of the Bill, the component parts of something like the LETB boards. As I understand it, the principle was that the majority of members of the board are local providers. That seems sensible because clearly they are the people who are going to have the knowledge and will inform the LETBs. Simply adding new members, each with a representative function, does not really aid the ability of a board to make decisions. It can become less effective and efficient, purely due to the numbers of people around the table.

There are many groups of workers and, indeed, patients who have got a case, but there are other ways of involving them. I very much accept what the noble Lord, Lord Turnberg, said about having due regard to universities and deans of medical schools. I am happy about the idea that one should have regard to advice that has been given, but I am not sure about having specific representatives that HEE decides are good for a local area on the board. Some areas want to do it differently. To me, that is fine. The size of the LETBs varies enormously; they can be the size of the whole of the north-west and the whole of the south-west, yet Wessex and Thames Valley are separate. These are to be local education and training boards; they need the freedom and flexibility to reflect the local area. Although I understand that people are anxious to ensure that the LETBs are efficient and represent local areas, views and constituent parts, it should be left to their flexibility and judgment.

Health and Social Care

Baroness Pitkeathley Excerpts

Wednesday 5th June 2013 Lords Chamber

[Earl Howe]

The essence of the answer to that is that improved outcomes will be achieved only when all parts of the system work together. If you have shared measures within the outcomes frameworks and measures that are complementary to each other, you will shine a light on areas of inequality and inform local and national action to advance equality. This focus on outcomes rather than processes enables an innovative approach to health and care services that is driven essentially by the needs of the local population. I will just add that local Healthwatch has a role to play in working with partners to make sure that the views of vulnerable and seldom heard groups in the population are heard.

[Baroness Pitkeathley]

My Lords, is any work being done on the outcomes of preventive work? I speak, for example, of installing a handrail to prevent a fall that results in an unnecessary and expensive hospital admission. These are often overlooked in terms of outcomes. Will the Minister tell the House if any work is being done on preventive work?

Care Bill [HL]

Baroness Pitkeathley Excerpts

Tuesday 21st May 2013 Lords Chamber

[Baroness Pitkeathley]

My Lords, like the noble and learned Lord who has just spoken, I—and several noble Lords speaking today—was a member of the Joint Scrutiny Committee. Like the noble and learned Lord, I join the thanks to the officials, the chairman and my fellow members. I very much welcome the changes that the Government have made to the draft Bill as a result of the committee’s report.

Your Lordships will many times have heard me and others—whom I have a habit of referring to as the usual suspects—detail how inadequate social care systems are for meeting the needs of the increasing numbers who need them. “The system is not fit for purpose”, “out of date”, “confusing” and “a lottery”—all those are familiar phrases to your Lordships’ House. So it is a great pleasure to welcome a Bill which attempts to address some, though by no means all, of the problems. Importantly, it addresses the issue of the law relating to social care. It encapsulates proposals made by the Law Commission report in May 2011. The Law Commission pointed out that the law relating to adult social care stretched back to the Beveridge reforms of the 1940s and included a plethora of other Acts, including the National Assistance Act 1948, parts of which are still in force. The law relating to people with disabilities and carers, as we have heard, is similarly contained in a variety of parts of Acts and Private Members’ legislation.

The Law Commission originally proposed that there should be a tightly defined process for determining the scope of adult social care. But when it consulted very widely, it decided instead to define the purpose of adult social care as promoting or contributing to the well-being of the individual. That recommendation was accepted by the Government and is central to the new policy. The whole of the new policy structure is shaped by the well-being provision, although I share with the noble and learned Lord, Lord Mackay, anxiety about the accountability of the Secretary of State for Health in this regard.

The enactment of the Care Bill will not just consolidate and streamline into a single statute 60 years of piecemeal law-making, it will place on a statutory footing for the first time both the principle and practice of self-directed personal care based on individual assessment. Particularly pleasing is that the well-being principle is also to be applied to the individual’s carers. It is around carers that I want to base the majority of my remarks this afternoon.

In the draft provisions it was not clear whether the important duty on local authorities to put the promotion of well-being at the heart of their delivery of care and support also applied to carers. The new reference to “individuals” rather than to “an adult”, which appeared to refer to an adult receiving care, now rectifies this and removes any doubt that carers are qualified. This is an important and welcome distinction.

The Bill also adds a new landmark duty that local authorities should have a duty to ensure that they plan for sufficient care and support services when enabling carers and disabled people to be supported, especially with regard to them being able to undertake paid employment.

A Private Member’s Bill was introduced by another member of the Joint Committee, Barbara Keeley MP, which would have put in place this sufficiency of support duty. Although the Bill did not progress, its vision has now been accepted by the Government who have responded in the Care Bill by placing a new requirement on local authorities to ensure that there are sufficient care and support services to meet current and future needs. This would have a particular focus on supporting carers to undertake paid work and caring where this is possible, although when we come to the issue of carers’ resources to provide that sufficiency, we will no doubt have many debates.

The new provisions in the Bill set out a framework for the development of more modern services that can help family members. As well as being hugely important in preventing financial hardship for families, this can also be seen as of great benefit to the wider economy. It has been estimated that carers giving up work costs the economy up to £5 billion a year.

Another very important change that has been made for carers is with regard to finance. The draft Bill did not make it clear that, as in the case of the person with care needs, a carer’s need for support should be assessed before their financial circumstances are considered. I am pleased to see that the Bill has been amended to put an assessment of support needs before financial assessment. Again, that is very important.

The draft legislation could have meant that carers could be wrongly charged for services provided to the person they care for. The Government have said that this was not their intention and they have made it clear that carers must not be charged. However, what is a carers’ service and what is a service for an older and disabled person are not yet clearly set out in the Bill. We will need to make further changes that will define what they are and prevent confusion and disputes down the line.

Two other areas about carers will need careful scrutiny as the Bill goes through and I hope that the Minister will comment on these. The first is the issue of young carers, as has already been mentioned. The Joint Committee that scrutinised the legislation called for amendments to ensure that young carers get equal rights to assessments and support in law, both in this Bill and the Children and Families Bill currently before Parliament. The Government have made some limited changes that mean that where a young person receiving care is in transition between children's and adult services, the circumstances where they or a young carer would be covered by provisions in the Bill would ease this transition.

However, the changes do not alter the fact that young carers will have lesser rights to assessment and support than adults caring for adults. The same thing will apply to parent carers, because we have to ensure that parent carers—those who look after disabled children—do not also end up with lesser rights, because the changes made for carers, and we hope for young carers, are very positive. Parent carers now have an imbalance of rights because they are not included, and we shall need to give this careful attention as the Bill proceeds.

Others have commented on the Dilnot proposals and I will not do so, except to say that, for many of us, the level of the proposed cap is disappointing. The effects of bringing many who are currently self-funders into the assessment system have not yet been sufficiently recognised.

In conclusion, there is no doubt that the Care Bill has the potential to make major improvements to how social care is delivered. However, we shall have to focus very carefully on several issues, apart from those I have mentioned already, if it is to achieve that potential. I will just list them now. The first is national eligibility criteria and where they are to be set: there is a great deal of anxiety about that. The second is the role of advocacy in helping people negotiate a system which, by the Government’s own admission, is complex and difficult to understand. The Joint Committee thought that advocacy ought to be part of the element of information and advice, but the Government have not accepted that. There is also, of course, the old issue of integration of health and social care, which we all know is so vital; the Government have recently made renewed commitments to such integration. Also under this heading, we need to look at the role of prevention, which is similarly such a vital part of integrated services. There is also the vexed issue of funding, on which I look forward to spending many happy hours. In order to make the vision encapsulated in this Bill a reality, the Government and the nation simply have to make resources available. Not to do so is a false economy and will store up many more problems for the future.

I hope our debates will enable us to look at a broader vision too, such as that encapsulated in the Ready for Ageing? report from the committee chaired by my noble friend Lord Filkin. If anyone imagines that the Bill before us today provides a long-term solution to all the problems in social care, they are very much mistaken. I hope the Minister will be able to acknowledge this. Recently I gave a lecture at King’s College entitled, “Social Care: Our Biggest Problem or Greatest Opportunity?”. My conclusion was that it was both. My noble friend Lord Filkin’s report is the clearest call yet that we have had for a new vision for social care—a different settlement for the older people we will all become. This is not just a matter for health and social care, but for whole communities, the whole of government and all political parties. This Bill is a welcome first step towards that new vision—or new settlement—but we must never lose sight of the fact that it is only a first step.

Mid Staffordshire Foundation Trust Inquiry

Baroness Pitkeathley Excerpts

Tuesday 26th March 2013 Lords Chamber

[Earl Howe]

I reassure the noble Baroness that all the concerns that she rightly raised are very much in our sights, not least the need for proper supervision of nurse trainees and the practical aspects of having the right level of support on the ward. This is why we believe that this idea should be piloted first, so that lessons can be learnt. Yes, we will involve the NMC, and indeed the Royal College of Nursing, in these plans. As regards ratios, having the right staffing in terms of numbers and skills is clearly vital for good care, but minimum staffing numbers and ratios, if laid down in a rigid way, risk leading to a lack of flexibility or organisations seeking to achieve staffing levels only at the minimum level. Neither of those is good for patients. However, I do not dismiss the general concept. It is ultimately up to local organisations to have the freedom to decide the skill mix of their workforce, based on the health needs of those on the wards.

[Baroness Pitkeathley]

My Lords, the principle of putting the needs of patients first will be welcomed by every Member of this House. However, does the Minister agree that this means looking at care in an integrated way, since the patient experience is very rarely one of either hospital or social care but a mixture—sometimes a very haphazard mixture—of the two? Can the Minister therefore give the House more detail about how the government proposals will facilitate the integration of care services across health and social care, particularly as there will be two separate inspectors and as the ability of the CQC to put the shortcomings right is apparently going to be passed to Monitor?

[Earl Howe]

My Lords, the main drivers and levers for increased integration will come from other directions, such as: the systems we are putting in place at local authority level and health and well-being board level; more sophisticated tariffs; better commissioning arrangements between the NHS and social care; and the financial imperative that all commissioners and providers now face. That will mean an imperative to ensure that resources are not wasted and are deployed to the best effect of patients.

We must also remember that the NHS outcomes framework will be the benchmark by which the success of the service is judged, just as the social care outcomes framework will act in that sphere in an equivalent way. The major domain in both areas is the patient experience. If we believe that integration is above all to be defined by reference to the patient’s experience, we can expect commissioners across the piece to address commissioning in a way that avoids disjointed care.

Care Services: Elderly People

Baroness Pitkeathley Excerpts

Wednesday 6th March 2013 Grand Committee

[Baroness Pitkeathley]

My Lords, I am grateful to my noble friend Lord Turnberg. When I knew I was going to be able to speak in this debate, I went back to a book I wrote in 1988 and there I found a quotation from Kathleen Jones in 1972. This is what she says about community care:

“To the politician, ‘community care’ is a useful piece of rhetoric; to the sociologist, it is a stick to beat institutional care with; to the civil servant, it is a cheap alternative to institutional care which can be passed to the local authority for action—or inaction; to the visionary, it is a dream of a new society in which people really do care; to social services departments, it is a nightmare of heightened public expectation and inadequate resources to meet them. We are only just beginning to find out what it means to the old”,

and “the chronic sick”. When I read that, I was so depressed that I thought, “Have we moved on at all since 1972?”.

What has changed hugely, as many noble Lords have reminded us, is the numbers. There are many more people now in need of community care, but we can agree that the key thing needed for the care of the so-called rising tide is a sufficient supply of good quality community care focused on the needs of the user and their carers. I hope the Minister will agree that this is the most urgent problem facing our society today. It is bigger than education, defence or, above all, the acute sector of the NHS, although sometimes one feels like a traitor for saying that.

The Francis report on Mid Staffs may be a very worthy document, but I submit that it has done us no favours by focusing our attention on the care of elderly people in hospital. Just sort it out, goes the view: appoint a hospital supremo and all will be well. As we all know, that is nonsense. Hospital care provides a tiny proportion of the need, and the real problem so far as older people are concerned is that far too many of them languish in hugely expensive hospital beds, as we have heard, simply because not enough care in the community is available. As one of the witnesses to the Joint Committee on which several of our colleagues have been serving said, community care is always the poor sister of the NHS. The social care system is in crisis, as we have heard, and we shall never solve it, perhaps, unless we learn to rebalance spending and attention between NHS care and social care.

Social care is very good value if we do it right. Am I hopeful? Do I still feel as depressed as I did when I read that quote from Kathleen Jones? I think some progress has been made. The Government have made a step—perhaps a small one—towards accepting the proposals of the Dilnot commission. The Care and Support Bill will come to us during the course of this year, we hope, which gives not only new rights for users and carers but new responsibilities to local authorities to give information, advice and advocacy when assessments are being done. The committee called more than 60 witnesses, and every one of them raised the issue of resources.

When it comes to community care, we always hear that we cannot afford it, but as Andrew Dilnot has powerfully said, it is not a question of cannot afford it but of will not afford it. The noble Lord, Lord Turnberg, has given us some ideas about how we could find the money, and I remind the Committee, as I have done before, that when we accepted the proposals of the Beveridge committee, we were absolutely skint as a nation. We were in the middle of the Second World War and had no money and no prospect of getting any, but we still accepted that visionary report. I maintain that we can do it again. I also maintain that getting care in the community right could be a vote winner because it is no longer about poor services for poor people. It touches everybody. I am sure that everybody in this Room has experienced trying to find community care for themselves or their relatives—or they will within the course of the next year or so. I believe it is something that affects everyone, and therefore it is a very attractive idea for political parties to embrace as we approach a general election. I am sure many of us will be looking at what is said in manifestos about that.

Finally, care in the community, however we improve it, largely means care by the community, and community largely means your family, so I must point out, as I do at every opportunity, that the contribution of unpaid carers is £119 billion. It makes sound economic as well as moral good sense to support them as the main providers of care in the community.

Social Care Funding

Baroness Pitkeathley Excerpts

Monday 11th February 2013 Lords Chamber

[Earl Howe]

My noble friend is absolutely right. One of the tasks that faces us over the next two or three years is to ensure that every member of the public has easy access to information which enables them to make plans and take decisions about their own or their family’s future. We will therefore be working very closely with local authorities on that front. It is important that there are websites. My department is already devoting a section of its website to appropriate information on this front. More generally, we need to ensure that the system is not only fair to people, but clear to people.

[Baroness Pitkeathley]

Following the question from the noble Baroness, Lady Jolly, I believe it is the Chinese who say that a journey of a thousand miles starts with a single step. We have certainly made more than a single step today, on which I congratulate the Government. Two major problems remain, as other noble Lords have said. First, there is not enough money in the system, and secondly, people do not know about it. They do not know that they have to pay for social care, never mind up to £75,000. Is the Minister confident that what he said about information and advice—and this is yet another responsibility for local authorities, which are already strapped for cash—will enable people to plan in the way to which he is so clearly committed?

[Earl Howe]

I quizzed my officials very closely on that very point only this morning and received very firm reassurances on that front. I completely agree with the noble Baroness about how important this is. She is right; there is a widespread lack of knowledge among the general public about what they are entitled to and what they may not be entitled to. Collectively, we need to put that right. I take her point about additional burdens on local authorities, but ultimately I hope that they will see it as in their own interests to inform the public before they are inundated with questions that will take them a lot of time and effort to answer. I can assure her that work on these lines will be very vigorous, and I will be happy to keep her up to date on the work we are doing over the months ahead.

Social Care: Funding

Baroness Pitkeathley Excerpts

Monday 21st January 2013 Lords Chamber

[Earl Howe]

My Lords, the main benefit of the Dilnot proposals is to protect people from unpredictable and catastrophic costs of long-term care. While the noble Lord could interpret the raising of the means test as a way of protecting the rich, I see the combination of the cap and the threshold as a way of giving greater certainty and predictability for all concerned, because none of us, whether we are rich or less rich, can know whether we will be subject to catastrophic care costs at a later stage in our lives. That is the inherent unfairness which Dilnot and the rest of the commission attempted to address.

[Baroness Pitkeathley]

My Lords, following on from that answer, does the Minister accept that uncertainty is the most difficult thing for vulnerable people and their families to cope with? They are uncertain about the level of services that they will have because of problems with local authority budgets and they are absolutely uncertain about what their financial liability will be. Therefore, saying that the Government will accept the Dilnot proposals but not saying when or at what level is only adding to that uncertainty in a most unacceptable way.

[Earl Howe]

My Lords, I might have hoped that the noble Baroness would welcome my initial Answer, which at least gives her the certainty that an announcement will be made before the Budget. As the noble Lord, Lord Warner, said, that is progress and, I hope, welcome progress. However, I take the point that the noble Baroness makes and the sooner we can introduce the certainty that she desires the better.

Carers

Baroness Pitkeathley Excerpts

Monday 14th January 2013 Lords Chamber

[Earl Howe]

My Lords, my noble friend makes an extremely important point. Our report, Recognised, Valued and Supported: Next Steps for the Carers Strategy, had four key priorities, one of which was to identify carers earlier. Healthcare professionals undoubtedly have a role to play in supporting those with caring responsibilities to identify themselves as carers in the first instance. We therefore made around £850,000 available in the previous financial year to the Royal College of General Practitioners, Carers UK and the Carers Trust to develop a range of initiatives to increase awareness and understanding of carers’ needs in primary care. We are building on that further.

[Baroness Pitkeathley]

My Lords, I remind the House that the figure usually given is £119 billion that is being saved from public funds. Since the census now shows that the number of carers has increased by 11%, no doubt that figure will go up. Since many carers give up paid work to become carers and only 600,000 of them receive the carer’s allowance, does the Minister agree that many of them will be building up poverty for themselves in the future? What guidance must be given, therefore when carers’ assessments are being made to enable them to stay in paid work for as long as possible?

[Earl Howe]

My Lords, the latest figure I have for carers from the census is that there are 5.4 million unpaid carers in England. The noble Baroness was right to mention the figure of £119 billion, although it is a figure we can argue about. It is probably an overestimate as regards the cost to public funds. However, she makes a very important point about employment. The Government fully recognise the importance of supporting carers to remain in work. The Department of Health has established a task and finish group with employers for carers to explore how to improve support for carers to remain in employment. Jobcentre Plus provides practical assistance for carers seeking work; in particular, it can offer practical support for all carers who are employed for less than 16 hours a week.