Care Bill [HL]

Baroness Wheeler Excerpts

Tuesday 4th June 2013 Lords Chamber

Moved by

[Baroness Wheeler]

8: Schedule 5, page 107, line 22, at end insert—
“( ) HEE must exercise its functions consistent with the promotion of a comprehensive health service, giving equal consideration to the importance of physical and mental health.”

--- Later in debate ---

[Baroness Wheeler]

My Lords, I shall speak also to Amendment 10. These two amendments seek to make sure that Clause 84 and Schedule 5 specify the responsibility of Health Education England to ensure, throughout its work, the promotion of a comprehensive health service which gives equal consideration to the importance of physical and mental health and the health of people with learning difficulties. This parity of esteem, putting mental health on a par with physical health, must be a key principle carried through HEE’s work and in the education and training of healthcare workers, and it is important that the Bill specifies this. Why is that? It is because the lack of parity continues to have a massive impact. The most recent psychiatric morbidity surveys show that, despite theoretical parity under existing legislation, only a minority of those with a mental disorder in England receive any intervention, in stark contrast to other disease areas, such as cancer, almost all of which have some intervention.

Labour is proud that it introduced the NHS constitution and is pleased that it now has widespread support. However, we acknowledge that it did not go far enough in ensuring that parity of esteem was entrenched into the constitution. This is especially important as the growing number of NHS bodies and organisations established under the Government’s NHS reforms are all required to take the constitution into account in all they do.

Noble Lords will recall that parity of esteem was a hard-fought-for, last-minute inclusion in the Health and Social Care Act. It is vital because it is important to do everything that we can to ensure that this key NHS objective is taken seriously and is underlined at every stage. We welcome the steps in the HEE mandate recognising HEE’s leadership role in this, including a focus on the mental health workforce to ensure that there are sufficient psychiatrists and other clinicians and specialist staff working to build the values and skills to facilitate continuous service improvement, developing training programmes which ensure that all staff have awareness of mental health problems and how they may affect their patients, and ensuring that the mental health needs of people with long-term health conditions are addressed concurrently and not as an afterthought.

We particularly welcome HEE’s leadership role in providing, through LETBs, training programmes to support staff in diagnosing the early symptoms of dementia so that they are aware of the needs of patients, carers and families. Building skills among GPs is especially important in this respect, as we know that patients often go undiagnosed for years. The target for Health Education England of 100,000 staff undertaking dementia foundation-level training by 2014 is a challenging one but it must be achieved if the current appalling level of undiagnosed cases is to be reduced. While focus on dementia is welcome, we must also ensure that other debilitating mental illnesses are addressed with equal vigour.

The lack of parity of esteem for mental health under the current system is widely recognised and acknowledged. The website of the mental health charity, Mind, sums this up well in reporting on the experiences of people with mental health problems. As it says:

“One person told us they get immediate attention for slightly high blood pressure, but face indifference and long waits about their mental health needs unless they are suicidal. Others have told us that they experience far better treatment in A&E for physical symptoms than when they need emergency help in a mental health crisis or for self-harm injuries. This is not acceptable—an emergency is an emergency”.

My noble friend Lord Patel of Bradford reminded us during the debate on the Queen’s Speech that only 13% of NHS funds are devoted to the treatment of mental health issues. Against this backdrop we strongly welcome the Royal College of Psychiatrists’ report, Whole-person Care: From Rhetoric to Reality, commissioned by the Department of Health and the NHS Commissioning Board last year. It sets out how progress on achieving parity of esteem can be made by,

“changes in attitudes, knowledge, professional training, and practice”,

and makes key recommendations to apply across the NHS on equivalent levels of access and waiting times for mental health services, specifically in emergency and crisis mental healthcare.

The RCP report has a number of recommendations relevant to HEE’s remit and role. These include how HEE should as a priority support the development of core skills and competences in health and public health professionals; the need for the General Medical Council and the Nursing and Midwifery Council to review medical and nursing study and training to give greater emphasis to mental health; and integrating mental and physical health within undergraduate medical training. I would welcome the Minister updating the House on what action the Government plan to take on this important report, the timescale for the Government’s response, and how any of the report’s recommendations will be fed into the Bill.

Whole-person care is Labour’s agenda for the future. It would bring together physical health, mental health and social care into a single service to meet all of a person’s health needs. Ed Miliband, in announcing Labour’s commission on whole-person care, emphasised that:

“In the 21st century, the challenge is to organise services around the needs of patients, rather than patients around the needs of services. That means teams of doctors, nurses, social workers and therapists all working together”.

In his landmark speech on mental health last year at the Royal College of Psychiatrists seminar, he acknowledged mental health as the biggest,

“unaddressed challenge of our age”.

He went on to say:

“We have to confront the unspoken discriminations too. Like the vast inequalities in funding for research. Like the lack of training in mental health of many NHS staff – whether in GP surgeries, outpatient clinics or A&E. Eight out of ten primary care professionals say they need more training in mental health than they have”.

Amendment 12 underlines the importance of HEE working,

“with persons who provide health services to ensure an adequate provision of continuing professional development for health care workers”.

That is particularly important in view of the recent findings in a member survey by the Royal College of Nursing, which pointed to a worrying decline in CPD training. The noble Lord, Lord Patel, has an amendment on CPD under the provisions for LETBs, so we will pick up this issue then.

As we progress through the Bill, we will argue strongly for parity of esteem between mental health and physical health to be underlined and specified in the Bill as a guiding principle. When the RCP report on whole-person care was published in March, its president, Professor Sue Bailey, called on government policy-makers, service commissioners and providers and the public to think in terms of the whole person, both body and mind, and to apply a parity test to all their activities and to their attitudes. For Health Education England, this parity test for the planning, education and training of healthcare workers is crucial. Our amendments give force to the HEE mandate provisions on parity of esteem, and we hope they will be accepted by the Government.

[Lord Rix]

My Lords, I support Amendment 10, but I should like to clarify one or two points in the wording. It is possible for a person with a learning disability to have a physical health problem. It is also possible for a person with a learning disability to have a mental health problem. But that is not the main cause or even sometimes the basic cause for their particular condition, which is learning disability. I would therefore have preferred the wording of paragraph (a) of Amendment 10 to have been “learning disability”. The same situation arises in paragraph (b) of Amendment 10. People with a learning disability have a learning difficulty. That is natural. However, there are plenty of people who are not learning disabled who also have a learning difficulty. I would like to have seen Amendment 10 include learning difficulties and learning disabilities, but I actually support the general thrust of the amendment. I hope that if it is accepted the wording of a learning disability can be made quite clear.

--- Later in debate ---

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

My Lords, the health service is dependent on having the right numbers of staff, with the right skills and behaviours. Quite rightly, patients expect the people who deliver health services to be well supported and to have the right professional and clinical skills. To achieve this, we need a system that can attract people with the right values, give them the right career advice, support the development of excellent professional and clinical skills, emphasise the centrality of providing care with compassion, kindness and respect, and ensure a workforce that is responsive to changing needs and innovations in services. That, in a nutshell, is why we have established Health Education England and the local education and training boards.

Health Education England is already established as a special health authority and is already working to put in place requirements similar to those placed on it in this legislation. Establishing Health Education England as a non-departmental public body will ensure that it has the independence and impartiality that it requires to plan, commission and quality-assure education and training for the long term. As an NDPB, it will be accountable to the Secretary of State and Parliament for ensuring that there is an effective education and training system in place. The establishment of Health Education England has been welcomed, I am glad to say, by stakeholders across the health and education system. It has the support of the Health Select Committee and the Joint Committee that scrutinised the draft Bill. It is viewed as an important step forward in promoting the development of the healthcare workforce and driving up standards.

Amendments 8 and 10 seek to ensure that Health Education England gives equal consideration to physical and mental health in the delivery of its education and training functions. I have no quarrel with noble Lords bringing us back to that familiar theme, but primary legislation is not required for Health Education England to give equal consideration to the importance of physical and mental health.

To start with what I hope is an obvious point, in establishing Health Education England, the Government are making clear their commitment to the development of the entire health and public health workforce. One of the significant weaknesses of previous workforce planning and education commissioning arrangements has been the fragmented approach, with responsibilities scattered across different bodies and silo approaches taken to considering the development needs of different professions and services. Health Education England will be different. It will be responsible for the planning and development of the whole workforce, whether in primary care, secondary care, public health or mental health. Although it will retain a strong focus on the development of different professions, it will do so with a multiprofessional remit and perspective that promotes multidisciplinary education and training where appropriate.

I would like to take the Committee back to the Health and Social Care Act 2012, which places a clear duty on the Secretary of State to ensure an effective education and training system for,

“persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England”—

which is a very wide scope. That duty is very important. It reflects the importance of education and training in the NHS and public health system, and is a key duty underpinning the Secretary of State’s duty to ensure,

“a comprehensive health service designed to secure improvement … in … physical and mental health”.

The Bill delegates the Secretary of State’s education and training duty to Health Education England, giving it a clear and unambiguous remit for workforce planning, education, training and development across England. I hope that that conveys to the Committee the direct legal linkage between this Bill and the 2012 Act in respect of the parity of esteem issue.

Clause 88 requires Health Education England to have regard to the Government’s mandate to NHS England. It is appropriate that the education and training objectives are aligned to service commissioning objectives in this way. It is especially relevant in the context of this amendment because the NHS England mandate requires mental and physical health conditions to be treated “with equal priority” and to,

“close the health gap between people with mental health problems and the population as a whole”.

The Government’s mandate to the Health Education England Special Health Authority reflects this and requires Health Education England,

“to focus on the mental health workforce”.

I listened with care, as I always do, to the noble Lord, Lord Rix. I simply say to him that Health Education England can support better education, training and development for staff so that they can better support people with learning disabilities and difficulties. The core components of education and training for all staff should be to treat people with kindness and compassion and communicate well with all patients and carers. That, I hope, goes without saying, but it is particularly relevant to those with learning difficulties and disabilities. In saying that, of course I recognise that there are certain specialist skills that people in that field require.

Amendment 12 relates to continuing professional development. I absolutely recognise that the continuing professional development of healthcare workers is important. This is enshrined in the NHS constitution, which places a commitment on all employers that supply NHS-funded services to invest in this area and provide their staff with the support and personal development that they need, as well as access to appropriate training to enable them to fulfil their duties.

Health Education England will play a crucial role in providing leadership in this area. The mandate that the Government published only recently for the Health Education England special health authority sends out a clear message that the staff working in our NHS and public health system are the health service’s most precious resource. We must do all we can to ensure that staff have the right values, training and skills to deliver the very highest quality of care for patients. To support the development of the existing NHS and public health workforce, the mandate sets out that Health Education England will work with Local Education and Training Boards and healthcare providers to ensure professional and personal development continues beyond the end of formal training to enable staff to deliver safe and high quality health and public health services, now and in the future. This will include supporting those staff who may wish to return to training.

I hope that those remarks are helpful to the noble Baroness. To cover a number of questions that were put to me, the noble Baroness, Lady Wheeler, asked about the Royal College of Psychiatrists report. We very much welcome the report. The Minister for Health and Care Services will be attending the report’s launch on 19 June and will be setting out what the Government will do to respond to the challenge that the Royal College has articulated.

The noble Lord, Lord Warner, asked what Health Education England will do to address the issue of reliance on locums and agency staff, a very pertinent question. Health Education England can make a significant contribution in this area. Better workforce planning, linked to service and financial planning, is a key aim of the new system that should ensure less reliance on locum and agency staff.

The noble Baroness, Lady Wall, asked me what Health Education England was doing to support career development for healthcare assistants. The capability of care assistants, and public confidence in that group of workers, is of increasing importance. Health Education England will work with employers to improve the capability of the care assistant workforce, including those in the care sector, as well as the standards of training that they receive. Health Education England will develop a strategy and an implementation plan to achieve that, building on the Cavendish review, which will be published quite soon, and on work by Skills for Health and Skills for Care on minimum training standards. The strategy should cover job roles, recruitment, induction, training standards and transparency, as well as identifying opportunities for career progression. I hope that those comments are helpful to the noble Baroness.

[Baroness Wheeler]

I thank the Minister for his thorough response and for his reassurances on the Government’s intentions in respect of parity of esteem. The debate as to whether parity of esteem is inferred or assumed in legislation, or should be specifically included, will continue. We will be strongly supporting this issue as we move through the Bill, with the comments of the noble Lord, Lord Rix, on the need to ensure the inclusion of people with learning difficulties. I am disappointed that the Minister is resisting this issue of inclusion. It would underline the importance of parity of esteem as a guiding principle, ensure consistency with the Health and Social Care Act and reinforce the HEE mandate role in this respect.

Amendment 12 received strong support from my noble friend Lord Warner, the noble Lord, Lord Willis, and the noble Baroness, Lady Emerton. I welcome that. My noble friend was right to underline the particular importance of CPD in the light of the current challenges facing the service. I look forward to the fuller debate later on in the Bill on this. With that, I beg leave to withdraw.

Amendment 8 withdrawn.

Care Bill [HL]

Baroness Wheeler Excerpts

Tuesday 21st May 2013 Lords Chamber

[Baroness Wheeler]

I thank the Minister for his very thorough and comprehensive introduction to the Bill. When the Care Bill was discussed last week in our debates on the Queen’s Speech, there were six overarching themes in the contributions from noble Lords.

First, there was a general welcome for the reform and consolidation of social care law, which we on these Benches initiated and strongly support in so far as it achieves a fairer, simpler and more sustainable system—three factors against which we will be closely testing the Bill through scrutiny and amendment.

Secondly, there was deep concern that this would be at best a partial solution unless a new legal framework is introduced in the context of addressing current and future social care funding needs. Given the scale of this Government’s cuts to local authority budgets, the Bill’s measures put forward in this context risk raising expectations that cannot possibly be met.

Thirdly, the Government’s proposals in the Bill on social care funding do not meet the Dilnot commission’s fairness criteria. Many in care homes will die before the cap at this level is reached; houses will still need to be sold; the cap will not in fact limit the costs that elderly people actually pay for their residential care; and the Bill will not mean that pensioners get their care for free if they have income or assets worth up to £123,000. The squeezed middle—those pensioners on average incomes who have worked hard, proudly invested in a home and tried to save for their older age—risk missing out.

Fourthly, the Bill offers only a partial response to the recommendations of the Francis report to address failures in hospital and care support. What happened at Stafford Hospital was terrible and lessons must be learnt. Last week Jeremy Hunt referred to Part 2 of the Bill as,

“a vital element of our response to the Francis report”.—[Official Report, Commons, 13/5/13; col. 350.]

But in reality the Government have been disappointingly limited in their response to those vital issues identified by Francis. Where is the Government’s response to his concerns over safe staffing levels and the risks to safety and care? Where are Francis’s full proposals on the statutory duty of candour? Where is the regulation of healthcare assistants?

Fifthly, there were concerns that once again, like the Health and Social Care Act, this Bill will not in practice lead to better integration of health and social care. How will the Bill translate this into practice? How will the work of the Government’s consultation on integrated care, launched last week, inform our consideration of the Bill? Will it report in time for any legislative steps to be adopted? How will the institutions of the Health and Social Care Act—the health and well-being boards and Healthwatch England—link in with the care requirements placed local authorities? How will the marketisation and fragmentation of that Act align with any integrating intention in this Bill?

Sixthly, there was deep concern and dismay across the House that the Government have backtracked on vital commitments on public health, particularly on standardised packaging for cigarettes. The care crisis facing this country is not simply one of an ageing population but also one of co-morbidities and many more people living with long-term health needs. Public health plays an essential part in our response to those demographic changes, and is hugely relevant to issues dealt with under Clause 2 and to maintaining well-being.

So, the good news: the Bill is welcomed by Labour as an important first step towards providing a consolidated legislative framework for our social care system based on the excellent report of the Law Commission inquiry set up by Labour in 2009 to streamline and unify social care law. It implements 66 of the commission’s 76 recommendations, refocusing care and support on more patient-centred services better suited to people’s lives and needs, improving access to information and advice, strengthening the legal rights of carers, standardising eligibility criteria and establishing well-being as the guiding principle.

We strongly support that. It takes our work on patient choice and control forward. It builds on the progress that Labour made on key areas such as prevention, personalisation of services and carer recognition and support in our landmark National Carers Strategy. It also addresses much of the unfinished business in our pre-election White Paper on a national care service.

Like other noble Lords, I commend the pre-legislative scrutiny work of the Joint Committee. The Bill enjoys support among patient and carer organisations, staff, and service users and providers, but with the proviso that key improvements are needed to address what the committee itself identified as gaps and risks of unintended consequences. For completeness, we also welcome the proposals on Health Education England and the Health Research Authority, albeit with some significant issues to explore as we progress the Bill.

Now for the not-so-good news. On its own, the Bill will not go anywhere near far enough to tackle the crisis that is engulfing health and social care today. In addition to the crisis in A&E, now acknowledged by the Secretary of State, we have hospitals full to bursting, the discharging of patients becoming ever more difficult, handovers to social care services slower and subject to more disputes and a social care sector struggling to fulfil the demands placed on it. On the front line, thousands of nursing posts have been lost and many services are under pressure. In social care, the recent report of the Association of Directors of Adult Social Services lays bare the scale and severity of the financial squeeze on councils, who, by the end of this spending round, will have been stripped of £2.7 billion from their adult social care services, equivalent to 20% of their care budgets, as demand for services increases.

New rights to services and support risk being meaningless as council budgets are cut to the bone and people are faced with spiralling charges. Will the noble Earl tell the House whether the resources for local authorities to deal with the additional responsibilities placed on them by the Bill, including carrying out the extra assessments of the estimated 450,000 self-funders, will be made available, and whether it will be new money? Is it accounted for in the impact assessment? Is he confident that councils will have the trained staff to complete those assessments on time?

We welcome the delayed consideration of Part 1 until completion of the spending review, but can the Minister reassure the House today that his department has shared with the Treasury the representations of the Care and Support Alliance, which has stressed that,

“without appropriate funding for the social care system … the aspirations of the Bill will not be reached”?

Can he also give a commitment to the House that the regulations associated with Part 1 will be available in draft by the time of our consideration? Without them, our scrutiny of vital issues such as eligibility criteria will be severely hampered.

On Dilnot, it is disappointing that the Government have watered down the commission’s proposals, proposals which Labour believes represent an important step forward in beginning to address social care funding. When he announced the Government’s response to Dilnot, the Secretary of State made great play and emphasis that the plans were “radical” and would,

“transform the funding of care and support in England—bringing a new degree of certainty, fairness and peace of mind to the costs of old age”.—[Official Report, Commons, 11/2/13; col. 592.]

He matched that with a promise that that would guard against someone’s property being sold and their savings wiped out. However, a £72,000 cap—£140,000 for a couple— will not be enough to stop many people with modest properties, especially in the north of England, selling their homes to pay for care. Under the deferred payment scheme, councils loan people money to cover their care costs, which now has to be paid back with interest, most likely by selling the family home after the elderly person has died. Nor will the Bill cap the costs that elderly people actually pay for social care unless differing local authority care charges are addressed, which could make a difference to care now. The cap introduced by this Bill will be based on the standard rate that local councils pay for residential care, which on average is £480 a week; but 125,000 self-funders face weekly bills that on average are £50 to £140 more than this average council rate and in some areas far higher. This extra amount will still have to be paid and not count towards the cap.

The Bill will not mean that pensioners get care for free if they have income or assets worth up to £123,000. People will still get free care only if they have income or assets under the lower means-tested limit that is not being increased and will still be £17,500 in 2017. Those with incomes or assets between this figure and £123,000 will get a sliding scale of support from councils as they do now. Can the Minister confirm that this is the case?

On these Benches we remain to be convinced that the Government can provide answers on these fundamental aspects. Can the Minister not recognise that the Government are overselling what the impact of the Bill’s current provisions will be, particularly bearing in mind that nobody will be benefiting at all until 2020 at the earliest?

Finally, I turn to the some of the other questions that noble Lords will no doubt raise during the Bill’s passage, and I look forward to the Minister’s response to them. Will the change in the legal language around the continuing care and social care boundary of the NHS, shifted by the Bill, result in the possibility of more people having to be means tested for residential care? What are the Minister’s estimates of the number of people who will fall out of the system and become ineligible for support under these proposals? Have the Government assessed the overall impact on disabled users of social care also hit by cuts in their benefit entitlement and support? What consultation have the Government had with the insurance industry and pension providers about the likelihood of markets developing to help self-funders bridge the gap up to the £72,000 cap?

We welcome the introduction of well-being as the guiding principle but should this duty not also be placed on the Secretary of State? On integration and prevention, why does housing still get only limited consideration and mention throughout the Bill? On young carers, when will the Government make their position clear in addressing via this Bill the gap in the law? His colleagues have resisted attempts to amend the Children and Families Bill to this effect. Why have the Government reintroduced the issue of after-care services for people with mental health problems leaving hospital after a period of detention? We thought that this issue was settled under the last health Bill, but it seems not.

Lurking in the background as we speak today is the reality of a social care system on the edge of collapse. Social care is being left to decline. Labour supports the principle of capping care costs, but we stress that a bigger and bolder response is needed by Government to meet the challenges of our ageing population. Whole-person care is our vision for a 21st-century health and care system that brings together physical and mental health, and social care, into a single service to meet all of a person’s care needs. Our independent commission has already started its work on looking at how health and social care services budgets can be brought together. “Integrated services” means not just a series of area or service specific initiatives, but a way of working for a whole service.

We have a major task ahead of us to improve this Bill and we on these Benches will work hard to meet this challenge, and ensure that older and disabled people, and their carers and families, get the best possible deal.

Care Quality Commission

Baroness Wheeler Excerpts

Thursday 14th March 2013 Lords Chamber

Asked by

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they propose to take in the light of the findings of the Care Quality Commission’s home care inspection review Not Just a Number.

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

My Lords, the Government were encouraged that almost three-quarters of the domiciliary care agencies inspected by the CQC for the review were found to be meeting essential standards.

As the regulator of health and adult social care, the CQC has a range of powers to ensure that services are safe and of good quality. The CQC has the Government’s full support to take firm action where it finds services are unacceptable or failing.

[Baroness Wheeler]

I thank the noble Earl for his response and welcome the CQC’s positive findings on the 75% of home care services it inspected. However, the 25% of failing providers are a cause for deep concern, particularly as regards the number of late or missed calls and their complete failure to have systems to document, assess or monitor the quality of care they are supposed to deliver. Where there is a live-in carer, late or missed calls can at least be managed in some way, even if the cared-for person cannot be got out of bed. However, if people are on their own, the consequences are deeply distressing and can be very serious. What information does the department have nationally across the sector about this very worrying issue? What action is being taken to address the problem? Should we not ensure that all providers are required to keep records of the numbers, reasons for and remedial actions taken for missed and late calls, including refunding charges to self-funders or to the local authority?

[Earl Howe]

My Lords, the noble Baroness is quite right: there is no room for complacency in this area. Care has to be right every time, not just three-quarters of the time. I noted from the CQC’s report that, although it recorded a number of common issues undermining the majority of good home care from a significant minority of providers, many of these were fairly minor. However, the noble Baroness has alighted on a very important failing among several of the agencies inspected. I do not have national information on late and missed calls but in the work that we are doing with local authorities, providers and, indeed, the CQC, all of whom share responsibility for driving improvement in services, this will inevitably be an area of focus for it.

Care Services: Elderly People

Baroness Wheeler Excerpts

Wednesday 6th March 2013 Grand Committee

[Baroness Wheeler]

My Lords, I, too, thank my noble friend Lord Turnberg for securing this debate, for his expert and thorough introduction, for setting the context, reminding us of the extent and scale of the issues across health and social care and getting the facts and figures over and done with so that the rest of us do not need to repeat them.

Your Lordships’ House spends a lot of time focusing on care and support for older people. We know that the old way of care pathways that address single health conditions does not meet the realities of an ageing population living with multiple conditions, and we know that prevention and the timely escalation of care of people in the community—in their homes, assisted supported housing or residential care—helps to prevent people going into hospital and to centre care on preserving the best quality of life. Our future strategy must view this issue in the wider context of what Age UK recently described as an, “extraordinary revolution in longevity”, which we all of course welcome and celebrate, both personally and for people generally.

Last week’s Guardian and today’s Independent trail the imminent report of the Lords Public Services and Demographic Change Committee, which will help to provide us with the evidence base for the strategic overview that we currently lack, including on pensions, pensioner poverty, health and social care, housing, income and age issues, social isolation and keeping in jobs older people who want to work. This will be an important report, and I hope that once it is published, the Government will schedule it for full debate.

Noble Lords have also referred to the Care and Support Bill and the pre-scrutiny Select Committee report that is due shortly. I have been following closely the evidence sessions and pay tribute to the expert and thorough work of the committee, four of whose members are here today, and to the individuals and organisations giving evidence. The debate on the detail is for another time, but I was particularly struck by the contributions from housing associations and voluntary sector providers stressing the importance of sharpening up the interface in the Bill between primary care, general practice, social care and housing. There are clearly pockets of excellent practice of NHS, local authority and voluntary sector co-operation and integrated working in the provision of specialist housing and housing support, for example, housing associations providing personal support in sheltered housing, thereby avoiding the need for residential care. I hope that the committee’s recommendations will help to take this agenda forward in an urgent and coherent way and that the Bill generally will provide the framework for enabling many issues that noble Lords have highlighted which would genuinely facilitate the delivery of more effective community and primary care.

This is such a frustratingly short debate that it is impossible to cover much at all, but it has provided us with the opportunity to focus on the need for a longer-term strategy on primary and community care. Noble Lords are, as usual, to be congratulated on providing a thorough debate and including the “big picture” issues of Dilnot implementation, future social care funding and the current crisis resulting from huge cuts in local authority budgets that make meeting existing and future demands impossible. We are, of course, also in the midst of the soul-searching and determination to do things better that come in the aftermath of the Francis report on the situation where frail, vulnerable older people received the worse care possible, as was referred to by my noble friend Lady Pitkeathley. I echo her concern that while the serious issues of failure of hospital care raised by Francis need to be addressed, we do not want the NHS to turn its full focus on to NHS hospital care and turn away from the need for primary care to step up to the plate if there is to be a dramatic shift to care in the community.

However, it is important to acknowledge the emphasis that Francis places on the importance of primary care and GPs. He points to the vital continuing relationship that GPs have with patients and the need for GPs to undertake a monitoring role on behalf of patients who receive acute hospital and other specialist services. As he puts it:

“They have a role as an independent, professionally qualified check on the quality of service, in particular in relation to assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern ... They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers”.

Most importantly, Francis stresses that GPs need,

“to take this continuing partnership with their patients seriously if they are to be successful commissioners of services”,

and,

“exploit … this new role in ensuring their patients get safe and effective care”.

That is one of the key questions for today’s debate. Are the Government confident that CCGs can meet the challenges of providing primary and community care? How is their focus to be shifted from hospitals to supporting community care? I look forward to the Minister’s response to the many questions asked by noble Lords.

On commissioning, I am getting to be a bit of a broken record on highlighting the need for effective commissioning of the community services that mainly benefit older people, such as chiropody, falls prevention, continence care and audiology. These are vital services that help to maintain well-being and independence, both in the community and in residential care. Yet, as Age UK has repeatedly pointed out, they are currently significantly undercommissioned and there are huge problems and variations in standards and availability of services.

I suspect that my recent experience locally when I took my disabled partner for his chiropody appointment and learned that Virgin Care would be taking over the previously supplied NHS services and would be dealing with problems only, not routine care such as clipping toenails, is rapidly becoming standard practice. The Department of Health’s guidance underlines the importance of foot care and the difference it makes to the lives of older people leading to reduced pain, increased mobility and a reduced risk of falls. Continence care support is also vital. If you talk to carers, it is such a major issue and can often tip them over the edge so that they stop caring. Of course there is also the impact it has on the person who is cared for. What action are the Government taking to ensure effective commissioning of chiropody, continence care and other key services such as audiology? Will GP commissioning seek to increase the number of district nurses who are under enormous pressure at the moment but who are so vital to community care support for people with long-term health conditions? Will it be able to reverse the current alarming decline in the number of specialist nurses, such as diabetic and epilepsy nurses, who play such a vital role in helping patients self-manage their condition in the home?

Health and Social Care Act

Baroness Wheeler Excerpts

Tuesday 5th March 2013 Lords Chamber

[Baroness Wheeler]

My Lords, I thank the Minister for reading out the response to the Urgent Question in another place. While we welcome the climbdown on the regulations, can he appreciate the sheer disbelief and consternation across the House at the regulations, coming as they do after the recent SI on local Healthwatch that even the Government’s own supporters described as complex, draconian and muddled? These regulations flew directly in the face of lengthy and repeated government assurances about Healthwatch’s independence and right to campaign. Now we have a repeat of the story with the Section 75 regulations, which again made a mockery of the assurances by both Commons and Lords Ministers during the passage of the Health and Social Care Act. In the words of the Minister, GP commissioning would be,

“under no legal obligation to create new markets, particularly where competition would not be effective in driving high standards and value for patients”.—[Official Report, 6/3/12; col.1691.]

As the Francis report made clear, GPs must exploit their new role as commissioners to the full to ensure that their patients get safe and effective care. How will care be safe and effective if the coalition’s competition policy on the NHS is in chaos? Despite all the upheavals inflicted on the NHS, there is still no clarity in policy. The Government’s U-turn is clearly a response to Labour’s fatal Motion. The writing is on the wall for their plans to marketise the NHS. Why did it take this Motion to make the Government think again?

Finally, can the Minister outline to the House the sequence of events going forward? Can he confirm that the Government cannot in fact withdraw the current regulations but must lay additional regulations to annul or amend the mess we are now in? When will the new regulations be laid and when will the House have a chance to consider them?

NHS: South London Healthcare Trust

Baroness Wheeler Excerpts

Tuesday 8th January 2013 Lords Chamber

[Baroness Wheeler]

I thank the Minister for repeating the Answer to the Urgent Question. We commend the work of the trust special administrator and support a number of the recommendations developed from previous reviews. However, it is difficult to understand how the Government consider this report to constitute the full strategic review of the sustainability of services across south-east London that is required. The TSA has overstepped its remit under the Health Act 2009 by including service changes to Lewisham hospital; and the parallel work by King’s Health Partners on reconfiguration under three other south-east London trusts has yet to be completed.

Can the Minister explain why the rules on making changes to hospitals have been changed to allow back-door reconfigurations in this way without proper scrutiny and consultation? What public consultation will there be on the King’s Health Partners report? Can he reassure the people of Lewisham that they will have their full consultation rights to challenge the closure of their A&E services and the other major changes being proposed?

[Earl Howe]

My Lords, I am grateful to the noble Baroness and I understand the concerns that she has raised.

The first question she asked me was whether I considered the trust special administrator to have overstepped his remit. The clear advice that we have received is that no part of the NHS can exist in a vacuum. The independent trust special administrator is responsible for developing recommendations to deal with the severe failings at South London Healthcare Trust based on local discussions and consultation. I hope that the statement I read out gave the House a flavour of how extensive those consultations have been. His recommendations must secure high-quality care for local people in a financially sustainable way.

However, as I have mentioned, each NHS trust is part of a complex, wider health system, and it is quite clearly the view of the administrator in this case that it is not possible to find a solution without considering the possible impact on other hospitals in the areas. That conclusion is one that my right honourable friend will have to consider very carefully, but Ministers have received clear advice that it is within the powers of the administrator to make recommendations about necessary changes to other local providers if they are a necessary and consequential part of finding a long-term solution to securing high-quality services for patients at that trust. I emphasise that I do not in any way wish to pre-empt the decision that my right honourable friend has to take within 20 working days. However, he will have to consider advice on the clinical, legal and financial aspects of the administrator’s recommendations and I have no doubt that concerns raised by the noble Baroness will be central to his consideration.

Social Care: Apprenticeships

Baroness Wheeler Excerpts

Thursday 29th November 2012 Lords Chamber

Asked By

[Baroness Wheeler]

To ask Her Majesty’s Government what progress they are making on establishing social care apprenticeships; and how voluntary registration of social care workers will assist apprentices and staff to provide the quality of care required in domiciliary and community settings.

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

My Lords, apprenticeships and voluntary registration for social care workers are part of the vision set out in the care and support White Paper and will contribute to improving quality of care. The latest figures report that more than 60,000 apprenticeships have started in 2011-12. A system of assured voluntary registers will help to support the delivery of quality care by enabling individuals to demonstrate that they meet set standards of education, training and competence.

[Baroness Wheeler]

I thank the Minister for his response and welcome the progress being made. As he knows, apprentices will join the current social care workforce of 1.6 million, more than two-thirds of whom now work in the voluntary, independent and private sectors or are employed directly by service users in their homes. Given the Government’s desire to have only a voluntary register for social care staff, can the Minister explain to the House how consistent quality and dignified care are to be delivered across this fragmented employer base?

Social Care

Baroness Wheeler Excerpts

Thursday 29th November 2012 Lords Chamber

[Baroness Wheeler]

My Lords, I, too, thank my noble friend Lady Pitkeathley for securing this debate and for once again giving us the opportunity to place a spotlight on the growing crisis in social care provision and funding as well as on the importance of developing joined-up services between the NHS and local authorities and within and across the range of services that local councils provide. As usual, my noble friend provides us with a clear strategic overview of the situation and of the impact of cuts to NHS and local authority budgets, as well as firmly rooting the debate in the day-to-day realities faced by thousands of people and their carers who are struggling to cope without the support that they need, often for help with basic everyday tasks, such as getting up, washing and eating.

We last debated social care when the Government’s long-awaited White Paper was published in July, setting out key law and system changes in the Care and Support Bill, and the process for pre-legislative scrutiny, on which we are about to embark, but, of course, sadly ducking the issue that needs to be addressed for any new system to be implemented and for it to work; namely, social care funding and Dilnot.

Dilnot was then widely seen to have effectively been kicked into the long grass by the Government’s in principle only decision. Since then we have had a “will they, won’t they” stop/start coalition dance on the funding issue. Over the summer, our hopes were raised by media reports about U-turns, rethinks, and Prime Ministerial determination to implement Dilnot. If you fast forward to this parliamentary Session, however, there is continued confusion, with the reappearance of the unattributed leaks from government sources about the issue not being a priority, and the Health Secretary himself telling the Tory Party conference that the costs were unaffordable, while, ironically, only a few weeks later, stating his ambition to make England,

“the best place in Europe to grow old”.

He was referring to recent welcome initiatives on dementia care, but with an estimated 1 million people likely to be suffering from dementia by 2021, and 600,000 family carers currently caring for people with dementia, surely the only long-term solution for ensuring that we can address their future care and support needs is to reach agreement on social care funding. Otherwise, the current system, or the new system post the Care and Support Bill, just will not be able to cope.

Most recently, we have yesterday’s Daily Telegraph report that the coalition Government are close to agreeing a cap on elderly care, which could form a centrepiece of the coalition’s mid-term re-launch next year. Like other noble Lords, I look forward to the Minister updating us on what is going on. Does he accept that the need for a long-term funding settlement for social care has never been more urgent?

The debate today focuses on the role of local authorities in the provision of social care, housing and other care services, and it is good for us to be considering council funding and responsibilities in this wider care context. Council responsibilities run across social care, adult and children’s, mental health and learning disabilities, disability support, education, housing, welfare, leisure and transport—the services that people needing social care use or interact with. Last week’s debate on services for people with neurological and other long-term health conditions, for example, underlined the complex care pathways across NHS, council and voluntary sector care provision that need to be better integrated, including health and social care with housing and welfare.

Huge responsibility is placed on local councils to provide or jointly fund these vital services, but we have heard from noble Lords how the scale of reductions across council budgets and in social care highlighted by previous speakers are having a major impact. ADASS and LGA estimate that £1.89 billion have been taken off adult social care budgets in the past two years and that there will be a likely overall funding gap of more than £16 billion a year in overall council spending through to 2020.

There is welcome evidence that the funding transferred from the NHS budget to support social care has helped to stimulate joint working, but the reality is that the bulk of this money is being used to offset cuts to services, although to their credit, surveys show that half of the councils in England are seeking to protect adult social care from the most drastic cuts they are having to make. However, Labour’s and other surveys show that this is predominantly being achieved by holding down residential care placements and agency home care hours costs, and we know that this is simply not sustainable. One large independent sector provider has said that the multi-million pound funding shortfall between the true cost of providing quality care that meets CQC standards and the fees paid by local authorities to care home providers has increased by 16% in just 12 months.

References have been made to this year’s survey by Labour, which showed an 11% fall in the past two years of the number of vulnerable, old and disabled people having home care services fully paid for by the local authority. Eight out of 10 councils provide free care only for people with substantial or critical need. It also found that the average charge for an hour of home care had risen over the same period by 10%.

Noble Lords have underlined the impact that local authority budget cuts have on hospitals as social care funding is squeezed. One often underestimated impact is on accident and emergency services, as more people come through because primary care is becoming less accessible and social care is reduced. The system often seems as if it is in danger of falling over.

The Minister has been asked many questions and I look forward to his response. I want to touch on a couple of those questions. On personalisation, with the personal budget deadline of April 2013 fast approaching, we need to assess any potential negative impacts on existing services such as the provision of daycare centres. I welcome the comments of the noble Baroness, Lady Barker, on the need for more economic modelling on new services, and the references of my noble friend Lord Warner to ensuring that money flows to support these new initiatives.

On children’s services, the right reverend Prelate the Bishop of Liverpool referred to a potential 20% of cuts in children’s services there, and the likely impact on the NHS. On residential care, I was struck by the key quality of care test suggested by my noble friend Lady Donaghy: namely, are residents’ comfort and well-being viewed as of less import than the potential for bed-wetting? The noble Baroness, Lady Campbell, summed up integration as a complex nut to crack. I think that we all recognise this. She rightly praised local authorities that have introduced innovation into care support, even while having to make what she called terrible decisions about care provision.

I would like, in the time left, to pick up on the crucial issue of mental health. Labour has pledged to do all it can to support achieving real parity of esteem between mental and physical health, as Ed Miliband made clear in a keynote speech last month to the Royal College of Psychiatrists. He described mental health as,

“the biggest unaddressed health challenge of our age”,

and said that it affects,

“one in six people across Britain”.

Local government is a key player in mental health, in shaping and commissioning services in social and residential care and in local community services such as advocacy, mental health outreach, befriending, drop-in groups and daycare provision, working with the NHS, community and voluntary sector providers.

As the chair of Blackfriars Settlement, a small local multi-service provider in the London Borough of Southwark, I can cite direct experience of how important the local authority role and support is, and how challenging and difficult it is for the voluntary sector to get funding to replace the reductions in funding. The settlement is one of a consortium of council funded voluntary organisations helping to deliver the borough’s mental health strategy. We have traditionally specialised in work with people with severe and enduring mental health problems, many of whom have been in the system for a long time. We are having to work hard to adapt our services to meet the new challenges on the ground. Our previous delivery model has been updated and adapted to provide a service menu for clients with personal budgets, and we are working hard to develop partnerships with local community groups on a number of projects. We have set up, with Big Lottery funding, a small social enterprise called Art to Print which provides employment and training in art and design production for local people with mental health problems, many of whom have never worked before. However, it is tough going and if we do not succeed in keeping these vital services going, our clients will just not have anywhere else to go.

The Centre for Mental Health underlines that social care input into mental health services is vital for recovery, but the information to measure and assess progress is hard to come by from local authorities because of the absence of systematic reporting on mental health spending and service provision at local level. The charity Rethink’s report, Lost in Localism, this year pointed out the difficulties of assessing the proportion of local authority social care spending on mental health, which is currently achievable only through freedom of information requests. Will the Minister outline any plans the Government have to improve data on local authority mental health spending and services which will help measure progress on how parity of esteem can become a reality?

There are significant reductions in parenting programmes’ budgets to support families at high risk, particularly parents who themselves have poor mental health. The British Association of Social Workers has estimated that around 40% of local authorities have removed, or are considering removing, mental health social workers from NHS-led mental health community and crisis teams. Action for Advocacy’s recent survey found that organisations providing advocacy services for vulnerable groups have had their funding cut by an average 36%, mainly by councils.

I was going to refer to a number of other things, but I see that time is running out. Therefore, I shall put two final questions to the Minister. Although the barriers to providing integrated services are well known, mental health has to date been one area where there have been long-standing partnership arrangements between the NHS and local authorities, including secondments and Section 75 agreements delegating functions to NHS trusts. Given this existing good platform, what are the Government doing to promote the continuation of this?

On parity of esteem, the NHS mandate commits the NHS Commissioning Board to deliver the Government’s commitment of at least 15% of adults with relevant mental health disorders having timely access to services with a recovery rate of 50%. What are the timescales, costs and funding sources for this? The Minister assured us that the mandate had been fully costed and could be carried out within these costs. Is 15% good enough?

Like the majority of noble Lords who have spoken in today’s debate, I hope that the Minister’s responses will show us that the Government understand the scale and urgency of the social care crisis and are prepared to take effective action in this Parliament to address it.

NHS: Women Doctors

Baroness Wheeler Excerpts

Tuesday 6th November 2012 Lords Chamber

[Earl Howe]

Yes, indeed, my Lords. The noble Baroness, Lady Deech, raised that in her report as an action point. It can be done at a trust level or at a higher level in the health service. But it is certainly important to monitor—I understand that the term is “credentialing” —the skill sets of those doctors, who may move out of the health service and want to move back in again, so that jobs can be found for them more easily.

[Baroness Wheeler]

My Lords, I am sure the Minister will agree that recruiting women into the medical profession is just as vital as retaining them once they are trained and working. Given the high costs of university fees and the burden that these place on young people, particularly those from poorer backgrounds and those with family and caring responsibilities, how will the Government ensure that women are not put off applying to medical school?

[Earl Howe]

My Lords, there is no evidence that there is a problem with female recruitment into the health service. Indeed, the male-to-female gender balance over the past few years has decreased from 1.83:1 in 2001 to 1.25:1 in 2011. However, I recognise that we should not be complacent. Even with the increased participation of women in medicine, we appreciate that more can be done to improve the selection of senior doctors into senior positions.

Care and Support

Baroness Wheeler Excerpts

Wednesday 11th July 2012 Lords Chamber

[Baroness Wheeler]

My Lords, I thank the noble Earl for the Statement. I am sure the House will agree that we have all waited a long time for this spring White Paper, and now the Government have finally managed to publish it by the skin of their teeth, with just 10 days to go before the Recess. Notwithstanding what is actually in it, we can at least take comfort that the White Paper’s publication at last fires the starter gun for the nationwide debate on the future funding of social care that we on these Benches and key stakeholders in the public, voluntary and independent provider sectors, as well as care professionals and service users—many of them forming part of the excellent Care and Support Alliance—have all been calling for.

The stakeholders know only too well the scale of the problems that have to be faced and the solutions that are needed on the full package of social care law and current and future funding. However, there is also an urgent need for social care to be pushed to the forefront of public debate and understanding as one of the biggest challenges facing Britain today. This public debate could and should have started much earlier if the Government’s stated momentum behind pushing the Dilnot commission into doing its work in six months had been maintained, and if the Government had put more energy and commitment into the cross-party talks and had seriously tried to address the critical funding issues. After all the delays, prevarication and speculation, those of us who were hoping against hope for some sense of an overall strategy, vision and action in the White Paper for dealing with the current and growing crisis in social care are sadly disappointed and let down. There is no vision of how a reformed system will work in practice or how it is to be sustained in the future in the face of growing demand and need.

At the minimum, we hoped for an outline programme and process for making key decisions on funding, including timescales and milestones for moving forward on addressing the full package of reforms that are needed. Instead, we have further consultation on issues, many of which have already been consulted on and on which there is already broad consensus. We have the failure to address the funding crisis, the prospect of the proposed care and support Bill not coming into effect until probably April 2015, and any implementation of the Dilnot options effectively long-grassed until after the next election.

The White Paper shows that the Government are completely out of touch with the scale and urgency of the care crisis. Across the country, elderly and disabled people are failing to qualify for basic personal care in their homes, or their package of care has been cut back to home visits of less than 15 minutes, or they have faced home care charges rising by 11% in some local authorities. We know, too, that the cost of residential home care is rising substantially in excess of what local authorities can pay, and people are spending their lifelong savings to pay for long-term care. The funding issues need to be faced and addressed now.

Of course we welcome the implementation of a large number of the much-needed changes to social care law proposed in the Law Commission’s excellent report of 2010. Social care law is in urgent need of reform, which is why the Labour Government set up the review in 2008. We welcome the proposals and consultation on reforming and simplifying the legal framework and ensuring that patient-centred services are better fitted to people’s lives and fit in with their need for choice and control. We strongly support new laws which help to make clear what people are and are not entitled to, and which help them to plan for the future.

In the time available, I have managed only a quick look through the documents, but it is worth pointing out to the House that an overwhelming number of the proposals were contained in Labour’s own White Paper on care, published before the last general election. Naturally, we welcome their reappearance, but it begs the question: why it has taken the Government nearly two years to regurgitate our proposals into their new draft Bill?

I stress that we also support proposals in the White Paper that take forward Labour’s personalisation of care agenda—again, as set out in our care White Paper. We support legislation to ensure the portability of social care packages, and we of course support proposals to extend carers’ respite breaks and their legal entitlements, as well as the extension of key information and advice services which we introduced through our landmark National Carers Strategy.

However, from these Benches we have repeatedly stressed that, unless these new social care laws are reformed in the context of also addressing the current and future funding problems, they will be ineffective and inoperable, and will lead to even greater unmet demand and suffering. Local authorities facing £1 billion of cuts will just not be able to afford to respond to laws designed to make care provision and eligibility consistent and more accessible across the country.

It is deeply disappointing and frustrating that the White Paper does not take the key step of recognising that there is not enough money in the system now. Not only is Dilnot implementation pushed into a further consultation and engagement process—despite the much-hyped promises of accepting Dilnot “in principle”—but the proposed transfer of funds of £300 million from the NHS to social care over a two-year period in 2013 and 2014 continues to support this fallacy: in other words, that it is all down to local authorities needing to better manage their finances and get their priorities right. Those councils are desperate for a new settlement on funding for social care, but the White Paper holds out little prospect of this happening and provides no answers to the funding crisis currently engulfing them. I cannot see any reference in the White Paper to how the Government propose to help councils to fund what seems to be their flagship proposal: to provide loans to older people so that their care costs can be paid for after they die. I should be grateful if the Minister could flesh out any of the details on this.

On long-term funding, the Alzheimer’s Society best summed it up when it said that accepting a cap on the funding contribution “in principle” is just an “empty promise”. People want to know what the contribution cap will be, when it will come in and how it will be funded. It is downright cruel to dangle in front of people the prospect of raising the savings threshold from £23,250 to £100,000 without a positive commitment and date for implementation when those people are currently struggling to self-fund their care, or part of it, and are seeing their life savings disappear now.

Labour has always been in earnest about the need for meaningful cross-party talks and entered into these last year in good faith. We meant business when we made the offer last year, and we mean it now. I ask the Minister whether his understanding of meaningful cross-party talks involves joint, two-way discussions on strategy, policy and options, and regular meetings, discussions and negotiations to reach a consensus, or whether it means irregular meetings, the last one of which was cancelled by the Government, who instead offered the Opposition a briefing just a few days before the White Paper was due to be published on what they intended to do—or not do, in this case. We know that that is what happened, although I welcome the behind-the-scenes signs over the past couple of days that the Government regret not putting more effort into making cross-party progress. For our part, Andy Burnham has pledged that if the Government offer a genuine, two-way discussion on the funding of care, with honesty about existing pressures and the difficult options, Labour will play its part.

I ask the Minister the following further questions. First, why was it not possible to reallocate to pay for social care a major part of this year’s £1.7 billion NHS underspend, which was clawed back by the Treasury? Would this not at least have been a start, providing real money behind the White Paper’s reform proposals? Secondly, will the Government be involving Andrew Dilnot himself in the implementation discussions once the consultation is completed? Does the Minister recognise that Mr Dilnot’s involvement would go some way towards building confidence among key stakeholders that the whole issue has not been long-grassed? Thirdly, can the Minister tell the House when the Government will publish an impact assessment of the cost of the overall changes proposed, and how they plan to implement the changes with no extra money and council budgets being slashed? Finally, in today’s Daily Telegraph NHS managers are warning that the NHS is at risk of collapse as cuts to social care budgets are leading to a huge rise in the number of admissions to hospital of older people who could be treated at home but cannot afford to pay for care. How do the Government propose to deal with this, and how will the White Paper proposals help to alleviate this alarming trend?

The White Paper reflects a positive sign of consensus on many of the key issues facing social care today, and some good promises about how social care should change. However, until these promises are backed by a recognition of the current scale of the crisis and proposals on how Dilnot can be implemented in the future—with firm commitments, timescales and milestones—schemes such as deferred payments and loans and pilots for end-of-life care can in effect be only interim, stopgap measures. They do not address the overall need for fairness, transparency, more resources across the whole system and long-term sustainability. Implementation of Dilnot must be the basis for that.

As a carer myself, I hope that the House will forgive me if I end by quoting the carer husband of a woman suffering from dementia who was movingly interviewed on Radio 4 this morning about his life as a 24-hour carer and the impact of social care cuts. He said:

“It’s the unknown that really gets to me … in the back of my mind is the constant feeling of uncertainty”.

In-principle decisions for implementation at some unspecified date in the future are no solution and offer no comfort, solace or relief to people who need help, care and support today.

The Government promised that they would legislate on a new legal and financial framework for social care in this parliamentary Session. The noble Earl promised that the Government would not shy away from or duck the funding issues—but I am afraid that that is exactly what they have done.