Health and Care Bill

Baroness Altmann Excerpts

2nd reading
Tuesday 7th December 2021 Lords Chamber

[Baroness Altmann (Con)]

My Lords, I too congratulate the noble Lord, Lord Stevens, on his excellent maiden speech. I am delighted that he has joined the House, with all his many years of expertise in this area. I look forward to his contributions at future stages of the Bill.

In the time available, I will focus on issues relevant to elderly social care. Some 10 million adults are affected by care needs. Some are short term and others very long term, but over the next 20 years the number of people over the age of 85 will rise from 1.4 million to 2.4 million. Estimates suggest that about 44% of the over-65s already have some form of disability. Clearly, the costs of delivering social care and the amount spent on it in our society will significantly increase.

Council expenditure on care is already over £20 billion a year, with around half of that on the over-65s. But this is almost the same in real terms as it was in 2010. What has happened is that councils are increasingly rationing care, and unmet care needs, especially among the elderly, are rising inexorably. The funding is starting from an exceptionally low base. Much more attention needs to be given to delivering social care.

There are welcome points in the Bill. I welcome the intention to provide a care and support plan to arrange services in order to help people live independently and to prevent or delay the need for care, and the recognition that it is best if people can stay in their own homes. I also welcome the new CQC duties to independently review and assess local authority performance in delivering what the 2014 Act was designed to deliver, which we still have not yet successfully done.

I echo the points other noble Lords made about the need to invest in the workforce, and the fears. What is the Government’s plan to ensure additional workforce capability and capacity now? I fear that we have had a couple of unforced errors—mandatory vaccination for care home staff before it is required in the NHS, and new immigration controls that mean we cannot get staff in from overseas. The pay for social care workers, for whom there is already a 30% turnover rate across the sector, especially front-line staff, is now lower than for shop assistants or cleaning staff, who have better working conditions. I would welcome the Government’s estimate of the number of care staff needed and how they plan to deliver those.

I welcome the extension of prevention measures and the focus on commissioning, with the CQC overseeing the payment of fair rates for care, but I note that the Government continually say that they intend to move towards the local authority paying a fair rate to cover costs. In 2017, the CMA estimated that self-funders pay an extra 41% to cross-subsidise the underpayments by those funded by the councils. Do the Government have an estimate of when councils will actually pay enough to cover the costs, so that we do not put extra burdens on the very people who need care and are funding it themselves?

Regarding the care cap, £86,000 is not a cap on the amount people need to pay for care. Clause 140 has made the inequity even worse. With a fixed cap, those of more modest wealth will inevitably lose far more as a proportion of their assets than people who are much wealthier or who live in areas with higher property values. I hope the Government will pay close attention to the needs of elderly people who do not yet receive care, and the unpaid carers who will look after them, often at the expense of their own health.

Health and Care Bill

Baroness Altmann Excerpts

Lords Hansard - Part 2 & Committee stage
Wednesday 26th January 2022 Lords Chamber

[Baroness Merron (Lab)]

My Lords, it is essential that we get the arrangements for the Care Quality Commission right throughout the Bill, and I am grateful to the noble Lord, Lord Lansley, for trying to do that through these amendments. If the health and social care provided is to be of the highest standards, we must ensure, through the powers of scrutiny and review in your Lordships’ House, that we enable the watchdog to have the proper tools and framework to achieve that, so I support the amendments.

As the noble Baroness, Lady Brinton, emphasised, this is about putting the responsibility in the right place to ensure that a key inspectorate can do an independent job and support proper integration and delivery. I hope the Minister will accept the good sense in these amendments.

[Baroness Altmann (Con)]

Can I briefly ask my noble friend whether part of the thinking behind the current wording might be that the remit of the CQC may need extending? For example, when it comes to private operators of social care, the CQC currently does not have the power to look at the financial stability of those operators. Is this provision perhaps based on the thought that the Secretary of State may need to widen the remit and powers of the CQC? If not, we will be returning to this at some point.

[Earl Howe (Con)]

My Lords, I thank my noble friend Lord Lansley for bringing this debate before the Committee. He has made some worthwhile points but I hope to be able to explain why I think his amendments should not be pressed.

My noble friend Lady Altmann is not quite right in what she suggested was the intention of Clause 26. Clause 26 will allow the CQC to look across the integrated care system to review how integrated care boards, local authorities and CQC-registered providers of health, public health and adult social care services are working together to deliver safe, high-quality and integrated care to the public. That will include the role of the integrated care partnership. These reviews serve several functions. They will provide valuable information to the public, help drive improvement, and review progress against our aspirations for delivering better, more joined-up care across the system.

These amendments would remove the requirements on the Secretary of State to set and approve the priorities for these reviews. They would also remove the Secretary of State’s ability to direct the CQC to revise the indicators of quality that it will determine for these reviews. Instead, the amendments would add a requirement on the CQC to consult on those indicators with the Secretary of State, prescribed persons and other persons considered appropriate.

I entirely see where my noble friend is coming from as regards the CQC’s independence, but I must tell him that we have thought about this issue very carefully and we think it is right that the Secretary of State, who is accountable to Parliament, should have the flexibility to set the overall strategic direction of these reviews, with priorities and objectives. That is not an open-ended facility. In the other place, we accepted an amendment to develop this further by making it clear that the priorities set by the Secretary of State must relate to leadership, integration, and quality and safety. The amendment would remove that certainty.

As I have already mentioned in previous debates, there will be quite a range of different forms of accountability and oversight within the system, including NHS England’s role in overseeing ICBs. As a result, we think that the Secretary of State should play a strategic role to ensure that the CQC reviews complement the other oversight and accountability mechanisms. This will be achieved, in part, through the Secretary of State’s approval of the quality indicators. To provide my noble friend with an analogy, we believe, as I am sure he does, that there is a proper role for the Secretary of State in setting the strategic direction of NHS England. He does this, of course, through the mandate.

Finally, the drafting of this clause is not an accident. It is drafted deliberately to protect the independence of the CQC in how it operates, while also encouraging consultation and collaboration. It will allow the CQC to develop its approach in collaboration with NHS England and other partners in the system. The CQC is already intending to develop its approach to these reviews co-operatively and is able to consider a wide range of views in doing so. We do not think it is necessary to require it to consult.

I hope this has given my noble friend some reassurance as to why we have taken the approach we have and, for these reasons, I ask him to withdraw his amendment.

Health and Care Bill

Baroness Altmann Excerpts

Lords Hansard - Part 1 & Committee stage
Monday 31st January 2022 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I strongly support this group of amendments. I particularly endorse Amendment 269 regarding young carers, which was spoken to so compellingly by the noble Lord, Lord Young.

I wish to speak primarily about Amendment 221, to which my name is attached. It is about protecting existing rights of carers. I know that the point has already been made, but it is worth repeating. Amendment 221 would retain existing rights being taken away by this Bill as it repeals the Community Care (Delayed Discharges etc.) Act 2003. I find that a pretty extraordinary position to be in.

I want briefly to focus on the impact of caring particularly on women and employment, without in any way wishing to diminish the very important role played by male carers within the family. It is just a fact that women are more likely than men to be carers. According to some research conducted by Carers UK with the Universities of Sheffield and Birmingham, women have a good chance of becoming carers 11 years before men. Women are also more likely to reduce their working hours in order to care, and they are more likely as a result to have lower incomes and end up under-pensioned in retirement.

As we have heard, hospital discharge can be a pivotal moment for people providing care, particularly women. This amendment would ensure that assumptions are not made about carers’ ability to care, even when they may be working at the same time, that a solution is discussed and, ideally, agreed between families and services, and that carers are provided with the support they need to enable them to care safely and well. For those carers who are juggling work and care, which I can relate to personally, it is essential that their health and well-being are supported. This also has a positive benefit for employers. During the pandemic, the Carers UK research already referred to found an increase of around 2.8 million in the number of people who were juggling work and care, the majority of whom were women. Prior to the pandemic, some 600 carers a day were giving up work to care. During the pandemic, as the noble Baroness, Lady Pitkeathley, reminded us, carers have become the backbone of the care system, protecting the NHS and social care in many cases from collapse.

The Carers UK research also found that 72% of carers providing substantial care and working were worried about continuing to juggle care and work, and 77% of carers said that they felt tired all the time at work because of their caring responsibilities. During the pandemic, 23% of working-age carers providing substantial care had given up work, lost their jobs, lowered working hours or lost income if they were self-employed.

As the NHS works to reduce the backlog of care, hospital discharges will become ever more critical, as will support for carers. The two go hand in hand, and we must not fail those who have so selflessly shouldered such a heavy load.

[Baroness Altmann (Con)]

My Lords, I shall speak to all the amendments in this group, but I have added my name to Amendment 217 in the name of the noble Baroness, Lady Wheeler. There are two separate but related issues in this group of amendments, and it might be helpful for a moment to focus on them. The first is the needs of patients who are facing discharge from hospital. The second is the needs of unpaid carers in situations where patients are sent home from hospital. That second issue is covered particularly by Amendments 219, 221, 225 and 269. I support all of them, and commend the work and the words of the noble Baroness, Lady Pitkeathley, and the passionate speech from my noble friend Lord Young.

I wholeheartedly share the concerns about the repeal of the provisions in the Care Act 2014. The issue of patients needing to be discharged from hospital sometimes seems to be spoken of as if we are discussing objects rather than people.

Health and Care Bill

Baroness Altmann Excerpts

Committee stage
Friday 4th February 2022 Lords Chamber

[Baroness Tyler of Enfield (LD)]

My Lords, I support these amendments from the noble Baroness, Lady Bennett. I thank her for putting them forward. The care sector is both complex and very little understood. Back in 2020, there were approximately 15,000 care homes in the UK, run by approximately 8,000 providers. Some were very small; others were providing very large networks of homes—it is a mixed economy. These figures are a couple of years old but, at that time, 84% of homes were run by the private sector, including by private equity firms, both British and offshore.

Funding is a complex mix of private funders, local authorities and the NHS. I was very grateful to the noble Baroness, Lady Bennett, for highlighting the work that the Financial Times has done, because I was first alerted to this issue by an investigation that the paper did back in 2019 which revealed how Britain’s four largest privately owned care home operators had racked up debts of £40,000 per bed, meaning that their annual interest charges absorbed eight weeks of average fees paid by local authorities on behalf of residents. Many have argued, and I absolutely agree, that this sort of debt-laden model, which demands an unsustainable level of return while shipping out profits of 12% to 16%, often to tax havens, is entirely inappropriate for social care.

I want to make it clear that I do not have an ideological problem with the private sector being involved in the care sector and providing care homes—provided that they are good quality—but I have a real problem with the financial models used. Most fair-minded people in this country, not least those whose loved ones are in care homes, would, frankly, be horrified if they knew how the money—either theirs, if they are self-funded residents, or indeed the money of hard-pressed local authorities—was being used and where it was being siphoned off to.

I greatly support amendments to increase transparency and reporting. Frankly, I would like to see the regulator being a lot tougher and a lot more proactive in this area, so I very much support the review in the amendment put forward by the noble Baroness.

[Baroness Altmann (Con)]

My Lords, I support the thrust of the amendments laid by the noble Baroness, Lady Bennett. I fully agree with her that there is a systemic problem in the care home sector.

In 1991, the community care Act reforms meant social care was transferred from a public sector function—or NHS function when it came to nursing homes—to what was called a mixed market. But, having observed the worsening care crisis, the financial engineering, the periodic failure of large care home operators and the inadequacy of regulation or oversight of their financial backing, I cannot help but urge my noble friends on the Front Bench to look urgently at the need for much greater controls. Southern Cross and Four Seasons Health Care have been in and out of insolvency or near bankruptcy for the past few years, but there are still inadequate controls on their ownership structure.

--- Later in debate ---

[Baroness Barker (LD)]

My Lords, it has been a great privilege to work alongside the noble Baroness, Lady Deech, and I can only admire the persistence with which she has stayed on this issue to get the change which so many people have wanted for so long, and for such good and compelling reasons. I am but one of several Members of your Lordships’ House who have taken part in debates on assisted reproduction over many years.

It was a privilege to discuss these matters in the presence of Baroness Warnock, who was responsible for setting the ethical framework, all those years ago, to which we still refer when dealing with these matters. She was a remarkable person and one of the most important things she did was to foresee that science, knowledge and society would change. What she did was to set down a basic ethical framework, to which we could return as knowledge and scientific understanding increased. This provision is one such part of that.

Other issues in the field of reproductive medicine are equally deserving of our attention. For example, we are starting to uncover the extent to which LGBT people face unfair discrimination when it comes to access to assisted reproductive technology. If, in a heterosexual couple, one of the partners happens to be HIV positive but it is undetectable, and therefore untransmissible, the couple will not be disbarred from receiving treatment; that is not so for lesbians and gay men.

In the last week, some of us who work on these issues have been engaging on the issue of access to telemedicine. In this field it is true, as it is right across the NHS, that it is important to make these services more widely and easily accessible to women by using telemedicine. I hope the Minister might confirm that on another important aspect of women being able to control their fertility, in access to abortion services, we may see the extension of the highly successful scheme which has been run throughout the pandemic to enable women to have consultations and receive treatment at home. In that vein, and in the hope that we may fairly soon have a more comprehensive review of advances in reproductive medicine, which is needed across the piece, it is very pleasing today to welcome this amendment.

[Baroness Altmann (Con)]

It is a pleasure to follow the noble Baroness, Lady Barker, and I too commend the noble Baroness, Lady Deech—my noble friend, really—for all her work in this area. I particularly thank my noble friends the Minister and Lord Bethell, who I know have listened carefully and responded in the most compassionate and caring way. They have done a great service for many women across the country. I thank my noble friend for these amendments.

[Baroness Thornton (Lab)]

When the Minister and I were discussing government amendments, on this issue I said: “If Baroness Deech is happy with this, then I am happy with this,” and indeed I am.

Health and Care Bill

Baroness Altmann Excerpts

Lords Hansard - Part 1 & Report stage
Monday 7th March 2022 Lords Chamber

I am afraid that we are on the wrong course here and getting out of it will not be easy. However, this is a weight of public expenditure that is ill directed, aimed at—and indeed entirely benefiting—the better-off half of the population, and which does nothing for the worse-off half of the population, who, most of all, need better care. It is misconceived policy in today’s circumstances and I hope that the amendments, apart from my own, will not carry.

[Baroness Altmann (Con)]

My Lords, I rise briefly to support Amendment 141, which I would have added my name to had my noble friend Lord Lansley not done so himself. As he is not here, from these Benches I add my support for the deletion of Clause 155. As an adviser to the Dilnot commission at the time—around 2011—I believe it runs directly counter to the aims of the cap, which had such strong cross-party support. I am sorry to say to my noble friend that I struggle to understand the Government’s concept of fairness in this regard when Clause 155 imposes much greater losses of wealth on the least well off and forces longer waits on them while those with significantly more assets lose only a small proportion of their wealth before state funding starts.

I support Amendment 141. I hope my noble friend will either be able to accept it or that the other place will have a chance to consider this unfair change, which was added at the last moment without giving Members there an opportunity to do so.

[Baroness Greengross (CB)]

My Lords, I am in favour of deleting Clause 155, as proposed by the noble Baronesses, Lady Wheeler, Lady Brinton and Lady Campbell. I will also speak to my Amendment 182, which would lower the social care cap to £51,000 from 2023. I will not be putting my Amendment 182 to a Division but I feel that it is important to bring it back on Report as this would be the level of the cap recommended by the 2011 Dilnot report, then adjusted for care cost inflation. I understand that the Government’s cap of £86,000 is based on the increase in property values since the Dilnot report was published—can the Minister please confirm that? If so, was this for properties throughout the country and does it factor in that, while property values in London have increased significantly over the last decade, in many parts of the country they simply have not? Can the Minister please explain how the Government came up with that figure?

Clause 155 is a break with what is currently in the Care Act, which would mean that means-tested support does not count for an individual’s progress towards the social care cost cap. According to analysis from the Institute for Fiscal Studies, with Clause 155, someone with that care need who has an annual income of £16,000 and assets of £100,000 would take almost six and a half years to reach the cap, whereas without Clause 155 the cap would be reached after three to four years. I declare my interest as set out in the register as co-chair of the All-Party Parliamentary Group on Dementia. For many people with long-lasting forms of dementia who require many years of care, Clause 155 will disadvantage them considerably.

I will be voting to delete Clause 155 and for the Government to return to the sound and sensible recommendations from the 2011 Dilnot report, with numbers adjusted for inflation, and implement them.

Health and Care Bill

Baroness Altmann Excerpts

Consideration of Commons amendments
Tuesday 26th April 2022 Lords Chamber

Motion D says that there must be an evaluation of the trailblazer and that assessments can happen as they go along, but there is a big risk to the Government there. If there are problems, which we believe there will be—not least the financial impact on some of the most vulnerable adults in our community—they will not surface until it is too late. Therefore, from these Benches we support Motion D1 and urge the Government, even at this last minute, to reconsider.

[Baroness Altmann (Con)]

My Lords, I follow the noble Baronesses, Lady Brinton and Lady Campbell, and will confine my brief remarks to social care, which I have long worked on. Sadly, the measures in the Bill will not rise to the challenge as required to sort out the social care system in our country.

I accept and congratulate the Government on the concessions that they have made. I am delighted to see Motion C on modern slavery. However, as far as social care is concerned, I would like to understand from my noble friend, on workforce planning, whether private care homes and non-state care home staff will be assessed as to adequacy. At the moment, there are horrendous staff shortages, and the current immigration policy does not seem to include carers—an essential element of the workforce—because of the pay structures. If he could explain what the social care workforce elements of the Government’s proposals are for the non-state social care sector, I would be most grateful.

I am not planning to vote against the Government on Motion D1, but I am afraid that I cannot support them. I put on record that I agree with everything that has been said about the Government’s changes to the social care cap. I believe that the measures are regressive; they will damage the least well off—or the lower end of the middle range of people, shall we say. They may be better than the current system, but they are not a solution and are not satisfactory. We will end up having to revisit the support for social care. Having said that, and in view of the fact that this is financial privilege, I will not vote against the Government on Motion D1.

[Baroness Bennett of Manor Castle (GP)]

My Lords, I rise very briefly to offer Green support for both Motions A1 and D1. Motion D1 has already been very amply covered, most notably by the noble Baroness, Lady Campbell of Surbiton, so I will just address my remarks to Motion A1.

I know that many Members of your Lordships’ House feel as though we do not want to be political about things—I might have thoughts about that—but this is not a political amendment at all. As the noble Baroness, Lady Merron, said, more than 100 of our major healthcare organisations have expressed support for this workforce planning approach. Just a couple of hours ago, and this addresses your Lordships’ House directly, the British Heart Foundation put out a press release saying that, without this amendment, it is

“unclear how ambitious targets laid out in the Elective Recovery Plan and other NHS delivery plans can be met.”

The chief executive said that

“the Government has missed an open goal by failing … to address the workforce shortage”.

In addition, just yesterday the King’s Fund put out a report saying that the Government—they can welcome this—are “on track” to meet their target of “50,000 extra nurses” by 2024. However, the King’s Fund points out that the level of vacancies is still the same as it was when that promise was made. Just plucking figures out of the air and going, “Hey, we’ve got this great figure”, is not enough; we need to plan for the future. That is why this amendment is absolutely crucial for our NHS.