NHS: Keogh Review
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Lord Hunt of Kings Heath
My Lords, before responding, I declare an interest as president-elect of GS1, chair of an NHS trust and a consultant trainer with Cumberlege Connections. First, I thank Sir Bruce Keogh and his team for this important review. I know Sir Bruce and have the utmost respect for him. His review presents a challenging but accurate picture of care standards and failings at the 14 trusts. As with both Francis reports, the Opposition accept the findings of this report in full.
At Health Questions earlier today in the other place, the Health Secretary claimed that this was a historical report, going back to 2005. However, it is not. These trusts were identified on the basis of mortality data for 2011 and 2012—this report is about this Government’s failings, happening on this Government’s watch. Anyone who supports the NHS must always be prepared to shine a spotlight on its failings so that it can face up to them and improve. However, in doing so, we must be fair to staff and to the NHS as a whole. In his report, Sir Bruce puts the failings at the 14 trusts in their proper context, by concluding that,
“mortality in all NHS hospitals has been falling over the last decade … by about 30%”.
He rightly reminds us of decades of neglect in the NHS in the 1980s and 1990s, when the noble Earl’s Government were in charge. Of the challenge facing the previous Government in their early days, he says:
“The key issue was not whether people were dying in our hospitals avoidably, but that they were dying whilst waiting for treatment”.
The noble Earl spoke about targets. The disgraceful record of his Government, with a target that they had in the patient’s charter of a maximum 18 months’ wait for treatment as an in-patient, was brought down by the targets that he decries to a maximum of 18 weeks. That is why we had targets.
In fact, the balanced picture in this report bears no resemblance to the Government’s leaking of the report over the weekend but it exposes one of the most cynical spin operations ever seen in this country. Nowhere in this report does a claim of 13,000 avoidable deaths appear. Indeed, Sir Bruce is absolutely clear. He says:
“However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths”.
Yet that is precisely what this Government chose to do in advance of this report.
In the past few minutes, details have emerged of an e-mail that Sir Bruce Keogh has sent. He is clearly very angry about the report’s leak by the Government to the press, and specifically about the 13,000 lives allegedly lost. The noble Earl talked about accountability, so will his Secretary of State be accountable for the disgraceful actions that occurred over the weekend in his department? Will the Secretary of State consider his position? He should certainly do so.
On mortality rates, does the noble Earl recognise that Robert Francis himself said that,
“it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care”?
Does he also accept the comment of the Liberal Democrat MP Andrew George that the leaks by the Tories on the Keogh report were obviously designed to mislead the media?
The result has been that these unfounded claims, spun out by the Government, will have alarmed people in the 14 areas affected. They have questioned the integrity of the staff working in those hospitals in difficult circumstances, all for their own self-serving political ends. This is unworthy of any responsible Government. On reading this review, the diversionary spin now makes sense as it is clear that those 14 hospitals have all shown signs of deterioration on this Government’s watch.
The noble Earl suggested that pressure had been put on the regulator to tone down criticisms. Does he accept the word of the noble Baroness, Lady Young, the former chair of CQC? She has written that CQC was not pressured by the previous Government to tone down its regulatory judgments or to hide quality failures.
Let me turn to staffing. One of the report’s central findings is that staffing is a major concern in all these trusts. The review states that,
“when the review teams visited the hospitals, they found frequent examples of inadequate numbers of nursing staff in some ward areas”.
The review team has already had to intervene in three areas on staffing to protect patient safety. Five of those trusts had warnings left in place by the previous Government. Does the noble Earl accept that it is shocking that they have been allowed to cut front-line staff to unsafe levels on his watch? The great sadness is that it appears that Ministers are in danger of forgetting the lessons of Stafford, where Robert Francis identified dangerous cuts to front-line staff as a primary cause of care failure.
Like Robert Francis, Sir Bruce makes recommendations on appropriate staffing levels. Can the noble Earl ignore this authoritative call any longer? What action is he going to take to ensure safe staffing levels in these 14 trusts and across the NHS? We accept that the loss of more than 4,000 nurses during the lifetime of this Government has now been laid bare as a monumental error. Will he intervene to stop those job cuts? Will he apologise for the fact that seven out of the 14 trusts investigated by Keogh have cut more than 1,000 nursing jobs since the election?
The noble Earl tells us that of the 11 trusts going into special measures, each hospital will be partnered with high-performing NHS organisations to provide mentorship and guidance in improving the quality and safety of care. That is to be welcomed but can he guarantee that this will not be deemed to be collusive action by the competition authorities?
I turn now to A&E performance, which is the barometer of the health service and the wider indicator of problems across the health and social care system. The report highlights major failings in A&E at many of the trusts. Of course, we know we have come through just about the worst winter we have had for a decade. At the end of last year, all 14 were in breach of the Government’s A&E target. Sir Bruce is clear that urgent action is needed to improve A&E, saying:
“We have established that one of the primary causes of high mortality in these 14 hospitals are found primarily in urgent and emergency care, and particularly in care for frail and elderly patients … all trusts were functioning at high levels of capacity in the urgent care pathway. This frequently led to challenges in A&E and, as a consequence, cancellations of operations due to bed shortages and difficulty meeting waiting time targets”.
Will the Government take immediate steps to work with the whole health economy to bring the 14 back up to national standards?
Even given the appalling way the Government have handled the Francis review, people will want solutions rather than politics so surely the right response is to accept the Francis recommendations in full, including the one on staffing levels. I can assure the noble Earl that if he were to do so the Opposition would work with him to ensure their swift passage through Parliament.
In conclusion, it is a sad fact that mistakes will be made in any walk of life, even in the National Health Service. The only real answer to all of these problems is for both sides of the House to recommit to full openness and transparency in the National Health Service. People who have been let down deserve nothing less.
Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Lord Lipsey
My Lords, I rise to make two brief points. First, this argument is not really about eligibility criteria but about money. It would be highly desirable to extend eligibility to people with only moderate needs, but we will find it extremely hard simply to cater for people with substantial needs unless the pot of money is substantially expanded. That is the elephant in the room. In all the discussions here, we are describing a marvellous new system, but we have not yet said how it will be paid for.
Secondly, I think that eligibility criteria are, to a degree, a bit of a phantom. We know that there is variation between authorities across the country: some accept people with moderate needs and some accept them with substantial needs. Quite aside from that, there is overwhelming evidence of enormous variety not between local authorities but within local authorities depending on who is assessing you and their state of mind. I quote in support of this a report from the National Care Standards Commission in 2005-06 and an excellent report by the PSSRU last year which tells you what actually goes on when people are being assessed. You might have a social worker who is terribly sympathetic to the older or disabled people she is assessing, and her boss who is, no doubt, sympathetic but who knows what budget he has to meet each month. In those cases, you simply get a wrestling match.
Thirdly, and to me most worryingly, once the cap comes in, people and their families will have a huge economic interest in demonstrating that they have substantial needs because that is when the meter starts ticking for them getting help. The danger is that those with, in some cases, the biggest needs will not be very good at gaming the system. Somebody with autism may be told by their parents to seem as bad as possible so they can get the meter ticking. They are not going to be very skilled at that, but the mums and dads of articulate middle-class people will have a different set of instructions to go on. There will always be a tendency to exaggerate—play up to the full may be a better way of putting it—their needs to get them graded as substantial.
I make these points, not to draw any firm conclusion, not even on the question of whether those with moderate needs should be catered for, but to say that more fundamental thinking has to go into deciding how eligibility criteria should be set and operated. This has not yet been apparent, even in the Government’s improved scheme which is encapsulated in the Bill.
Lord Hunt of Kings Heath
My Lords, my Amendments 88R and 88S take us back to the amendments which I moved last week on eligibility criteria, inspired by the noble Baroness, Lady Campbell. Promoting individuals’ well-being, assessing their needs and those of carers, deciding on eligibility and the priority for needs to be met, developing them with an appropriate care and support plan, enabling the best use of a personal budget and/or direct payments and ensuring continuity of capacity during and after a move, such as a house move, are all processes or stages in which the active engagement of NHS professionals or services could have a positive effect on the outcome for individuals and carers.
In his response, the noble Earl said that he agreed and that the Care Bill already allowed for that kind of co-operation from the NHS through Clauses 1 and 3. He also pointed out that Clause 12(1)(f) sets out regulations where a local authority must consult with someone with expertise before undertaking an assessment. He went on to say:
“Regulations may also set out conditions around co-operation with the NHS, by specifying the circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare”. —[Official Report, 3/7/13; col. 1272.]
That is helpful but I wonder if we should go further and place an explicit responsibility on the NHS so that we know it plays its part in full.
Amendment 88Q, tabled by the noble Baroness, Lady Grey-Thompson, and my Amendment 88T focus on the eligibility criteria in the draft regulations. We support national eligibility criteria. As the consultation paper says,
“the needs which are determined to be ‘eligible’ vary from one area to another”,
at the moment, with local authorities,
“able to set their own ‘eligibility threshold’ or ‘criteria’…This approach has led to perceived wide distances between areas and inconsistency in the offer made to local people, confusion and legal challenge. Because local authorities are able to vary the threshold over time, it also leads to the fear that people may lose their care and support if ‘eligible needs’ are reclassified locally”.
It is also very helpful to have the draft regulations available for debate and I have been able to discuss them with a number of stakeholders in the last few days. The noble Baroness is absolutely right that there is concern among many stakeholders about the level at which the criteria are set. This is reflected in the amendment in her name and those of the noble Lord, Lord Low, and my noble friend Lord Touhig. However, we must also take account of the points raised by my noble friends Lord Warner and Lord Lipsey because this is, in the end, an issue of funding. I hope that, when she winds up, the noble Baroness will address the issue of affordability. This may be a technical point, but this might be a matter of supply, since the Commons might well assert their own position in this regard. The noble Earl, Lord Howe, will, no doubt, advise us on that matter.
The guidance is very important and my noble friend Lord Warner said that it was a good first shot. I agree with him and it is certainly something to work on. However, could it warrant more parliamentary scrutiny than is normally given to regulations? We usually have a debate of about one hour; the conventions allow us to defeat a statutory instrument on very few occasions, and there is no opportunity to amend those regulations. We have benefited enormously from having a Joint Select Committee to advise us on the draft Bill: might it be right to have a similar process in relation to the regulations? I hope the noble Earl might be sympathetic to my Amendment 88T, which asks for a joint parliamentary committee process to look at the regulations before they are laid before Parliament.
Lord Hunt of Kings Heath
My Lords, I hesitate to come between my noble friends Lord Warner, Lord Lipsey and Lord Campbell-Savours, and indeed knowing what is good for me I am not intending to do so. I say to my noble friend Lord Campbell-Savours that I understand the point that he is making and I agree that Dilnot is not the answer to many of the really pressing problems that we are talking about.
I want to tempt the noble Earl to say a little bit more on two areas which have been referred to by noble Lords. The first is the complexity for local authorities of what they have to administer. The noble Earl has not really responded in detail on this matter so far. Indeed, it is noticeable that local authorities have not responded. We have received a huge amount of evidence, but not very much from local authorities and the local authority associations. This worries me. I understand why local authorities would be keen to play a prime part in the administration of this new system, but these are genuine concerns about whether there is capacity to make changes of this complexity happen. Nothing would be worse than the new system coming into being and collapsing almost on day one. At the moment, that is my view on what is going to happen. I do not know what the Government intend in terms of testing out the robustness of the system for when it is due to come in. I hope that at some point during our debate the noble Earl will be able to tell us.
Secondly, the next group of amendments deals with the public understanding the complexity of the system being considered, but it seems to me that this issue relates to the point about insurance raised by my noble friend Lord Lipsey. My understanding is that one benefit of full implementation of Dilnot—although I am not sure that the Government have gone down that path—would be that, if the public knew that their liabilities would be capped, there would be likely to be a ready insurance market. A number of us have looked with interest at the comments of the Association of British Insurers and other parts of the insurance industry. I have to say there does not at the moment seem to be much optimism about whether there is going to be a market and whether packages are going to be developed. This may come up in later amendments, but at some point I hope that the noble Earl will give a little more information about the Government’s view of the potential of the insurance market to develop products which the public can understand and will be willing to invest in.
Earl Howe
My Lords, as the noble Lord, Lord Lipsey, explained very clearly, these amendments would mean that the capped system counted time rather than costs. I agree that there are advantages to this approach. The Dilnot commission, in considering this option, said that using years instead of costs would be easier to administer and simpler to understand, and I appreciate those arguments. However, the commission also made the case that to adopt this approach would disadvantage those with more intensive care needs, who over a given period of time could spend significantly more on care than those with less intensive needs, so that what we might gain in simplicity we should lose in fairness. I am sure that we all want to see a fair care and support system giving the most support to those in the greatest need. Using time instead of costs would undermine that goal.
We are committed to using notional spend—in other words, the equivalent of what the local authority would pay to meet an adult’s eligible care needs. As with using time, it is in fact relatively simple to administer because it fits in with the current system of needs assessment. It also ensures that people with more intensive needs are not disadvantaged. That is why the Government agree with the Dilnot Commission, which said,
“the only suitable way of deciding when a person has reached the cap is to meter notional spend.”
The noble Lord, Lord Lipsey, pointed to the understandable fear that Dilnot will mean spending money on administration rather than on meeting people’s needs. I accept that times are challenging for councils, but we are committed to funding these reforms. Critically, we are also committed to co-producing the implementation of the reforms to minimise the bureaucracy that accompanies them and maximise the benefits that they bring. The noble Lord suggested that local authorities might not be ready to implement Dilnot in 2016, and the noble Lord, Lord Hunt, also asked about this, and whether we were intending to test the robustness of the system. We shall be coming to the issue of readiness in the next group, but I agree with the noble Lord, Lord Warner, that there is sufficient time to develop what he referred to as a taxi-meter system.
The noble Lord, Lord Campbell-Savours, took us to a point that he has made in this Chamber before about Dilnot, and his view that it is fundamentally unfair. I simply say to him that the vast majority of state support, under the Dilnot system, will be provided to the roughly 40% of older people with the lowest income and the lowest wealth. The cap, and the extended means test, provide the most reassurance to that particular group. Our view is that we need a system that protects people with the greatest lifetime care needs. It is not about protecting people with the greatest wealth.
To clarify the question that the noble Lord, Lord Warner, raised in the previous group of amendments about the guidance under Clause 71, this will indeed be statutory guidance, and it will look and feel like a code of practice. Importantly, it will have the same legal status. However, we do not think that guidance should be subject to parliamentary scrutiny every time it is updated, as with a code of practice Statutory guidance under this Bill will have the same status as the current guidance issued under Section 7 of the Local Authority Social Services Act 1970. I hope that this is helpful.
In a later group of amendments we will come to what local authorities think about the new system and indeed the whole area of financial services. However, I was reassured that the Local Government Association said that it fully supports and welcomes the inclusion of a cap on what an individual will pay. The Association of British Insurers has welcomed the announcement that we have made as a positive step forward in tackling the challenges of an ageing society. Arising out of that is a sector-led review that is working constructively with government to understand how the market will develop and create the right environments for products to succeed. That review will be completed over the summer.
I hope that with those comments the noble Lord, Lord Lipsey, will for now be content to withdraw his amendment. I hope that he found my comments, if not ones that he can agree with immediately, at least ones that he will put into the context of the Bill in, I hope, a manner that he will understand.
Lord Hunt of Kings Heath
My Lords, my Amendment 90ZA requires the Secretary of State to report to Parliament,
“in advance of this section coming into force with the Government’s assessment of the likely impact of the cap on care costs; and … annually once the section is in effect, with the Government’s assessment of the impact of the cap, in particular its distributional impact across the income spectrum”.
I echo some of the points already made. The operation of the cap ought to be, and continue to be, subject to ministerial oversight. The opportunity to report to Parliament and for us to have an annual debate should not be missed. This links into the amendment of my noble friend Lord Lipsey, Amendment 92ZZB, because it would enable a ministerial advisory group to feed into an annual report on how the scheme is being implemented and whether changes need to be made.
It is important to bear in mind the concern of my noble friend Lord Campbell-Savours that simply operating Dilnot will favour the better off at the expense of the worse off. We must keep an eye on how it impacts on the distributional spectrum in this regard. That is why I have the second part of my amendment.
Like other noble Lords, I agree with Amendment 89E in the name of the noble Lord, Lord Sharkey, and Amendment 90 in the name of the noble Baroness, Lady Greengross. I have learnt over the past few months how complex this issue is, and if noble Lords do not understand the full complexity of the scheme—and I gladly hold my hand up that I have yet to believe that I have full mastery of how it will operate—how can members of the public be expected to understand its full consequences?
In our debate on Clause 2, we discussed the responsibilities of local authorities in providing advice and we debated the need for independent financial advice to be made available. The consequences for a person making the wrong decision on funding could be catastrophic. It is therefore important that advice is readily available, and I agree with those noble Lords who think that it ought to be a national responsibility. Whether I would give it to the current Secretary of State, I am not quite so sure.
I remember how the Government spun this Bill in the Queen’s Speech and the Prime Minister giving the impression that no one would for ever more have to sell their home and that the £72,000 cap was the limit. However, as we have gone through the Bill has become quite clear that neither is the case. I agree with my noble friend Lord Campbell-Savours that the Government have not thought through the implications of what the noble Earl said last week about the issue of transparency.
The point is that most people have to spend more than £72,000 because self-funders do not pay local authority rates. In his sophisticated response last week, the noble Earl suggested that local authorities took advantage of procurement at scale, which is why they were able to get a rate lower than self-funders. That was a remarkable argument. Most people see this as a case where local authorities underpay and that if homes only existed under local authority rates many of them would not be viable. It is therefore not surprising that many homes are on a cliff edge of viability on the one hand and at risk of being put out of business because of CQC inspections on the other. There is no doubt that it is generally thought that self-funders subsidise the people in those homes who are paid for by the local authority.
However, most people do not know that. Only an inside circle is aware of the issue. However, come the new implementation, everyone will know—as the noble Earl said last week, it will be transparent—and people will not put up with it. That is why, first, it is essential that more thought is given to implementation. I am not sure whether my noble friend Lord Lipsey is right to want to delay it by a year, but I am sure that he is right to say to the Government that they need to look carefully at the practicalities of implementation.
Secondly, it is important that self-funders are in future fully aware of the consequences of any decisions they take. At the moment, I and many other noble Lords are not convinced that the public are aware. That is why it is so important that a duty is laid on Ministers to fund, and continue to fund, a national campaign of information and that we come back to our debates on Clause 2 in relation to independent advice being made available.
Thirdly, I hope that the noble Earl will readily accept the amendment of my noble friend Lord Lipsey about the need for a ministerial advisory committee, which could then enable the Secretary of State to report to Parliament annually in relation to the implementation of the Dilnot proposals.
The noble Earl will be aware that, in general—my noble friend Lord Campbell-Savours aside—the Care Bill enjoys support. However, there is a risk of our disagreeing on implementation. If he can reassure us on the readiness of local authorities, on the willingness to provide independent advice and on the willingness to establish some kind of independent mechanism to report on a regular basis, it would provide a great deal of comfort.
Earl Howe
My Lords, the clauses on the capped-costs system represent a significant step forward, ending decades of uncertainty, with the introduction of a clear system that fairly shares costs. For the first time, people will be protected from spiralling costs and will no longer have to fear that their home will be sold while they are in a care home. In response to Amendment 90ZA, I can confirm that we published an impact assessment of the reforms which includes the distributional impact by income.
The current system exposes those with little savings or modest housing wealth to the greatest risk of losing everything to pay for their care and support. We will enable people to keep more of their capital and still receive a contribution from the local authority towards their residential care costs. Under new regulations, those with capital assets of less than £118,000 will see the local authority pay a proportion of their residential care costs rather than only those with assets of under £23,250.
As I mentioned earlier, the vast majority of state support will be provided to the 40% of older people with the lowest income and wealth. The cap and extension to means-tested support provides the most reassurance to this group. This is about protecting people with the greatest lifetime care needs and not people with the greatest wealth. The reforms must be sustainable and affordable for the long term, which is why we have accepted the Dilnot commission’s recommendation that the level of the cap should be adjusted annually in line with inflation. It is an approach used in taxes, pensions and benefits, ensuring they remain equally fair year after year.
I turn to amendments 92ZZB, 92ZZC and 104ZC. The noble Lord, Lord Lipsey, shares our aim in drawing up the Care Bill of ensuring the system can respond to changing circumstances. However, that dynamism must be balanced with some certainty about the basis for changes. That is why Clause 16 requires annual adjustments to be made to the cap and to an adult’s accrued costs, so that they keep pace with inflation. Clause 66 provides some certainty that changes are likely to occur only as a result of the annual adjustment or five-yearly review. In reviewing the level of the cap and the means-test threshold, the Government will want to involve a range of experts in assessing how external factors such as demographic change and healthy life expectancy are affecting affordability and the benefits of the capped costs system. A standing independent committee is therefore unnecessary and could suggest that the system is subject to constant change—which may, perversely, result in fewer people planning and preparing on the basis of these reforms.
Amendments 90A, 90B and 90C would require the annual adjustment to be made in line with average care costs. The first point to make is that there is no nationally recognised measure for care costs inflation. Linking the annual adjustment to a care costs inflation measure that has no national benchmark would not give people, or the financial services industry, certainty or confidence in the system. It would of course be possible to develop such a measure, but we feel it is unnecessary, as a robust proxy already exists. Average earnings is one element of the measures used to determine the state pension and therefore represent changes in people’s ability to pay. Earnings is a national statistic certified as compliant with the code of practice for official statistics. In addition, care costs and average earnings are related since labour is a substantial proportion of the cost of care. The latest Laing & Buisson market survey states that,
“in the longer term, fees are inevitably driven by costs … the major cost item is payroll”.
Turning to Amendments 89E, 90 and 104ZD, which is where my noble friend Lord Sharkey began this debate, I fully agree that it is critical that people are made aware of the reforms and what they will mean. The Dilnot commission rightly recommended that there should be an exercise in raising awareness alongside implementation of the reforms. Many people do not realise that they may have to pay for their care and support, which acts as a significant barrier to effective planning and prevention. The Committee will be aware from the debate on Clause 4 that we know that easier access to good quality, trusted information and advice is a critical enabler. The Bill places a duty on local authorities to provide information and advice, including on the capped cost system.
I assure the noble Lord, Lord Campbell-Savours, that we have absolutely no intention to or interest in allowing spin to replace clear and balanced information for the public. In improving awareness and advice, national and local must work together. It will be in the interests of local authorities, the public, government and the financial services industry to make sure that people are aware of the reforms and have access to the right information and advice at the right time so that they can plan and prepare to meet their care and support needs. We will seek views in the forthcoming consultation on the design and technical implementation of the funding reforms, which will include addressing the best way to raise awareness of these reforms nationally and locally.
My noble friend Lord Sharkey made the good point that awareness and understanding of the Dilnot reforms has to be evaluated and measured over time. As with any other policy, we will seek to evaluate the effectiveness of this particular policy, but we believe that to require an annual report in the Bill would incur a potentially high and unnecessary cost. There are other ways of delivering the same aim.
Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Lord Warner
My Lords, I support the creative thinking of my noble friend. The truth of the matter is that we certainly did not have enough time to go into the kind of detail that he has done, which he has explained very clearly. I have to confess that we were not aware of the nursing allowance. Perhaps we should have been. If we had been, I think that we would have justified the scrapping of it by saying that that would be used to help to finance our mainstream proposals.
Also, we said in our report that we thought that the Government should look again at the personal expenses allowance. We thought that it was extremely mean. In a way, it has not kept pace with inflation over the years and it now seems a rather derisory amount. Therefore, anything that could be done to improve that without increasing the cost of public expenditure would seem to us a good idea.
I commend my noble friend for his creativity. I hope that the Government will take his amendment away and look at it seriously to see whether something can be done with it, because I think that it is an improvement on our recommendations.
Lord Hunt of Kings Heath
My Lords, I, too, have a great deal of sympathy for the core of my noble friend’s proposal to change the means test to increase personal allowances to support people so that they have enough money for what he described as “small treats”. Like my noble friend Lord Warner, I should be interested in the noble Earl’s response to that point.
I also sympathise with my noble friend’s second proposal to help those with modest assets by making the means test less severe. It is clear to most of us that the benefits of Dilnot will go to the better off. I think that one must be sympathetic to my noble friend’s aim of trying to spread the benefits more widely. Of course, that comes with a cost, and my noble friend’s answer to that is the proposal to abolish the nursing care allowance or to phase it out. Perhaps the term is grandparenting; I am not sure of the phrase but the Lords reform proposals come to mind—the transition.
Whether that is the right approach must of course be subject to some debate, and I would certainly need some convincing about the phasing out of the nursing care allowance. However, I think that my noble friend has done us a service and I hope that we will have further discussions on it between now and Report.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, on one level I sympathise with the intention of the noble Lord, Lord Lipsey, to redistribute funding between health and care and support so as to increase the personal expenses allowance and local authority support for those in residential care. However, we need to face the reality of the current economic climate. One important aspect of our reforms is that the greatest support will go to those with the greatest need, and that is surely the policy aim that we need to keep most closely in mind in this context.
Currently, the NHS funds nursing homes to support the provision of registered nursing care. This reduces the burden on the NHS of having to provide NHS nurses in residential care homes. Removing this funding would risk increasing costs elsewhere in the NHS, but it would also breach a serious point of principle. If we were to stop people in residential care homes from being eligible for NHS-funded nursing care, it would undermine one of the founding principles of the NHS, which is that it should be a service free at the point of delivery. I am sure that noble Lords would agree that we would not like to see that.
I understand why the noble Lord seeks to increase the personal expenses allowance. If someone is contributing to the costs of their residential care from their net income, for example from their pension, the personal expenses allowance is the amount people can retain to spend as they wish. This is currently set, as he rightly said, at £23.90. The amendment would increase it to £32.75. When living at home, people pay for their food and heating from their income. It is right that people should continue to contribute towards these costs in residential care. The personal expenses allowance reflects the fact that for most people these costs represent a large proportion of their income, but it allows people to retain some of their income for other uses. The reality is that spending additional resources on the personal expenses allowance would reduce the resources available to provide support to those with the greatest needs.
I heard what the noble Lord, Lord Lipsey, said about the loss of the attendance allowance meaning that people would be worse off. Local authorities should support people to maximise their income. If a given individual would be better off receiving the attendance allowance, the local authority should support them to achieve this. We will bear this in mind as we draw up the regulations.
I turn now to Amendment 91, which relates to financial assessments. One of the problems the Dilnot recommendations attempt to tackle is the cliff edge between being a self-funder and being supported by the local authority. By extending the means test for people in residential care, we aim to avoid a situation where a small change in a person’s capital results in a large change in what they pay for care.
From 2016, the maximum tariff income for someone with £118,000 in assets will be £404 per week. If we reduced the rate at which people contribute toward their care costs from their assets to £1 per week for every £500 of assets, the contribution for someone with £118,000 in assets would become £202 per week. This means that an individual facing a typical care home fee would be over £200 per week better off if they had assets of £117,000 than if they had assets of £119,000. This would reintroduce the cliff edge that surely none of us wants to see.
I believe that our plans represent a fair balance between the individual and the state. People with care needs will receive additional support with care and support costs through the extended means test, safe in the knowledge that health services will remain free at the point of use and that they are protected by the cap from unlimited care costs. I hope the noble Lord will see that there is method in the Government’s proposals. While I totally understand much of his rationale, I think our proposals have a better balance. I hope that he will feel able to withdraw his amendment.
Lord Warner
My Lords, I intervene on this to talk very briefly about what the Dilnot commission said on this issue. I will quote just two sentences from page 22 of our final report, which are worth putting on the record. We said very clearly:
“The state-funded care element will be based on a local authority care package, but people will be free to top up from their own resources, should they wish. If someone moved to a different local authority, they would take with them a record of their contributions to date”.
That is a very clear statement of what our policy was. When we were taking evidence, there was not a lot given to us about the extent of top-ups.
If I fast forward to my time on the Joint Select Committee with other Members of this House, the issue of top-ups seemed to have changed quite significantly between the time when the commission reported, having considered all this, and the time that the Joint Select Committee was working on it. There were not good data, other than that many of us have been increasingly learning that the top-up levels have been quite considerable in some homes. There is clearly a problem with the cross-subsidising of people who are state funded from self-funders. The issue is now complex and I do not know how good the Government’s data are on the use of top-ups. We were clear that you could count towards the cap only what the state-funded element of that payment was, which would be determined by what the local authority would pay in its area for the care being provided. If we depart from that principle, we will end up in chaos—and probably end up with a much higher public expenditure bill.
There is an issue here that the Government need to think about, but in principle we should do nothing to stop people topping up if they and their family are prepared to provide for a higher level of care. The present rules were drawn up for a different time and on top-ups, the world has moved on. We need to get this straight before we finish this Bill.
Lord Hunt of Kings Heath
My Lords, I, too, would welcome a debate about top-ups and the Government’s present position and response to the Dilnot proposals, as enunciated by my noble friend Lord Warner. It would also be helpful if the noble Earl could give us a little thinking about how the Government expect this to work out in practice.
We start with the fact that a local authority has to have an assessment to add to the baseline to set the clock running, so as to get to the £72,000 cap. We have already discussed transparency and the problems arising where self-funders find that they have in fact been subsidising those people funded by the local authority. I would be particularly interested to know from the noble Earl what calculations have been undertaken by his department about the impact on self-funders when responsibility is taken over by the local authority once the cap has been reached. Has any work been done on the extent to which those self-funders will be forced to move home because the local authority will not fund them at the rate that they have been self-funding, while the home itself is requiring those people to move?
My noble friend Lord Lipsey referred to the general experience—we have seen it in the health service—that when very frail elderly people are forced to move from one care setting to another their life outcomes are very poor indeed. Clearly, it would be wholly unsatisfactory if, as a result of bringing in the £72,000 cap, we had the perverse incentive of forcing a lot of movements by frail, vulnerable people that would have a deleterious effect on their health and life outcomes.
That brings us to whether removing the top-up restriction would be an appropriate response. My noble friends have put forward a persuasive case. It is important that the Government should enable the House to come to a view on these matters, having made an assessment of how the introduction of state support for self-funders who have reached the cap is going to work in practice.
Health: Anorexia and Bulimia Nervosa
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Earl Howe
My Lords, I am sure that this is an area that NICE will need to look at when it refreshes its guidance to the clinical community. The noble Countess is absolutely right to raise the issue. CFS/ME can often be misdiagnosed; it can be mistaken for other conditions without proper differential diagnosis having taken place. We know that there is more work to be done in this area. However, the range of programmes now available to GPs, some of which I have referred to, can be helpful in this area.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. Perhaps I can take the noble Earl back to my noble friend’s question. She mentioned “parity of esteem”, which of course the House legislated for in the 2012 health and social care legislation. Could he tell the House how the Government intend to ensure parity of esteem, particularly ensuring that mental health services are given their fair share of resources in the health service? How do the Government intend to take that forward?
Earl Howe
My Lords, I do not wish to duck the fact that this is a very difficult area to define. We all know that we want to achieve parity of esteem. It depends on ensuring not only that mental health services are given their fair share of the budget but that the right treatments are delivered to the right people, and that everyone in the country has access to appropriate treatments. We are currently firming up with NHS England what the right metrics are in order to judge whether they have met that aim. I will write to the noble Lord with the latest news on that front.
Health: Prescription Drugs
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Lord Hunt of Kings Heath
My Lords, the noble Earl will be aware that in the past few years nurses have been given much more authority, once they have been properly trained and authorised, to prescribe medicines. Can he confirm that the measures he has talked about will apply to nurse prescribers as well as to doctors?
National Health Service (Licensing and Pricing) Regulations 2013
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Baroness Finlay of Llandaff
I have a short query, which I hope that the Minister can clarify for me. It relates to the cross-border flow between England and Wales, either of providers or patients as users of services where NHS Wales is paying for services provided by NHS England or a provider in England. I would like reassurance that there will be no way that the experience of patients going from Wales into England, or the ability for providers from Wales to provide services to patients along the border, are in any way jeopardised within these arrangements and that they have equality within the provision.
Lord Hunt of Kings Heath
My Lords, I declare an interest as chair of an NHS foundation trust, president elect of GS1 UK and a consultant and trainer with Cumberlege Connections. I am grateful to the Minister for his explanation of these regulations. I want to put a few points to him.
I start with Part 2 on licensing, specifically paragraph 3 concerning monetary penalties. Can I ask the Minister about the logic of fining providers, when all that happens is that worse care will be provided for patients as the organisation will have less money? I think that the figure of up to 10% of turnover would virtually bankrupt most providers. While I certainly accept the need for penalties and consequences for failure, I wonder whether they would be better being not financial, as the reality is that they will not happen in many cases because the people who suffer will be those who get services. I just wonder about the logic of that.
It took NHS England months to wake up to the fact that the A&E problems were to do with the failure of systems, but for months it was pressing CCGs in some parts of the country to fine hospitals for poor A&E performance. I think that NHS England has completely lost the plot when it comes to understanding what is happening in the health service. I cannot think of a more hopeless response to the crisis than to come along and say, “We should fine hospitals”. I worry about this whole approach to fining. I say to the Minister that there are very limited signs that systems understand the winter problems and there is a real reluctance to get to grips with what needs to happen. This is a worry for the future which may not have much to do with the regulations, but my seeing the Minister here represents a good opportunity to raise them with him.
Does the Minister think that fines and targets can lead to some perverse incentives? Of course, it is right to issue targets, but I wonder whether the Minister might comment on a very interesting section of the Chief Medical Officer’s Report for 2013, published earlier this year, where she refers to the low number of instances of MRSA and C. diff. I do not think that there is any doubt that the targets that were set for the health service have been responsible for the focus that has led to this very welcome improvement. My understanding is that part of the response to this by the NHS has been to use antibiotics which should have been reserved for hard-to-treat infections. There is now real concern that the antibiotics that go with those hard-to-treat infections have been used rather widely, which is causing great problems in more general infection control. According to the CMO, while the typical, large, 1,000-bed acute NHS hospital has two to three MRSA bacteraemias per year and 50 to 60 C. diff cases, 400 to 500 bacteraemias involving Gram-negative bacteria can occur in a 1,000-bed-type hospital, 10% to 15% of them being due to strains resistance to those antibiotics for hard-to-treat infections. You can reach a point where individual targets become counterproductive because the focus of the NHS is simply on C. diff and MRSA and not on the wider infections which clearly need to be tackled as well.
Will the regulations lead to more specific targeting which can in turn lead to perverse incentives, or is a more sophisticated approach likely to be taken? It is clear that the Chief Medical Officer is concerned about the way in which some MRSA and C. diff targets are leading to perverse behaviours.
On Part 3, the rationale for each of the thresholds described for penalties, prices and licence changes has not been explained in relation to an evidence base. In other words, why are the thresholds where they are? What work has been done to suggest that those are the right thresholds? Of course, now they will only be tested post-implementation, but it would have been good to have seen a clearer review mechanism that enabled a sensible approach.
In respect of the mechanisms to lodge an objection to the pricing methodology, my understanding is that the Foundation Trust Network has stated throughout the development of the policy that the 51% threshold for an objection, together with the denominator comprising all tariff services, is too high a threshold to be met. Is the noble Earl prepared to look at this? That might be a reasonable approach for general objections to the general approach, but it is insufficiently sensitive to address sections of the tariff that may be inadequately compensated—cancer services, for example. The noble Earl will be aware that there were issues around the tariff for children’s services and women’s services. My reading of that is that if you were a specialist adviser your chances of reaching the 51% threshold would be very limited. Could this be looked at?
If my noble friend Lord Warner were here I am sure he would raise this. It is the question of what happens to non-foundation trusts. I know that Monitor is working closely with the NHS Trust Development Authority, but I would welcome clarity about what will happen to trusts outside Monitor’s remit to ensure that there is an even-handed approach across all providers in the sector. No one is more admiring of the work of Sir Peter Carr as chair of the NHS Trust Development Authority. The noble Earl knows that Sir Peter has held chairmanships under both Governments for many years. While he is a marvellous person, there is a fear that he will hold the chairmanship of the NHS Trust Development Authority for many years to come because of the issue about what on earth will happen to those non-foundation trusts that are clearly not going to reach FT status any time soon.
The noble Earl mentioned the Competition Commission.
Lord Hunt of Kings Heath
My Lords, I was just going to refer the Minister to his remarks about the Competition Commission, because it is relevant to the regulation. There is great confusion in the health service about the commission’s role. The Minister will know that there have been interventions in Dorset and Bristol on what seem to be entirely sensible proposals. In Dorset it was the merger of two small acute trusts, while in Bristol it was the “divvying up”, I suppose the phrase is, of services between two trusts in order to allow for more patients to be treated and all the benefits that you get from that, with one trust focusing on some services and the other focusing on others. In anyone’s terms, those are both examples of the kind of configuration of services that is entirely sensible and that the Government in other guises are supporting.
It is quite clear that the OFT has been trying to get into the health service for some years. I will not get into Section 75 now but the OFT now feels that it can get into the health service, although it is very difficult to see what the point of that would be. The OFT is independent, I understand that, but Ministers have been silent about this. There is utter confusion in the health service and, I believe, among the regulators about how to run these two issues—on the one hand, the Competition Commission and OFT approach, and on the other the need for us to be aggressive in terms of the reconfiguration, and in many cases the centralisation, of services. This matter needs to be teased out.
The regulations ought to be considered in relation to more general policy on pricing as part of the national tariff. The Minister will know that in October last year, when the House of Commons Health Committee had its annual accountability hearing with Monitor, David Bennett, the leader of Monitor, talked about perverse incentives with regard to the tariff. He said that he was not sure that they were fundamental to the pricing system but he agreed that the way it is working can create perverse incentives. One example he used was that if we want to move activity out of hospitals and into a community setting, one thing we have to think about is that there some real transition costs which will have to be paid one way or another. The question is: is the tariff being adjusted to allow for that?
The Health Select Committee published its subsequent report in March of this year and concluded:
“The setting of the tariff is of great significance to the NHS because of its implications … for short term cash flows in the system, and for longer term incentives for”,
service changes. It recommended that,
“Monitor and the NHS Commissioning Board … attach a high priority to this process … because NHS parties need to know the likely tariff in 2014–15 as soon as possible, but also because the long term framework of the tariff will have an immediate effect on service design and the integration of service provision”.
I would be interested to know whether it is the noble Earl’s view that progress is in fact being made, so that the regulations and the tariff to which they relate are much more sensitive to the need for change and reconfiguration in the health service. We must reorganise our services to get higher quality, and the work that Bruce Keogh is doing is surely driving us towards this. However, it sometimes seems as though some of our regulatory apparatus is now at risk of getting in the way of what, on anyone’s evidence base, would be a sensible move. I would be interested if the noble Earl is able to respond to any of those points.
Earl Howe
My Lords, I am grateful to both noble Lords who have spoken. First, I hope that I can reassure the noble Baroness, Lady Finlay, on the question she posed about the cross-border aspects of patient flows and the tariffs that apply. The tariff will apply only to services commissioned by commissioners in England: that is to say, CCGs and NHS England. Any provider who provides healthcare services for the purposes of the NHS which are covered by the proposed tariff will be able to object to Monitor’s proposed methodology, so I do not see that patients in Wales or on the border need to be anxious about this.
The noble Lord, Lord Hunt, asked a series of questions. First, he questioned the wisdom of allowing Monitor to fine providers. It is worth saying that the discretionary requirements which Monitor can impose, as laid down in these regulations, are based on those used for other regulatory offences. In fact, they are based on Part 3 of the Regulatory Enforcement and Sanctions Act 2008. That menu of options has been picked up and put into the 2012 Act.
As regards fines, we need to be clear—and it is certainly my understanding—that Monitor regards fines as a last resort. It will need to consider each case carefully and has a responsibility to ensure that its regulatory actions are reasonable, while deterring poor conduct in the future. It must also consider whether its other powers would be more appropriate. I understand the point that the noble Lord has raised but it is unlikely that we will see Monitor exercising this power with any frequency. We must bear in mind that 10% of turnover is of course a maximum figure.
The noble Lord asked about the thresholds as laid down in the regulations. The 20% threshold relating to licensing is based on a similar process which was in place for modifying licences in the energy sector. We considered that the situation here in the health service was comparable, and it is a threshold that commanded general acceptance.
Lord Hunt of Kings Heath
I am of course aware of that but the reality is that the Competition Commission and the OFT did not really start intervening in the NHS. Clearly, they have been interested in areas such as dentistry for some time but they have not intervened in the wider NHS. I think that the problem is that it is now very unclear what is to be done when a reconfiguration of services takes place and, although I do not want to anticipate tomorrow’s debate on funding, it must be in the interest of greater centralisation of services, which, in a Competition Commission/OFT view, might be said to lead to reduced competition.
The problem is that it takes long enough to get change through in the NHS. The costs of delay to the health service if there is a Competition Commission referral and an investigation are very high. I wonder whether we can really afford it, given the imperative to get on with service changes. I know that guidance has been issued by Monitor which has reflected on the various roles, but at the end there is a lot of confusion. The Competition Commission and the OFT have not exactly made themselves available to debate either in Westminster or in the NHS about those issues. All we can read are the slightly acerbic comments by the staff of the Competition Commission and the OFT. I am not aware that they have ever made themselves available for a general discussion about their policy approach, which might be helpful in these circumstances.
Care Bill [HL]
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Baroness Emerton
My Lords, in moving this amendment I shall also speak to Amendment 86PA.
Clause 5 emphasises quality, which is to be welcomed, and places promoting diversity and quality in the provision of services in the Bill. However, on behalf of nurses, the Royal College of Nursing thinks that it is not enough merely to quote “quality”. Local authorities are responsible for commissioning services from providers and have a duty to ensure that these providers and services are effective to meet the needs of the individual. It does not believe that at the moment local authorities are fulfilling these duties and responsibilities if they commission providers who fail to deliver high-quality care and, worse, provide care that detrimentally impacts on the health and well-being of individuals, as has been demonstrated in some recent high-profile cases.
As commissioners, local authorities must be part of a system-wide approach to safeguarding vulnerable groups. They are therefore falling negligent in their role if they commission providers and services that are not sustainable and fail both financially and clinically.
The potential impact of this was demonstrated recently with Southern Cross, where the health and well-being—and, indeed, lives—of care home residents were put at risk following the failure of its business model. For this reason, I believe that local authorities have a responsibility for ensuring that services that are commissioned by them are of high quality and sustainable. The two amendments are to that effect. Amendment 86HA seeks to insert the word “sustainable” and Amendment 86PA seeks to insert the words,
“the importance of ensuring the sustainability and high quality of the providers it commissions”.
I beg to move.
Lord Hunt of Kings Heath
My Lords, as this is my first intervention, I refer noble Lords to my interests as president elect of GSI, chair of an NHS foundation trust and a consultant and trainer with Cumberlege Connections.
I have three amendments in this group. Amendment 86J seeks to delete “high quality services” and instead insert,
““services appropriate to their needs as identified in the needs assessment and carer’s assessment”.
The problem with the draft as it currently stands is that it is very vague and entirely subjective depending on who is defining “high quality services”. Perhaps the noble Earl can clarify how the Government think it ought to be defined. Otherwise, there is a risk of uncertainty and inconsistency which, certainly when it comes to eligibility criteria, the Bill is designed to eradicate.
My second Amendment 86K would ensure that those in receipt of care and those involved in providing care are involved in shaping the market, as required under Clause 5. I have received a number of submissions about the market-making role of local authorities, and I was concerned to receive a submission from the Association of Directors of Adult Social Services, which said that while the intention of Clause 5 in promoting quality and diversity within the market is laudable, ADASS was of the view that the proposed duty placed on local authorities is wholly unrealistic. It points to a large number of providers that have no relationship or contact with local authorities, and says that combined with increased personalisation and limited leverage through the regulation framework, the ability of local authorities alone to influence diversity and quality of service is restricted.
I was very disappointed with that response, and rather taken aback by it. I hope that the noble Earl will share my view that in fact local authorities ought to be able to influence not only the market but the quality of care provided by private providers to a very great extent. Would the Minister accept that, to be effective, local authorities need to have a strong engagement both with users of services and carers, and with those who are providing services, too? That is why I tabled the amendment.
I listened with great interest to the noble Baroness, Lady Emerton, and I very much agree with her about the need to ensure quality in provision of service. That brings me to my own substantive Amendment 86P, which is very much concerned with the conditions under which care workers are employed in the main by the private sector. This is a hugely important issue. Clearly, we have a growing number of disabled and older people who need care and support. The people working in the care sector are vital. We need quality people who are highly trained and who can give the right commitment to the vulnerable people they are asked to care for. Clause 5 is important because what we see is a very fragmented industry delivering care that in many cases is of questionable quality and employing insecure, low paid, unregulated staff. Amendment 86P is concerned with the importance of fostering a sustainable workforce to encourage the acquisition of skills and decent working conditions that support the continuity and quality of care.
I was shocked to see a parliamentary Answer from the Minister’s honourable friend Mr Lamb recently, showing that more than 300,000 people working in the care sector are employed on zero-hours contracts. The point that I wish to make is this: how can people who do not have the security of knowing what they will earn pass on a sense of security to the people whom they care for? The rise in zero-hours contracts is bad for service users, many of whom are, of course, extremely vulnerable. There is another issue. People who are being cared for want to see the same person to have a continuity of care relationship. We know that that is severely hindered by those wretched zero-hours contracts. I believe that secure employment would allow staff to concentrate on caring rather than worrying about whether they are earning enough money for themselves and their families to live on.
I ought to declare an interest as a member of UNISON, which produced an excellent report, Time to Care, which undertook a survey in 2012 of care home workers. It showed that 80% of those who responded had to rush work or leave a client early to go to another call on what is called call cramming— in other words, too many calls for a care worker to undertake—and 56% received between the national minimum wage and £8 an hour. The majority did not receive set wages. Not surprisingly, turnover is high, while wages and conditions are poor.
Here is a shocking statistic. Nearly 57.8% are not paid for travelling time between visits. This morning I met a carer in Southwark who works roughly 20 hours on a zero-hours contract. She reckons that, because of the travelling time, she actually works for 27 hours, but is paid for only 20. The problem is that there is a race to the bottom because local authorities are, in my view, neglecting their responsibilities for ensuring that, when they place contracts, they are with good quality organisations. The companies who are exploiting their workers in this way are winning contracts at the expense of companies who treat their employees wisely. No wonder, therefore, that 36.7% of respondents are often allocated different clients on a daily basis, so that there is no chance of any relationship being developed.
There are many other statistics. The scandal of the 15-minute visit is well known. Indeed, the UK Homecare Association survey shows that three-quarters of all trips to old people have to be completed in less than half an hour and one in 10 is limited to no more than 15 minutes.
In Committee last week, I discussed with the Minister whether the CQC could be persuaded—or indeed, I hope, instructed—by your Lordships, to prioritise the regulation and inspection of local authorities in their commissioning duties. We have heard a lot about the CQC’s past failures and future hopes. It is clear that the focus is going to be on the NHS. I do not disagree with that, but when you think of the thousands of vulnerable people dependent on care workers, I wonder if the priority is right. If I were in the CQC’s shoes, I would focus on the care sector and particularly on local authorities and their own responsibilities. That is probably the best way to get into this issue.
We could have a debate about the regulation of social care workers. We could debate mandatory training and the noble Baroness, Lady Emerton, has tabled an amendment which would very much focus on that. I hope the Minister will recognise that we have a problem here. If we are to see this legislation enacted in the way that we all hope it will be, I am convinced that we have to look at the way that workers in the care sector are employed and do everything we can to prevent the abuse that we are seeing with these zero-hours contracts.
Baroness Greengross
My Lords, I rise to speak to the amendments in my name—Amendments 86L, 86M, 86N and 86Q. These amendments are all about quality of care. We know what happens at the moment. There is the opposite of a monopoly in that there are lots of sellers, but largely one buyer of care. Many care homes know this. The local authority is in a very strong position and will tell the care home managers—in the private or voluntary sectors—that they will take 20 beds and negotiate a price which is very low. That means that the care home cannot provide a decent quality of care at that unrealistic price. This has been talked about and written about by Laing and Buisson and various other bodies. It is a known fact among those who follow very closely what goes on, but at the moment it is not really known to the public.
Earl Howe
Under the cap arrangement, there will be for all to see a notional rate that the local authority will pay for care. That is the rate at which the progress against the cap will be measured for a particular individual in a particular area. We are moving to a different system.
Lord Hunt of Kings Heath
We are almost anticipating a later debate when it comes to the Dilnot cap. This is an important issue. It is well-known, is it not, that self-funders essentially subsidise those people funded by local authorities. We know that some homes simply would not be viable if they existed only on local authority rates. In a transparent era, will self-funders put up with that? The cap relates only to local authority rates, so self-funders, in many cases, will have to pay much more than £72,000 before they can look to the local authority for support. If they now know that in addition to having to pay well above the £72,000 they have actually been subsidising people who have been supported by local authorities, I think it is going to lead to some severe problems.
I do not expect the noble Earl to be able to respond in detail, and perhaps this is in anticipation of the debate that we will have in our next session, but I am not sure whether the issue of fairness has been factored in to an understanding of how this is going to work in practice.
Earl Howe
Local authorities and individuals can pay different prices for care. That can be because individuals have consciously chosen premium facilities or because the local authority has negotiated a lower price in exchange for buying care for a larger number of people, which can often happen as well. As is the case now, local authorities and providers will continue to negotiate arrangements and fees for providing care and support. This process should ensure that contracts reflect the market price for providing care. Local authorities that fail to negotiate properly with providers and do not have regard to the actual cost risk legal challenges to the care fees that they set. However, in response to the noble Lord, Lord Campbell-Savours, I would say that in future the independent personal budget will set out the cost to the local authority. That is the transparency point that I was trying to get at earlier.
Care Bill [HL]
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Baroness Pitkeathley
My Lords, in the unavoidable absence of my noble friend Lord Warner, I shall move Amendment 74 and speak also to Amendment 75.
These two amendments give an opportunity to put into the Bill further emphasis on the importance of integration. Amendment 74 requires reviews by CQC of regulated health providers to cover the integration of those services with other relevant services. Amendment 75 does the same for reviews of local authority adult social care services. They are a clear reminder in the Bill that when CQC carries out such reviews it will have to pay attention to the issue of integration of services for the benefit of patients and service users.
I shall not detain the Committee today with yet another speech of a kind that I have made many times before on the importance of integration of health and social care services from the point of view of patients, service users and their carers. We all know how important that is. The Committee is familiar with the arguments and, more importantly, so is the Minister. Indeed, the Chancellor of the Exchequer, no less, acknowledged this in his announcement in the comprehensive spending review in regard to joint budgets. The announcement has been widely welcomed, although caution has been expressed about how these budgets will operate in practice.
The amendments are a modest attempt to give some practical effect to the aspiration for integration which we all share. I hope the Minister will say that it is a good idea, “Let’s do it”, and get us off to a cracking start this afternoon. I beg to move.
Lord Hunt of Kings Heath
My Lords, I declare an interest as a chair of a NHS foundation trust and as a consultant and trainer with Cumberlege Connections. I am happy to support my noble friend Lady Pitkeathley’s Amendments 74 and 75, which rightfully push the CQC into the direction of integration of services. I also sympathise with the amendments of the noble Baroness, Lady Greengross, Amendments 76ZZA and 76ZAA, to which she will speak later.
My Amendments 74A, 76ZA and 76ZB and my opposition to Clause 80 stand part go to the core of the purpose of CQC and its approach to performance assessment in health and social care. Inevitably, recent events at that regulator in relation to Morecambe Bay and before that at Mid Staffordshire will readily come to mind. There can be no doubt that the current leadership of CQC faces a major challenge in changing the culture of the organisation and its approach to inspections. It has much to do to restore both public confidence and confidence within the NHS about the way in which it operates. That is why this clause is so important.
Clause 80 substitutes Section 46 of the 2008 Act and provides that the CQC’s duty to conduct periodic reviews, assess performance and publish reports of such assessments, which are henceforth to be known as “ratings”, is to apply in respect of any regulated activities and any registered service providers as may be prescribed in regulations. In addition, where regulations so provide, the CQC must also review and assess the performance of the provision and commissioning of adult social services by English local authorities. CQC is to be given responsibility for determining the quality indicators against which services and providers will be assessed. This may include measures of financial performance and governance if the CQC deems this appropriate. Different quality indicators, methods and frequency in periods may be used for different types of cases. The CQC may also review the indicators of quality and method statement from time to time as it sees fit.
Let me say at once that I support the broad intention of these clauses to make the CQC responsible for rating providers and local authorities. I say again that one should not underestimate the task. It is important that the CQC is not put under undue pressure to rush to change the way that it operates and to introduce new ratings without proper pilots being done and without having enough time to do it.
I refer the noble Earl to the Nuffield Trust’s work. As he knows, the Nuffield Trust was commissioned to carry out a review for the Secretary of State into the possibility of rating providers of health and social care. It argued that the new ratings must be given adequate time to work together with a range of stakeholders in developing a system which enables both patient choice and professional leadership to drive up standards of quality. That is vital. Yet I am concerned by the document issued by the CQC recently that indicates that it is to start inspecting and regulating NHS acute hospitals, in the ways that it set out in that document, from October 2013. Indeed, from December 2013, it will begin to rate NHS acute trusts and NHS foundation acute trusts, aiming to complete them before the end of 2015.
Have Ministers put pressure on the CQC around the timing of those ratings? Secondly, does the noble Earl not think that there is a risk that the CQC will be forced to rush into a new system without proper consideration? I remind him that the chairman of the CQC has recently made a number of statements. First, he has said that the approach to inspections by the previous leadership was wrong; it was wrong to go for generalist inspections. He also says that the culture of the organisation was wrong. Given that there are about 1,000 people employed by the CQC, although I am not absolutely certain, how on earth is the culture going to change in a short period of three or four months? I just do not think it is going to happen.
I have great admiration for the current leadership of CQC, but the risk is that it is going to be forced into a new system too quickly and it could fall over. As a result, its credibility will be very much damaged. Let us face it; it is almost starting from a negative position. I must confess that I am surprised that such an ambitious timetable has been set.
Who will be assessed? As I have already intimated, the clause provides for the Secretary of State to draw up regulations laying out exactly which services the CQC will rate. They are likely to be hospitals, GP practices, care homes, domiciliary care services across both the public and privates sectors and local authorities. Will the noble Earl confirm that? Will he say why this is not specified in the Bill? Does he not consider it important enough for Parliament to decide which bodies should be assessed, and to do so in primary legislation rather than through regulations?
I asked at Second Reading whether clinical commissioning groups are to be assessed. If not, why not? The Bill allows for local authorities to be assessed for their performance in the commissioning of adult social services, so I cannot really see why NHS commissioners—the CCGs—should not be similarly covered. The same logic then applies to NHS England which, after all, has been given a massive commissioning budget in relation to specialist services. If it is appropriate for local authorities to be assessed for their commissioning responsibility, surely all health commissioners should be similarly assessed. That must apply to NHS England because otherwise I do not see who will hold it to account for the mammoth amount of resources it will spend on commissioning specialist services.
I am particularly interested in local authority assessment, particularly in the way that services are commissioned. Can the noble Earl tell me whether this is intended to be a priority for the CQC? He will know that there is real concern about the practices of many private sector providers in social care in using zero-hour contracts and allocating only 15 minutes with each client. It is vital for the CQC to be able to investigate the way in which local authorities commission those services. We will come to this in Clause 5 but it would be very useful if the noble Earl could confirm that the commissioning responsibilities of local authorities will be a priority for the CQC.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been a very useful debate and in addressing this group of amendments, it might be helpful if I began by setting out why we believe this clause is necessary.
At the moment, there is no straightforward way for members of the public to get a clear view of performance in hospitals and care homes, nor is there a measure to help drive up performance, so we believe that a new system is needed to give patients and the public a fair, balanced and easy to understand assessment of the quality of care provided. Clear ratings on performance will help to incentivise providers to improve their services, as they will be able to see how well they are doing. One of the central principles behind this clause is that it will enable the CQC to develop the new performance assessment system—informed by the views of stakeholders, of course, but nevertheless independent of government. In its report into ratings, the Nuffield Trust said:
“While there is a legitimate role for … government … to influence priorities, the process should largely be sector-led including the public and users”.
I am rather pleased that we did not debate this group of amendments on the previous Committee day because the CQC has, in the mean time, published a consultation on changes to the way in which it regulates, inspects and monitors care. I draw that to the attention in particular of the noble Lord, Lord Campbell-Savours, whose points I will address in a moment. This consultation, A New Start, sets out the commission’s initial thinking on the timetable for implementing ratings. The consultation document also sets out some detailed thoughts on how the CQC will rate NHS acute hospitals. I take the point made by the noble Lord, Lord Sutherland: this rating process will have to have some fundamental differences from that followed by Ofsted. However, the ratings will be based primarily on inspection judgments. They will be informed by a series of indicators, using data already available and the findings of other bodies such as those from accreditation schemes, clinical peer review and the judgments of other regulators. The CQC will be consulting on this model more fully later this year.
Noble Lords have raised concerns about the ability of a rating system to reflect the complexity of NHS acute hospitals. I assure the Committee that both the CQC and the Government are fully alive to this risk. The CQC is committed to producing ratings at a level which recognises the complexity of NHS services and is useful to people who use them, as well as those who commission NHS care. It is therefore proposing to provide ratings for certain individual services, such as emergency and maternity services, as well as for each hospital.
A rating will also be provided against each of the CQC’s key questions. They are: is the service safe? Is it effective? Is it caring? Is it responsive to people’s needs, and is it well led? This will mean that where the evidence is available, a trust would have five ratings at three different levels—for the individual service level, for the hospital site and for the whole trust. I am sure that noble Lords will agree that this is an ambitious aim, and one that seeks to reflect the complexity of the organisations that provide care.
The Government will draw up regulations that will enable the CQC to develop the programme of performance assessment in the manner outlined in A New Start. The consultation is the first small, but important, step in the process of developing a robust system of performance assessment of providers of health and adult social care. The first ratings of acute hospitals will appear at the end of this year: I will come on to the timetable in a moment. This will be another significant step in developing a ratings system, but it will not be the end of the journey. The Government are clear that the development of ratings will be a process of continuous evolution.
Amendments, 74, 75, 76ZA, 76ZZA and 76ZAA set out areas that the CQC must or could consider as part of its performance assessment of providers. These amendments would mean that the CQC would be required to include or consider the specific issues raised as part of its methodology. The Government share the view of noble Lords on the importance of the issues they have raised through these amendments. I am sure we can all agree that they are useful ideas. However, I hope that they will equally accept the importance of the central principle that we believe should be adhered to: that the CQC should be given freedom to develop its own methodology for the new performance assessments. The clause is deliberately designed to be flexible in that sense. I therefore hope that noble Lords will be content to withdraw their amendments, in the knowledge that the CQC is ready and willing to listen to all good ideas as it puts its final plans together.
The noble Lord, Lord Hunt, has also tabled Amendment 76ZB, which would require the CQC to undertake a pilot of its new performance assessment system and require the evaluation report to be approved by Parliament. The Government agree that the CQC’s new performance assessment methodology should be subject to evaluation. This is why, in our response to the Francis inquiry, Patients First and Foremost, the Government made the commitment that:
“The Department of Health will commission an independent evaluation of the operation of the new ratings system, and this will inform future adaptations”.
The amendment would give Parliament a power of veto over the methodology which the CQC develops for performance assessment. This is not desirable as it would constrain the freedom of the CQC to act on the findings of its consultation with stakeholders. I therefore hope that noble Lords will be content not to move that amendment.
Amendment 74A would require the CQC to undertake performance assessments of commissioners of healthcare services, specifically clinical commissioning groups and NHS England. The wording of Clause 80 could enable the CQC to undertake reviews of local authority commissioning of adult social care services. The absence of a similar requirement for healthcare commissioning therefore requires an explanation. The requirement for the CQC to review healthcare commissioning was removed by the Health and Social Care Act 2012 on 1 April 2013 when primary care trusts were abolished. This is because the function of supporting the development of the commissioning system for healthcare in England has become the responsibility of NHS England. NHS England’s role is to determine how the performance of healthcare commissioners, including clinical commissioning groups, is assessed and managed. There is therefore no need for the CQC to carry out a virtually identical role. I trust that the noble Baroness will be content to withdraw her amendment, but I would like to address the particular points raised.
Lord Hunt of Kings Heath
I do not quite see the logic of that, because in a sense NHS England has a vested interest in ensuring that all is well with the CCGs. It is not an independent body in the way that the CQC would be.
The other question is about NHS England itself. It is a massive commissioner of specialist services. If a local authority is to be assessed, I still do not see why NHS England ought not to be subject to some kind of independent assessment. It could have a huge impact on where specialist services are going to be provided in future. We know that Ministers are no longer prepared to answer questions about lots of things that NHS England does, so there seems now to be a gap in the architecture.
Earl Howe
Ministers most certainly are willing and able to answer questions about what NHS England is doing, and will continue to do so. Parliament, of course, will be entitled to keep NHS England’s performance in the spotlight; that architecture was built into the 2012 Act very deliberately. I do not accept the noble Lord’s point about clinical commissioning groups, because it is for NHS England to assure itself that the commissioning system for healthcare in England is working properly. There will be a high degree of transparency in that regard. The performance management role of NHS England will be right there, and I think that the proof of that will emerge over the coming months.
Perhaps I could cover the individual points raised by noble Lords. The first point was raised by the noble Lord, Lord Hunt, and echoed by the noble Lord, Lord Campbell-Savours, about how we expect the CQC culture to change in a relatively short time. I say to both noble Lords that I firmly believe that the CQC is already very much a changed organisation. It has a new leadership team in which I have full confidence. It has a new board—which, incidentally, the noble Lord, Lord Hunt, may be interested to know will include Kay Sheldon—and I think it has a new attitude to openness and transparency, as its handling of the Grant Thornton report demonstrates.
On 16 July, the CQC’s chief inspector of hospitals, Professor Sir Mike Richards, will start in post, so that is very soon. By September the CQC will be publishing a list of hospitals that it has the greatest concerns about, and it will be using its new surveillance system to develop this list. The CQC is committed to learning from the past and pressing ahead rapidly to improve for the future. I agree with the noble Baroness, Lady Howarth, that the CQC needs stability.
“( ) The Secretary of State, in making regulations or issuing guidelines under this Part, must have regard to the general duty of local authorities in exercising a function under this Part in the case of an individual to promote that individual’s well-being.”
Lord Hunt of Kings Heath
My Lords, I shall speak also to my Amendments 78D and 88L. I am also supportive of Amendment 79, which very much follows the thinking behind my own Amendment 78. I also support Amendment 78ZA, in the names of the noble Lord, Lord Bichard, and the noble Baroness, Lady Tyler. I am sympathetic, too, to the amendments tabled by the noble Lord, Lord Black. I have also added my name to Amendments 78A and 78B in the name of the noble Baroness, Lady Barker. She will speak substantively to those amendments, which we have proposed in a number of Bills going back many years. They try to make sure that, when a regulator is dealing with a religious care home, regulations do not get in the way of the spiritual beliefs of the residents in that home.
Amendment 78 takes us to the very important well-being principle. In its consultation paper which led to the consolidation of the social care legislation that we see in this Bill, the Law Commission proposed that there should be tightly defined processes for determining the scope of adult social care. That follows on from the debate that we have just had. Replies to that consultation persuaded the Law Commission 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 their new approach to adult social care.
Clause 1 provides for a set of legal principles which govern how local authorities are to carry out their care and support functions for adults under the Bill. Subsection (1) establishes the overarching principle that local authorities must promote the well-being of the adult when carrying out functions under the Bill in relation to that adult. This duty applies both in relation to adults who use services and to carers. The well-being principle applies to local authorities when they exercise a function in the case of an adult. My understanding is that it is not intended to be directly enforceable as an individual right, but to carry legal weight where a local authority’s failure to follow the principle may be challenged through judicial review.
This issue was considered very carefully by the Joint Select Committee, which commented specifically on the role of the Secretary of State in relation to the well-being principle. It took the view that many of the details that will shape the way in which local authorities discharge their functions under the Bill are subject to regulations and guidance issued by the Secretary of State. We will, of course, come on to one example—that is, the regulations in relation to eligibility, which we will debate not, I suspect, tonight but on another day.
The Joint Select Committee referred to Section 1B(1) of the National Health Service Act 2006, which provides:
“In exercising functions in relation to the health service, the Secretary of State must have regard to the NHS Constitution”.
The Select Committee suggested that the Secretary of State should be obliged to have regard to the requirements of Clause 1 on well-being when exercising the functions under the draft Bill. In giving evidence to the Joint Select Committee, the Minister replied:
“We absolutely want the wellbeing principle to apply comprehensively”.
The Joint Select Committee comments:
“We welcome the importance that Ministers attach to the well-being principle. We recommend that the draft Bill should include a provision requiring the Secretary of State, when making regulations or issuing guidance, to have regard to the general duty of local authorities under clause 1”.
We debated this at Second Reading. The noble Earl, Lord Howe, said that,
“Clause 1 is intended to apply at an individual level, when a local authority makes a decision. This individual focus on the specific well-being and outcomes for that person is at the heart of the way that the Bill has been drafted. It is not intended to apply in a more general way”.—[Official Report, 21/5/13; col. 829.]
He went on to say that it would therefore not be appropriate for the Secretary of State to be subject to the same duty, as the Secretary of State does not make decisions at the individual level.
I think there is an element of Ministers almost washing their hands of what actually goes on at ground level in health and social care. We have already seen that in the Health and Social Care Act 2012, and we are seeing some elements of that here. Of course, the Bill places a responsibility on local authorities to promote well-being in the way they implement the provisions of the Bill locally. However, if the Secretary of State were to issue regulations without having regard to the promotion of well-being, there is a risk that those regulations or guidance will conflict with the well-being principle. That would place local authorities in an impossible situation. For instance, if the eligibility criteria issued in regulations by the Secretary of State do not take full account of all aspects of well-being in Clause 1, local authorities may find that people who need support to promote well-being as defined in Clause 1 fall outside the eligibility criteria. I will come on to debating the eligibility criteria, but there are some aspects of the eligibility criteria which would suggest that they do not meet the well-being principles in Clause 1. I hope the noble Earl will think very carefully about this. There is a broad consensus in your Lordships’ House and within the Select Committee dealing with the draft Bill that the Secretary of State, when issuing regulations and giving guidance to local authorities, ought to be operating under the same principle of well-being as those local authorities are. It seems to go straight back to the debate instituted by the noble Lord, Lord Best, in relation to the Government legislating but not giving the wherewithal to local authorities to actually carry out that legislation effectively.
I turn to Amendments 78D and 88L, which are concerned with ensuring that health needs are taken fully into account in decisions taken by the local authority. I fully acknowledge that I have been inspired to do this by the noble Baroness, Lady Campbell. The starting point here is that it is essential to look at this through the prism of person-centred integration. As a starting point, we need to look at ways to put the individual’s and carer’s need for integrated working in the Bill and outline a statutory framework for person-centred integration that will support and incentivise local moves towards more integrated working. There are clearly points of contact here with the scheme which the Minister’s honourable friend Mr Norman Lamb announced recently for local pilots on health and social care integration.
Promoting the individual’s well-being, assessing their needs and those of their carers, deciding on eligibility and the priority for needs to be met, developing them with an appropriate care and support plan, enabling the best use of a personal budget and/or direct payment, and ensuring continuity of capacity during and after a move such as a house move are all processes or stages in which active engagement of NHS professionals or services could have a positive effect on the outcomes for individuals and carers. Integrated approaches by social care and the NHS can inform decisions, expand options, widen choice, retain or restore capability, prevent or reverse deterioration, avoid admission to and accelerate discharge from more intensive support and enable more efficient, equitable and economic use of scarce resources.
These amendments, which aim to ensure that happens in relation to the whole well-being agenda, are entirely relevant to the eligibility criteria. I remind the noble Earl that Mr Lamb, in his foreword to the document that we have received, makes the observation that,
“there needs to be better integration between local authorities and the NHS to remove gaps and build services around the needs of people”.
The discussion document’s only reference is in one paragraph which says:
“The assessment process in the Bill … provides for joint assessments between local authorities and other bodies such as the NHS. Improved integration will ensure that the person does not have to undergo separate assessments and will support better care planning to meet the individual’s overall health and care needs, or to join up whole-family assessments which look at an adult needing care alongside those who care for them”.
Of course, that is welcome as far as it goes, but there is a risk that it depends on an ill-defined concept of better integration and may well fall short of a holistic approach to well-being, assessment, care and support planning, carer support and review. We will come to the draft regulations later. This has a significant bearing on assessments for health and social care integration. The intention is to scrap the present assessment system, based on judgments about degrees of risk to areas of individual capability and exclusion from participation in various aspects of ordinary living. The new model proposes to examine people’s ability to carry out various personal care tasks and undertake a selections of household tasks. The rationale offered is that the new system will be more objective and fairer in its application, but there are some concerns here. First, this is explicitly a deficit-model of assessment, requiring individuals, their carers, relatives and social workers to almost play up or exaggerate the things that they are unable to do in order to qualify for support. In many ways, that replicates the very bad approaches that we have seen in some welfare assessments. It is certainly bad for morale and distorts the overall framework for making decisions. In one sense, one can argue that it reverses efforts over the past 20 years to maximise independence, choice and control and build on the strengths, contributions and aspirations that people can have. I must say to the noble Earl that is has some very uncomfortable reminiscence of the new approach to disability benefits, whereby people are required to prove limitations under the inexpert and unsympathetic eye of ATOL assessors. I hope that is not the approach that is going to be taken in relation to the eligibility criteria. There will be very great concern if that is to be the case.
The noble Baroness, Lady Campbell, has many examples, which I hope she might be able to intervene and provide, of disabled people with high health and social care support needs, who are ready for discharge but languishing in costly high-dependency hospital units because clinical commissioning groups have almost ground to a halt due to decision-making, with arguments about who pays being one of the many reasons for this. It is absolutely essential to ensure that when we debate and take forward the well-being concept, which of course we welcome, not only do we have a situation where the Secretary of State is subject to those principles as well, but the health service plays its part in ensuring a wholly integrated approach. As we come to debate the eligibility criteria, that is going to be a very important factor for our consideration. I beg to move.
Lord Bichard
My Lords, I support the amendment and in particular speak to my own Amendment 78ZA, which seeks to place the concepts of dignity and respect on the face of the Bill at the outset. I should declare an interest as chairman of the Social Care Institute for Excellence.
A week or so ago I visited a residential home in Edgbaston, Birmingham, and I came away convinced that I could happily live there. I am not sure that they would want me but I was convinced that I could live there if they would have me. As I reflected on that visit I asked myself why I felt so positively, because I do not always feel that way about a visit. The accommodation was comfortable, clean and not overly institutionalised. The staff were skilled and well qualified. There was a rich programme of voluntary recreational activities and a great deal of interaction between the local community and the home. A special school was visiting on a regular basis and there was clearly a bond between the residents and the students at the special school.
All very impressive, but above all, I experienced a place where residents were treated with dignity and with respect by staff who seemed to understand that people’s greatest need at a time when they have to receive some support is not to lose their dignity. Those residents wanted, above all else, to retain their dignity, and so would I.
Earl Howe
I agree that dignity is a very important concept, which is why we expressly amended the Bill to include that word right at the beginning. Clause 1, which defines the well-being principle, is the foundation for everything that follows. While one could pepper the Bill with references to the word “dignity”, I am not sure that that would add very much in practice.
Lord Hunt of Kings Heath
My Lords, I am grateful to the Minister for that response. I hope that he will reflect a little on the amendment from the noble Lord, Lord Bichard, and the noble Baroness, Lady Tyler. I understand what he is saying about the words in the Bill; I think that noble Lords just wanted to find a way of giving that greater focus. That will be well worth giving further consideration to. With regard to the amendment from the noble Baroness, Lady Barker, I am grateful for the reassurance that the Minister has given.
On Amendments 78 and 79, the Minister has essentially said that he still sticks to the general principle that the well-being clause applies to local authorities and individuals. The point here, though, and the reason why I am glad he is taking it away, is a point raised by a number of noble Lords: this legislation, which is a wholesale recasting in the light of the Law Commission’s work, is likely to endure for many years to come. That is why it is so important that the link between the Secretary of State’s duties, and those of local authorities, and the Secretary of State’s powers regarding guidance and regulations are brought together. I hope that the Minister will find a way of getting this into the Bill.
The noble Baroness, Lady Campbell, was very eloquent when she talked about what happens if health and social care do not provide an integrated service. She gave an example of a very distressing case of someone who could be out of hospital and back into work. This was down to a failure of two public bodies to sort things out. I know that the Minister says that in fact the legislation is okay; the problem is that these public bodies will continue to fail people who fall between two stools. These bodies do not seem to have an understanding that it is imperative for them to look after the interests of those individuals. I hope that the noble Baroness might return to this at a later stage.
The noble Lord, Lord Black, made some wholly persuasive arguments. My noble friend Lady Wheeler reminded me that Canine Partnerships is another organisation that is very much involved in pet companions for people with stroke, epilepsy and other illnesses. I myself have come across organisations in Birmingham in connection with the health service that do a fantastic job. All I would say is that if the noble Lord put this to a vote, the Opposition would be right behind him, so let us see. I beg leave to withdraw the amendment.
Care Bill [HL]
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Lord Low of Dalston
My Lords, I was waiting to see whether the noble Lord, Lord Hunt, was going to speak to his amendments in this group—
Lord Hunt of Kings Heath
Thank you very much. My Lords, I think this is a very interesting group of amendments and the noble Baroness, Lady Greengross, in her Amendments 78C and 79K—to which I have added my name—and her other amendments makes some very important points about the need for a preventive approach, including its health dimension. My noble friend Lord Touhig has added his powerful voice to it.
In Amendments 79K and 80A there is a real issue here about the national minimum eligibility threshold. It would provide some certainty for some adults about whether their care needs will be met, but we know there will be many people whose needs remain just below the level at which local authorities will at a minimum need to meet through the national eligibility criteria. We know the Ending the Other Care Crisis report produced by Scope with four other charities estimates that 105,000 working-aged disabled adults will in fact continue to rely on universal services. This places greater responsibility on local authorities to put in place the necessary services to help prevent, delay or reduce care needs.
There is an argument for framing Clause 2 more positively to encompass the many diverse forms of preventive support that local authorities could put in place to prevent deterioration in the well-being of adults in their area. We want local authorities to be more ambitious and to think about prevention more positively. While understanding the pressures that undoubtedly local authorities will be under, these amendments would give a very powerful voice to the need to go down the preventive route.
My Amendment 79A, to which the noble Lord, Lord Low, has added his name, continues the same theme on placing a general duty on local authorities to prevent, delay or reduce the need for care and support. We know that in Clause 2 there is a requirement on local authorities to look at how they can make the best use of community facilities to prevent, delay and reduce needs for care and support. That is very welcome indeed but the question is: to what extent are local authorities geared to put that into practice? Hence I have tabled this amendment. I think we need give a push to local authorities to take this seriously. I hope the noble Earl will be sympathetic to agreeing to some form of amendment which would reflect this in Clause 2.
The noble Lord, Lord Low, has a number of other amendments in this area which I would very much wish to support, although I have not lent my name to them. They are very well framed and important. Coming back to the issue we discussed in the debate just before the dinner break, this legislation may well stay on the statute book for many years to come, so it is really important to get it right. The emphasis that the noble Lords, Lord Low and Lord Rix, have given to these points bears careful consideration, so I am very happy to support them.
Lord Low of Dalston
I thank the noble Lord for his anticipatory support of my amendments, and perhaps I may return the compliment by saying that my name is on five amendments in this group and I have the most copious set of notes I have ever had in any debate. I hope that noble Lords will bear with me at this time of night, but with five amendments, there is quite a bit to go through.
As the noble Lord, Lord Hunt, said, I have put my name to his Amendment 79A and to that tabled by the noble Baroness, Lady Greengross, and in the names of the noble Lords, Lord Hunt and Lord Touhig, Amendment 79K. There are the same group of Peers on Amendment 80A, but Amendments 80C and 87F are in my name only, so I shall obviously spend a bit more time on them.
Before that, I shall say a few words on Amendments 79A, 79K and 80A. Clause 2 would be stronger if local authorities were also placed under a general duty to take prevention into account in exercising any of their functions under Part 1, not just those relating to direct provision of care. Amendment 79A would ensure that local authorities act to “prevent, delay or reduce” individual care needs across every one of their functions. Amendment 79K would ensure that the prevention duty focuses on what a local authority must do to prevent a deterioration in well-being, in addition to preventing, delaying or reducing the need for care and support. Amendment 80A would oblige authorities to have regard not just to the importance of identifying adults and carers with needs for care and support and the services available to meet those needs, but,
“the steps it could take to improve and enhance the provision of services, facilities or resources in its area”.
The idea would be to ensure that local authorities actively consider what more they could do to prevent needs for care and support above and beyond identifying existing services, facilities and resources in the authority’s area.
The Bill currently stops short of that, which is bad news for the hundreds of thousands of older and disabled people who are not deemed eligible for adult care and support. It is also bad news for the Government’s aspiration to rebalance the system away from crisis interventions in a more preventive direction. The amendments suggest a more strategic approach which, by putting in place services at the community level, not just directed at individual care, could ensure that those who did not reach the eligibility threshold were, nevertheless, not bereft of support entirely. In other words, they provide a means of enabling available resources to go further by deploying them strategically in aid of prevention.
The kind of preventive services I am thinking of might be of six types. First, there are enabling services, preventing harm before it occurs—as you might say, working well away from the cliff edge. Secondly, there are services that prevent care needs from developing: for example, reablement or specialist rehabilitation to help an adult with sensory loss or a falls prevention service for older people discharged from hospital. Thirdly, there are prompt interventions, detecting and responding to early signs of difficulty, forestalling problems which could lead to more serious consequences —as you might say, working just over the edge of the cliff. Fourthly, there are services that help to delay care needs once they have started to emerge, for example, home adaptations for those no longer independently mobile or befriending services for the recently bereaved, perhaps funded by the local authority but delivered by a local Age UK. Fifthly, there are services that reduce care needs once they have started to intensify, for example, a stroke rehabilitation service provided alongside the NHS to help adults to regain control over key activities of daily living.
Sixthly and finally, there are acute interventions reducing the impact of a situation spiralling down—working well down the cliff, you might say. Wales furnishes an example in the Social Services and Well-being (Wales) Bill, which is currently before the Welsh Assembly. I hope the Minister might be willing to take a look at that. The corresponding section of that Bill, Section 6(4), explicitly states that a local authority must, in the exercise of its other functions, have regard to this preventive services clause in the Bill.
Baroness Royall of Blaisdon
My Lords, I shall speak to Amendment 79L tabled by the noble Lord, Lord Patel, who unfortunately cannot be in his place this evening. The purpose of the amendment to which I have added my name is to ensure that carers are identified and signposted to the enhanced support outlined in the Bill as early as possible and before they reach crisis point. I put my name to this amendment following a discussion with Macmillan, to which I am very grateful for its excellent briefing, about the situation of approximately 905,000 cancer carers in England, half of whom are not receiving any support despite the fact that cancer has a real impact on their lives. Of course, the impact is nowhere near as big as that on the person with cancer but nearly half of carers say that it affects their mental health and well-being; one in five says that it affects their relationships and working life; and 15% say that it affects their household finances. Almost half of cancer carers identify at least one type of support they are not currently receiving that would assist them with their caring duties. They are in real need of help but are not aware of who or where to turn for support.
As many noble Lords will know from personal experience, the real problem is that many cancer carers do not think of themselves as carers but they might well need information, advice or support. Indeed, my noble friend Lady Pitkeathley has just made the same point in general about all carers. They have no idea about things such as the local authority carers’ assessment, which is the gateway to statutory support. Consequently, the number of cancer carers who have had such an assessment is far lower than for those caring for people with other conditions and disabilities. Evidence shows that health professionals simply do not identify cancer carers as carers and do not signpost them to help or support.
Therefore, while I welcome the fact that the Care Bill enhances rights for carers, including placing a new duty on local authorities to undertake a carers’ assessment for all carers and to meet the eligible needs of carers, there is a gap which this amendment is designed to fill. Cancer carers have a lot of contact with the NHS but they seldom come into contact with local authorities. This amendment would help to ensure that all NHS bodies work with local authorities to improve the identification of all carers so that in turn they can be assessed and access appropriate support.
In the Care and Support White Paper the Government said that,
“there is still an unacceptable variation in access to tailored support for carers”.
It outlines its requirement for,
“NHS organisations to work with their local authority partners … to agree plans and budgets for identifying and supporting carers”.
This amendment would provide a vehicle for ensuring that this optimal practice of joint identification and partnership became a reality throughout England where, at the moment, the identification is at best patchy and at worst non-existent. Local authorities should take the lead but they could benefit greatly from the help of many relevant health bodies such as NHS England, CCGs, and primary care and hospital trusts which already have procedures and systems in place to identify carers. Clearly, that does not always happen.
The amendment would not lead to additional expenditure. In fact, if carers were identified as early as possible, when in most cases they just need signposting to information and advice, it could save money. Fewer carers would reach the sort of crisis point that requires NHS support for themselves and local authority support for the person for whom they are caring.
On Saturday, I was in Torbay and I talked with some people about their excellent system of integrated healthcare in which they understand that a whole-system approach is needed to support carers and that proactive identification is needed by the NHS. I was therefore interested to read a quote from Mr James Drummond, lead officer for integrated services at the Torbay and Southern Devon Health and Care NHS Trust, in which he says:
“If we wait for carers to approach us we may not engage until there is a crisis. Proactive identification is good practice, but national support is needed to spread this across the country. It should be made clear that identifying carers and signposting them to support is the responsibility of all health and social care professionals, not just local authorities”.
That says it all. I know that the Government recognise the need for the NHS and local authorities to work together on this important issue so I very much hope that the noble Earl will use this amendment and agree to look at ways of formally involving the NHS in the local authority duty to identify carers.
Lord Hunt of Kings Heath
My Lords, this is a very important group of amendments, and I very much support my noble friend Lady Pitkeathley in her Amendments 78F, 79E, 79H, 88C, 88E and 88F. I also support my noble friend the Leader of the Opposition in her Amendment 79L, emphasising the importance of working with the National Health Service.
My Amendments 79F, 79J and 79M to Clause 2 concern the position of young carers. They aim essentially to ensure that local authorities provide or arrange services to prevent young carers from developing needs for care and support, as well as preventing and reducing needs for adults and adult carers. The 2011 census identified 178,000 young carers who have to care for a relative in England and Wales alone. It is good that the Government have now acknowledged that, given the changes being introduced by the Care Bill for adult carers, the law must also be reviewed for young carers. However, we need a much clearer indication of what these changes will look like and particularly of how the Care Bill will ensure that adults receive sufficient care and support so that children are protected from excessive and inappropriate caring roles. We cannot have a situation where people have unmet care and support needs, which results in children and young people having to meet these needs.
I recently met a young man who had been caring for someone in his family for most of his life. He told me that it would have made a huge difference to him if his family had received support earlier. If this had happened, his caring responsibilities might not have had such a clear and serious impact on his education. He is doing well now and hopes to go to university, but it has clearly been extremely challenging for him to stay in education, and there are many thousands of other young people who have been similarly affected. That is why my amendments to Clause 2 are so important. They make clear that local authorities must take steps to prevent children from carrying out caring duties that have a detrimental effect on their health and well-being. Can the noble Earl assure me that the Care Bill will be amended to ensure that this is the case? If he can, I would welcome an indication of which parts of the Bill will be amended so that young carers are protected.
My other amendments on this issue are to Clause 12, which provides for regulations on whole-family assessment. Again, the Government have indicated that they will look at how the law might be changed for young carers in the Bill, but it is not clear how that might be done. We know that currently adult social care services and health services routinely fail to identify children who may be caring for an adult, even where the adult is assessed. That also applies to educational establishments. That means that often children can continue to undertake harmful caring roles and end up developing needs for care and support themselves.
It is very important that adult needs assessments relate to any child in the household, so that inappropriate caring by children is prevented and children's needs for support are prevented or reduced. The law must be clear that adult services need to help to identify young carers. The presence of a young carer should always constitute an appearance of need for the family and should automatically trigger an assessment of the person for whom they care. Can the noble Earl confirm that this is indeed the Government’s view? Will it be made clear, through primary care or regulations, that there should be consideration of whether a joint child and adult assessment would be appropriate and that children’s services should work together; consideration of whether any child should be assessed for support in their own right under children’s law; and consideration of whether lower-level support may be needed for the whole family, including the child?
It is a pity that we are taking this important debate at so late an hour, and no doubt we will return to this matter on Report, but I look forward to the noble Earl’s response.
NHS: Mid-Staffordshire NHS Trust
Lord Hunt of Kings Heath Excerpts(12 years, 7 months ago)
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Earl Howe
My Lords, the latest figure that I have for the cost of the Department of Health’s media centre is for 2011-12 and is £2.57 million. I will write to my noble friend as soon as I have more recent figures. She may be interested to know that the names and contact details of each of the department’s press officers are published on the GOV.UK website. Currently, 28 Department of Health press officers are listed there. I do not have to hand the details of the number of press officers employed by NHS England, but, again, I shall write to my noble friend with that information. In the department and in NHS England, internal line management arrangements are in place to measure performance.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. I was very interested in the Minister’s first response, in which he agreed that oversensational statements about the NHS are doing great damage. Has he shared that view with his right honourable friend the Secretary of State? Hardly a day goes by without the Secretary of State taking an opportunity to attack various aspects of the National Health Service. Will he take it from me that this is having a very bad effect on morale in the NHS? His right honourable friend should desist, and a period of silence from him would be very welcome.