NHS: Mental Illness

Baroness Greengross Excerpts

Tuesday 17th July 2012 Lords Chamber

[Baroness Greengross]

My Lords, is the noble Earl able to deal with two blatant forms of age discrimination? The first is that the talking therapies are very often denied to older people; pharmaceutical alternatives are cheaper. The other is that, when a diagnosis of dementia is made, the way in which services are organised now means that those services have to be funded by local authority social care rather than the NHS. Given that dementia is a terminal disease, does the noble Earl not feel that this is unfair?

[Earl Howe]

My Lords, yes, and we have laid great emphasis on the need to bear down on unreasonable discrimination against elderly people. The noble Baroness is aware that the requirement to reduce inappropriate anti-psychotic medication for the elderly is a key part of the Prime Minister’s dementia challenge. Therefore, I identify completely with the remarks of the noble Baroness on that issue.

Carers: In Sickness and in Health

Baroness Greengross Excerpts

Wednesday 11th July 2012 Lords Chamber

[Baroness Greengross]

My Lords, have the Government developed any plans to support carers after the person for whom they are caring dies? Many carers spend up to 20 years doing the caring job. Once the person for whom they are caring dies, they are stranded. They have no job to go back to. They have lost most of their friends and are totally isolated. They suffer bereavement in a different way from the rest of us and need long-term support. Are there any plans to deal with this problem?

[Earl Howe]

As ever, the noble Baroness makes a really important point, and it is one that we fully recognise. In our plans to roll out psychological therapies, carers are very much within the scope of our thinking. As the noble Baroness will know, last year we published a four-year plan of action. We are investing around £400 million—the same sum of money that I referred to but additional to the other sum—in talking therapies: the Improving Access to Psychological Therapies programme. I am sure the noble Baroness will be glad to know that that investment is already making marked improvements, and there is a substantial increase in the number of people receiving the benefit of IAPT.

NHS: Spending Formula

Baroness Greengross Excerpts

Tuesday 3rd July 2012 Lords Chamber

[Earl Howe]

My Lords, it is of course for the devolved Administration in Wales to decide on their own allocation of the health budget for Wales. That is not within my gift, as the noble Lord will understand. However, certainly within England we would expect the funding allocations to support the principle of securing equivalent access to NHS services, relative to the prospective burden of disease and disability. Because we have an independent NHS Commissioning Board, people can be assured that this will put beyond doubt that allocations are driven as far as possible by each population’s need for healthcare services and not by extraneous factors.

[Baroness Greengross]

My Lords, later this afternoon the All-Party Group on Dementia, which I am privileged to chair, will launch a report on the rates of diagnosis, the challenge of dementia and how it can be met. We know that more than half of all people with the disease have not been diagnosed. Diagnosis offers access to a memory clinic that can reduce the impact of the disease or postpone its worst effects. Is the Minister aware that the variations across the country are horrific and that people do not know where to go? Will the Government do something to ensure that everybody has access to the care and support that they need in an area that they can reach?

[Earl Howe]

My Lords, we come back to the issue of age in this context. I say again that we believe, as did the previous Government, that age is the primary driver of an individual’s need for health services. The very young and the elderly, whose populations are not evenly distributed throughout the country, tend to make more use of health services than the rest of the population—the noble Baroness gave a very graphic and important example of where that applies. This principle is reflected in the most recent PCT-weighted capitation formula. As I said earlier, there are imbalances that, over time, we will seek to correct.

Dementia

Baroness Greengross Excerpts

Thursday 28th June 2012 Lords Chamber

[Baroness Greengross]

My Lords, I start with three lots of congratulations. First, I congratulate the noble Lord, Lord Touhig, on securing this debate, which is of the utmost importance, and on speaking so eloquently, as did the other noble Lords who have spoken. Secondly, I congratulate the previous Government on introducing the dementia strategy and on the research summit, which I was privileged to co-chair. At the summit, important plans were laid, which could lead to a lot of change. Thirdly, I congratulate the Prime Minister. I was in the hall when he spoke and heard his speech. I have never heard him speak as well as he did on the dementia challenge. He is obviously very committed to this, as am I—I am passionate about it—and it was wonderful to hear what he said.

What has changed is that we are having a debate on dementia when people are not afraid to mention it. It is, as the Prime Minister said, as things were with cancer a long time ago and later were with AIDS. We can now talk about dementia. People know that it is absolutely essential to get things going and changing with regard to dementia. We must implement the action. The Government are committed to what the previous Government were committed to. We have all-party agreement that this is of the utmost urgency. We must get this right now.

What we face is largely due to recent medical success. We are now able to control or get rid of many of the acute illnesses that used to take people away from us, particularly cancer, heart disease and so on. We have had wonderful success but must now face, in effect, an enormous crisis, which is mounting not just in this country but across the world. It is on a par with climate change and it is of the utmost urgency that we get this right. We have to get more money into research and care, we must have staff who can do the caring, and families must be helped with the caring that they need to do. There is an enormous amount that needs to be done. The fear of people in this country is now not nearly as much about cancer as it is about dementia. As the noble Lord said, one in three of us will die from it and the costs are immense. If we get things right, we can reduce those costs.

The all-party group has 70 Members from both Houses and the wonderful thing is that they come to the meetings. I chair three other all-party groups and am a member of others. People do not come—they are too busy doing other things—but the group on dementia is very well attended. We have had some marvellous results from the inquiries that we have carried out on some of the subjects mentioned by the noble Baroness, Lady Barker, such as early diagnosis, anti-psychotic drugs and staying too long in hospital if you have dementia. That last is totally inappropriate, both for the person with dementia who goes in with a broken arm or a fractured femur but also for all the other patients who cannot sleep, rest or get better. It is appalling. To be blunt, we know that 20% of our acute hospitals now need converting into primary-care-led hospitals where the sort of treatment from which people with dementia and others with chronic diseases could benefit is introduced. It is quite difficult to persuade Members of the other place that they will be re-elected if they join forces in changing the hospitals in their local constituencies. However, that is what needs to be done if we are to meet the need of the fast-growing numbers of people who suffer from one of the dementias.

We also know that early diagnosis is essential. As the noble Baroness, Lady Barker, said, there are things that can be done. There is some hope now. Early interventions into the neural networks can achieve change. It is not far off that we will actually be able to do something about dementia, not just helping people to live better but moving towards a cure. We must all get together to get the research under way and properly funded, globally as well as nationally, and all benefit from it. It is essential that early intervention in neural networks is pursued.

Much has been said about the need for better hospital care for people who do go into hospital, and about better care in the community, in which I have been very much involved, looking at the human rights of people who need care and support in their own home. I will not joint the debate with the Minister about where human rights are applied, but I will say that human rights are really important as a training tool, where you start with the person and look at respect, dignity, the right to have some social interaction with others and the right to family life. That means that you do not separate husband and wife if they go into a care home. The care worker has to spend more than 15 minutes with the patient, because you cannot clean them up, give them a meal, arrange their day, get things ready, look after them a litte and have a chat in 15 minutes. We have to change the rules and standards of care in people’s homes. If we look at those issues as an infringement of human rights, it helps us to train people to get it right. I do not blame the providers of care in people’s homes. Many of them are struggling to make ends meet, too. We need a better system of funding for that. We need local authorities to come together, as some are now doing, so that those people who have to do everything in 15 minutes and then travel without being compensated for the travel or time of travel will not have to do so. At least several boroughs or local authorities are getting together to minimise the risk of that happening. So things can be done which do not cost a great deal.

We have to get cost-effective care. We have to look at the standards of care and the training of staff. We also have to look at the status of staff. Care work, work with people in their own homes or care homes, is low status and very low paid. Why would they continue to do that? They are very committed or they would not have got into it in the first place. In fact, if you go and work on the Tesco cash till, you get shares in the company, you have mates to talk to, you have regular hours and, when you go home, you know that your work is finished. That does not happen if you are caring for people with dementia. It does not happen if you are caring for vulnerable people anywhere. This is why our staff leave and take up other jobs—they are under pressure. We really must get the care regime right.

Moreover, we must make sure that “integration” really means something, because if we do not join up our services and include housing and care, both health and social care—and we have an opportunity to do it—and if we do not get it right, we will be letting down some of the most vulnerable people in society. The role of health and well-being boards and the commissioning groups are critical to getting this right. We can, in fact, do it now. If we also look at annual budgets of local authorities and make sure they do not continue to be threatened with the loss of their central government grant, we can begin to get some preventive work introduced locally as well. It is a disgrace that we can only look after people when they are in a critical condition. If I were a director of adult social services, that is what I would do—we would all do it—and that does not help people to remain fit and well for as long as they possibly can.

We can and must do something about dementia. We have all-party agreement on the urgency of this, and on the need for change in our attitudes and in our services, and in the integration of care for those with a terminal disease, which does not get treated as a whole at the moment. If we do not get agreement and act now, we cannot call ourselves a reasonably compassionate society.

Older People: Health and Social Care

Baroness Greengross Excerpts

Monday 18th June 2012 Lords Chamber

[Earl Howe]

My Lords, the right reverend Prelate draws attention to an area that we have focused on quite hard in recent months, and the NHS constitution has been changed to strengthen the areas around whistleblowing. In the care home context, often the care home is looking after someone who is not publicly funded and the arrangements there are often ones that the care home itself has put in place. We believe that the CQC needs to focus carefully on the arrangements in the care homes that it inspects to ensure that staff feel free to speak up if they are aware of any problems of maltreatment or anything of that kind.

[Baroness Greengross]

My Lords, does the Minister agree with the final recommendation in the report that we need a major cultural shift if we are to get this right? A very simple and straightforward way of ensuring that would be if every person receiving care was protected under human rights legislation. That would simplify this and make it work straightaway.

[Earl Howe]

The noble Baroness is right. This is about a culture shift and nothing unfortunately can happen overnight. To extend the Human Rights Act to apply to private providers in purely private arrangements in which there is no involvement by a public body would be a radical extension of the Act. The Ministry of Justice leads on humans rights but we will be discussing this recommendation with it and will consider whether further action is needed. However, we need to remember that everyone in a care setting is already protected by the law. I have mentioned to the right reverend Prelate the Care Quality Commission’s registration requirements which set essential levels of safety and quality in the provision of services. Those cover, in a nutshell, the care and welfare of service users, safeguarding service users from abuse and respecting and involving service users. The CQC has extensive enforcement powers to ensure that those standards are met.

Social Care: Legislation

Baroness Greengross Excerpts

Monday 11th June 2012 Lords Chamber

[Earl Howe]

As the noble Baroness will know, one of the main reasons that we wanted to engage widely in recent months with the sector was the very issue that she raised. The quality of social care, the training of those in the workforce and the supply of carers, both paid and unpaid, are concerns going into the future. As the noble Baroness will find out, this will be a major focus of the White Paper.

[Baroness Greengross]

My Lords, will the Minister reassure some of us who have worked closely with the Dilnot recommendations that the Government will take into account the huge savings to the NHS which, following the initial costs, will result from implementing the proposals? The cost of implementation is very limited compared with the huge annual costs of such care to the NHS. Adequate social care will remove much of that from the NHS.

[Earl Howe]

I take the noble Baroness’s point. Nevertheless, she will recognise that Ministers in government cannot ignore cost pressures arising from proposals such as those of Dilnot. We have calculated those costs at £2.2 billion. This is not money that can be drummed up easily. Nevertheless, we are looking at ways in which to address that particular issue.

Health and Social Care Bill

Baroness Greengross Excerpts

Tuesday 13th March 2012 Lords Chamber

Moved by

[Baroness Greengross]

292A: Before Clause 280, insert the following new Clause—
“Human Rights Act 1988: provision of certain personal care and health care services to be public function
(1) A person who is commissioned to provide—
(a) personal care to an individual living in their own home, or(b) a health care service,shall be taken to be exercising a function of a public nature in providing such a service.(2) In subsection (1)(a) “personal care” in relation to England has the same meaning as in paragraph 2 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and in relation to Scotland has the same meaning as “personal care and personal support” as defined in section 2(28) of the Regulation of Care (Scotland) Act 2001 and section 1(1)(c) and Schedule 1 to the Community Care and Health (Scotland) Act 2001.
(3) In subsection (1)(a) and (b) “functions of a public nature” has the same meaning as in section 6(3) of the Human Rights Act 1998 (acts of public authorities).”

[Baroness Greengross]

My Lords, if I am a very frail, vulnerable, sick person in need of support or care, and I go into a residential home, my human rights will be protected. In this case, that means the right to dignity, respect, and privacy if I am having intimate care. If I have exactly the same needs and exactly the same services provided for me in my own home, my human rights are not protected. But I am the same person. My human rights now depend on whether I am down the road in a residential home or have the same services in my own home. That cannot be right. This amendment is designed to close the loophole in the law that allows this. It means that if a public body has arranged or contracted the service, it is a public function within the meaning of Section 6(3)(b) of the Human Rights Act, so it brings certainty that I will get my human rights protected. These are not controversial rights—it is just decent care.

We know that almost half a million older people receive essential care in their own homes, commissioned by their local authority in England, excluding the other devolved areas. Approximately 84 per cent of these people lack the protection of the Human Rights Act because their care is provided, as we now know, by private or third sector organisations. We received compelling evidence of the extent of human rights breaches in home care settings in the findings of the Equality and Human Rights Commission’s formal inquiry into the human rights of older people receiving home care. As the lead commissioner on ageing, I was part of that inquiry.

This amendment is supported by many organisations. Among them are Age UK, the British Institute for Human Rights, Disability Rights UK, the Equality and Diversity Forum, Justice, Liberty, Mencap, the Scottish Human Rights Commission and the Northern Ireland Human Rights Commission. In its report Implementation of the Right of Disabled People to Independent Living, published on 1 March 2012, the Joint Committee on Human Rights recommended that the Health and Social Care Bill should be amended in this way.

My understanding, however, is that while the Government have no argument with the view that the Human Rights Act should apply to private and third sector organisations providing publicly commissioned home care, it seems that they consider that the law provides this coverage already and that this amendment is therefore unnecessary. I share the commission’s view that private providers of services, under arrangements made with the relevant statutory bodies under the NHS Act as amended by the Bill, will not necessarily continue to be carrying out a function of a public nature. The Equality and Human Rights Commission feels that the Department of Health’s analysis of current case law is a bit overoptimistic. Were this question to be determined by a court, the outcome could not be predicted with any certainty.

I want to thank the Minister for giving a huge amount of his time and consideration to these issues. I know that he is wholeheartedly in support of the principles behind my amendment. It is plain that he has an undoubted commitment to avoiding human rights abuses in health and care settings. However, the fact remains that any relevant assurances that he might give us, while very welcome, must fall short of providing the urgent legal clarity about the scope of the Act that I believe to be very important. They would not provide service users with clear legal redress for human rights abuses or breaches, or give providers an immediate legal incentive to apply human rights standards to service delivery.

I am not suggesting that legislative provisions are the only guarantee of human rights protection, but I would argue that they are an important part of the solution. I recognise that, going forward, the Government’s policy agenda could—and, I hope, will—provide opportunities to embed more effectively a human rights approach in health and social care. Seeking change in service culture and practice of services is very important. However, while these policy opportunities are very worthy of consideration, closing this legal loophole would put down a clear legal benchmark that would positively help to build cultural change in the health and social care sector. Such policies that the Government now have, however well-intentioned, are not a substitute for clear legal obligations under the Human Rights Act. Those would give individuals the right of redress against service providers for human rights breaches.

The Government might also have reservations that making express reference to human rights in a health context could cast doubt on other areas beyond health or social care where public services are provided by private bodies. However, I do not agree that a reference solely in health and social care would cast such doubts on other policy areas. Thinking about the operation of such a reference in reverse, it would be difficult to see how a specific reference in justice or education legislation could reasonably affect social care or healthcare.

In closing, I must reiterate that I feel that the law is not certain. In my view, the current legal position is evidently unsatisfactory. There may good arguments to support the view that providers should consider themselves bound by the Act and the duty. There are also legal arguments against that position. There is no way to predict what view a court might adopt. Support for this amendment will clarify beyond doubt the fact that a person commissioned to provide home-based social care or healthcare is performing a public function with the responsibilities that are within such a function and within the meaning of the Human Rights Act and the Equality Act. I hope that the Minister will find it possible to support this amendment. I beg to move.

[Lord Rix]

My Lords, I wish to support Amendment 292A, tabled by my noble friend Lady Greengross. As I am sure your Lordships will appreciate, I approach this issue from the perspective of people with a learning disability and would argue that the provisions of the Human Rights Act should be universally applied and not dependent as to whether an individual receives personal care in a residential setting or in their own home. Such a disparity is both unfair and unjustified, and it is right that we take the necessary steps to clarify matters.

For example, let me remind your Lordships of the appalling abuse highlighted by the BBC’s “Panorama” programme in May of last year. Winterbourne View, near Bristol, was a privately owned assessment and treatment centre where residents with a learning disability were subject to an horrendous culture of ongoing bullying combined with physical and psychological abuse.

I make reference to the abuse at Winterbourne View because, following an amendment in 2008 to the then Health and Social Care Bill, which is now the Act, the law was changed to ensure that care homes in the private and third sectors, when providing care that is publicly commissioned, were within the scope of the Human Rights Act. This was the correct step to take and ensures that all legislation, regulations and guidance regarding personal care which is publicly commissioned and provided for in residential settings is underpinned by the tenets of the Human Rights Act.

For those who face the ongoing consequences of prejudice and discrimination every day of their lives—such as people with a learning disability—the Human Rights Act can have benefits that go well beyond the preconceptions of those who are eager to dismiss it as a dangerous irrelevance. However, while the individuals concerned who suffered abuse in Winterbourne View or any other residential setting are able to turn to the Human Rights Act in seeking recourse for what occurred, if a similar type of abuse happened while they were receiving publicly funded personal care within the parameters of their own home, it may be assumed by victims, local authorities and others that they would not be able to do so due to the lack of clarity. This is self-evidently a completely unacceptable state of affairs and we should not be willing to tolerate such an absurd inconsistency. I would also add that if the CQC had the resources to undertake a greater number of unannounced inspections in all residential settings, it would be easier to identify abuse at an even earlier stage.

When applying the Human Rights Act the principle question must be, “To what extent has an individual’s human rights been violated?”. It should not be, “Under what type of roof did the alleged abuse take place?”. In my view, abuse is abuse is abuse, and it is as simple as that. Respecting an individual’s human rights should be universally applied and not subject to arbitrary levels of determination, such as the situation in which we currently find ourselves.

The Government claim that the loophole does not exist and so there is no need for the matter to be clarified in the way that the amendment requires. What is not in doubt is that, under the current circumstances, it is explicit under statute that when receiving publicly funded personal care services in residential settings, an individual’s human rights can be upheld via the Human Rights Act. However, when that care is received in their own homes, the situation is much more ambiguous and less certain. Therefore, I remain hopeful that the support of Ministers for this amendment will be willingly and freely given.

--- Later in debate ---

[Earl Howe]

I am grateful to the noble Lord. My main point is that, whether by accident or design, the previous Government did the right thing in our view, and that is clearly the advice of the Ministry of Justice, which is in the lead on human rights matters.

I hope I have explained why I cannot support this amendment, despite the Government’s wholehearted support for the principles involved, and that I have demonstrated how seriously we take the issues that the noble Baroness raised. To that end, I can today make four very clear statements. I can confirm that the Government maintain an expansive view of the interpretation of Section 6 and, where we have the opportunity and it is appropriate to do so, we would intervene in legal cases in support of that interpretation. I can confirm that human rights will of course be part of the underpinning framework in adult social care law. Any reforms to the law on care and support will need to ensure consistency with the obligations placed on local authorities by the Human Rights Act. I can commit to hosting a round table, along with my honourable friend the Minister of State for Care Services, to bring together all key partners, including, if she wishes, the noble Baroness, to establish how our strategy on adult social care ensures protection of human rights. Finally, I confirm that if the independent commission on human rights makes any recommendations in its final report about the reform of Section 6 of the Human Rights Act, the Government will give them serious consideration.

On this basis, I hope that the noble Baroness will recognise the extent to which we have tried to address her concerns and will feel able to withdraw her amendment. If not, I beg noble Lords to think twice before voting for it.

[Baroness Greengross]

My Lords, I thank the Minister for what he has just said, which was extremely encouraging. I have never doubted his commitment to getting this right. I am not a lawyer, but listening to the discussion, I think there was some misunderstanding about the wording of the amendment and the context in which it stands. For example, the word “certain” is defined in the next paragraph as,

“personal care to an individual living in their own home”.

I agree that there could be ambiguity if somebody goes to stay with their daughter and I agree that there could be ambiguity in the drafting, although the amendment was not drafted by me but by the EHRC with the help of very learned lawyers who have worked on this extremely hard. It is limited not to services provided by anybody but to services commissioned or arranged by a public body. Therefore, those particular points that were raised by noble Lords do not apply, although if I thought they did I would agree that it would be a bit silly to try to insist on this amendment.

I feel that in spite of the Minister’s very welcome commitment—we have had time together when he has expressed this so I know that he feels this way—I would like to see the work that the noble Lord, Lord Wills, referred to carried forward, as so many other good policies have been, as there is no party-political disagreement about the aims of particular bits of legislation or the desire to get things right. I would like this to be the case. I am really sorry that the Government feel that we have to wait for those very worthwhile undertakings and pieces of work to be taken on board before we can protect these very vulnerable people who are just not being protected because they happen to be doing what all older people seem to want, which is getting services in their own home rather than going to a residential home. That is what the Government seem to want them to do, and that is what most older and vulnerable people want, as well as many younger disabled people who want to live independently, and many people with learning disabilities. This is not just about one group, although it primarily concerns older people. I just feel sad. I ask the noble Earl to continue with his good intentions but to build on them by incorporating a redrafted amendment in those intentions. On that basis, I feel bound to say that I should like to test the opinion of the House.

Health and Social Care Bill

Baroness Greengross Excerpts

Thursday 19th January 2012 Lords Chamber

[Earl Howe]

My Lords, I have not seen that report, but clearly there is concern, following Southern Cross, as to whether difficulties such as those should be predictable in some way. I am sure that a lot of thought is being devoted to trying to avert such crises in the future. I will look at that report and write to the noble Lord with any comments.

[Baroness Greengross]

The Bill is called the Health and Social Care Bill. If the recommendations of the Dilnot commission for social care are implemented speedily with cross-party support there will be a huge saving to the NHS, where many frail and vulnerable people are inappropriately treated because the impending crisis in social care has not been addressed. Does the noble Earl agree that that is the case?

[Earl Howe]

I strongly agree. The noble Baroness will know that running right the way through the Bill are duties around the integration of services between health and social care and indeed between different aspects of healthcare. By giving clinicians greater autonomy to decide what good care looks like for their patients in an area, I am confident that we will see fewer unplanned admissions to hospital, which cost a great deal of money, and much better preventive care for patients delivered by healthcare and social care professionals.

Health: End-of-life Care

Baroness Greengross Excerpts

Monday 16th January 2012 Lords Chamber

Asked By

[Baroness Greengross]

To ask Her Majesty’s Government what measures are in place to inform people of the steps they need to take to ensure their wishes regarding medical treatment at the end of life are respected if they lose capacity.

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

My Lords, the Department of Health makes annual resources available to the NHS and local authorities to implement the Mental Capacity Act. These resources are for them to inform and support people who may have lost or be about to lose capacity about their wishes regarding treatment and care. The department’s end-of-life care strategy provides further guidance in this area.

[Baroness Greengross]

I thank the Minister for that helpful reply. Advance directives are now well established in this country, and it is accepted that patients’ wishes in this respect should be followed wherever possible. What systems does the NHS use to record the existence of advance directives and to ensure that they are accessible to doctors as well as available to them so that patients’ wishes can be respected? Where patients have made an advance decision in this regard, what evidence does the Department of Health have on the degree of adherence to their end-of-life medical preferences?

[Earl Howe]

My Lords, the department does not hold information about the degree of adherence to advance decisions, but I can tell the noble Baroness that there are a number of systems available in the NHS that enable patients to record their preferences for care at the end of life and the choices that they would like to make, including saying where, if possible, they want to be when they die. We know that there is widespread use in the NHS of the Preferred Priorities for Care tool that supports decisions about preferences.

We have also supported the piloting of electronic palliative care co-ordination systems to ensure that a person’s wishes and preferences for care are taken into account and to improve communication between the professions and organisations. The Information Standards Board is currently considering a proposed standard setting out a core data set to support the implementation of those systems.

Health and Social Care Bill

Baroness Greengross Excerpts

Monday 19th December 2011 Lords Chamber

[Baroness Finlay of Llandaff]

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

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

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

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

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

[Baroness Greengross]

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

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

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

[Baroness Jolly]

I have put my name to Amendments 328B and 330ZAA. I send the apologies of the noble Baroness, Lady Tyler, who is not well. She had hoped to be able to speak to these instead of me. First, I should like to make a few general points about health and well-being boards. It should go without saying that the Liberal Democrats really welcome local democracy in health and the far greater involvement of local authorities than is the case at the moment, as well as the use of scrutiny committees. We are somewhat saddened that in the legislation there is only one elected decision-maker on a health and well-being board. I understand the Government’s unwillingness to prescribe, but they have not quite got the balance right. There may be as many elected councillors as other voting stakeholders, with maybe a casting vote given to the chair. That feels much more like localism in action than what we currently have.

Linked with that is the role of district councils, which is not mentioned terribly clearly. Here I have another apology, because I know that the noble Lord, Lord Greaves, had hoped to speak on this point. What we are losing in his eloquence we are probably making up for in brevity, but I still feel as strongly as I am sure he will. I can almost feel him behind me now, as I speak, but he is not well and is not able to be with us.

Where are district councils in this framework? I know that a lot of local authorities have now become unitary, but there are really key parts of England where strong county councils are well underpinned by district councils. They need to be there, because they provide planning, housing, leisure and environmental health—all these things that have to be well woven into the fabric of this Bill and the delivery of services. They are also part of the solution for the big public health issues. Three examples come to mind without even having to think very hard. Wearing their leisure hat, obesity is a very big issue. Some people prescribe exercise for obesity. On housing, in my neck of the woods, with the warm, wet westerlies, housing gets damp very easily. That brings with it chronic heart and lung problems, particularly if you cannot afford to heat. District councils also play a key role in housing on mental health issues. They are often providers for county councils and PCTs and I know that they would hope for a similar relationship with clinical commissioning groups, when things become established. They should be at the table of the health and well-being boards. I appreciate that you cannot have every district council having one representative. In Kent, where there are 16, or in Devon, where there are eight, you cannot bring those in, but there needs to be some arrangement for working together to ensure that district councils should be there.