House of Lords
Health: HIV
(12 years ago)
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Lord Collins of Highbury
To ask Her Majesty’s Government whether they intend to endorse the standards of care for people living with HIV published by the British HIV Association on 29 November.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Department of Health commends the British HIV Association for these important standards, which we welcome. The NHS provides excellent care for people living with HIV. These standards are important in setting out best practice to support continuing high-quality HIV care services for all HIV patients. They will provide a valuable resource and inform the commissioning of comprehensive HIV care services.
Lord Collins of Highbury
I thank the Minister for that response. One recommendation made by BHIVA related to self-management. As with many other long-term conditions, this approach can help people with HIV to gain confidence, skills and knowledge to manage their own health, with resulting improvements in the quality of life and independence. In the light of changes in the commissioning process, who will now have responsibility for funding the excellent self-management services currently provided by organisations such as the Terrence Higgins Trust and Positive East?
Earl Howe
My Lords, the noble Lord is quite correct. Self-management is one of the BHIVA standards. I agree that self-management and supporting patients to manage their own care, both for HIV and, for that matter, any other long-term condition, are very important for promoting the best treatment outcomes for individuals. A variety of approaches will be needed to support individuals to self-manage their HIV. There are already some innovative programmes, such as the online resource, My HIV, for people living with HIV, delivered by the Terrence Higgins Trust. The key to this is for commissioners of services to work together in future to ensure that self-care is part of the HIV care pathway, and GPs will have a role to play in that.
Lord Fowler
My Lords, I declare an interest as patron of the British HIV Association. Is it not the case that we now have 100,000 people living with HIV in this country but that a quarter of them are undiagnosed, so obviously risk spreading the infection further? Does that not mean that we must persuade even more people to come forward for testing? In that respect, will the Government now commit themselves to bringing forward proposals to allow home testing?
Earl Howe
My noble friend is quite right. As he will know, this is National HIV Testing Week. We support the Terrence Higgins Trust and its partners in this important new initiative. The NHS medical director has written to all medical directors about the week and the importance of healthcare professionals being alert to the need to offer HIV testing. As regards self-testing, we agree that the current regulations are not sustainable, which is why we are reviewing our policy on banning the sale of home HIV testing kits. We support repeal but we are required to do a short consultation setting out our reasons. We plan to do that early next year.
Baroness Masham of Ilton
My Lords, is the Minister aware that we have some of the best services in the world for HIV/AIDS? Can he give an assurance that, with the changes in the National Health Service now, there will not be a dilution of these services?
Earl Howe
My Lords, yes. We believe that the complex needs of people with HIV will be best served by the work being done by the HIV national clinical reference group of the NHS Commissioning Board. The board will commission these services in the future, and that will drive greater consistency and quality throughout the system.
Baroness Trumpington
Our turn. I am not sure whether I am in order but I should like to congratulate, through this House, the Minister on his award yesterday as Minister of the Year in the Lords.
Lord Hughes of Woodside
My Lords, I am grateful that I gave way. In view of the reports of an alarming increase in the incidence of HIV, is not the old adage that prevention is better than cure even more important? Is this significant rise in HIV incidence caused by less use of condoms, or what?
Earl Howe
In fact, the numbers are more or less stable if one compares this year to last. However, the noble Lord is right: we cannot drop our guard in this area. There is a pressing need to reduce undiagnosed HIV. It is estimated that about 23,000 people are undiagnosed and 47% of those newly diagnosed with HIV are diagnosed late—that was the figure for last year. That is why the prevention campaign through local authorities will be so critical in this area.
Lord Maclennan of Rogart
My Lords, in view of the extensiveness and particularity of this important report, will the Government contemplate producing a response which deals with the matters particularly focused on? Will they seek to ensure that, due to the increase in non-AIDS comorbidity and the complexity of HIV drug interactions, clear protocols are established between primary and secondary care as there is some patient disquiet, particularly about primary care?
Earl Howe
My Lords, my noble friend is absolutely right that this is a complex condition. As regards a response to the BHIVA report, we are planning to publish an integrated sexual health strategy which will embrace all aspects of sexual health, including HIV. The vast majority of HIV in the UK is sexually transmitted. HIV and sexual health services are closely linked, as he will know, and we believe that it is in that strategy that the appropriate guidelines should be set out.
Baroness McIntosh of Hudnall
My Lords, will the noble Earl bear in mind that the stigma around people with HIV is still an extraordinarily important issue? Will he encourage healthcare providers to ensure that as much as possible is done to reduce this disincentive to people to come forward for testing?
Earl Howe
The noble Baroness is of course right to say that stigma is an issue, and it is doubtless why many people do not come forward for testing. Through the National HIV Testing Week we are encouraging doctors in all parts of England to consider this matter and to see what role they can play in terms of having the right conversations with patients who are in the most at-risk groups.
Social Care: Apprenticeships
(12 years ago)
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Baroness Wheeler
To ask Her Majesty’s Government what progress they are making on establishing social care apprenticeships; and how voluntary registration of social care workers will assist apprentices and staff to provide the quality of care required in domiciliary and community settings.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, apprenticeships and voluntary registration for social care workers are part of the vision set out in the care and support White Paper and will contribute to improving quality of care. The latest figures report that more than 60,000 apprenticeships have started in 2011-12. A system of assured voluntary registers will help to support the delivery of quality care by enabling individuals to demonstrate that they meet set standards of education, training and competence.
Baroness Wheeler
I thank the Minister for his response and welcome the progress being made. As he knows, apprentices will join the current social care workforce of 1.6 million, more than two-thirds of whom now work in the voluntary, independent and private sectors or are employed directly by service users in their homes. Given the Government’s desire to have only a voluntary register for social care staff, can the Minister explain to the House how consistent quality and dignified care are to be delivered across this fragmented employer base?
Earl Howe
My Lords, I agree that quality in the apprenticeship programme is essential and the Government are committed to the pursuit of quality. The noble Baroness will know that from April next year the role of NICE is to be expanded to embrace social care, and no doubt it will focus on quality standards in that area. The care and support White Paper acknowledges the need to ensure that there are enough skilled people to deliver high-quality care in the future. We believe that expanding apprenticeships in social care will involve a continual driving up of the apprenticeship offer. To ensure high quality, all apprenticeships need to entail a rigorous period of learning and the practice of new skills under approved training providers. That involves a minimum of 12 months for a 16 to 18 year-old; it also applies to adult apprenticeships.
Lord Martin of Springburn
My Lords, will these apprenticeships be available to young boys and girls who perhaps do not have academic qualifications when they leave school?
Earl Howe
Yes, my Lords. Health and social care is the second largest area of apprenticeships in the country. We think that they provide a route for the young people the noble Lord has described to acquire skills and add to the capacity and capability of the social care workforce. They also provide a rung on the ladder to more senior positions in young people’s career progression.
Baroness Williams of Crosby
My noble friend will know that, apart from those who are apprentices, a great many people are currently serving in the area of social care for whom in-service training would be extremely useful. I am talking about older people. Can he tell us whether, in the training discussions held in the NHS and in social care, any plans are being made to try to provide at least some in-service training for people already working in the field?
Earl Howe
My Lords, a great deal of work is going on, not least in the field of leadership. As I have mentioned, the National Institute for Clinical Excellence, soon to be the National Institute for Health and Clinical Excellence, will be issuing quality standards in this area. Skills for Care is also working to refine and improve the standards that social workers need to adhere to—and, of course, social workers as opposed to social care apprentices are statutorily regulated.
Lord Laming
My Lords, the noble Earl and the House will have been shocked by a number of recent reports about the exploitation of the vulnerability of people who are receiving social care, either in institutions or in their own homes. Can the noble Earl assure the House that the Government will do everything they can to ensure clear managerial accountability for the quality of care that is delivered, and will ask the inspectorates to make sure that they will do what they can to assess the quality in the different parts of social care services?
Earl Howe
The noble Lord makes some centrally important points. The CQC, which is the regulator of national minimum standards in this area, is very clear that the need to safeguard the vulnerable is one of the most important tasks that it has to assure itself about when inspecting providers. The role that employers play is key here and he is right to point out that it is the responsibility of management to ensure not only that those working for them have the right skills but that there is also the right supervision, for apprentices in particular.
Baroness Farrington of Ribbleton
My Lords, can the Minister assure the House that a voluntary scheme will not allow those very people who have a culture of not caring or of neglect—we know that happens from time to time in this sector—not to take up the option of voluntary registration? Surely it is most important in this field that we protect people from the very people who may well not take voluntary action.
Earl Howe
My Lords, accreditation by the Professional Standards Authority will help to foster high standards, because it will allow practitioners and people who use services to distinguish more easily between registers that meet nationally accredited standards and those that do not, and therefore between those social care workers who are accredited to a high standard and those who are not. In addition, we have commissioned Skills for Health and Skills for Care to develop a code of conduct and recommended induction and minimum training standards for healthcare support workers, as she will know. The key here is to progress to a system that encourages employers to employ those with the right qualifications and for users to be able to see that the employees in an organisation are accredited.
Energy: Nuclear Power
Lord Foulkes of Cumnock
To ask Her Majesty’s Government what contribution they propose nuclear generation should make to a balanced energy policy.
The Parliamentary Under-Secretary of State, Department of Energy and Climate Change (Baroness Verma)
My Lords, the long-term vision for electricity market reform is of a market where low-carbon generators compete fairly under a robust carbon price. New nuclear should be able to contribute as much as possible to the need for new capacity within that framework. Last month, the Government welcomed Hitachi’s purchase of Horizon Nuclear Power for £700 million in a deal that will help to meet energy security and decarbonisation objectives, and bring massive economic benefit. This demonstrates confidence in our new nuclear policy.
Lord Foulkes of Cumnock
First, I thank the Government for publishing their Energy Bill to coincide with my Question. Does the Minister agree with me that, with the imminent rundown in our current generation and the inability of renewables to provide base-load generation, new nuclear is absolutely vital? Although some companies have announced their intention to go ahead with new nuclear, there have not been any go-aheads yet. Will the Government, as soon as possible, announce an agreement on pricing so that new nuclear can start as quickly as possible?
Baroness Verma
My Lords, the noble Lord of course knows that we are very keen to ensure that we have a diverse energy mix, and part of that will be new nuclear. He also knows that some processes take a little longer than others. However, new nuclear will help to diversify our electricity supply. Each nuclear power plant will be able to give reliable base-load electricity to around 6 million homes per year. We look forward to working alongside all our energy providers, including nuclear.
Lord Jenkin of Roding
My Lords, the question of new nuclear is slightly overshadowed because, in America, the extremely low price of unconventional gas is causing some anxiety to the nuclear industry. Will my noble friend accept that the Government’s policy of contracts for difference being introduced in the Energy Bill— the noble Lord, Lord Foulkes, has drawn my attention to the fact that the Bill is being published today; I have not seen it—is hugely important to the reassurance of the nuclear industry that it will be able to operate successfully and at a profit? Can my noble friend say when the actual strike prices will be announced, because that is the key?
Baroness Verma
My noble friend is of course right that there needs to be certainty. However, he will know that these things take a lot of negotiating and a lot of detail needs to be worked out. When I am able to offer my noble friend a definitive answer, I shall bring it to the House.
Lord West of Spithead
My Lords, how much have we drawn on the British experience and expertise built up in the naval nuclear programme during the past 50 years in trying to move forward this important ability to generate power from nuclear energy? I am very happy to take an answer from both parts of the coalition on this one.
Baroness Verma
As the noble Lord will know from his own previous role in government, we draw on expertise from all sides.
Baroness Miller of Chilthorne Domer
My Lords, is not one of the difficulties faced in establishing any new nuclear build, as the Defra report published last January highlighted, the fact that all eight proposed sites have a low-to-high risk of flooding, most of them ending up with a high risk of flooding within the proposed life of the new nuclear plants? Has the cost of added sea defences where sites can be defended—of course, they cannot be defended where there is coastal erosion—been added into the equation?
Baroness Verma
My Lords, my noble friend raises a very important point given the circumstances of recent days. However, she will know that no planning permission for any site is given unless there is a proper investigation of environmental impact on nuclear plants.
Viscount Hanworth
My Lords, is it not clear to the Government that their pursuit of a free-market ideology has led to the collapse of their plans for Britain’s nuclear energy? Is it not time to establish a national agency that could commission the building of our nuclear power stations and that would be empowered if necessary to borrow funds on the open market to finance such vital infrastructure? Can the Minister give an opinion on this?
Baroness Verma
My Lords, the noble Viscount will be pleased to hear that at least this Government have taken new nuclear very seriously, as they have other energy sources. I remind him that his Government were in power for 13 years and failed to address any of these problems.
Lord Ryder of Wensum
My Lords, the Government have been in office for two and a half years. Why cannot my noble friend the Minister answer the question posed to her by my noble friend Lord Jenkin after two and a half years?
Baroness Verma
I go back to what I said to my noble friend Lord Jenkin: these things take time and are under negotiation. I am sure that my noble friend will appreciate that the outcome needs to satisfy many parties.
Lord Avebury
My Lords, when do the Government expect to receive the report of the Nuclear Decommissioning Authority on the future management or reuse of the 100 tonnes of plutonium that are now held at Sellafield at an estimated cost up to 2030 of £16.9 billion? What consideration are the Government giving to the offer by GE Hitachi to build two PRISM reactors that would reuse this material and be provided at no cost to the Government? That would generate 630 megawatts of electricity that would cost the taxpayer nothing.
Baroness Verma
I know that my noble friend is very involved with this issue. While we have a preferred option, we are always open to other forms of disposal. We will keep the noble Lord informed of what we are doing, if he is interested to know.
Flooding: Insurance
(12 years ago)
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Lord Greaves
To ask Her Majesty’s Government what action they are taking to make sure that house insurance is available for residents in areas that are liable to flooding.
The Parliamentary Under-Secretary of State, Department for Environment, Food and Rural Affairs (Lord De Mauley)
My Lords, the future of flood insurance is a priority for the Government. We remain committed to discussions with the insurance industry and others about what replaces the statement of principles. We want a solution that ensures affordable insurance bills for those at flood risk but does not place unsustainable costs on wider policyholders and the taxpayer. Our primary focus is flood-risk management, on which we are spending more than £2.17 billion over four years.
Lord Greaves
My Lords, there are now at least 200,000 households in high-risk flood areas whose properties are virtually uninsurable against flood. The discussions with the insurance industry have been taking place for years. There are now only seven months before the existing statement of principles runs out, and that itself is less useful by the week. Do the Government support the practical proposal from the Association of British Insurers, on behalf of the insurance industry, for a non-profit-making flood insurance fund to provide insurance against flooding for properties in high-risk areas basically funded by cross-subsidies from the rest of us who are fortunate enough not to live in high-risk flood areas? If so, why are the negotiations on this matter being blocked by high-ranking Ministers in the coalition Government from another party?
Lord De Mauley
My Lords, this is a serious matter. We have been working very hard with the industry on this extremely complex issue. We need a lasting solution that ensures affordable insurance bills for those at flood risk but does not place unsustainable costs on wider policyholders and the taxpayer. The ball is now in the industry’s court. The ABI understands the Government’s position. It is up to the ABI to come back to us with a practical and sustainable option that provides insurance for those that need it without increasing bills for all or placing unacceptable burdens on the taxpayer.
Lord Knight of Weymouth
My Lords, first, I offer sympathy to those who have lost loved ones and suffered the trauma of flooding in the past week. This is the third time since July that this matter has been raised at Question Time. The Minister consistently tells us that the Government are in intense and constructive negotiations with the insurance industry. Today, he tells us that it is a priority. Yet today I received an e-mail from the Association of British Insurers saying that negotiations are currently at an impasse. The Minister now says that it is up to the Association of British Insurers to come up with a better deal and yet he has been asked a perfectly good question by the noble Lord, Lord Greaves, on whether he agrees with the proposal that it has put forward. When will Defra sort this out and give comfort to the 200,000 people who are really struggling to get flood insurance?
Lord De Mauley
My Lords, I absolutely agree with the noble Lord on his first point. We really feel strongly for those affected by this. The emergency services, local authorities and the Environment Agency have been working extremely hard for them and I pay tribute to that. In answer to the noble Lord’s question, the statement of principles that his party put in place takes no account of the affordability of insurance, so I will not take any criticism from the other side.
Baroness Browning
My Lords, I declare an interest, having been flooded in 1997 and 2008. In his discussions with the insurance industry, does my noble friend ever mention not just that those of us who are in that position are very nervous about what will happen to our insurance next year but the fact that our houses are unsellable? There are elderly people who need to go into residential care, but they cannot sell their home. Others, like me, retire and want to move nearer to their families. Those properties are blighted. In a very small lane in rural Devon that has a lot of old thatched houses and cottages, some of which are listed, if they are not insured, eventually they will just be allowed to deteriorate and fall down.
Lord De Mauley
My noble friend is of course right that there are concerns about the continued availability of insurance to householders—mortgage holders and those looking to sell their houses. We are working with those involved better to understand what the impact on the mortgage market might be. I am certainly encouraged that the Council of Mortgage Lenders is quoted as saying that the focus needs to be on finding a solution on flood insurance, rather than worrying householders unnecessarily about how lenders might choose to react. That has a knock-on effect on the selling market to which my noble friend refers. I also point out that in July, we published a guide to obtain flood insurance in high-risk areas in collaboration with the National Flood Forum and industry representatives, which I think is helpful.
Lord Curry of Kirkharle
I, too, encourage the Minister to bring those discussions to a conclusion as soon as possible. I declare an interest: I was chair of a mutual insurance company until the end of last year. I have a further concern. Those companies which have a strong CSR policy could be commercially disadvantaged in the marketplace compared with those who take a purely commercial approach. It is also deeply regrettable that planning permission is still being granted in areas that the Environment Agency has identified as potentially subject to flooding, which is simply aggravating the problem in the long term.
Lord De Mauley
The noble Lord makes a couple of good points. In answer to his last one, development in areas of flood risk is permitted only exceptionally, where there are wider sustainability considerations, and must in all cases be safe, must not increase flood risk elsewhere; and, where possible, overall flood risk should be reduced.
Business of the House
(12 years ago)
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Lord Strathclyde
That the debate on the Motion in the name of Baroness Pitkeathley set down for today shall be limited to three hours and that in the name of Lord Harrison to two hours.
Lord Foulkes of Cumnock
My Lords, the Leader of the House has moved that the debate on the Motion in the name of my noble friend Lord Harrison should last for two hours. On the Order Paper, after that, there are, astonishingly, to be two Statements by two separate Ministers on the same subject. This entirely unprecedented action, which is also happening in the House of Commons, has, I understand, had to have the approval of the Speaker of the House of Commons, because it is unique. It has never happened before and the Speaker had to agree to it. You, Lord Speaker, do not have the power in this self-regulating House to agree to such an arrangement, an entirely unprecedented arrangement. The only power lies with us in the House to agree to that. I do not remember, recall or recognise that we have agreed to that. Does the Leader of the House intend to seek the approval of the House for such an unusual and unprecedented arrangement?
Lord Cormack
My Lords, when he replies to that, can my noble friend the Leader of the House tell us whether the Statements are going to be antiphonal or sequential, and whether the Ministers will be questioned after each section of the Statement or at the end? Can he also tell us in what precise capacity the noble Lord, Lord McNally, is to address the House? Is he speaking as the leader of a political party in this House, or is he speaking on behalf of the Government? If he is speaking on behalf of the Government and my noble friend is speaking on behalf of the Government, what conclusions can we draw from that extraordinary state of affairs?
Lord Strathclyde
My Lords, I am delighted that so many noble Lords are sharp-eyed and have spotted that the annunciator has said that there will be two Statements after the Labour Party debates this afternoon. I am very happy to explain the position to the House. The noble Lord, Lord Foulkes, says that this is unprecedented. It is certainly unprecedented in living memory.
Lord Strathclyde
But, my Lords, I gather that in the 1930s this sort of arrangement apparently took place. We have a coalition. On occasions—
Lord Strathclyde
On occasions, the different parties of the coalition should be able to make their views known to Parliament, and it looks as though this afternoon is one of those occasions.
As to the propriety of this House, what we are doing in this House is really quite simple. We are simply repeating Statements that have been made in the House of Commons: one being made by the Prime Minister and the other by the Deputy Prime Minister. As is standard practice on these occasions these Statements were offered to the Opposition, who can agree either to take them or not, or to defer them. Quite rightly, they agreed to take them. If the House does not wish to listen to me or to my noble friend Lord McNally repeating the Statements of the Prime Minister and the Deputy Prime Minister, it really does not need to at all. It will be quite late, after all, on a Thursday afternoon.
As to my noble friend Lord Cormack’s question, the Statements will be taken sequentially. What is interesting is that I am not entirely certain exactly how the Labour Party will approach this. I shall repeat the Statement of the Prime Minister, the Opposition will then reply, and then there will be 20 minutes’ Back-Bench time in the normal way that we wholly understand. After that is over, my noble friend Lord McNally will repeat a Statement of the Deputy Prime Minister. I am full of interest as to whether the Opposition will then say nothing, repeat the reply that they have already made or, more intriguingly, make a different reply to my noble friend’s Statement. There will then be another 20 minutes, if noble Lords wish to comment on it, and then we shall go on to the next business.
Lord Hunt of Kings Heath
My Lords, I am very grateful to the noble Lord, Lord Strathclyde, for so eloquently explaining the difficulties that the Government have found themselves in. Presumably that was an offer for me to make a statement—and presumably from the government Benches—because it seems that anyone can speak for the Government on these matters.
This really is a genuine first, when the coalition is so comprehensively divided that we have to go through this ludicrous episode this afternoon. I remind the noble Lord, Lord Strathclyde, that the Companion states:
“Statements by ministers on matters of public importance may be made by leave of the House without notice”.
He has not really answered his noble friend Lord Cormack. When the noble Lord speaks as Leader of the House, will he be speaking for the Government? When the noble Lord, Lord McNally, speaks, will he speak on behalf of the Government? Or do we have two Governments, or perhaps no Government? Is this a precedent for the future? This afternoon in the other place there is to be an energy Statement. Is Mr Davey going to make one Statement on wind farms and Mr John Hayes another? I also do not think that it would be amiss for me to point out to your Lordships’ House that the coalition is not exactly united on Europe. Can we look forward to two Statements on Europe when the noble Lord, Lord Strathclyde, repeats a Statement on Council meetings in future?
The noble Lord, Lord Strathclyde, has been very keen in recent weeks to remind your Lordships’ House of the importance of sticking to the rules, but now we are apparently just waving the Companion away. Indeed, the Companion seems to have become the noble Lord’s flexible friend. Perhaps the real message for your Lordships’ House today is that this coalition Government’s days are numbered—and a jolly good thing too.
Lord Touhig
If the Statements are to be taken this way, would it then be in order for the noble Lord, Lord McNally, to question the noble Lord, Lord Strathclyde, on his Statement, and for the noble Lord to question the noble Lord, Lord McNally, on his?
Lord Dykes
I am sure that my noble friend wishes to help the House in this unusual situation. Will he give the example from the 1930s where a precedent was established?
Lord Richard
Before the noble Lord replies, I wonder if I could ask him one simple question. There are two parties in the coalition: the Conservative Party and the Liberal Democrats. The Conservative view will be put by the noble Lord, Lord Strathclyde, and the Liberal Democrat view will be put by the noble Lord, Lord McNally. Which of them represents the policy of the Government?
Lord Foulkes of Cumnock
My Lords, in relation to the point that I raised initially about who should agree to two Statements, now that we have had an excellent explanation by the Leader of the House, I am absolutely certain that this House would agree unanimously and that we look forward to the entertainment later this afternoon.
Lord Greaves
My Lords—before my convenor speaks—is it not the case that the British constitution, in its wonderful unwritten form, consists of precedents, all of which have been developed in a completely pragmatic, evolutionary way in order to meet the circumstances of the day? It is indeed a different situation when we have a coalition like this and an issue like this. Is it not extraordinary that the Labour Party is the conservative force here that cannot keep up with these evolutionary, pragmatic changes which inevitably take place when we have a completely different situation with a coalition Government?
Lord Alderdice
Does my noble friend the Leader of the House share my curiosity that there was such unanimity in this House, and indeed in the other place, in welcoming the developments of very unusual forms of coalition in my part of the United Kingdom and regarding those as important pieces of political progress, and yet when it comes to having to face exactly the same kinds of issues of coalition together in this place, there seems to be a mixture of puzzlement and amusement? Would it not be wise for those who may find themselves in a coalition Government in the future to be a little more circumspect or they will find such matters being quoted against them, as has repeatedly been the case in the last little while on a number of matters of policy where the Labour Party in its previous incarnation said rather different things from what it has said while on the opposition Benches?
Lord Forsyth of Drumlean
Surely this House is about holding the Government to account, and we have Statements so that we can hold the Government to account—not for people to issue their manifestos on particular issues. Surely the purpose of this House is to hold the Government to account, but we need someone to tell us what the Government’s policy is. We cannot have a pick-and-mix approach to government policy. Are we to find that Ministers speaking from the Front Bench give two answers to the same question? What conclusion can we reach if they give different answers to the same question?
Lord Cormack
Is it now not abundantly plain that antiphonal would be better?
Lord Strathclyde
My Lords, I think that my noble friend Lord Cormack is enjoying himself far too much by repeating that word. Actually, I think the whole House is enjoying itself far too much and we really need to bring this very short debate to an end. My noble friend Lord Alderdice had it pretty well. We have a coalition and we are gently feeling our way on occasion as to the right approach.
I do think that the noble Lord, Lord Hunt, protests a little bit too much. I am sure that although from his Front Bench he will make one Statement, he will find a lot of disagreement with what he says from his Back-Benchers in both Houses.
The noble Lord, Lord Dykes, asked when the precedent was. I took a view a long time ago that any precedent from before the Second World War probably was not worth having, so I have not got it at my fingertips. However, I am reliably informed that it does exist. If I thought that we were breaking the rules of the House in doing this I would have said that to the House and then made a recommendation. There is absolutely nothing in the Companion that stops us having an innovative procedure on this, which is precisely what we are doing.
I know that noble Lords—the noble Lord, Lord Richard, and my noble friend Lord Forsyth—are exercised about what, therefore, is government policy. My right honourable friend the Prime Minister set up this inquiry on behalf of the Government. He will make his Statement on behalf of the Government in the House of Commons; I shall repeat it here. However, my right honourable friend the Deputy Prime Minister has taken the opportunity, as I think that both Houses will wish him to do, to make a separate Statement which will represent a view of the second party of the coalition. I think that we have flexible enough rules to be able to deal with that, and I very much look forward to the debate later on this afternoon.
Lord Hunt of Kings Heath
My Lords, I do not want to detain the House, although clearly the noble Lord, Lord Strathclyde, is enjoying this debate. However, I would refer him to the Companion. It refers to “a government announcement”—it does not talk about separate government announcements. The noble Lord cannot have it both ways. He has just said that he will be making a Statement this afternoon. He has still not answered the point as to who on earth he is making that Statement on behalf of.
Lord Strathclyde
My Lords, this is pedantry. If the noble Lords opposite really did not want these Statements they could have said so and the Statements would not be taking place.
Baroness Farrington of Ribbleton
My Lords, can the noble Lord the Leader of the House confirm that because this procedure is being accepted by him—and, I presume, very shortly by the House—we can therefore assume that the party other than the Conservative Party in the coalition did not feel strongly enough on student tuition costs or the Health Bill to issue a separate Statement?
Lord Strathclyde
My Lords, the noble Baroness, and no doubt other noble Lords, can make all sorts of accusations to my noble friends as part of this coalition. I think that it might be better if we wait until we have seen the response of Lord Justice Leveson and the Statements, and then the noble Baroness can make whatever point she wishes.
Social Care
(12 years ago)
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Baroness Pitkeathley
That this House takes note of the impact of changes in local authority budgets on the provision of social care and its integration with other health, housing and care services.
Baroness Pitkeathley
Well, my Lords, here we are again. It is almost exactly a year since I last introduced a debate on social care, and once again I feel like Captain Renault in my favourite film, “Casablanca”, rounding up the usual suspects. Noble Lords speaking today are once again those with form on this issue, although I am pleased to say that we have some new recruits to our numbers as well.
Last year’s debate focused on the report of the Dilnot commission, and it is a matter of great regret to me—and to many others, I am sure—that, in spite of general agreement around the House at that time that doing nothing was not an option, still no decision has been taken about these important proposals. Andrew Dilnot and his colleagues continue to press the issue with hope and enthusiasm, and we hear lots of rumours that we may have an announcement in the Autumn Budget Statement, next spring, next Budget or in the next spending review—but still no actual commitment.
In his response to the debate last year, the Minister said that we have an opportunity to get this right and we must not miss it. No one could possibly disagree with that but I must begin this debate by recording my intense disappointment that, one year on, we are no further ahead with implementing a long-term solution to the problems of social care.
However, we are focusing today on the immediate problems faced by local authorities and the impact of those on the rest of the system. When we discuss integration, as we often have during the past year, we usually focus on the particular interface between health and social care services. The topic of this debate is deliberately wider, though, acknowledging that care needs do not come in discrete packages but are stretched across the whole of an elderly or disabled person’s life, including their housing, their families and their income.
We must acknowledge that we are not in exactly the same place that we were last year. The Health and Social Care Bill that we were debating then is now an Act, and many promises were made about how it would make integration between health and social care easier. It perhaps is too early to say whether this is becoming a universal reality but none of the reports coming out of local authorities and the NHS fill one with hope. In a recent survey by the NHS Confederation, for example, 66% of NHS leaders said that shortfalls in local authority spending had impacted on their services last year. Delayed transfers of care cost the NHS about £200 million a year, and the human distress that such delays cause to patients and families is incalculable.
I know that the Minister will remind us that in last year’s CSR the Government transferred an extra £2 billion to social care by 2015, £1 billion of that coming from the NHS. Local authorities were grateful for that, of course, although it has been called a sticking-plaster solution. Even if it were to be allocated on a permanent basis, £2 billion is not nearly adequate to meet the needs of the social care system. While the transfer of funds from the NHS to social care has been crucial, not all areas have been able to use the money in the way intended—for example, on hospital discharge, reablement and intermediate care. These have made a difference in some areas but too often they paper over cracks in a system that is groaning and only storing up more problems for the future.
In summary—I will say this briefly since I know that the usual suspects are only too familiar with it—the system is not fit for purpose and we spend inadequate amounts on care and support both publicly and privately. Social care funding has totally failed to keep pace with demographic change. Since 2004, while spending in the NHS has risen by £25 billion, spending on social care has risen by just £43 million.
I am always aware of saying how inadequate our care provision is, lest it be seen as criticism of the many dedicated people who work in the system providing care and sometimes pushing the boundaries to focus on prevention and innovative ways of meeting need. We cannot avoid recognising that the way in which local authorities have dealt with the fact that need has far outstretched funding has been to increase charges and rapidly to raise the threshold at which you can qualify for care. You get care only if your needs are seen as substantial or critical.
In too many areas, services are provided only to those whose care needs are the most severe. The LGA has stated that it expects a funding gap for local authority services of £16.5 billion a year by 2019, or a 29% shortfall, between revenue and spending pressures. It further estimates that in the not-too-distant future, social care and waste spending together will absorb such a huge percentage of their funding that other services will have to take an 80% cut.
Without action on funding and integration, even very basic care—those basic 15 minutes a day, which is all that many elderly and disabled people can expect—will not be available in future. Only this week, the weather sees us having to factor into local authority budgets the huge extra costs that many of them will have as a result of the floods. Not only is this level of care completely inadequate but the fact that it is provided only to those with severe or critical needs makes a nonsense of the prevention that all sides say is the key to ensuring that care needs do not escalate to crisis point.
Moreover, this takes no account at all of the many people who currently meet their own care needs in full. Not only may they have to use local authority services in future but no attempt to preserve the quality of the services can be made for those people. Mencap provides clear evidence that local authorities are struggling with reduced funding from central government and increased demand for services. Over the past three years, one in three local authorities has closed day services and 57% of people with a learning disability no longer receive any day-service provision. Carers UK reports that carers are being affected by the closure of council-run services and by the cuts to grants to the voluntary sector, which provides vital services locally. One carer said that getting respite care service nowadays is like getting blood out of a stone.
When people’s care needs are not met by social care systems, what happens? They turn, of course, to the NHS. This results in increased demand for unplanned and emergency services and delays in hospital discharge. In addition, 88% of GPs surveyed recently by Carers UK report that their patients are being put at risk due to a lack of social care support.
These extra pressures come at a time when the NHS is already under severe financial pressure. The CSR protected NHS funding to some degree but did not take account of rising demand and rapidly increasing healthcare costs. We all know that the NHS is expected to make £20 billion of savings and efficiencies by 2014-15, and the recent report from the CQC paints a sad picture of how cost-cutting is being put ahead of patient welfare, with 16% of hospitals surveyed not meeting the CQC standards for having enough staff on duty to care properly for patients, and warns that this may lead to a culture in which unacceptable standards of care become the norm. Yesterday’s report from the King’s Fund paints a similar picture for the NHS of bed closures, lost services and low morale.
No one could possibly disagree that the NHS and all care services must be run as efficiently as possible. One of the most important ways in which to make efficiencies in either health or social care is through integrating services, an issue that we have debated many times in your Lordships’ House. The money transferred to local authorities from the NHS has helped to stimulate integration and certainly to develop interest in it, but evidence given by the King’s Fund to the Health Select Committee notes that a lack of urgency in delivering integrated care remains and, indeed, that the huge upheaval that we have seen in the NHS since last year has hampered progress and resulted in lost momentum. In this context, it was a positive step to see a paragraph in the recently published mandate emphasise the role of the Commissioning Board in driving and co-ordinating engagement with local councils. For the sake of the increasing numbers of people in urgent need of co-ordinated services, we must hope that the mandate delivers.
The other significant development since last year is, of course, the draft Care and Support Bill. I am honoured to be a member, along with my noble friend Lord Warner, of the pre-legislative scrutiny committee considering this. We shall spend many happy hours with colleagues from this House and another place hearing evidence, testing proposals and debating provisions. There is not time to go into the detail of that Bill here, save to say that there are many welcome proposals in it, and the Government are to be congratulated on an excellent attempt to achieve co-ordination of the many disparate strands of care legislation and to give greater recognition and more rights to users and carers.
In terms of the issue that we are debating today, it is hard to feel anything but anxiety about the extra duties placed on local authorities and on how on earth they are to be funded. Do not mistake me—I could not be more delighted that support for carers will be strengthened or that there will be an obligation on local authorities to provide information and advice to promote diversity and quality, or with the references to assessments and care and support plans, as well as a very much to be praised reference to national eligibility criteria. But even those far-reaching reforms could be viewed as a sticking-plaster solution if we do not tackle the fundamental problem of how social care is funded. The inconsistency between fully funded NHS care and means-tested social care not only confuses users and carers but inevitably hampers the delivery of a comprehensive care package.
Noble Lords may have noticed thus far my subtle references to a need for more money in the system. In conclusion, I want to focus on money. I know that the Government’s response to calls for more money in the system is always, understandably, “There is no more money”. As Andrew Dilnot frequently says, though, it is a question not of “can’t afford it” but of “won’t afford it”. Our GDP shows that we are five times better off than we were in 1948. Time and again, we find that social care properly delivered, of good reliable quality and with an emphasis on preventive care is a better way of caring for older and disabled people than healthcare, especially in a hospital bed, could ever be. If we pool the risk—after all, only one in five of us will ever need high levels of social care—and give it the priority that it deserves, we can afford it. It is a matter of priorities. We can easily find several billion pounds by stopping tax avoidance if we really put our minds to it.
We need to start thinking long-term about the real costs of failures in social care and think more broadly about what those failures will mean to the economy as a whole. I shall give an example. Diminishing social care from councils has hit business productivity. As fewer older and disabled people are able to access social care services, growing numbers of family members are being forced to give up work to care for their loved ones. An estimated 1 million people have given up paid work or reduced their working hours to care for their loved ones. The LSE tells us that the public expenditure cost of families giving up work is £1.3 billion a year in additional expenditure on carers’ benefits and lost tax revenues. If lost earnings are taken into account, the figure rises to £5.3 billion. These are the sort of long-term effects of the current shortages in funding that we should be considering.
I know, as do all noble Lords, that the Minister cannot make a commitment here today to put more much needed money into the system. However, I know him to be a man of commitment and vision, as well as a very busy one today—I also know that the whole House will be delighted with the award that he received last night—and I ask that he commits to taking the message from your Lordships’ House back to his department and to the coalition Government and tries to persuade colleagues to see that investing properly in social care is just that—an investment, not a drain. It saves costs down the line, assuages one of the worst worries of citizens and will earn the thanks of the nation, both those in need of care at present and all of us who may need it in future.
As for the argument that says that times are hard and this is not the time to enter into major extra commitments, I remind your Lordships that the Beveridge report of 70 years ago was published and accepted in the middle of a world war, yet our forebears had no problem with the vision and commitment to take on those far-reaching changes even though the country was, in the words of one noble Lord in this House this week, absolutely skint. We are not skint. We live in a time of relative peace and prosperity. Should we not be prepared to follow in the footsteps of those courageous forebears? I beg to move.
Baroness Gardner of Parkes
My Lords, I am one of those old hands to whom the noble Baroness, Lady Pitkeathley, referred in her speech. No one knows more on this subject than she does and I pay tribute to the great work that she has always done. However, there is nothing new in this problem. It has grown hugely but there is nothing new about it. I was chairman of social services on a London council in the 1970s under the then Wilson Government. We were terribly short of money and had to choose between providing social care or saving the buildings in which we were doing it. We did not have the money for both. These extremely difficult choices have always had to be made.
Like the noble Baroness, Lady Pitkeathley, I am very disappointed that, one year on, we still have not had a real response to the Dilnot report. However, as she said, everything is stretched. The linkage between housing, health and care has always been terribly important. There is nothing new in that. I would be sorry to see unacceptable standards become the norm, as the noble Baroness fears, but we have reached the point where there is simply no money. Local authorities have done everything they can to reduce their expenditure. They have put a lot of the care out to agencies because that saves hugely on management costs and staff costs and they believe that that is more effective. I am not so sure of that. I met a woman who was going to take on a caring job and found that she had to see eight different clients a day at eight different venues, each one supposedly for an hour. However, in that hour she had to do everything for that client. As has been said, 15 minutes is more the norm—someone runs in, makes a cup of tea, gives the client a bath or dresses them and then is gone. If they are doing breakfast for people, those people are getting their breakfast at all times of the day because the same person is running from house to house.
The woman who applied to the local authority agency found that she would have been paid nothing for her travelling time between jobs, which could be half an hour or more. She would have had to locate each address herself and then go to it. The whole thing was not on. This is a very genuine and loving Latin American woman. I came across her through an immigration issue. She has been here for many years. She works for 48 hours non-stop, day and night, for an elderly lady. She lives with her, looks after her, gets up in the middle of the night and does everything. She does this on a self-employed basis. I have raised this matter before in the House. If you are self-employed, there is no talk of a working wage or even a minimum wage. There is no wage protection for carers who are self-employed. The family of the lady with dementia pays her £100 for two days and two nights—48 hours. That is £2-something an hour. How can we expect people to work for that sort of money?
We rely on people working. In the past you could rely on family because people lived near to one another. In my GLC days you could exchange your social housing and move nearer those who could care for you. None of that—or very little—is available now. Most people are lucky to have a roof over their heads at all. It has reached the point where local authorities have combined forces so that several boroughs can work together to reduce costs and spread the load. These things are not easy now. People are reaching the limit of their resilience. They have made efforts again and again. We keep trying and we make a little progress, and then we find that the demands are growing all the time. The huge growth in the number of elderly people who survive is perhaps something that no one could have foreseen. Perhaps it is a reflection of how successful our health service and way of life are. The basic issue is money.
I went—I think it was yesterday but I lose track of time—to a meeting on the future of nursing. Everyone talked about the need for more time for each nurse to do her job. We read press reports on this. Nothing could have been reported more than the issue we are debating. I have picked out three headlines. The first is very emotive and states:
“Hungry, sick, neglected: the care home scandal”.
The next one states:
“Urgent action needed to tackle care failings that lead to horrific abuse”.
These things are absolutely vital. Care inspections are very important, but will be effective only if they are unannounced and unexpected. If you have told people that you are coming, you will not get the true picture at all. Today, I read in the paper:
“Cruelty had been ‘normalised’ in parts of the NHS, the Health Secretary declared yesterday”.
It may be that that emotive word had been picked out, but what is happening in most cases is not deliberate cruelty. In many cases people are giving a marvellous service. However, the cases that all the press sensation is about are ones where staff are failing.
I was in hospital two or three years ago. I was put in a ward full of elderly people. All night the woman in the bed next to me said, “Help, help, help”—non-stop, for the whole night. Of course the nurse responding to that had become case hardened, because she had heard the woman saying “help” not just the night I was there but probably every day and night of the week. People are amazingly patient and good, but it is an impossible task. Everyone knows that it comes down to the need for more money—but where are we going to find it? The medical set-up is also in a state of chaos while staff adjust to all the changes. It is extremely difficult.
We want to see social care of good, reliable quality. We want to see specialist hospital facilities used only where there is a real benefit from them. We do not want people to be occupying hospital beds that could be used by acute care cases when another type of accommodation might be better. It is alarming for people. They know that they do not have the money to pay for things themselves. But the changes in family patterns—the geographical thing—are very worrying.
Expectation is another big problem. We have all raised expectations to a point where we expect everything to be perfect all the time, but no one has the money for that. This is an extremely complicated issue that we have to be very aware of, and today’s debate must help to increase awareness and show all the various aspects of it. There is no simple solution. I wish there was. It is going to take a lot of time and effort and we will still be relying to a very large extent on volunteers, which the noble Baroness, Lady Pitkeathley, knows so much about.
Baroness Barker
My Lords, I, too, am one of the usual suspects. I thank the noble Baroness, Lady Pitkeathley, for bringing us back to this subject.
I will start by pointing out the contrast between today and a year ago. A year ago, we were inundated with messages about what people thought about the Health and Social Care Act and their fears for the NHS. Now, when we are talking about social care, which probably has a bigger impact on more people, we have received almost nothing. I know that over recent weeks a number of noble Lords have attended a lot of very good briefings and meetings with some of the more noted social care policy bodies—but apart from that, nothing. That is very telling. The future well-being of many of our citizens relies on the extent to which the NHS engages with, understands and promotes social care, so that fewer people end up going to hospital and those who do quickly return to the place where most healthcare will happen in future—their own homes. That is the debate that we should be having with people in the NHS, and we are not.
It is understandable that people talk in apocalyptic terms about social care. The Barnet graph of doom says it all. I have to say that the LGA laid it on by doing exactly what I would have done in those circumstances, which is to pick the very worst case.
The key issues in social care arise because of the successes of the NHS. The NHS was designed for and spectacularly successful at organising acute care for treatable conditions. As a result, the majority of people now live with long-term care conditions, but we still have a health service based on that old model. We need to work out ways in which the NHS and local authorities together can buy packages of health and social care that enable people to go along a health and care pathway. At the moment most people’s experience of health or social care is that a part of it may work fantastically well but it is not related to any other parts of the pathway of their lives. That experience and the economic models that underlie it are the key things that we have to turn our attention to.
I want to say a little bit about personalisation, a subject that I talk about quite a lot, as the noble Earl, Lord Howe, will know. It is the chosen method of the previous Government and this Government for addressing some of the many deficiencies in social care. I think that the noble Baroness, Lady Campbell of Surbiton, will be delighted when I say that the big problem with personalisation is that it has been taken by many people in its most basic and crude form to mean a direct payment and a list of providers. It is about much more than that. It is about more than disaggregating existing services and giving people money to purchase them. It is about finding new ways to enable people to have the power to shape the services they need. The Housing Learning and Improvement Network is currently engaged in working on some very interesting different forms of collectivisation of personal payments, enabling people, for example, to combine in buying a core housing service and then buying different personal services to turn what was previously residential care into assisted living. That is the sort of work which local authorities and, in future, the NHS need to support so that we can ensure that more older people remain in assisted living for longer, rather than ending up in hospital and acute care.
We have a plethora of examples of how community care can be improved and work very well in preventing people needing higher levels of care. All the usual suspects will recognise Dorset POPP, North East Lincolnshire Care Trust Plus and Southwark Circle—all of them packed with evidence about how older people can thrive in supported settings. However, to the best of my knowledge none of them has a model of economic sustainability. My key question for the Minister is whether, in this coming year—with the potential of health and well-being boards and the potential which arises from some of the changes in the NHS radically to alter the way in which services are commissioned, designed and provided—the Government will continue to work on developing economic models which can show us whether those small localised examples can be either scaled up or replicated in different parts of the country.
We are in danger of missing the point that the creation of health and well-being boards gives us the potential to do what is brought out in the subject of this debate—to create communities in places where older people want to be. They want to be at home; they do not want to be in hospital. It is for the Government to provide these new bodies with research, which so far has been lacking, into the efficacy of social care compared with acute treatment to enable the joint pathways of care that I talked about earlier not only to be real in terms of the services that they give older people but to be viable models in which the NHS feels it can safely invest, as opposed to investing, as it has done, in acute care.
In my remaining final minute, I want to say that so far we have achieved something quite remarkable—a consensus on Andrew Dilnot’s report. I hope that that consensus continues because, whatever one may think of its deficiencies, it is the only game in town. It is important that a form of Dilnot comes about soon and that it should be a compulsory and not a voluntary scheme. If that does not happen, we will never get the economic basis on which to build the new future of health and social care to which we aspire.
Baroness Campbell of Surbiton
My Lords, I, too, am very grateful to the noble Baroness, Lady Pitkeathley, for securing this debate. We have worked together for many, many years, and I am afraid that I am another usual suspect.
The integration of social care is a complex nut to crack. I am sure that Ministers with responsibility for health, both acute and primary, local government, housing, and work and pensions will also wish to pay attention to what is said here today. Together, they are responsible for the solution.
There is widespread agreement that care and support services are underfunded. The distinguished economist Andrew Dilnot, expertly advised by the noble Lord, Lord Warner, said as much in his report on how to fund the future of social care. There is not enough money in the system and we all know it. It is not just that the growth in demand for support has not been matched by a growth in resources; it is also clear that the needs and circumstances, and the aspirations, of disabled people, old and young, are increasingly complex. I am far from alone in your Lordships’ House in speaking from personal experience on these matters.
Budget restrictions are causing local authorities to make terrible decisions. Would any of your Lordships wish to tell a severely disabled lady that she cannot have help to go to the toilet at night and that she must wear incontinence pads even though she is not incontinent? Would you wish your names to be on a letter telling a frail, elderly couple that charges for their home care are to be increased by 30% when they cannot even pay their heating bill? These things are happening now and every day.
Yet, around the country some local authorities and their NHS partners are tackling these pressures with more constructiveness, co-operation and creativity than others. The Social Care Institute for Excellence, of which I had the privilege to be the founding chair, is looking at such examples through the eyes of service users. I applaud this approach. Service users are genuine experts by experience. For some local authorities the funding challenges have been a catalyst for new ways of working. They have encouraged the statutory authorities to work in partnership with people and their families; to listen to what they want to achieve and how they want to live their lives; and to work out the best way of supporting them to stay independent. Some councils are using a whole range of resources to come up with really innovative solutions tailored to individual circumstances. They have rediscovered the value of putting people—not services or resources—at the centre of decision-making. This is music to my ears. It reassures me that many in charge of care and support will not simply take the easy and destructive option of cutting services in a sheep-like fashion.
I was deeply troubled when I heard of a local authority, Worcestershire, announcing a blanket policy of cuts, including capping non-residential care costs to a level equivalent to the residential care rate. I knew that it would not be long before yet another authority followed suit, and I was right. At least three other local authorities are now proposing the same policy. There is nothing creative or collaborative about this approach. Such a policy has the potential to overturn three decades of building an independent living culture for those with the highest support needs. Surely we do not want to go back to the 1970s when disabled people and those with long-term medical conditions were invisible in society—patients or residents but not people, expected to live out their days in a hospital or nursing home, or trapped at home in the back bedroom. Denial of independent living is a breach of the UN Convention on the Rights of Persons with Disabilities.
I would like to remind your Lordships of the late Baroness Lane-Fox. She was a remarkable disabled Peer with a much larger electric wheelchair than mine. She championed the cause of patients living in iron lungs at Guy’s Hospital during the 1970s and early 1980s. She brokered an initiative between government, healthcare, social care and housing to get them living in the community. These victims of polio were under the care of Dr Geoffrey Spencer, a visionary physician who placed nothing in the “too difficult” tray. I do not know whether any of your Lordships have ever seen an iron lung. It is like a seven-foot cylindrical missile on wheels—a challenge for an integrated team in the 21st century, let alone one in 1981 when Felicity Lane-Fox joined the Conservative Benches and captured the imagination and support of this House and the other place, and got money where there was no money to pay for it. In those days, as I said earlier, there was no budget line. We were really, really strapped for cash. There were no complex-needs commissioning boards and no integrated housing or social service practice guidance, just a shared belief that these patients should enjoy the same human rights as the rest of society and should be prioritised. Government money for their care in hospital was creatively redirected and renamed as “health research”. Occupational therapists and clinicians worked with local authorities as one team. Together, they liberated these reluctant bed-blockers, who became known as “responauts”—a remarkable achievement.
Now fast-forward 30 years to 2011. The JCHR conducted an inquiry into disabled people’s right to independent living. We heard from witnesses about situations not so different from those of the hospital-bound responauts. It struck me how easy it has been over the past few years of austerity to slip back to a time when young and old people with significant support needs were second-class citizens, denied their human and civil rights. It is a travesty that lessons learnt from an emerging human rights approach to the funding and delivery of care and support in this country have been so easily cast aside in the name of austerity.
At the launch of the JCHR report, I found myself making pleas not dissimilar to those made by Baroness Lane-Fox 30 years ago—this time for a young Asian man with Duchenne muscular dystrophy, stuck in the same respiratory unit as the 1979 responauts. He was there for four months longer than was necessary, surrounded by critically ill patients, reminding him daily of his recent trauma. The reason was not financial. The cost to the state was more than £900 per day, as opposed to a maximum of £400 in the community. No, the reason was that the local authority social care services had no budget compared to their health services partner. The result was the usual “who pays?” war, preventing a joined-up approach. This caused the inability of both to put the young man and his family at the centre of planning. His well established independent living arrangements were torn apart by the long unnecessary stay in hospital. He lost opportunities to work and further his career, and his overall well-being suffered inextricably. He paid a high personal cost and much-needed public money was wasted.
The JCHR made many recommendations in its Article 19 inquiry report last year—recommendations that will help the Government to regain their international reputation for delivering a human rights approach to care and support in this country. They challenge us all to understand, and action, the true meaning of mutually supportive systems, spending and consuming.
In conclusion—I know I am running out of time—I would be grateful if the Minister would tell your Lordships about the current status of the Government’s plans to address the conclusions and recommendations in the JCHR report. To date, it simply has not been good enough
Among the concerns of witnesses at that inquiry was, of course, the closure of the independent living fund. Will the Minister explain how the Government will ensure that money currently safeguarded through the mechanism of the Independent Living Fund will continue to be used only for modern independent living purposes? Will he again reconsider ring-fencing that money?
Please, do not let this be another debate where we share human rights stories. The UN Convention on the Rights of Persons with Disabilities embodies 21st-century ideals of what public support services should be striving towards. Rather than allow the backward slide to accelerate, let us begin by taking Dilnot off the shelf and working together to fix social care.
The Lord Bishop of Liverpool
My Lords, I begin by declaring that I am not one of the usual suspects in this debate and I hope that the noble Baroness, Lady Pitkeathley, and others will forgive me, as a novice, speaking. I defer, of course, to her experience and expertise and that of other noble Baronesses who have spoken, especially the noble Baroness, Lady Campbell. On behalf of the communities in Liverpool, I thank the noble Baroness for this debate and for the opportunity to consider the impact of the reduced local authority budgets on the welfare of the people of Merseyside, and to localise the debate in that way, if possible.
I do not deny the need to be financially prudent or the need to live within our means. I also understand how difficult it is for the Government to be pressed persistently to fund all the demands on the public purse. The question I want to press in the debate is not whether there should be cuts to the budget but, rather, how assured the Government are that the financial settlement across the nation is fair. In his response to the debate, I would like to hear the Minister say that he is prepared to review the local authority settlement in terms of the provision for social care.
The city of Liverpool is expected to reduce its spending by 52% over the next four years. This cut is more draconian than elsewhere and leaves us asking why the north-west seems to be targeted more severely than, say, places such as London, Bournemouth or Brighton. For people to be able to accept such drastic measures there has to be a sense of fairness across the country. I hesitate to paint the picture of need in Liverpool for fear of giving the wrong impression of the city and of the region. The truth is that Liverpool is a thriving European city, with a vibrant cultural life, three universities and an enterprising business community. The elected mayor is pragmatic politically, seeking every opportunity to gain investment in the city.
However, alongside this cultural and economic renaissance, there are areas of consolidated poverty that demand intervention. We have the highest percentage of people with a history of substance abuse and some of the highest rates of unemployment, cancer and teenage pregnancy. That is why there is genuine fear in the city over the impact of 25% cuts in adult social care over the next four years and 25% cuts in children’s services.
The council knows that throwing money at these problems is not the solution, which is why it is already working in partnerships to maximise the value of the money already invested, and economies are certainly being made through better co-ordination and management. However, save as it tries, there remains an axe hanging over the head of the support services—the home visits and support for the elderly and the mentally ill. If these go under the axe, it will only put more pressure on the front-line services, as we have already heard. To support someone in their own home costs Liverpool City Council up to £250 per week. If you cut these services and the patient ends up in a nursing home, the cost goes from £250 to £550 per week. I would be glad if the Minister could tell us how the Government view this problem and whether they are prepared to be more creative and flexible, channelling between the different silos of policy and funding to avoid the social disaster that might follow. It is demoralising for the city council to analyse the statistics across the country and discover that, far from there being a level playing field, there are staggeringly steep differences in funding across the nation, which makes the pain of applying these cuts even more severe.
I have refrained from anecdotes, although I could give noble Lords many of them. In fact, the cuts and the anecdotes are much greater and more numerous than people are already testifying to, because once these 52% cuts have really kicked in there will be dramatic stories of people who are not cared for in their own homes and further afield. Will the Minister please review the settlement and give us an assurance that these cuts are fair across the country?
Baroness Wheatcroft
My Lords, I should like to add my thanks to the noble Baroness, Lady Pitkeathley, for securing this important debate and for her eloquent speech which showed how well she knows this important sector and the issues it faces. She also made an eloquent plea, as have others, for more money. But money is not the only answer to this problem, and that is just as well because, as we know, we are living in a time of austerity and the money to do everything we would like to do simply is not there. We have to look for more creative and collaborative solutions, as the noble Baroness, Lady Campbell, has just said. We have to look for more integration and the greater use of computer technology. We have to be inventive.
There are productivity gains to be had. A recent report from the King’s Fund pointed to the fact that there is a great search for cuts as an end in itself rather than a search for the productivity gains that could deliver cuts in spending. A recent report from the Policy Exchange, of which I am delighted to be a trustee, sets out the following sentiment:
“If we could provide integrated care bringing together primary, community, acute and social care we could provide better care for the frail elderly and save a great deal of money”.
That statement was made by David Prior, the chairman of the Norfolk and Norwich University Hospital NHS Foundation Trust—and he was talking only about integration within the NHS itself. Here we are talking about the need for integration across the NHS, social services and housing, but none of that can be done until the NHS itself manages to bring down some of the extraordinary barriers it has put up between the various parts of its own organisation. The NHS could and should be a much more integrated and efficient organisation. Experiments are being carried out in parts of the country, but nowhere near enough is being done on that front. Even the Local Government Association accepts the need for reform and that money alone will not be enough to solve the problems we now face in this area.
The state cannot do it all. Although we have already heard some appalling stories of people who are really suffering, I would maintain that that is not just because of the cuts; they are suffering because of some very severe breakdowns in our society. Those who have seen the Times today will have noted the headline on the front page about the number of people in our country who will spend Christmas alone this year—some 250,000. The Times quotes a survey which has found that one in 10 of those aged over 75 confesses to being intensely lonely all of the time. Loneliness is not just a misery in itself; it is a cause of ill health. It drives people to see their doctors. It is something that we all need to address together. Family breakdown has caused severe agony in this country. We have to look for creative solutions to help those who are growing old not to feel lonely and end up seeking medical help. They need to be integrated into communities and not to live in single-person households, as so many do, unless that is what they really want. We should be able to offer more constructive, healthy and enjoyable alternatives. While they are still fit and well, we need to get people to move into communities where they will have the sort of wonderful life that we in this House enjoy. It actually encourages life expectancy far beyond the norm. People need to be in groups. If they were living in groups, the state could provide at much less expense the sort of 24-hour care that will eventually be required.
We have heard about people who have had to give up their jobs to care for elderly members of their families, but they are rarities now. What we need is to make sure that the community as a whole takes on the responsibility of looking after its elderly. There are other constructive ways in which we can do this. Some schemes arrange for younger people with nowhere to live to be paired with elderly people who live in houses with too much space. The relationship benefits both sides. The young person agrees to do a certain amount of work helping around the house and doing the shopping, although just being there is often more than enough. That sort of help can preserve an elderly person’s sanity and keep them fit for many years.
We will hear again today about the need for more money and more spending, but I think that we could spend what we have more effectively, more efficiently and more creatively.
Baroness Donaghy
My Lords, I am extremely grateful to my noble friend Lady Pitkeathley for her perseverance in this important area. Those of us who sat through the debates on the Local Government Finance Bill can be in no doubt about the parlous state of local government funding, and the Question asked in the House yesterday about cuts in arts funding in Newcastle brought it home even more how councils are having to set priorities which are assessed on the least harm rather than the most good. I start from the standpoint of being a supporter of local government, but that is not to say that there are no failings in the system, if you can call the state of social care in this country a system. I will concentrate my remarks on care for the elderly and, in particular, those who need nursing care as opposed to residential care.
A growing number of frail elderly people are living alone when it is no longer safe for them to do so. The care they receive, if they receive it, is often totally inadequate for their needs. This is not new, as the noble Baroness, Lady Barker, pointed out, it is just getting worse. Let us look at the demographics. Last year, 720,000 people reached the age of 65, the largest number ever to do so. They are the cod liver oil generation and they are better nourished than any previous generation. Some continue in paid employment, and a considerable proportion of their number will still be around in 2031 when they reach the age of 85. That is good news, but by then many more will require support in their homes or in residential or nursing care. Moreover, many among those 720,000 people are already caring for elderly relations, as I did a few years ago. They are finding out for the first time in their lives the extent of the financial and administrative hurdles they have to overcome on behalf of their loved one or ones.
Today’s 85 year-olds are not a sufficient political lobby to frighten any Chancellor of the Exchequer into taking action on social care, but the generation that retired last year is a different matter. Their experience as carers and their concern for their own futures will affect the political agenda. By way of a word of advice to my noble friend Lady Pitkeathley, if she moves the same Motion for debate this time next year, she ought to ask the noble Lord, Lord Sassoon or his successor to reply instead of the noble Earl, Lord Howe, because this is a Treasury issue.
We all believe that care is in desperate need of reform, that it is urgent and that cross-party consent is probably the only way we are going to achieve it. Having said that, I first participated in a debate on the urgent need to integrate health and local government services for the elderly in 1973—so the word “urgent” is losing its meaning. It is shocking to learn that social care for older people in England makes up about 1% of total public expenditure in the UK. We know that much of NHS expenditure is also concentrated in this area, to some extent subsidising the failure of social care, the lack of adequate housing and the diminution of the role of extended families. Although the Government have announced new social care funding, rising from £1.18 billion in 2011-12 to £2 billion per year by 2014-15, which of course is welcome, that is in the context of overall cuts and cancelled funding from central government of £3.5 billion.
This area has always been underfunded. Age UK has said that,
“care is not fit for purpose”.
Each year, the level of unmet need has increased as people are excluded from accessing services or have their care packages reduced. In 2009-10, the total hours of support purchased by local authorities for older people fell from 2 million hours to 1.85 million hours. People who are unable to undertake essential personal care tasks find themselves ineligible for support depending on where they live. It is estimated that 800,000 older people with care-related needs receive no support of any kind from public or private sector agencies. This figure is likely to rise to 1 million people by 2020. Those who are poor and have no family support face a grim future.
As the noble Baroness, Lady Wheatcroft, said, although funding is of course very important, we must look to different ways of spending it. We should find out why our elderly are more isolated than elderly people in some other countries in Europe, where specially built communities exist. Perhaps older people in this country cling on to their own— sometimes hopelessly inappropriate—accommodation because it is preferable to going into a home or living with their children. Of course there are purpose-built homes with community facilities now, but we must find ways of ensuring that, once someone has bought a property in such a purpose-built facility, the annual service and maintenance charges do not overtake their budget and reach nightmarish levels. At a time when housing budgets are facing dire shortfalls, it may seem fanciful to demand new forms of housing or to persuade the elderly to move from the suburbs into the city, as they do in Copenhagen, but when times are desperate we need to be at our most imaginative.
Another area that I think deserves independent examination is the administration of the estates of deceased nursing home residents, many of whom have no living family member. I realise it is not something that the CQC can deal with, but I feel that a lot of money is being made by some solicitors, and probably banks, with little oversight. This is an area where local authorities could become entrepreneurial—the salaries of the staff who are employed would be covered several times over and the elderly residents’ interests would be better protected.
We should ask ourselves whether nursing homes, as presently constituted, are the right model for the future. There is no doubt that cuts in local authority funding force authorities to cut the fees they pay to private nursing homes, which forces many to close. After all, local authorities fund about half the places, but shareholder value may well be the decisive factor. Is the comfort and well-being of the patients in nursing homes given more priority than their potential for bed-wetting? I ask these questions because of my own experience. The CQC report is, if anything, an understatement of the real problem. I wish my noble friends Lady Pitkeathley and Lord Warner, and other colleagues, all the best in their endeavours to keep Dilnot alive.
Baroness Tyler of Enfield
My Lords, I add my congratulations to the noble Baroness, Lady Pitkeathley, on being such an excellent and enduring champion in this area. I view the issue of how adult social care is provided to vulnerable elderly people and to those with disabilities as the pre-eminent social issue facing this country.
Integration has been a buzzword around health and care services for a long time. Overcoming the entrenched divisions between health, social care, housing and wider services is indeed a major challenge, particularly with the great financial pressures that we are currently under, which is very much the focus of this debate. It is important that we are realistic about some of the barriers faced, which include cultural barriers as well as those to do with separate funding and planning systems and separate workforce training—I could go on. We probably all agree that making a reality of integrated care is now an absolute imperative.
I talked about the need for realism. Despite what has been described as its optimistic modelling, the LGA’s funding outlook report confronts us with some pretty brutal figures, such as a £16.5 billion shortfall in funding by 2020. Of course these kinds of savings cannot come from efficiency alone. In my view, it will require a fundamental and system-wide reform. I am also clear that more money is needed. The Barnet graph of doom has been very effective in placing a spotlight on the very real dilemmas faced by local authorities; but equally, it must not lead to a complete counsel of despair. Through well co-ordinated services that look to prevention as well as crisis response, it should be possible to make some contribution to the efficiencies needed and certainly to achieve greater cost-effectiveness, for example by reducing emergency admissions or readmissions and by speeding up discharge from hospital to the community. Integrated care can no longer be reserved as somewhere for rhetoric but has to become a reality. How do we actually do that? The most important thing is getting the right financial incentives in the system, both nationally and locally.
The additional money that was announced in the last spending review for social care was welcome. I am well aware that £1 billion of that was redeployed from the NHS. However, the evidence that we have seen so far says that too often that money has to be used to offset budget cuts and to meet changing demographic needs rather than to promote integration. Ultimately, real progress should focus on aligning the whole of the £121 billion currently spent on health and social care around the needs of individuals, particularly by pooling some of the local budgets, and having shared budgets and a much more strategic assessment of the funding needs in the round.
I have talked about joining up statutory services, which I think is key, but I also want to draw the attention of the House today to the value and potential of our voluntary sector in tackling some of the important problems of isolation and loneliness, which have already been referred to by other noble Lords. If you ask older people which local services make the biggest difference to their lives, they point to lunch clubs, keep-fit classes and day centres. It is often through organised group activities that many older people keep active, make friends and stay engaged with the world around them. We know that problems of isolation and loneliness are not just emotional—they have a very real impact on people’s physical and mental health. Research shows that loneliness can increase the risk of heart disease, blood clots and dementia, and that it encourages people to exercise less, drink more and avoid going out. It can also mean that people are more likely to undergo early admission into residential or nursing care. The introduction of a new loneliness measure as part of the adult social care initiative is therefore a very welcome move. But how is this going to be achieved in practice? I would be very grateful if the Minister could explain the thinking in this area.
For many who take part, volunteer-led local services are rare, even unique, opportunities for social interaction in a friendly and supportive environment. By creating networks of people who are looking out for one another, local services can generate vital sources of informal care, with benefits which resonate across the health and social care services. Instead of an older person’s health deteriorating without anyone noticing before a crisis happens, these services can prompt earlier intervention and help prevent problems escalating.
Sadly, these schemes and activities often do not get the support that they need. Alongside the tightened local authority budgets about which we have heard quite a lot today, the emphasis on personalisation is inadvertently taking its toll on some such voluntary sector services. As we have heard today—not least from my noble friend Lady Barker—personalisation is a perfectly good principle and has many benefits, but it has also had some unintended results. Fragmented amounts of money are difficult to tack together and shared approaches can become much harder. So, yes, of course, we must start with the individual, but what that sometimes reveals is the importance of collective and inclusive approaches which benefit both the people involved and the public purse.
These services do not need to cost much. Largely dependent on local volunteers, such initiatives have got by up till now mainly on small grants from their local authorities. Age UK, which does so much vital work in this area, recently told me of a discussion with one director of social services whose first instinct had been to withdraw funding from her local daycare services provided by the voluntary sector to help make the books balance, but she then realised, when she looked at it more carefully, just what a cost-effective and crucial access point they offered. Not only did the service enable her to stay in touch with how the older people in her area were doing but it provided a platform for delivering key services.
As I said at the beginning of my speech, as funding is reined in, so the focus shifts to acute needs. Daycare services, under pressure to take on older people with illnesses such as dementia, become less suitable places for older people looking for a lower level care. Of course, it is no criticism of local authorities that, when resources are scarce and they are being reduced to their bare essentials, acute needs become the main focus.
I conclude by returning to the big picture. I chose to make the focus of my remarks today the often undervalued and underfunded contribution of the voluntary sector—it is dear to my heart—but the big picture is critical. As so many other noble Lords have said, there are two key issues for the Government to address: first, the current funding gap for social care and, secondly, the need to implement a long-term, sustainable funding settlement for social care. On the former, without further action on funding, even the basic and too often inadequate social care currently provided will no longer be available from local authority-funded care. On the longer-term issue, there is a wide consensus, which I strongly share, that the Dilnot proposals are the most credible and practical solution. Difficult as it is in the current financial climate, the Government must make a firm commitment in the next spending review to implement Dilnot. The time for talk and deliberation is over; it is now time for action.
Lord Warner
My Lords, I congratulate my noble friend on securing this debate and opening it in her customarily clear, knowledgeable and wise way. I shall not repeat her analysis. I want to talk about the funding crisis. It is pretty clear from the contributions so far that there is a funding crisis in social care in a wider context. I shall touch on Dilnot—here, I declare my interest as a member of the Dilnot commission—but we cannot solve the problems of stabilising social care funding by Dilnot alone.
We are seeing local government in many areas having to concentrate virtually all its discretionary spending on adult social care and child protection, a situation to which the right reverend Prelate drew our attention. This will mean that big cities in particular lose those civic services around arts, leisure and other things which make for a civilised society as their authorities concentrate on social care and child protection. Yet these sacrifices may be insufficient to preserve good-quality, publicly funded social care services. Eligibility criteria will be tightened even further. Quality of care will deteriorate in a labour-intensive sector where the people providing the services have less money to ensure the quality and training of staff. These things are happening now on a considerable scale and the situation will only get worse. Local authorities will continue to chop their payments for publicly funded care.
We will see, and it has already started, private payers taking more of the services because the providers of those services, which are largely no longer public bodies, will have to concentrate their investment and activities on people who pay the true cost of care. Increasingly, that is not those who are in receipt of publicly funded social care.
Nothing stops the remorseless arithmetic of demography. The ageing and longevity of the population base of adult social care inexorably increase demand for care. With more than a third of the adult population having long-term conditions, and often with multiple morbidities, the demands on health and social care services will rise year by year for at least the next two decades. Yet we still pretend that the core business of the NHS is acute hospital treatment, when it is now community-based care involving care pathways that embrace health and social care and often housing and financial support. Yet our funding is in separate silos, with strong incentives to cost-shunt and to protect hospital budgets.
We have to begin treating the Department of Health budget as a single budget to be spent in the most cost-effective way for people’s care needs. We need to reimagine the whole system as a care system with a medical treatment adjunct rather than as a hospital treatment system with a care adjunct. We need money flows and payment systems that reinforce that new approach, rather than one that incentivises and reinforces episodes of care in acute hospitals and diverts money from overstretched community-based care. This means radically changing political and public attitudes to hospitals so that we can reduce the excessive number of 24/7 acute hospitals trying to provide a full range of medical specialties and concentrate specialist services on fewer sites. Not only would that be more cost-effective but it would be safer in many areas, such as maternity, for the public who receive those services. Money is now locked up and being spent in inappropriate ways in acute hospitals. That money should be extracted and used to boost community health and social care services.
We cannot expect local commissioners to produce these changes without national leadership. I am all in favour of localism, but to expect local commissioners to engineer these big-scale changes is frankly fantasy politics. I would like to see set up an independent, medical-specialty review of 24/7 acute services, led by specialist doctors and possibly under the aegis of the Academy of Medical Royal Colleges. I would ask them to see how these specialist services could be reconfigured on fewer sites, with the objective of safer specialist services that released—let us say—£l0 billion over five years to create a new time-limited care development fund. The fund’s mission would be the joint development by local authorities, clinical commissioning groups and health and well-being boards of more community-based care services. It is not a fantasy idea. In the US, Medicare is setting up a $10 billion fund to develop these kinds of community-based services.
Even with such changes, we still need major reform of the funding of social care to make it sustainable in the long term. This is because people have to save more for their old age and use more of their own assets to pay for their care, especially by equity release from housing assets. To do this we have to find a way of implementing some version of the Dilnot recommendations instead of sheltering behind the current fiscal difficulties to not do so.
As my noble friend said, there are ways of funding the relatively modest cost of starting on Dilnot. If we set the Dilnot cap at £50,000 or £60,000 and implemented the commission’s other recommendations, it would cost barely £1 billion a year or less to make that start. We could do this for three years by using underspends on NHS capital rather than repatriating them to the Treasury, and then if necessary find other funding sources including subsidies from the care development fund that I am proposing. There is a lot of money knocking around in government that could actually get Dilnot going in a reasonable way.
We cannot ask the social care world to adapt and find new ways of working without demanding much more from its wealthy relative, the NHS. Without more radical funding reform involving more use of NHS resources for social care, the good intentions of the draft Care and Support Bill will simply remain a wish list with no Santa Claus to deliver it. I hope the Minister—and my own Front Bench both here and in another place—will see these as constructive suggestions for further consideration.
Lord Sutherland of Houndwood
My Lords, I too, thank the noble Baroness, Lady Pitkeathley, for organising what seems to be an annual reunion of those of us who are the usual suspects. I would like to think that after the Minister’s speech the noble Baroness will organise an annual celebration, but perhaps I will hold my breath on that.
My remarks are intended to help establish two main points. First, the lack of central policy in England on the relationship between social care and healthcare is creating huge uncertainties for both providers and clients. Secondly, much of the difficulty already recounted in the debate is to be found in the practicalities of providing unified care services for many of those who need them. These difficulties of both policy and implementation will not be resolved until there is clear leadership at both national and local levels. Alongside this, structures must be created to enable the positive implementation of new policies. I pay tribute to the analysis that the noble Lord, Lord Warner, just gave on this.
What of the uncertainties that I mentioned? The legacy of a decade and more of a failure of leadership to face demographic realities is that it has brought huge uncertainty and consequent misery. The realities have been known for a long time. The demographic changes in society are as plain as plain could be. Whether we think of the developed or the developing world, even China now has begun to take note of the fact that the one child per family policy is building future demographic nightmares. To compare that with something else, the facts of climate change are all too evident this week as much as any. Those facts now have a leadership response from the Government and things are beginning to happen. Perhaps some would like them to happen more quickly but they are beginning.
The realities of demographic change are equally plain if not less contestable. Why does no similar cold shower of reality bring minds and political will to the table of demographic change? I can think of many reasons for that. One is that we always have on our desks the “too hard” basket. It is easy—and has been too easy—to put this set of issues into that basket. I confess that my own “too hard” basket at home contains a series of domestic tasks that I think are too hard but my wife clearly does not. However, if I were a government Minister, I would have a rather different use for that basket. That is what tends to happen.
The second possible reason is that it will cost too much. The issue has been raised of how much is too much when the reality of demographic change, rather than evading it, calls for a change in leadership direction. Reality, not habit and precedent, should dictate priorities in spending. If reality means spending less on this or that to face demographic change, then so be it. That is not a request for an additional or new priority to be added, but rather to reassert and re-examine what our priorities are. Are they still top of the list in view of demographic change?
A third reason given for doing nothing is, “We shall deal with this after the next election”. We have heard that more than once. What we have after the next election is usually a request for a review, report or even a commission. God forbid that that is where we will be in 2015, but we begin to worry that that will be the reality. The burst of enthusiasm that leaders have before elections for this issue tails off into long discussion and prevarication. The Dilnot report is the latest example of this—and, some are beginning to fear, the latest victim.
What are the uncertainties of which I speak? There are uncertainties, for example, for those attempting to make provision for themselves and their family. There are questions that they all ask: “Where do I go?”, “Whom do I ask?”, “How much will it cost?”, “Can I afford it?” and, “Can I insure against future need?”. Those are real questions masking real uncertainties. There is uncertainty for those in the insurance industry, who could surely help us here. They ask: “Are the risks pooled in any way?”, “Is there a cap on liability?” and, “How much will the market bear as a charge for insurance products in this area?”. We tend not to pay too much attention to private providers and the banks which finance them, but they have uncertainty, too: “Should I invest in building new care homes?”, “Should I invest in extending, refurbishing and improving my current stock of care homes?”, “Will local authorities commission places from me?” and, “Will they be able to afford to do so?”. Bankers might reasonably ask: “Should my bank offer loans to any of the above?”. Unless there is investment, there will not be adequate provision for the future. The banks would reasonably ask what the rate of return will be.
Then, of course, there are the uncertainties for those already in the care system: “Will I have to sell my house?”, “What happens if the money runs out?”, “Is my care package portable if I move to be nearer relatives?” and, “Are benefits assessed and commissioned to common standards or is there still a postcode lottery?”. I acknowledge the points made by the right reverend Prelate the Bishop of Liverpool on that. There will be differences and those will become accentuated. Successive Governments have failed to deal with these core uncertainties over at least 15 years. Ironically, the only certainty is the remorseless march of demographic change and yet we do not recognise it for what it is. The system is burst and we must fix it, and fixing it means radical thought and change.
In conclusion, I refer the Government to some recent research sources which point to future action. The King’s Fund has already been mentioned more than once. It commissioned a series of studies recently, including an excellent and balanced study by Raphael Wittenberg and his colleagues from the LSE. These complement work in this area in pointing to the central pathway down which we must travel—a unified system of providing and funding care, initially and most importantly by removing disincentives to combining assessment, commissioning and the provision of care packages. As the noble Lord, Lord Warner, pointed out, the disincentives are there now and we have to get away from that. We all know something of the problem of delayed discharges and unplanned hospital admissions—indeed, of unplanned readmissions. The separation of the budgets for health and social care and restrictions within healthcare budgets between one area and another add to the difficulty rather than contract it.
Lastly, in the University of Edinburgh and the Royal Infirmary, Edinburgh, there is important new research about what happens to those discharged from intensive care units. The researchers reckon that approximately 60% will be readmitted. Many of those readmissions are unplanned. The reason for that—this is an area to which not enough attention has been given—is a lack of coherent and adequate community provision. A re-examination of priorities would show real leadership.
Baroness Wilkins
My Lords, I, too, warmly congratulate my noble friend Lady Pitkeathley on obtaining this debate. Most especially, I applaud her for highlighting the significant role which housing plays in this debate. The impact which the lack of housing—poor, inaccessible and unsafe homes—have on our health and social care is too often ignored. It is rarely even mentioned, but cuts in the housing budget impact significantly on increasing expenditure on health and social care. I thank Sue Adams of Care and Repair England for her advice and help.
The crisis in housing means that, at last, it is moving up the political agenda. The Government have set out plans for a £220 care and support specialised housing fund to encourage providers to develop new accommodation options for older and disabled people. That is very welcome, but it comes in response to a severe housing shortage and a scandalous lack of new homes being built. In the past year, new home starts fell by 9%. Building new homes takes time. In the mean time, the Government’s benefit and housing policies are greatly exacerbating the problem, creating what many people have termed a perfect storm. The benefit cap, the bedroom tax and the removal of permanent tenancies and succession rights will all serve to increase the ill health of those affected and impact particularly severely on disabled and older people, multiplying the pressures on the health and social care services.
In 2006, a PSSRU discussion paper pointed out that, if we do nothing to change the current housing situation, occupied places in care homes and hospitals would need to rise by 151% by 2051. Some estimate long-term care expenditure will rise by around 325% in real terms by 2041. With such a depressing prospect, let us not waste this crisis but seize the opportunity to put effective reforms in place.
The Papworth Trust published a timely report this month based on a survey of 640 disabled and older people. It clearly demonstrates the cost to our health and social care budgets of not addressing the problems with housing. The trust’s research found that almost one in four people could not get around their home safely and two in five said that the design of their home meant that they needed help to do everyday things, such as cooking—all increasing their dependence on other people and potential costs to the health and social care budgets. The great majority of those people did not require rehousing, with the cost and upheaval that that entails, but the provision of relatively simple adaptations, such as grab rails, more accessible shelves and cupboards or level-access showers.
There is ample evidence that spending on those relatively simple adaptations to people’s homes can produce major savings to the health and social care budgets. A study published this year by the London School of Economics suggests that the annual spend of about £270 million on disabled facilities grants is worth up to £560 million in health and social care savings and quality-of-life gains. In other words, for every pound spent on DFGs, two pounds is saved on health and social care costs. A fractured hip can cost the state an estimated £28,000, so £30 on a grab rail is quite good value for money. Falls by older people cost more than £1 billion a year in the UK. The Welsh Government have estimated that a programme to help older people to remain living independently in their own homes has saved the NHS and social care budgets more than £101 million since it was set up 10 years ago.
Local authorities administer the home adaptation services, so cuts to local authority budgets are impacting on an already inadequate, overstretched and underfunded service. The service consists of two main elements: disabled facilities grants, which provided finance; and home improvement agencies, providing help and advice. For many years, there have been calls to strengthen the system and address its many problems.
A survey of English local authorities published in August this year by the Labour Party through freedom of information requests found that 17% fewer grant applications were approved in the past two years. That means that an estimated 10,700 fewer people received funding for home adaptations in 2011-12 than in 2009-10. Over the past two years, there has been a 31% increase in the number of delayed discharges from hospitals due to lack of appropriate home adaptations. That is costing the NHS £985,000 a month.
Despite a welcome extra £20 million provided by the Government for DFGs in January 2011, the money is not ring-fenced, with the result that some local authorities have used the extra funding to reduce their contribution rather than to fund extra work. The trust’s report of October this year found that, of the 326 local authorities which receive DFG funding from the Government, 62 have stopped providing Home Improvement Agency services altogether. That figure has doubled since June 2010.
The Papworth report recommends a radical overhaul of the DFG system. It sees it as wrong that responsibility for home adaptation lies solely with district councils, and proposes that local government and health money is pooled together in a DFG pot to be administered by the new health and well-being boards and clinical commissioning groups.
Finally, anyone who heard yesterday the devastating account of the research done into the situation of spinal-cord injured people in care homes, recently published by ASPIRE, could not fail to acknowledge the crucial role which housing plays in reducing the health and social care budgets. Following successful rehabilitation in a spinal injuries centre, the scandalous lack of accessible housing results in 20% of those patients being discharged by their local authorities into an elderly care home, with an average stay of two years. Twenty-five per cent of those people had tried to kill themselves. ASPIRE has made repeated requests to meet the housing Minister, with no success to date. I ask the noble Earl to do all he can to facilitate that meeting.
In conclusion, there is no denying that we are in a crisis, but let us not waste the opportunity that this crisis offers to make sure that we put in place the essential reforms needed, just as Beveridge did in the Second World War.
Lord Shipley
My Lords, I thank the noble Baroness, Lady Pitkeathley, for initiating this debate and declare my interest as a vice-president of the Local Government Association. My contribution will amount to a plea for urgent clarity in the future funding of adult social care. Time is short, given the enormous pressures on local authority budgets, where the cuts in central government grant amount to 28% overall in the four years up to 2014-15 but which in their implementation have impacted most heavily on the poorer parts of the country, where demand for publicly funded social care can be very high.
It has been generally agreed for some time that social care reform is essential. From the perspective of elderly people, local government, central government, the NHS, the voluntary sector and care providers, clear policy decisions are necessary to enable planning to take place and responsibilities to be agreed that will stand the test of time. Without that clarity, councils risk running out of money. That is a very serious matter, so I hope that the reports published yesterday that work is concluding on the recommendations of the Dilnot report prove to be true.
However, this is not just about Dilnot. There is a financial vacuum which needs to be overcome, of course, but it is not just about affordability. Government policy needs to be agreed as a crucial building block for allocating financial responsibilities. Policy-making affects individuals needing support; councils trying to cope with rising demand and reducing budgets; central government trying to cope with having less money to distribute; voluntary groups trying to plan and deliver services; the NHS trying to control its costs; and care home providers trying to maintain both capacity and standards of care.
From the perspective of local government, by 2019-20 there will be a funding gap of £16.5 billion—or 29%—between the revenue available and the spending pressures forecast. Assuming that social care is funded as now and that other essential statutory requirements are met by councils, there will be cuts of two-thirds in cash terms to all local government services other than social care. If concessionary fares are also fully funded and capital financing charges are met, 90% of current spending on other services will disappear. I believe this to be simply undeliverable for those other services include leisure, libraries and transport, all of which play a major role in the lives of elderly people and their health and well-being.
From the perspective of central government, net public spending on social care and continuing healthcare for older people will rise from £9 billion in 2010 to £13 billion in the early 2020s if current demand and spending assumptions apply—a rise of a little under 50%. There is actually a current funding gap, which has in practice been papered over through temporary financial solutions. The imperative of a long-term solution commanding all-party support has become overwhelming. Dilnot has been estimated to cost £2 billion. Current suggestions are that the cost will prove to be higher and require a higher cap. All this tells us that there is a very serious financial problem. I hope that the Minister will be able to say a little more about how the Government plan to address this funding problem and, in particular, what might be done in the very short term given that the focus of cuts is at the moment being applied to the poorer parts of the country.
We should remember that older people are a massive asset to their communities. They may become recipients of care but they are for many years essential providers of help and support to neighbours, families and friends, saving substantial sums of public money through their voluntary action. Implementing Dilnot would give many of them, and their families, peace of mind and confidence in their financial planning. It would also give the Government greater certainty about how to manage a 60% forecast growth in the number of over-75s within the next 20 years.
Perhaps I may draw your Lordships’ attention to the perspective of care home providers. Providers are claiming that there is now a funding gap of approaching £1 billion between the cost of providing quality care and the amounts paid to them by councils. Indeed, it is claimed that the average residential care home fee paid by councils does not meet the essential standards of the Care Quality Commission. If this is true, there needs to be an urgent review of why and what can be done because one of the consequences of inaction is a risk of more hospitalisations. We should note that fewer older people are now getting care, with a reduction from 1.2 million to 1.06 million in the past three years, which in itself may increase the numbers entering hospital directly. Yet we know that investment in prevention and in the voluntary sector saves money for the NHS. We also know that delayed transfers from hospitals are estimated to cost the NHS £200 million a year, which pooled budgeting might reduce.
While the Caring for our Future White Paper is in principle welcome, unless answers to Dilnot and related funding problems are given speedily there is a danger that councils will cut spending on social care, reducing levels of support to “critical only” and reducing fee payments in real terms to providers. Some older people who are not able to afford extra costs might then have to be looked after by the NHS. The long-term costs to the NHS of this could be substantial, which is why we need so urgently an agreed funding system for care.
In conclusion, we spend £121 billion on health and social care. I feel certain that the King’s Fund is right when it says that budgets should be pooled locally, with a single strategic assessment of the funding needs of the NHS and social care. It is vital that health and well-being boards should work well because they will drive the integration of adult care and health, which should in turn generate some efficiency savings to be redirected into service provision. It is vital that spending on prevention gets protected because in the end that is better for the individual but cheaper, too, for the public purse. Above all, it is vital that we get clarity in implementing Dilnot as the first step in building a system of adult social care that is sustainable into the future.
Much of this is about the medium to longer term but there is a massive problem now in some parts of the country. Over the past two years, I understand that the NHS has sent back to the Treasury some £3 billion. If that is the case, might the Government return that to health and well-being boards to enable them to find local solutions to their specific funding problems and for those parts of the country suffering the biggest cuts to get further support to reduce their impact?
Lord MacKenzie of Culkein
My Lords, I join in the thanks to my noble friend Lady Pitkeathley for securing this important debate and for her most eloquent speech. This debate is about the ambition to integrate health and social care. I am not, I think, one of the usual suspects because nurses of my generation were not very good on social care. One of the joys of being in this House is that one is always on a learning curve.
The integration of health and social care is a laudable objective and whether it succeeds, as we all hope it will, will depend on a number of important matters. Are NHS trusts, local authorities, clinical commissioning groups and health and well-being boards going to work well together, or will a new commissioning and marketisation framework, together with the existing barriers, lead to fragmentation and diversification in care services and perhaps disrupt any consensus? Will we get the innovation that we need? That must be the way forward. Or could it be that without proper regulatory guidance and funding, any new social service will end up like the present model—best described as patchy, incomplete and with a lot of staff who are poorly trained and paid, and unregulated. Will there be multiprofessional input into clinical commissioning groups? Will nurses be properly involved in hospital discharge policy and the development of community care?
The elephant in the room is: will there be sufficient money? It is fine to talk about efficiencies but so many so-called efficiencies are, in reality, not showing any demonstrable improvement in care. All too often they are a euphemism for cuts, rather than savings being reinvested into services. There are dark clouds on the horizon. The worst scenario, if I can repeat a phrase used a few minutes ago, is a perfect storm of demographic pressures combined with cuts in central grant support, council tax freezes and NHS organisational change, which could lead to a worsening of social care and further reductions in services, leaving the Government’s aspirations and policy in tatters. A lot of the money from the NHS that is designed to encourage joint working is, in reality, being used to avoid further cuts in services. That is a real concern.
I am also concerned about what might be said to be an auction race to the bottom, with providers appearing to win contracts by bidding at lowest cost rather than on quality. For example, when the Serco conglomerate took over the excellent Suffolk Community Healthcare, it was predicted by UNISON that there would be job losses. That was, I understand, denied. Now Serco, following its usual pattern, has proposed cutting more than one in six posts. That is how one can underbid an already good provider by some £10 million. The combination of financial restriction and the delivery of quality care is, to say the least, extremely difficult.
In domiciliary care, there is much reported worry, and much has been said about it today. I fail to see how we can have dignity, client choice and safeguarding with the present “time and task” system, which is so often the pattern. A recent UNISON survey showed a situation for many care staff which rather reminds me of the low-cost airline model of employment, with staff under pressure and paying for their uniform and training, quick turnarounds and wages varying every week. As the noble Baroness, Lady Gardner of Parkes, said, many of these care staff are not being paid for time travelling between visits and have zero-hours contracts. There is one difference: easyJet would not tolerate for one moment its customers being treated in the way that vulnerable elderly people or people with disabilities are being cared for in short, 15-minute visits. It is not possible in so many domiciliary care settings for there to be proper adherence to safeguarding principles and practice, and much too often the possibility of the client exercising choice is not a realistic proposition.
The situation in many care homes is little better. Nurses I speak to report that there are intolerable staffing pressures with often poorly trained staff. When things go wrong, the staff are made scapegoats when the resources are not being provided and managers and home owners are not held accountable.
The pattern is repeated for nurses working in the community. A recent Royal College of Nursing survey showed that 6% of respondents said they could deliver the quality of care that they wished to, and 75% of community nurses indicated that pressure on the nursing team had increased, leading to considerable concern about their capacity to protect adults and children at risk. Much of this problem emanates from cuts in social care budgets.
Who picks up the pieces? We have already heard today, and UNISON and the RCN remind us, as does the King’s Fund, that it is the National Health Service. Pressures on social care budgets lead to increased emergency admissions and pressures on A&E departments and continue the revolving door, with which we are so familiar, delivering inappropriate care in the wrong setting. That is not good for the National Health Service or for patients who are so often denied, for example, the prospect of good palliative care at the end of life at home or in a hospice.
The health charity sector is also suffering at a time when the need for its contribution has perhaps never been greater. There is no doubt that the Government will be looking to it to pick up more of the pieces as funding from local authorities and NHS commissioning is cut. Smaller charities, in particular, are affected, with the probability that staffing will be reduced or, as in the case of that great charity, Turning Point, that staff will be dismissed to be re-employed on poorer terms and conditions. That is an unenviable choice for dedicated staff and for the charities that do so much to fill gaps in our health and social services.
Social care is a complex subject. There are many areas one could speak on, for example, housing and so on. Others have spoken eloquently on them, so I shall conclude by mentioning the Local Government Association’s “Show Us You Care” campaign. I will not repeat all the details or even the bullet points. The Government know full well what that campaign is about. It is about the current funding problems, the future of social care, fairness and the ability in the future to maintain roads, libraries, swimming pools and so on.
This leads me neatly to the Dilnot commission, which has been much mentioned this afternoon. My noble friend Lord Warner said that it may not solve all the problems, but I think it will go some considerable way and would be a good start. I hope that the Minister can tell us when we will hear about the Government’s proposals following on from that excellent piece of work. There were reports in yesterday’s press that we might hear something in the near future, and it would be wonderful if the Minister could confirm that that is the case.
I again thank my noble friend Lady Pitkeathley, and I look forward to what the Minister will tell us when he winds up.
Lord Lipsey
My Lords, it is said that there are many Members of your Lordships’ House who habitually recite Trollope in their sleep, but I do not think many of them will have read his novel The Fixed Period, and I do not suggest that they do because it is pretty dreadful. It is set on the island of Brittanula where the law says that on reaching the very advanced age of 67—two years less than the age of the average Member of your Lordships’ House—people should be admitted to the college, as it is called, to spend a final year reflecting on their life. Then they are placed in a warm bath amid the smell of incense and their veins are opened so their life flows away. It turns out that this solution to the problems that we are considering today has certain disadvantages—for example, healthy inhabitants in their 66th year frequently try to flee the island—but, and this is the serious point, if we continue as we are in this country, the disadvantages of Brittanula may seem as nothing compared with the disadvantages of continuing life into an old age which, for poor people in particular, is characterised by neglect and degradation on an incomparable scale.
The signs of stress are already there. Fewer councils provide home care services for those with less than substantial needs. There are tales of care homes on the verge of bankruptcy because they cannot afford to provide decent services on the inadequate rates local authorities pay and of 15-minute home visits, which is barely time to change a diaper, let alone to have a chat.
The Government have sought to take some steps to mitigate the worst effects of fiscal stringency, although whether the extra money notionally made available is actually flowing through to services on the ground is another matter. Care services have been cut by less than other services, as the excellent IFS briefing circulated for this debate shows. There has been a cut of 4% in social care, but planning and development has been cut by 43%. However, this is cold comfort, for the plain fact is that we should not be contemplating spending less on care services—that is, if we want to avoid the Trollope solution—but more because the number of older people is growing rapidly. The number of those aged 65 or more will go up by 27% between 2010 and 2022, according to the OPCS. We should be spending more because the number of old people in impaired health at the end of life is increasing. There will be a 32% rise in those with disabilities in that period, according to the PSSRU at the LSE. The old hope that as we lived longer, we would have shorter or the same periods of ill health at the end of our life is unfortunately not necessarily being realised, and more people seem to be lingering on in more difficult states. We should be spending more because the cost of providing care will escalate. You cannot readily increase productivity in care in the way you can in some other walks of life. Just think about it; how do you change a nappy quicker? We should be spending more, increasingly, I am afraid, as the Government’s anti-immigration policies bite, making it harder to attract decent staff.
We are not allowed visual aids in this Chamber, or I should now hold up the notorious Barnet graph of doom, which was referred to by the noble Baroness, Lady Barker. It shows what the council expects to spend on services and, on another line, what it expects to be allowed to spend in total. By 2030, spending on social services alone, the bulk of that on old people, exceeds the total budget. Either no bins will be emptied in Barnet and there will be no libraries or parks—no town hall, even—or there will be further big cuts for old people.
It is important that the more that needs to be spent does not have to be just public money; we know there are restrictions on that. There is private money available, most particularly, the very large sums that increasing numbers of people have locked up in a valuable asset; namely, their house. It is surely right that they contribute from that to the cost of their care and do not just give it to their children, much though they may wish to do so, and as desirable as it often is. Their care should come first. Of course, half the people in care homes at the moment do not have to pay because their wealth and income are too low. There will need to be public money for them.
Where does Dilnot fit into this? We are in danger of confusing Dilnot with the shortage of funds. Dilnot is not aimed at the shortage of funds problem. It is aimed at quite a different problem: the care lottery which means that some people, the better-off people, will not need to spend anything on care because they will live to a hearty age and then die, whereas others will need to find literally hundreds of thousands of pounds to fund their care. That is deeply unfair.
The Dilnot solution has attracted consensus support. I am part of that consensus, but with one proviso. Public spending is limited. The more we spend to implement Dilnot, the less we will have to put in place better care services. We are given a choice, and we have to be careful that it is weighted in favour of decent care services, not in favour of more help for people to pay for them. I favour Dilnot, but on as cheap a basis as possible, with a £75,000 cap the minimum that should be contemplated, as was floated in the White Paper.
Finally, and wearily, I turn to the integration of health and social care. Wearily for this reason: I, we, all of us have been talking about this for years and years. It features in every single report that comes out on the subject, and to say that progress is “patchy” is to take an extremely optimistic view. I am afraid that I do not expect that to change soon. Everybody pays lip service to integrated care, but the brute fact is that, on one side, you have local authority budgets with one set of incentives, including the incentive to pass as much cost as possible to health authorities; and, on the other side, you have health authorities with another set of incentives, including the incentive to pass as much cost as possible to local authorities. While that persists, we will not get very far. Without integrated budgets, you will not get integrated services. It is as simple as that in principle, if extremely hard to put right in practice.
Baroness Scott of Needham Market
My Lords, I thank the noble Baroness, Lady Pitkeathley, for securing today’s debate. Like the right reverend Prelate, I am not one of the usual suspects; I rather share his nervousness about stepping into this. However, as the chair of the England Volunteering Development Council, I want to speak today to talk a little about the role of volunteers and the voluntary sector as they relate to social care.
Of course, people are living longer across all age groups, with much more complex needs, and there is a rightful expectation that they will be cared for. The noble Baroness, Lady Campbell, was quite right to set this in a human rights context. The strain of trying to provide social care and the scale and cost of this provision have been well highlighted in the briefings from the LGA and the NHS. It still begs a response from the Government. While I accept that Dilnot is not the answer to everything, it still represents the best that I have seen in many years. Therefore, I am also looking forward to hearing what the Government might say. I was very taken by the comments of my noble friend Lord Sutherland about the worry and stress on individuals who are concerned about what may face them as they get older.
In medical terms, this is not a crisis but a chronic condition. The situation has been getting worse for many years, as my noble friend Lady Gardner points out; it did not start in May 2010, nor will it end at the end of this Parliament. We therefore have to look at more long-term sustainable solutions, of which I would argue the voluntary sector is a part. That is particularly the case with the growing concern about the quality of care and the isolation and vulnerability of people, either in private care settings, as we heard in the Southern Cross case, in their own homes or even in hospitals, as we saw in the recent reports from the Patients Association and the CQC.
Set against this, there is an important role for volunteers to play in the care of vulnerable people as befrienders and advocates, and in complementing much of the work of the statutory services. I was pleased that my noble friend Lord Shipley made the point that older people are also of huge benefit to society. We must not always couch the “aging population” debate in negative terms.
The genuine integration of social care cannot happen unless there is a real community dimension to it, and that means using volunteers. For example, we need to have a proper look at how care homes can be opened up to the community, with more volunteers going in to offer personalised support, friendship and advocacy, and helping to generate a better quality-of-life experience. No regulator can be on hand all the time, nor can they see everything. Indeed, in my experience, regulators operating within statutory frameworks, subject to legal challenge and so on, often focus on systems and fail to be centred on individuals. As a complement to the work of regulators, volunteers can be around to see that individuals’ interests are foremost.
Volunteers can add enough support to enable someone to stay at home instead of in hospital. It is a much more humane as well as cost-effective approach, a point made well by my noble friend Lady Barker. Indeed, having someone around a little more of the time who can spot problems in earlier stages can reduce the need for later acute visits and hospitalisation. There are some very good case studies in the briefing from the WRVS.
I noted with interest last week the PM’s announcement on dementia, which came the week after an announcement that prisoners on release would be provided with one-to-one support. Both of these initiatives will rely on volunteers to deliver them. I make two points to the Government on this. First, the enthusiasm for volunteering that we saw during the Olympics had a lot to do with involvement in an iconic, one-off event. It is a different proposition to go from that one-off commitment to a weekly commitment to one individual who can have very difficult needs. Secondly, volunteering is not free. The Government have to put money in to recruit volunteers, to sort out the ones who are suitable and to train and organise them. The great lesson that we should learn from the Olympic volunteering programme is that it worked because the money went it to make sure that it worked.
Moving from individual volunteers to voluntary organisations, a piece of work needs to be done, on which I am sure that Volunteering England would be happy to work with the Government, on the placement of volunteers in care homes. I recognise that placing volunteers in a commercial operation is a controversial proposition. We probably need to do some work to develop protocols for that, as I know that Volunteering England already has with the rather tricky question of job substitution.
It is just over 20 years since I went into local government. At the start we always just talked about inputs; it was about how much we were spending. Then we started thinking about the outputs, and then finally we started talking about outcomes. Voluntary organisations by their nature are focused on outcomes; it is what they do. The conundrum now is that, with tight budgets, the focus on outcomes runs the risk of becoming lost. For example, a local charity or social enterprise that uses ex-offenders to deliver a lunch club to older people has multiple benefits, but they are quite hard to monetise. Outcome-based procurement requires commissioners to be much less prescriptive about how something is delivered and just to empower providers to deliver it. Commissioners often look down their noses at these soft outcomes—“Give us hard facts”, they say—but there is nothing soft or woolly about measuring the internal changes that service users experience.
There is a problem with commissioning. Public authorities are not good at seeing the added value that comes, for example, from giving contracts to organisations that use small local suppliers or those that employ long-term unemployed or people with mental health problems. Among local authorities and health authorities, procurement is the sort of area where cutbacks have resulted in fewer staff. They tend to take the rather easy route of offering single, larger contracts that are much less likely to deliver added value. Small to medium voluntary sector organisations and social enterprises do not always have the capacity to join in a lengthy bidding process. Even larger ones like CABs and volunteer centres are having their core funding cut. If you do not have core funding, you do not have an organisation to make robust bids. The social value Bill has been designed to get at some of this, but help is still needed to learn how to value certain things and to assist smaller organisations in the procurement jungle.
We should not still be having this debate; we have been talking about it for years. Therefore, will the Minister say something about how the new commissioning arrangements will work in this regard, and how he sees the voluntary sector interfacing with the health and well-being boards? I genuinely believe that the voluntary, community and social enterprise sectors have a fundamental role to play in securing and facilitating this community involvement and genuine integration of health and social care. However, it needs the Government to think carefully about their policies in a whole range of areas.
Baroness Greengross
My Lords, the reason why we are facing this huge crisis in health and social care is the amazing advance that has been made, mostly in medical care, in controlling a lot of acute conditions that used to kill people. Those people are now able to continue to live and we must celebrate that. However, because we have not changed the systems adequately to cope with that advance, we are in crisis. We should not think of it all negatively, but we should be quicker to change and adapt our systems to cope with what has happened.
Integrating the two funding streams of health and social care seems a huge problem. However, if we take advantage of the localism agenda and the fact that funding from Government is coming down to the clinical commissioning groups and the health and well-being boards at a local level, and if that money can be ring-fenced and secured at that level, the CCGs or the boards can mix the funding and solve that crisis by using it in the best way available to meet the needs of this population. It cannot be difficult to achieve that. Maybe the Minister will tell me whether he thinks that that is nonsense or whether it might be possible; I cannot see why it is not.
We need to get other changes into the system very quickly, including the culture change from a clinically driven focus on acute care to a patient-driven focus on long-term conditions. That is all part of the same change. Because it needs to be managed differently, it is a question of managing it at the different levels—national, regional and local. We must bring more to the forefront of these caring changes. The allied domains of care—housing and welfare benefits, the DLA and attendance allowance—are all part of the changes that have to be incorporated into getting this right.
We must also remember that we are not dealing just with elderly people. As the noble Baroness, Lady Campbell, among others, has reminded us, we are dealing with people with disabilities who now, thankfully, live to a greater age. Their care goes across their life, so we need a pan-age mechanism for treating people on an equal basis. At the moment, that does not happen. Younger people who need long-term care get a breadth of care plans that is not available to older people. Therefore, discrimination is often apparent in the system that we have now.
We have to expand the evidence base for early intervention and really understand the benefits of that. The ILC, with which I work, has done a lot to look at saving money through people going into extra-care housing. It has clearly demonstrated that this saves a huge amount of money because people do not go into much more expensive care in a care home or even in hospital until a much later age. I believe that that is a system change that we can achieve. I hope that the Minister will confirm he feels that this is possible.
We know that by speeding up home adaptations and equipment, we can also help people to stay at home for longer. The city of Hull did something that is purely common sense. It realised that no one would ask for a ramp or a plastic lavatory seat unless they needed it because neither is very decorative in one’s home. It decided that, rather than wait for someone to assess the need and then exchange information, which takes several months, before allocating a ramp or a loo seat to anyone, it would just give them to anyone who asked. Hull has saved a huge amount of money and immediately speeded up the process by doing that. Things can be done.
The goals that the Government have indicated that they want to achieve are achievable if sometimes we just use common sense. We are all determined to speed up the process of what we need to do to make life tolerable for a whole lot of people who at the moment are subject to quite a lot of neglect. There have been many illustrations of that in the speeches made by noble Lords today.
The recent Nuffield Trust report on integrated care for patients and populations gave the Government measures that I hope they will adopt—in fact, I think that they already have. I hope that we will get clear, measurable goals to improve the experience of people; that we will be able to enhance these goals by guaranteeing a certain standard of care for patients with complex needs; and that we, and the Government, will recognise that we are talking about people for whom time is very precious. They do not have that much longer to live, so we have to have timetables that are kept to and we have to understand the complex needs of the population that we are seeking to serve. I hope that the Minister, who I know feels very strongly about these issues, in representing the Government can assure us that he will take into consideration those and the many other points that have been raised today.
Lord Turnberg
My Lords, I, too, thank my noble friend Lady Pitkeathley for introducing this timely debate. She made a remarkably robust case and we have had some excellent, well informed speeches today. I imagine that it is very hard for the Minister not to have got the message, even though I suspect he does not need it. I, too, am struck by the faint ring of familiarity about this debate.
I want to focus on just two aspects: standards of care for the elderly and the mentally ill, and the integration of hospital and community services. Last week, we had two important reports. One was on the prosecution of those responsible for maltreating an elephant and the other from the Care Quality Commission about the poor standards of care for the elderly and mentally ill—and here, this elephant in the room, although rather more devastating, disappeared from the news rather too quickly.
The CQC painted a picture in which, faced with a rising demand from increasing numbers of elderly patients suffering from an often complex mixture of diseases, many nursing homes and some NHS hospitals were failing to meet basic standards of care. Failing to treat patients with the dignity that they need, failing to feed them properly and failing to care for their basic needs was just too common for comfort. Very importantly, it also found that management and staff vacancy rates were very high. As a result, poorly trained staff were rushed and asked to take on tasks for which they were ill equipped. Patients with complex multiple diseases need well trained staff, and these are in short supply.
All this may sound familiar and similar to repeated reports going back at least 15 years. We have had Age Concern’s report in 1997, the Healthcare Commission in 2004, its successor in 2007, and now in 2012, with so far not much change. If we do not do something now, it will just get worse. So is there anything we can do, apart from putting more money in? Of course, we need more money. Incidentally, the noble Lord, Lord Shipley, spoke about the valuable contribution that the elderly make to society. I do not think that we should forget that the elderly—that is, those over 65—who are supposed to be retired contribute to the national Exchequer through taxed income, and that needs examining. Apart from putting more money in, though, we could look again at the need for the proper training and registration of healthcare assistants. It was a grave error that we were unable to persuade the Government to include in the recent Health and Social Care Act a requirement for healthcare assistants to be trained and registered. I hope that the Minister will look again at the proposal to wait three years before we can revisit that decision.
I turn to the need to co-ordinate care between hospital and community, which has been the subject of some discussion this afternoon, and the need for the seamless care that we are supposed to provide. The problem has been well rehearsed, with elderly patients sitting in acute hospital beds when they would be better off at home or in accommodation more suited to their needs. There are many causes, including, of course, the lack of resources in the community that we have heard about, but often it is the result of failures in communication between the hospital and social services—and it is particularly bad at weekends and holidays. No one seems to take responsibility for this liaison, which is so essential, yet we know what to do, and indeed it is being done in many places. We do not have to go to Canada, where they have set up a very effective multidisciplinary team devoted to integrating care; we have excellent examples in Torbay, which is always being cited, where they have a single, merged care trust. Hereford and Devon have different but innovative schemes for integration. It is not only in leafy, affluent parts of the country where they are making a change; great work is going on in Bradford, Wolverhampton and South Birmingham.
So we know what to do, and one wonders why it is not being done everywhere. Partly it is a lack of lack of local leadership, and perhaps a touch of NIH syndrome—“not invented here”—that sets up resistance to change. Equally, though, we have not seen enough pressure and incentives from the centre. We need to use more carrots and sticks, as well as local leadership. Perhaps the emphasis in the new NHS mandate on care of the elderly and mentally ill will give us the push that we desperately need, and yesterday’s speech by the Secretary of State shows that it has moved up the agenda. I reiterate that we need action on many fronts: to encourage integration between hospital and social services; to ensure the better training and recruitment of healthcare assistants; and, as the noble Baroness, Lady Pitkeathley, pleaded, to have more resources for community services.
Baroness Wheeler
My Lords, I, too, thank my noble friend Lady Pitkeathley for securing this debate and for once again giving us the opportunity to place a spotlight on the growing crisis in social care provision and funding as well as on the importance of developing joined-up services between the NHS and local authorities and within and across the range of services that local councils provide. As usual, my noble friend provides us with a clear strategic overview of the situation and of the impact of cuts to NHS and local authority budgets, as well as firmly rooting the debate in the day-to-day realities faced by thousands of people and their carers who are struggling to cope without the support that they need, often for help with basic everyday tasks, such as getting up, washing and eating.
We last debated social care when the Government’s long-awaited White Paper was published in July, setting out key law and system changes in the Care and Support Bill, and the process for pre-legislative scrutiny, on which we are about to embark, but, of course, sadly ducking the issue that needs to be addressed for any new system to be implemented and for it to work; namely, social care funding and Dilnot.
Dilnot was then widely seen to have effectively been kicked into the long grass by the Government’s in principle only decision. Since then we have had a “will they, won’t they” stop/start coalition dance on the funding issue. Over the summer, our hopes were raised by media reports about U-turns, rethinks, and Prime Ministerial determination to implement Dilnot. If you fast forward to this parliamentary Session, however, there is continued confusion, with the reappearance of the unattributed leaks from government sources about the issue not being a priority, and the Health Secretary himself telling the Tory Party conference that the costs were unaffordable, while, ironically, only a few weeks later, stating his ambition to make England,
“the best place in Europe to grow old”.
He was referring to recent welcome initiatives on dementia care, but with an estimated 1 million people likely to be suffering from dementia by 2021, and 600,000 family carers currently caring for people with dementia, surely the only long-term solution for ensuring that we can address their future care and support needs is to reach agreement on social care funding. Otherwise, the current system, or the new system post the Care and Support Bill, just will not be able to cope.
Most recently, we have yesterday’s Daily Telegraph report that the coalition Government are close to agreeing a cap on elderly care, which could form a centrepiece of the coalition’s mid-term re-launch next year. Like other noble Lords, I look forward to the Minister updating us on what is going on. Does he accept that the need for a long-term funding settlement for social care has never been more urgent?
The debate today focuses on the role of local authorities in the provision of social care, housing and other care services, and it is good for us to be considering council funding and responsibilities in this wider care context. Council responsibilities run across social care, adult and children’s, mental health and learning disabilities, disability support, education, housing, welfare, leisure and transport—the services that people needing social care use or interact with. Last week’s debate on services for people with neurological and other long-term health conditions, for example, underlined the complex care pathways across NHS, council and voluntary sector care provision that need to be better integrated, including health and social care with housing and welfare.
Huge responsibility is placed on local councils to provide or jointly fund these vital services, but we have heard from noble Lords how the scale of reductions across council budgets and in social care highlighted by previous speakers are having a major impact. ADASS and LGA estimate that £1.89 billion have been taken off adult social care budgets in the past two years and that there will be a likely overall funding gap of more than £16 billion a year in overall council spending through to 2020.
There is welcome evidence that the funding transferred from the NHS budget to support social care has helped to stimulate joint working, but the reality is that the bulk of this money is being used to offset cuts to services, although to their credit, surveys show that half of the councils in England are seeking to protect adult social care from the most drastic cuts they are having to make. However, Labour’s and other surveys show that this is predominantly being achieved by holding down residential care placements and agency home care hours costs, and we know that this is simply not sustainable. One large independent sector provider has said that the multi-million pound funding shortfall between the true cost of providing quality care that meets CQC standards and the fees paid by local authorities to care home providers has increased by 16% in just 12 months.
References have been made to this year’s survey by Labour, which showed an 11% fall in the past two years of the number of vulnerable, old and disabled people having home care services fully paid for by the local authority. Eight out of 10 councils provide free care only for people with substantial or critical need. It also found that the average charge for an hour of home care had risen over the same period by 10%.
Noble Lords have underlined the impact that local authority budget cuts have on hospitals as social care funding is squeezed. One often underestimated impact is on accident and emergency services, as more people come through because primary care is becoming less accessible and social care is reduced. The system often seems as if it is in danger of falling over.
The Minister has been asked many questions and I look forward to his response. I want to touch on a couple of those questions. On personalisation, with the personal budget deadline of April 2013 fast approaching, we need to assess any potential negative impacts on existing services such as the provision of daycare centres. I welcome the comments of the noble Baroness, Lady Barker, on the need for more economic modelling on new services, and the references of my noble friend Lord Warner to ensuring that money flows to support these new initiatives.
On children’s services, the right reverend Prelate the Bishop of Liverpool referred to a potential 20% of cuts in children’s services there, and the likely impact on the NHS. On residential care, I was struck by the key quality of care test suggested by my noble friend Lady Donaghy: namely, are residents’ comfort and well-being viewed as of less import than the potential for bed-wetting? The noble Baroness, Lady Campbell, summed up integration as a complex nut to crack. I think that we all recognise this. She rightly praised local authorities that have introduced innovation into care support, even while having to make what she called terrible decisions about care provision.
I would like, in the time left, to pick up on the crucial issue of mental health. Labour has pledged to do all it can to support achieving real parity of esteem between mental and physical health, as Ed Miliband made clear in a keynote speech last month to the Royal College of Psychiatrists. He described mental health as,
“the biggest unaddressed health challenge of our age”,
and said that it affects,
“one in six people across Britain”.
Local government is a key player in mental health, in shaping and commissioning services in social and residential care and in local community services such as advocacy, mental health outreach, befriending, drop-in groups and daycare provision, working with the NHS, community and voluntary sector providers.
As the chair of Blackfriars Settlement, a small local multi-service provider in the London Borough of Southwark, I can cite direct experience of how important the local authority role and support is, and how challenging and difficult it is for the voluntary sector to get funding to replace the reductions in funding. The settlement is one of a consortium of council funded voluntary organisations helping to deliver the borough’s mental health strategy. We have traditionally specialised in work with people with severe and enduring mental health problems, many of whom have been in the system for a long time. We are having to work hard to adapt our services to meet the new challenges on the ground. Our previous delivery model has been updated and adapted to provide a service menu for clients with personal budgets, and we are working hard to develop partnerships with local community groups on a number of projects. We have set up, with Big Lottery funding, a small social enterprise called Art to Print which provides employment and training in art and design production for local people with mental health problems, many of whom have never worked before. However, it is tough going and if we do not succeed in keeping these vital services going, our clients will just not have anywhere else to go.
The Centre for Mental Health underlines that social care input into mental health services is vital for recovery, but the information to measure and assess progress is hard to come by from local authorities because of the absence of systematic reporting on mental health spending and service provision at local level. The charity Rethink’s report, Lost in Localism, this year pointed out the difficulties of assessing the proportion of local authority social care spending on mental health, which is currently achievable only through freedom of information requests. Will the Minister outline any plans the Government have to improve data on local authority mental health spending and services which will help measure progress on how parity of esteem can become a reality?
There are significant reductions in parenting programmes’ budgets to support families at high risk, particularly parents who themselves have poor mental health. The British Association of Social Workers has estimated that around 40% of local authorities have removed, or are considering removing, mental health social workers from NHS-led mental health community and crisis teams. Action for Advocacy’s recent survey found that organisations providing advocacy services for vulnerable groups have had their funding cut by an average 36%, mainly by councils.
I was going to refer to a number of other things, but I see that time is running out. Therefore, I shall put two final questions to the Minister. Although the barriers to providing integrated services are well known, mental health has to date been one area where there have been long-standing partnership arrangements between the NHS and local authorities, including secondments and Section 75 agreements delegating functions to NHS trusts. Given this existing good platform, what are the Government doing to promote the continuation of this?
On parity of esteem, the NHS mandate commits the NHS Commissioning Board to deliver the Government’s commitment of at least 15% of adults with relevant mental health disorders having timely access to services with a recovery rate of 50%. What are the timescales, costs and funding sources for this? The Minister assured us that the mandate had been fully costed and could be carried out within these costs. Is 15% good enough?
Like the majority of noble Lords who have spoken in today’s debate, I hope that the Minister’s responses will show us that the Government understand the scale and urgency of the social care crisis and are prepared to take effective action in this Parliament to address it.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Baroness, Lady Pitkeathley, for calling this debate and for having introduced it so well. As the contributions today have amply illustrated, this is a subject of vital importance.
Care and support will affect most people in England at some point in their lives. More than 80% of people in their 60s now will need care in their old age. The fact that people are now living longer thanks to medical advances is something that we should all celebrate. The Government see care and support as essential to helping people live lives that are full and independent. Our vision is, first, for timely care that is preventive rather than simply catching people at a point of crisis. Secondly, to pick up a theme so well articulated by my noble friends Lady Wheatcroft and Lady Barker, and the noble Baroness, Lady Campbell, we believe that care is best when centred on the person and their family. This means that it is joined up with the other services that they use—health, housing and in the community. We also recognise that good, integrated care is important for the sustainability of the NHS.
Due to the economic situation, this spending review has been challenging for local government. However, we have been clear that social care must be protected. We moved swiftly to allocate an additional £7.2 billion over the spending review period to protect adult care. Since then we have allocated an additional half a billion pounds. We remain firmly of the view that the funding we have provided is enough to allow authorities to maintain access to services and to provide good-quality care. Independent research from the King’s Fund corroborates this. This does depend on authorities providing care and support in a cost-effective way, which is a principle we insist on for all public spending. The funding we provide assumes that authorities improve cost-effectiveness by 3% each year in this spending review period. This is an ambitious programme of efficiency savings, but one that partners in the care sector, including the LGA and ADASS, agreed was achievable.
The opportunity is there to make savings and improve outcomes for users at the same time: through investing in reablement—to pick up the word “investment” used by the noble Baroness, Lady Pitkeathley—so that people regain their independence following a crisis; through developing integrated crisis services to deliver health and social support quickly; through rolling out telecare, which is proven to move support from clinics and institutions into the home; and minimising back-office administration to focus resources on users. The Government have provided sufficient funding but authorities are responsible for how it is used. This is an important principle. Whitehall cannot dictate what is best for communities; nor do councils want it to. However, this means that we cannot guarantee that all authorities will prioritise social care or deliver it in the same way.
Social care has been protected more than other services. Many areas have increased their spending but, unfortunately, this is not the case everywhere. It is true that expenditure has fallen when seen at a national level. However, this is not the story of cuts that some critics have made out, and there is only limited evidence of impact on services or on users. My noble friend Lady Tyler will be interested to know that ADASS has found that three-quarters of the reductions are from increased cost-effectiveness. That is, councils are making savings by doing things better. They are achieving an average of 5% efficiency, which is 2% higher than we expected. There are exciting successes and my noble friend Lady Tyler referred to some. For example, Dorset has invested £1.6 million to help people regain independence at home after a crisis. It expects to save £3 million a year from providing preventive, integrated care. That is exactly the type of initiative that we want to see.
Councils have broadly maintained eligibility for services. A few have raised eligibility levels from “moderate”, but only to join the overwhelming majority of councils that already set eligibility at “substantial”. No council has raised eligibility higher than this. We have seen a reduction in the number of people receiving state-funded residential and domiciliary care, but this reflects a return on preventive policies such as those mentioned by the noble Baronesses, Lady Wilkins and Lady Greengross, that are helping people stay independent and in their own home.
The noble Baroness, Lady Pitkeathley, referred to integration of services. This theme was taken up by the noble Baroness, Lady Campbell, the noble Lord, Lord Turnberg, and others. When money is tight for local government, as it is for the NHS and the public sector, the most important way that health and social care services can meet this challenge is through better co-operation and more integrated working. I stress this to the right reverend Prelate the Bishop of Liverpool. It is why the SR settlement includes annual transfers from the NHS to be spent within social care. This year the NHS has provided £622 million in funding for social care.
Local authorities must agree with their PCT how the money will be used. From 2013-14, the conversation will take place through health and well-being boards and will involve the CCG, public health and social care. This is a real opportunity for integrated care. The evidence to date is that, precisely as we had hoped, local areas are investing the NHS contribution in reablement services, and are working in partnership with hospitals. There are some excellent examples of this. Some were cited by the noble Lord, Lord Turnberg. I was in Calderdale last week. Calderdale CCG has taken a joint approach with the local authority and other partners to introduce an integrated intermediate-tier service, informed by a consultation with patients, carers and the public. The single point of access was launched about a year ago. Services are delivered by Calderdale Council’s gateway to care. Patients and carers now need to make only one call to get access to a range of support and reablement services.
It is no coincidence that we have placed such emphasis on integration in the mandate to the NHS Commissioning Board and in the NHS outcomes framework. The department is doing a great deal of work in this area with the board, Monitor and the Local Government Association. We will publish a framework next year.
My noble friend Lady Barker asked what the Government would do by way of an economic evaluation of integrated care. We constantly evaluate new initiatives to get the best possible evidence to inform our policies. In addition, we are engaging with academics and partners from across the sector. For example, a number of local authorities are currently piloting a community budgets approach to integration. We are working with, and offering support to, local authorities to evaluate their pilots, and we will continue to look at emerging evidence.
Looking ahead, we are increasing NHS funding for care services over the next two years. By 2014-15 the NHS will provide £900 million in support for local care services. This increase in joint working will benefit health and care, and patients and the public. We have also invested in housing. I completely agreed with the noble Baronesses, Lady Donaghy and Lady Wilkins, that where the elderly choose to live is of real importance to their independence and well-being. In October, the Government announced an extra £300 million of capital funding to encourage providers to develop new accommodation for older people and disabled adults.
The noble Baroness, Lady Greengross, was absolutely right, as she so often is, that this will support people to stay independent for longer by allowing them to receive care in their own home and by reducing the need for them to go into care homes and hospitals. We have announced a national eligibility threshold that from 2015 will ensure consistent access to care and will end the postcode lottery. The measures in the care and support White Paper and accompanying draft Bill will ensure that prevention, personalisation and integration will become the standard. I will refer to those again in a second.
The right reverend Prelate the Bishop of Liverpool urged the Government to review the local authority funding settlement. We will of course review funding in the next spending review period. When we look at the current situation, it is not in fact accurate to say—as was implied by one or two noble Lords—that cuts to central government grants have hit poorer councils hardest. This year’s formula grant reductions are generally smaller for the most deprived areas and larger for the less deprived ones. The data that we have seen do not show that the most deprived areas have seen the greatest reductions in social care spend. The 10 councils with the greatest increases in spending on social care include Knowsley and Rochdale, which are two of the most deprived local authority areas in the country.
The noble Baroness, Lady Pitkeathley, referred to increases in charges. Of course, she knows that charging decisions for community-based services are the responsibility of local authorities, in line with guidance produced by the department. We have no evidence of widespread increases in what authorities charge for services. However, as a general point, I recognise that this has been an extremely challenging settlement for local government. A number of councils are cutting services or tightening eligibility, as I mentioned. Those councils will have to justify their decisions to the communities that they serve. While any change is regrettable, only six local authorities have tightened eligibility criteria this year, compared to 15 last year. Of these, none has tightened beyond the broad average position of “substantial”.
A recent report by Demos and Scope, Coping with the Cuts, suggested that there was no direct correlation between the budget reductions faced by adult social care services and the impact on local people. This demonstrates that if local authorities make appropriate efficiency savings and develop innovative solutions, they can maintain and improve people’s outcomes and access to the services that they need.
A number of noble Lords, including the noble Lord, Lord Warner, in his extremely thoughtful and constructive speech, the noble Baronesses, Lady Wheeler and Lady Pitkeathley, the noble Lord, Lord Sutherland, and my noble friends Lord Shipley and Lady Tyler, referred to the need to address funding reform and to the Dilnot report. We have stated that we agree with the principles of the Dilnot recommendations. However, I hope that I may be forgiven for repeating that funding reform is complex. In the current economic climate, it is right for us to wait until the spending review, when we can consider funding reform alongside other spending priorities. The noble Lord, Lord Lipsey, was right to make that point.
This will give us time to engage with stakeholders on these difficult issues, which we are already doing, to ensure that we have the right information before making a decision, not least on points of detail that affect the cost and practicalities of implementing a cap. This matter is definitely not on the back burner. Solving social care funding remains one of the key priorities of our time. In response to a number of noble Lords, I will say that since the Dilnot report was published the Government have been very clear about the value that they place on political consensus, and about their commitment to cross-party dialogue in pursuit of that objective. Our offer to the Opposition remains on the table. It is of course up to them to decide when and how to work with us on this.
A number of noble Lords, including the noble Lords, Lord MacKenzie and Lord Sutherland, and my noble friends Lady Barker and Lord Shipley referred to the problem of delayed transfers out of hospital. I will say as a general point that no one should have to stay in hospital longer than is necessary. The NHS must work collaboratively and innovatively with local authorities to help improve discharge, reduce delays and improve outcomes for patients. Older people often need particular support after a spell in hospital. That is why we have made available the £300 million in the current year to develop local reablement services and help people settle back into their homes and recover their strength and independence.
My noble friend Lord Shipley rightly mentioned pooled budgets. As I mentioned, in 2012-13 PCTs will also receive a total of £622 million to invest in social care services. That is in addition to funding for reablement services. In the year up to September 2012 the number of patients with delayed transfers was 5% lower than in the previous year. Delays because of social care issues fell by 12% over the same period.
My noble friend Lady Gardner and the noble Lord, Lord MacKenzie, spoke very powerfully about the tendency for care visits to last for about 15 minutes. While local authorities are responsible for the commissioning of services, not the Government, both the Government and ADASS are fully in agreement that 15-minute visits for personal care are absolutely unacceptable. We will bring an end to commissioning practices that undermine people’s dignity and choice, including commissioning care by the minute. We will work with commissioners, care providers, people who use services, carers and the Think Local, Act Personal partnership to end these practices.
My noble friend Lady Gardner also, rightly, pointed out the need for good regulation by the CQC to ensure quality. The CQC can and will take action where it finds residential services that are not meeting essential standards, and this action ranges from requiring improvement plans to restrictions on, or even the closure of, care and nursing homes in extreme cases.
The noble Lord, Lord Turnberg, spoke powerfully about the quality of care, as did the noble Baroness, Lady Campbell, about the importance of dignity and respect. The care and support White Paper sets out our plans. A national minimum eligibility threshold will make access to care more consistent. People will have clear, practical information and advice on the care system and new ways to report poor care. People will have easy access to information to help them narrow down their search for quality care providers. The new quality profiles will bring much needed transparency to the quality of care people can expect from a care provider. More care workers will be trained, including an ambition to double the number of care apprenticeships by 2017—a subject we debated earlier today. Dignity and respect will be at the heart of a new code of conduct and national minimum training standards.
The noble Baroness, Lady Campbell, spoke about the JCHR and human rights. She raised some extremely important issues and I listened with care to what she said. I hope that she will allow me to write to her to update her as to where we are on that subject.
The noble Baroness, Lady Greengross, spoke about the need to encourage preventive services in particular and I quite agree with all that she said on that subject. As part of the shift to a more preventive approach to care and support, the draft care and support Bill includes a duty on local authorities to commission and provide preventive services. Preventing needs from arising, or reducing them where they exist, is a critical part of local authorities’ responsibilities for care and support.
My noble friend Lady Wheatcroft referred to the centrally important phenomenon of social isolation and loneliness among the elderly. I agree that communities should ensure that people are not alone or isolated. Social isolation is a measure that will be covered in the social care outcomes framework. I will write to her with more information about that.
The noble Baroness, Lady Wilkins, spoke about housing and her wish to meet the Minister for Housing, and about the disabled facilities grant. The draft care and support Bill will set out new duties to be placed on local authorities to ensure that adult social care and housing departments work together. This will support adaptations and ensure that services are joined up better with people’s care and support. I hear her concerns about the disabled facilities grant and grants for housing. I will discuss them with my housing colleagues and respond to her in writing.
My noble friend Lady Scott and the noble Baroness, Lady Wheeler, highlighted the importance of voluntary organisations and volunteers in helping to care for our ageing population, including in the field of mental health. Of course, the Government agree that volunteers and charities play a crucial role, which we must support. I will respond with a note containing more detail on this, including how voluntary organisations may contract with health and well-being boards.
My noble friend Lady Barker and the noble Baroness, Lady Wheeler, spoke about personalisation; in particular, personal budgets, which are only part of the personalisation agenda. Again, the draft care and support Bill places personal budgets in law as the default option for adults and carers alike. People will be provided with a clear allocation of resources so that they can control as much of their care and support as they wish. This will ensure that all people in need of care and support benefit from the choice and control that personal budgets can bring, not least those suffering from mental health conditions.
We have supported social care in this spending review and have made additional funding available. We have provided funding in forms that support integrated and preventive care, extra resources from the NHS and extra resources for housing. There is variation in how well councils are coping with tighter funding. However, many councils are rising to the challenge; they are prioritising care, increasing efficiency and maintaining outcomes for their users. It is clear that this is where councils should be focusing and where we expect services to be by 2015.
Baroness Pitkeathley
My Lords, it is a comfort to me that the number of usual suspects swelled gratifyingly for this debate—a sign, perhaps, that we are getting nearer to understanding that this is the pre-eminent social issue of our times, in terms of both the current gap and the need for long-term solutions.
We have had a wide-ranging debate and a powerful set of speeches. There is agreement that there is a crisis—or rather a series of crises, in the short, medium and long term—and suggestions for how to tackle those. We have had ideas and examples focusing on innovation, integration, efficiency, and we have even had ideas about how we can get more money into the system. We also have agreement about the urgency of the need and about the importance of that old chestnut for many of us, integrated care.
The Minister has given us his usual thoughtful response, for which I thank him, and we all know his sincere commitment to finding a solution to the problem of social care, although I find it hard to recognise the picture of local services he paints from the ones presented to me. I shall take pleasure in checking this out with the group of 200 carers whom I am addressing tomorrow at a carers’ rights day. I shall ask them for their opinion of the situation.
I return to my original thought—which others have echoed, including the Minister—that social care should be seen as an investment, as a way of saving money, especially for the NHS. But this needs much more sharing of money and much less silo thinking, and more focus on the consequences of not doing it rather than on the cost of doing it. For example, if we just take Dilnot—and I am grateful for the calls from many Peers for Dilnot to be implemented—we know that the cost of implementation is about £2 billion. It is not the whole solution, as many noble Lords have said, but no one has yet found a better place to start. To set that £2 billion in context, family carers are contributing care worth at least £119 billion a year. If only 10% of them give up because they are too exhausted, stressed and poor to continue, that will cost £12 billion—six times the cost of Dilnot. Can we not afford to make the investment that local authorities, the NHS and, above all, the users and carers deserve?
The issue of social care needs radical thought and change, and leadership at national level. As has been said, the inexorable arithmetic of the demographics means that we cannot ignore it and put it into the “too difficult” box, however tempting that may be. Without tackling the resource issue, things will only get worse. Will we be here again next year, reporting on how the situation has deteriorated further? I sincerely hope not. I thank all noble Lords who have spoken, and beg to move.
NHS: Diabetic Services
(12 years ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Harrison
That this House takes note of the management of diabetic services in the National Health Service.
Lord Harrison
My Lords, as a type 1 diabetic of 43 years’ standing, I have received unparalleled support from the NHS and, in recent decades, from health professionals in Chester and Liverpool. I am ever grateful for their continuing expertise and engagement. However, recently I have witnessed a worrying decline in the care offered to me and other diabetics. First, my excellent local hospital no longer invites me for my annual diabetic check-up. Similarly, the regular check on my eyes at the hospital is being curtailed, blindness being a not infrequent complication of diabetes for one in seven of us.
My big concern here is that the onus is falling on the individual diabetic to repair to the GP at the first signs of disquieting changes in his or her health for referral to the relevant specialist. That is all well and good if you are alert and dedicated to preserving your health, as am I, but that is not true of all of us. I have sat in the waiting rooms of diabetic clinics next to other, less articulate and perhaps less personally organised patients, who have turned up at the wrong hospital, never mind getting the date and time of their appointment wrong. In a hospital that I know, missing an appointment means instant dismissal from the clinic, with all the morbid consequences for the diabetic involved. Moreover, the regular diabetic check-up uncovers trends and problems that patients may not have recognised themselves. Action can be taken. Potential blindness, the amputation of a septic foot or the continuation of an unhealthy lifestyle can be diverted by action, and a life or a limb can be saved.
Therefore, my first question to the Minister is this: does he recognise that there is folly in short-termism, such as the cutting of annual clinics, which brings in its wake long-term deleterious consequences for the individual and, in the end, greater NHS expenditure in administering to the diabetic at peril?
A very recent example of a laudable NHS innovation is the potential treatment and advice to be given to patients online to save GP surgery time. However, that may lead to a greater exposure to danger for diabetics. All such worthy changes and innovations in the treatment of diabetics must be tempered by acknowledging that penumbra of citizens afflicted with diabetes who are less accustomed to the computer cursor. How will the Minister ensure that the computer-averse are not left behind? Perhaps, too, the Minister, who is admired on all sides of the House for his deep knowledge of his brief, could roundly repudiate the Tory GP Back-Bencher who foolishly opined last week that type 2 diabetics were to blame for their condition and should be deprived of NHS services as a punishment. That kind of response to the diabetes epidemic is unworthy and unrealistic. Nevertheless, diabetes is the UK’s number one health threat. Some 3.7 million of us live with the condition and a further 7 million are at high risk of type 2 diabetes. Half of those diagnosed with type 2 already have serious complications, thereby incurring increasing costs for the NHS budget, which currently stands at £10 billion a year and is rising. Action now on this killer disease is imperative. There is a need for a matching application of enthusiasm, expertise and expenditure to be granted to defeating diabetes that have rightly been developed for heart disease and cancer treatment in recent decades.
The National Audit Office found that diabetic care in the NHS is poor, with low achievements of treatment standards and high numbers of avoidable deaths. Indeed, 80% of the NHS costs are spent on the complications stemming from the condition, which are largely avoidable. Can we tolerate the fact that 24,000 people die each year from the condition needlessly, avoidably and with attendant unsung misery to their families and friends? The excoriating report of the Commons Public Accounts Committee rightly demands, in the words of its chair, Margaret Hodge, “straightforward care and support” for diabetics. Can the Minister be equally straightforward and respond to the detailed shortcomings exposed in the PAC report on diabetes care?
The noble Baroness, Lady Young, the chief executive of Diabetes UK, who is on duty in New York today, notes the postcode-lottery nature of diabetes cover across the UK. Can the Minister guarantee the maintenance of high standards, as in the established “15 healthcare essentials” for diabetics, so woefully underpowered in application at the moment? As the PAC report shows, these essential desiderata are simply not being met. Tailored education about their condition is essential for individual diabetics but this ambition fails to be fulfilled. Can the Minister comment on the important work done by the DAFNE programme? This is already being delivered in 70 centres around Britain and helps to provide proper cholesterol control among other tasks, such as promoting healthy eating among diabetics. Given the imprimatur that it has received from NICE, can this programme not have wider reach and support within the NHS?
April is the cruellest month, for in April next year we are to come under the reformed regime of local commissioning in the NHS. Some of us quake in our boots at this prospect. The PAC report tells us that the current NHS accountability structures have palpably failed to hold commissioners of diabetic services to account for poor performance. Indeed, it details other failings. Only one in two patients receives all the basic tests to monitor their condition, and only one in five achieves recommended levels for blood glucose and blood pressure, as well as the vital cholesterol norms. Will the Minister respond to the charge that the department is failing to incentivise delivery of all these aspects of its recommended standards of care through the medium of the payments system and that it neglects to gather the cost information and to carry out general monitoring? These responsibilities of the department are vital for proper reform.
I do indeed stand in the Chamber before your Lordships today because of the excellent care that has been accorded to my feet. I suffer from severe neuropathy, where one has no feeling at all in the feet, and I have a minor debriding of part of one foot. My wife and I have become foot fetishists in constantly visually examining my feet for any minor changes that might presage drastic and draconian complications. Indeed, at the recent Putting Feet First reception, Diabetes UK and the College of Podiatry noted that 125 amputations are carried out each week, of which 80% are preventable, costing the NHS some £700 million each year. Can the Minister ensure that all diabetics become foot fetishists in assiduously committing to look at their feet twice daily? Can he also ensure that health professionals are aware of the imperative to so monitor feet and that the integrated pathway approach to the diabetic foot, which characterised the approach of the care I received from Broadgreen in Liverpool, is applied universally? Incidentally, that is where my shoes are made at a cost to the NHS, but it means that I can become economically productive, as can many other diabetics, because they can get on their feet and do a job.
I await with interest the speech of the noble Lord, Lord Kakkar, on the imperative of an integrated approach to the treatment of diabetes as a whole. I hope that the noble Lord might also offer us some insights into Britain’s ethnic groups, who suffer disproportionately from diabetes. Indeed, he and the Minister may know of the recent research findings from Imperial College London detailing the worryingly high incidence of type 2 diabetes among our Asian, black African and African Caribbean communities. At November’s south Asian health education reception in the Lords, we learnt of the courses run in temples, mosques, gurdwaras and community centres assessing diabetic risk among these populations. Perhaps our Christian church-based communities might take up that useful contribution. I note the presence of the right reverend Prelate the Bishop of Liverpool, who might communicate that to colleagues.
Beyond that, I ask the Minister what is being done at the European Union level to share best practice among health professionals and health Ministers on the treatment of diabetes—I sense that the desirable exchange of knowledge is piecemeal at best—and also about our engagement internationally on reducing the terrible toll of 4 million deaths each year round the world. Tragically the notion that diabetes is the rich world’s disease is sorely mistaken. I ask the Minister, if I may, when he last had a conversation with another Minister from the European Union on the question of diabetes. It would be intriguing to know.
Let us return home. In-patient care studies, according to the 2011 in-patient audit, reveal: stark problems in the referral processes; a decline in diabetic consultant availability; no fewer than one in three entities lacking diabetic in-patient specialist nurses and, more specifically, no essential podiatric provision; and diet advice to diabetics deteriorating. A diabetic nurse at the Countess of Chester replied to my inquiry, “How can we do things better in the NHS?”, by volunteering that she would like to visit all the wards in the hospital and peek under the bedclothes to see the feet of new patients. No, she is not another foot fetishist. The purpose of such inspections is to identify potential problems by scrutinising feet when there is a captive audience within the hospital.
The national Health Check programme which was introduced four years ago to promote early diagnosis has been patchily implemented. Many PCTs fail to offer such checks. Next year this responsibility falls to local authorities whose budgets are being negligently cut by the Government, who continue to pile responsibility on responsibility on local authorities with no additional compensating funding. Can the Minister give us some hope and allay this fear?
Recently the Minister kindly replied to some Written Questions that I posed on the incidence of the very frightening and life-threatening condition for children of diabetic ketoacidosis. Some one in five children is diagnosed with type 1 diabetes through a DKA episode. What improvements are being made in the early diagnosis of children’s typically type 1 diabetes, and also in the auxiliary help given to parents and carers who, untutored, have to face the heart-rending job of explaining to their child the necessity of insulin injections and renouncing chocolates? I celebrate all those parents and carers who so dedicatedly help bring their children to maturity by their love and unstinting work. I know that others will highlight the needs of the diabetic child but it is imperative that paediatric and adult services combine to offer effective, tailored care for the individual child. Does HMG support the so-called transition clinic to help the child come to terms with their diabetes? Transition clinics are characterised by their multidisciplinary approach.
Could the Minister also report on the work done by his department and the education services on the diabetic child’s exclusion in so many ways from PE, school trips and so on? They are denied access to necessary medicines for the lack of a nurse or private space to inject insulin or take a blood reading. They can experience bullying as a result of being the child excluded by a diabetic condition. These are all examples of plain discrimination that must be tackled head-on in the classroom. Sometimes there is also a need for children and adults to have access to appropriate psychological and emotional support services. To many diabetics their condition is inexplicable, frightening and paralysing socially. Given that some two in five diabetics suffer poor psychological well-being, can HMG assure us that resources will be found?
Finally, when he replies, will the Minister tackle the vexed question of giving appropriate help to diabetics in hospitals? Sometimes appalling food is served up. I well remember the very sweet puddings that I was offered in the two periods that I stayed in hospital. I am most grateful to colleagues here today and hope to hear a report from the Minister that will perhaps give us some hope of ensuring that diabetic services are maintained at a level that is appropriate for the population.
Lord Rennard
The 3 million people living with diabetes in the UK will share my gratitude to the noble Lord, Lord Harrison, for securing this important debate today. So, in particular, should the 850,000 people in this country who have the condition but are unaware of it, and the 7 million people he referred to who are at high risk of developing type 2 diabetes.
I wish, first, to declare an interest as the director of communications of the British Healthcare Trade Association, but my personal interest in diabetes is longstanding. My father was an insulin-dependent diabetic. It was possibly the shock of losing a leg when wounded in the First World War that brought on his diabetic condition. He was, therefore, one of the first people in the world to benefit from insulin, as far back as the 1920s. Without it, obviously, I would not be here today. My father went on to live a relatively long life. Indeed, he was 71 when I was born and 73 when he died.
I was myself diagnosed with type 2 diabetes at the relatively early age for this condition of 34, some 18 years ago, and I have been dependent on insulin for the past seven years. I am personally grateful to the staff at St Thomas’s hospital, just across the river from here, for their help and support in managing this condition, especially when I let it get significantly out of control for a long period several years ago. I had to work hard and change things in my life to achieve better control. However, the issues surrounding diabetes are of great concern not just to those who may be directly affected or those closest to them but to everyone because of the growing scale of the problem, its consequences and the costs of trying to deal with it.
The number of people with diabetes in this country is expected to increase by 23% to 3.8 million by 2020. This will have a huge impact on NHS resources unless the efficiency and effectiveness of existing services are improved. We all know about the commitment to £20 billion of efficiency savings under the Nicholson challenge. The biggest challenge in diabetes will be how to commission cost-effective care while at the same time improving the quality of services and delivering excellent outcomes for patients. To do this, we need to recognise the growing scale of the challenge. Since 1996 the number of people living with diabetes has increased from 1.4 million to 2.9 million. We need to look at the weaknesses in the system at present. In England, almost half of the people with type 2 diabetes—47 per cent of them—are missing out on the nine basic health checks recommended by NICE, such as foot care and retinopathy screening.
Fewer than one in five people with diabetes are achieving the recommended standards for controlling blood glucose, blood pressure and cholesterol levels. We have to recognise that variations in the quality of care for diabetes patients cannot be explained by need or spending alone, and are influenced by the way in which local health services are organised and managed. We have to look at the human cost of diabetes and the adverse effects of the disease. The mismanagement of diabetes can lead to heart disease, stroke, blindness, kidney disease and amputations that in many cases could have been prevented. More than 100 amputations take place in England every week due to diabetes, while 4,200 people in England are blind due to diabetic complications, and this figure increases by 1,280 each year. There are 24,000 people with diabetes in England who die each year from causes that could have been avoided through better management of their condition.
It is estimated that already almost 10% of the NHS budget is spent on diabetes, around £10 billion a year. When we factor in the loss of working days, early death and informal care costs, the cost of the condition to the NHS will rise to almost £40 billion by 2035. When we look at the current situation for diabetes patients, we learn from the Public Accounts Committee that NHS accountability structures have failed to hold commissioners of diabetic services to account for poor performance as they have no mandatory performance targets like those in place for other conditions such as cancer.
The committee also found that information on diabetes is not being used effectively by the NHS to assess the quality of care and to seek to improve it, and that many people with diabetes develop avoidable complications because they are not effectively supported to manage their condition.
So, what must be done? Inequalities exist in the quality of diabetes care across the country and they need to be addressed if we are to develop better outcomes for patients and improve efficiencies in the NHS. The National Institute for Health and Clinical Excellence quality standard for diabetes should act as a benchmark to improve the quality of diabetes care.
The National Audit Office report on the management of diabetes in the NHS called for a review of the current system of incentives, so that GPs are paid for diabetes care only if they ensure that all nine care processes are delivered to people with the condition. Other recommendations call for greater collaboration and co-ordination between the new organisations and levers of the reformed NHS, such as the NHS Commissioning Board and Public Health England.
I know that NHS Diabetes is developing an implementation guide for treating diabetes patients in the NHS, which, in contrast to the diabetes action plan, will examine how diabetes care is commissioned and its implications for patients. We need to ensure that it addresses the health and economic impact of diabetes-related complications. In particular, I hope that the implementation guide will address how to reduce the variations that exist in diabetes care and the outcomes across the country.
Raising awareness of the causes, symptoms and consequences of diabetes is also crucial for increasing understanding about the disease and improving outcomes. I know from my own experience that diabetes specialist nurses play an essential role in helping patients to manage their condition and are a key source of information and advice for patients. Their posts should be protected during the current transition and all patients should have access to a named diabetes specialist nurse during their treatment.
I hope that the Government will make a commitment to the delivery of a national approach to addressing diabetes from 2013, set out by clear milestones and procedures for delivery, and using the recommendations of the National Audit Office as a guideline. The development of integrated care pathways should be encouraged as a means of reducing the postcode lottery of care for diabetes patients and reducing adverse outcomes of the disease, including mortality. Local health and well-being boards should scrutinise local commissioning plans to ensure that the delivery of diabetes services is joined up across public health, the NHS and social care. Finally, local commissioners should implement the NICE quality standard for diabetes and, where commissioners are not complying with the standard, they must be made to set out their reasons in their commissioning plans.
Baroness Masham of Ilton
My Lords, I thank the noble Lord, Lord Harrison, for raising the issue of the need for good managed services for people with diabetes today. I consider the noble Lord to be the expert patient for diabetes in your Lordships’ House.
The All-Party Parliamentary Group on Diabetes is very active and effective, keeping parliamentarians from both Houses up to date with the many needs of people of all ages living with diabetes. Diabetes spans several government departments—first, the NHS—but it is also a serious public health issue. With many aspects of diabetes going over to local authorities, I hope Public Health England will take diabetes as a priority. Unless primary and secondary care services work closely together, the treatment of diabetes will suffer.
I cannot stress enough the importance of the diabetic nurse and I am glad that that has already been stressed by the previous two speakers. Diabetic nurses can be the important link between primary and secondary care. They teach patients and their carers about diabetes and also community nurses. They are a vital resource for the management of diabetic services. When there are problems with insulin and patient stability, the diabetic nurse is often at the end of the telephone to give advice.
Diabetes often causes extra complications. Some years ago, a well known and well liked television presenter, Richard Whiteley, from Yorkshire, who hosted the programme “Countdown”, went into hospital for a heart operation, but sadly died due to complications because he was diabetic. More research needs to be undertaken into the causes of type 2 diabetes. I read in the press yesterday of a link between type 2 diabetes and food sweeteners:
“A sweetener used in food manufacture could be partly to blame for rising rates of type 2 diabetes … Countries that use large amounts of high fructose corn syrup (HFCS) have higher rates of the disease than those that consume little, says a new study”.
Professor Stanley Ulijaszek from Oxford University, who co-led the study, said:
“This research suggests that HFCS can increase the risk of type-2 diabetes, which is one of the most common causes of death in the world today”.
The syrup is widely used in drinks and processed foods because it acts as a sweetener, helps to keep food moist and is cheaper than regular cane sugar. Tim Lobstein, director of policy for the UK-based International Association for the Study of Obesity, has said that,
“if HFCS is a risk factor for diabetes—one of the world’s most serious chronic diseases—then we need to rewrite national dietary guidelines … and foods should carry warning labels”.
Diabetes can be a very complex condition. During this time of change in the NHS, many people are unsure of where their services will be coming from. There is dismay when people hear of the closure of A&E departments and walk-in clinics. Evenings, weekends and bank holidays mean that for long periods it is impossible to see a GP. There are real risks for people living with diabetes when things go wrong. They may have a hypo and need urgent help. Diabetes has become a ticking time bomb with increasing rates of the condition in many places around the world. When we were on holiday in Barbados some time ago, a taxi driver told us that he took the day off every Sunday in order to bicycle from one end of the island to the other. But he also said that the sugar workers used to slash the sugar cane manually, using much sweat and energy. Today they sit on tractors and everything is done mechanically. Diabetes has hugely increased in modern life.
Recently we saw an interesting presentation about the diabetic leg. We were told that the West Country is the worst region for amputations due to infections in the leg as a result of circulation problems caused by diabetes. Specialist centres in London ensure that people’s legs can be saved through expert vascular surgery. There seems to be a postcode lottery in different parts of the country.
This week, international attention is focused on HIV and AIDS. When someone has HIV/AIDS and diabetes, sometimes along with other co-infections, treatment can be very complicated, and some HIV drugs can encourage the development of diabetes. I have discussed this with Dr Jane Anderson, a marvellously dedicated HIV specialist who works at the Homerton University Hospital. She has seen co-infected patients with problems. These patients need the expertise of endocrinologists and HIV specialists to sort out their complications.
For good management, all those who are involved with those who have diabetes must be well educated about the condition. They may be teachers, medical personnel, or those involved in sports and leisure or food and drink, but it is diabetics themselves and the people closest to them who are the most important of all. The aim should be to keep fit within the community and to lead happy and healthy lives.
Baroness Thornton
My Lords, I thank my noble friend Lord Harrison for bringing this important debate to the House. I am going to concentrate on one aspect of diabetes services today, and it is one that I have raised in the House at least once since 2010. I wish to examine the impact and efficacy of podiatry services for those with diabetes. The Minister may recall that in April last year I asked him about nail-cutting services, including his own, and on 4 November 2010 I asked,
“how the Government can ensure that both the teams and the technology are available and funded”—[Official Report, 4/11/10; col. 1828.]
to avoid amputations and deaths. So here we are a year later returning to what is a worsening situation. I thank the College of Podiatry for its excellent brief on this matter.
The starting point for my contribution is the undeniably shocking statistic that was mentioned by my noble friend. Each week, 125 amputations take place, and in many ways it is even more shocking that 80% of those are preventable. My contention is not only that something must be done, and done urgently, to bear down on this unacceptable state of affairs but that to do so would save the NHS money. There really cannot be any reason not to give this issue some real priority, end suffering and save money. Why can that not be the case?
We all know that 4% of the population currently suffers from diabetes and 15% to 20% of those will develop a foot ulcer at some time. It has been estimated that 61,000 people with diabetes in England have foot ulcers at any one time. It is certainly possible to manage foot ulcers but too many are being missed, not spotted in time or not being treated swiftly enough, unfortunately leading sometimes to complications, surgery and amputations. Amputation is not only devastating but significantly increases the likelihood of death. According to NHS Diabetes statistics, the mortality rate for those with diabetic ulcers and who have had amputations is greater than for those with breast or prostate cancer. Although the five-year survival rate for those with breast or prostate cancer is now about or above 80%, for those with diabetic foot ulcers it is worse, at just under 60%. In other words, two out of five people with foot ulcers that are not treated will not survive for five years or more. I am afraid to say that once someone has had a lower limb amputation their survival rate worsens considerably—after five years it has been estimated somewhere between 68% to 79% will die. Of these amputations, which lead to these deaths, 80% are preventable.
Ulcers and amputations also cost the NHS, according to the acknowledged expert Marion Kerr, between £600 million and £700 million each year. If better foot care was available and these amputations were prevented, that much money would be saved. However, as things stand, the number of amputations is going up not down, as the diabetic population increases. I invite the Minister to support the alliance that has come together under the Putting Feet First banner, which has already been mentioned and which includes NHS Diabetes and Diabetes UK as well as the College of Podiatry. Does the Minister think that it would be sensible to say—I will use the word “target” but I do not mind what terminology he uses—that there should be a 50% reduction in amputations by, say, 2018? How does he believe that could be delivered? It seems to me that surely an effort from everyone, from the national Commissioning Board to CCGs and from the Government to clinicians on the ground, is what is needed. Of course there is also a huge role for patients learning to manage their own condition and becoming, as my noble friend put it, “foot fetishists”, specifically by taking care to maintain their own healthy feet.
However, it is indisputable that better services are also needed and that this will require more podiatrists, more specialist nurses and more multidisciplinary teams. I wonder how this might be delivered with the urgency required at a time when economies, reorganisation and cuts in podiatry services are already apparent. What will the Government do to drive forward a programme that delivers across the country?
Currently there is, as has been mentioned, a staggering tenfold variation in amputation rates across former PCT areas. Such a variation, as an example of a postcode lottery, is surely unacceptable. However, it is not surprising if one knows that more than half of hospitals do not have a multidisciplinary foot care team, while 31% of hospitals do not even have an in-patient podiatry service, an increase from 27% in 2010. There is evidence that one of the current problems is that GPs have no incentive to refer their patients on to foot protection teams for education, follow up and so on. There is evidence that the number of posts is being frozen or reduced, which is not the way to deal with a preventable problem. With that, staff are also experiencing “de-banding”, leading to reduced morale.
The College of Podiatry, along with Diabetes UK and NHS Diabetes, believes that the time has come for this goal to be promoted by the Government, adopted by the NHS Commissioning Board and worked towards by every clinical commissioning group. The QIPP—quality, innovation, productivity and performance—agenda also provides an opportunity to redesign services along the best practice lines so that there is a multidisciplinary foot care team in each hospital as well as foot protection teams in every community. However, unfortunately at the moment there is evidence that the opposite is happening and that services are not improving. The danger of new arrangements is that this important issue falls between the cracks, is left to local decision-making and does not get the prioritisation it deserves.
The College of Podiatry tells me that it is,
“fearful that public expenditure constraints mean that rather than being prioritised through the QIPP agenda, current podiatric services are at best, being frozen and in some cases being reduced, with patient services including the diabetic foot service deteriorating as a consequence”.
We know that best practice exists. For example, the multidisciplinary foot care team approach for in-patients with diabetes in Southampton led to a reduction in the length of in-patient stays from 50 days to 18. Not only were patient outcomes improved but annual savings to the NHS of £889,000 were generated on the back of an investment of £180,000. Let us imagine if that were repeated everywhere.
To address this issue is wholly in line with the outcomes that the NHS mandate has identified for the NHS Commissioning Board; that is, reducing preventive mortality, improving care for the chronically sick and driving up patients’ experience of care. The Putting Feet First campaign has already produced guidance and circulated it to CCGs and existing PCT commissioners showing how savings and improved patient services might be achieved. What is required now is political prioritisation; what is required is a guarantee of an increased supply of podiatrists. Given that the number of those suffering from diabetes will have increased to 5 million by 2025 and that as diabetes increases so do preventable amputations, it really is imperative that action is taken now to end what is really nothing short of a scandal.
Lord Kakkar
My Lords, I join others in congratulating the noble Lord, Lord Harrison, on having secured this important debate and declare my own interest as professor of surgery and consultant surgeon at University College London Hospitals NHS Foundation Trust. We have heard during this debate about the profound burden of diabetes in our country. Some 24,000 excess deaths are reported in those with diabetes annually, some 13,000 strokes, 11,000 heart attacks and more than 4,000 minor and major amputations, in addition to the complications seen in the eye, the kidney and the nervous system. All have a profound impact on the individuals who suffer from this potentially devastating disease. As a result, and quite rightly, diabetes has received an awful lot of attention, not only in clinical practice and research but in government during the past 10 to 12 years, with the growing recognition that the burden of this chronic disease on society and the National Health Service will be profound.
The recent inquiry by the Public Accounts Committee in the other place failed to reach a consensus position with Her Majesty’s Government on the cost to the National Health Service of diabetes, but the figures range between some £4.6 billion and £10 billion, looking at the broad impact of the disease on NHS services. This is quite striking at a time when the service needs to spend its resources more efficiently and effectively. Among the issues raised in that report are: how diabetic services should be commissioned, why commissioning to date through primary care trusts appears to have failed patients and how looking at the new arrangements for the delivery and commissioning of NHS services as a result of the Health and Social Care Act 2012 might be used to improve outcomes for diabetic patients.
What we know in terms of reports and strategies such as the national service framework in 2001 and the production of NICE clinical standards in 2011 is that simple interventions provided annually for patients with diabetes can have a profound impact on improving their clinical outcomes. These include, for instance, annual examination of the eyes to determine whether patients are developing retinopathy; annual, or more frequent if necessary, examination of the feet to guard against diabetic foot complications; regular measurement of the blood sugar, particularly glycosylated haemoglobin, to determine whether the longer-term management of sugar is appropriate; the evaluation of blood lipids and blood pressure, because cardiovascular complications in diabetics can be more devastating and occur with greater frequency; and, of course, testing the urine for protein and testing the blood for creatinine to determine whether the kidney is being affected by diabetes and whether more careful clinical attention needs to be paid to protecting that important organ. In addition, it is well recognised that education of diabetics is vital. Of course, the preparation of women with diabetes for pregnancy is vital, too, to ensure that we do not see the devastating potential complications of diabetes during pregnancy.
These complications and the measures are well understood. What is often forgotten is the fact that diabetics entering hospital for management of other conditions will often have complications at a much higher rate and frequency as a result of having diabetes. One of the most important is, of course, the development of infection in hospital, which is seen more frequently in patients in whom diabetes is not appropriately controlled. It is quite right to say that multidisciplinary care is vital.
To return to the NICE care standards and processes described—simple, authoritative measures—if we ask how frequently and successfully those are being applied to patients with diabetes in communities around the country, the data are quite startling. For interventions that could prevent a heart attack, stroke, amputation or early death, we find that only 50% of diabetics have all nine simple care measures applied on an annual basis. In two PCTs, less than 10% of patients have those nine standards assessed on an annual basis, and in the best PCT only 69% have those measures conducted on a regular basis. The reality of the situation is that the Department of Health, giving evidence to the Public Accounts Committee in the other place, stated that 100% achievement of these nine care processes was unrealistic and a more realistic target was only 75%. That seems rather disappointing, bearing in mind the burden not only for the individual patient but for society more generally and the NHS in terms of its resources attending complications of diabetes.
It is clear that the current arrangements for holding commissioners to account have failed. Of course, we will see the disappearance of those arrangements—and of primary care trusts—on 31 March next year. The provision of these appropriate care measures to much larger numbers of diabetic patients would be a first, early and important test of the new commissioning arrangements through the NHS Commissioning Board and the clinical commissioning groups.
With that in mind, is the Minister able to say what progress has been made with regard to putting at the centre of diabetic care the provision of integrated care pathways? It is quite right for a chronic condition that the majority of care should be provided in the community setting but it is also very clear for diabetics that provision of or access to ancillary services is vital. We have heard about feet and eye services, but there is also access to specialists in hospital because diabetes is much more than a disease of blood sugar. It is a complex metabolic condition with profound cardiovascular, neurological and peripheral vascular implications. It is very important that any commissioning arrangements incentivise excellent care in the community but also make it mandatory for early referral to more specialist centres for early intervention on developing complications.
In this regard, will the quality outcomes framework in primary care be modified to incentivise integrated care? Will payment by results for secondary and tertiary care providers ensure that integrated care across multiple providers in the community and in hospital becomes the norm rather than the exception for the provision of the management of diabetes? In addition, if more care is to be given at the primary care level, it is vital that general practitioners are properly trained and continue to receive ongoing training and professional development to ensure that appropriate care is given to diabetic patients, and that we have an emphasis on ongoing research in both the primary and secondary environments if more patients are to be managed out of hospital.
Finally, the question of the role of Public Health England has been raised. This is a major societal problem with major public health implications. It is critical that Public Health England takes as one of its early priorities the question of screening for diabetes in high-risk populations—for instance, in certain ethnic minority communities, as we heard about from the noble Lord, Lord Harrison—and sees that every opportunity is used to ensure that patients who develop diabetes can be identified early rather than later and that intervention can be provided to avoid potentially devastating complications.
Lord Morris of Aberavon
My Lords, I am particularly grateful to my noble friend Lord Harrison for choosing to raise the subject of diabetic services. I will concentrate on type 1, in which I declare a family interest. I have had the advantage of consulting Professor Amiel of King’s College Hospital and hope to visit the research unit of Professor Johnson in Oxford in January for further discussion. I am grateful for the excellent briefing by JDRF.
The recently published report by the House Of Commons Public Accounts Committee, which has already been referred to, notes that the incidence of diabetes has doubled in the past five years. The report concentrates on type 2, which comprises the greater number, and is one of the most damning I have ever read. It states:
“There is no strong national leadership, no effective accountability arrangements for commissioners, and no appropriate performance incentives for providers. We have seen no evidence that the Department will ensure that these issues are addressed effectively in the new NHS structure”.
My simple question for the Minister is: are things going to get better after that damning report?
Type 1 diabetes is a chronic, life-threatening condition which has a lifelong impact on those diagnosed and their families. I hope that this debate will send a clear message that the cause of type 1 diabetes does not involve lifestyle factors such as obesity, poor diet or lack of exercise. There is currently no way to prevent the condition and no cure.
I have been trying for some time to get a complete breakdown of the cost of management of type 1, as opposed to type 2. I have had only modest success in the disaggregation of the figures. I firmly believe that when you have a clear idea of specific costs, you can start to prioritise and direct funds. It is estimated that the direct and indirect cost to the National Health Service of treating type 1 is nearly £2 billion a year; 400,000 people are affected, including 26,000 children; and the numbers are growing at 4% per year. The current spending for research on type 1 is inadequate and falls way behind that of other developed countries. In 2009, government spending bodies committed £51 million to fund research into diabetes. Of this, only £6 million was applicable to type 1.
When I was a young Transport Minister in 1966, just before the ark, I learnt of the methods of cost-benefit analysis. It must be painfully obvious that as 26,000 children are already affected and they are growing in number, the cost of lifetime care will be disproportionately high and merits the targeting of research funding. There is an immense issue of management to achieve a target of long-term blood glucose levels. The challenge for the family is that a child aged five faces 19,000 injections by the time he is 18, and will have pricked his finger to draw blood 50,000 times, according to the JDRF.
NICE recommends insulin pump therapy as a clinically and cost-efficient treatment option for type 1. A report by the Medical Technology Group points to significant inequality of provision of pumps across England and a lack of adherence to NICE guidelines. NICE recommends that 12% of people with type 1 should be eligible for a pump and that for children under 12 it should be 33%. The average rate of pump utilisation is 3.9%, which is still the lowest in Europe though substantially better than it was a few years ago. In the United States, provision is estimated at 33%. Mr Burstow, a Health Minister, was able to assure me on 25 April this year that we were generally in line with the United States. How he could reach that conclusion is beyond comprehension. Perhaps the Minister will be able to correct it. If the number of pumps was increased by seven percentage points to reach the 12% benchmark, additional savings on consultant visits and hospital admissions would add between £37 million and £62 million, hence my attachment to cost-benefit analysis.
I welcome the announcement of the publication of NHS scoreboards for availability, delays and access to treatment. Those PCTs not complying—a number of which have been indicated in the various reports—will have to explain themselves, I trust.
It has been emphasised to me by clinicians that providing a pump is part of a package, with structured education first. If injections do not achieve treatment targets, then there is a move on to the provision of a pump. Many achieve the required outcome without it. Evidence-based work is still evolving on how best to provide such education for children. Increasing the skilled force within the NHS to provide such structured education is not without cost. We need to raise the profile of this need if we are to achieve equity of access to such skilled healthcare professionals across the country and across the range for people with type 1 diabetes.
It would be a tragedy if the needs of those with type 1 were lost within the greater number of those with type 2. The current reorganisation of the NHS could be a great opportunity to improve the availability of treatment for those with type 1. I understand that representations were made to the Department of Health for recognition that type 1 people are a small group with a need for highly specialised support. However, the request that type 1 diabetes be commissioned separately, or at least differently, from type 2 has not been approved.
I welcome the work that is being done at King’s, Cambridge, Oxford and Sheffield on the artificial pancreas. It is vital that adequate funding is provided for what could be a welcome and major breakthrough and that, particularly in this period of change, the general issue of funding for type 1 will be addressed. I am told that there has never been a real budget for type 1 services, which have been developed on the back of academic interest and clinical recognition of need. Greater investment by the Department of Health in both the research still required to develop a viable artificial pancreas and in providing technology, as and when it becomes available, and on its role, benefits and limitations, would be very welcome to all concerned for those who suffer from type 1 diabetes. I hope that in my short remarks I have highlighted the separate needs of those with type 1 as well as type 2.
Lord Roberts of Llandudno
My Lords, first, can I say how much I appreciate the opportunity granted to me by the noble Lord, Lord Harrison, by his entering this area? I enter with tremendous humility as well as deep concern because many have spoken in a personal way. They know the problems while we on the outside—we are possibly not going to be there long on the outside—do not know in depth what the real problem is, while they face this situation day after day.
Last year, on a wet night, I was crossing Westminster Bridge. We had just finished here, so it must have been after 10 o’clock. On the other side, just where County Hall used to be, a man was lying in the pouring rain. What should I do? Was he bait? Would other men attack me and mug me? Or was he desperately ill and in need of attention? I did not know. Rightly or wrongly, I went on my way, but others might have been more Christian than me.
We need awareness of the various conditions that people face. There has been a series of television advertisements about stroke, and HIV/AIDS had a tremendous media and television presence. Do we not need something—television adverts—so that we, the ordinary public, are made aware of the emergency that some people might encounter? Low blood sugar can induce something that might be thought of as drunkenness, but we do not know that. We must learn. Some sort of advertising is necessary in order to make us aware because, as my noble friend Lord Rennard said, 3 million people are now suffering from diabetes. I tried to work out what that means in Wales. It means 150,000 people in Wales, or about 5,000 or 6,000 people in each parliamentary constituency. It is a massive number that we have to take great notice of. We could produce adverts for television about what to do if you see somebody ill and have some idea of what the problem might be.
A good place to start is with children in schools. I am told that most children who have diabetes have type 1 diabetes. Other children in their school should be made aware that there is a problem. Teachers must also be aware so that they are able to be confident in the way that they deal with children who have problems. We are told that there are 26,500 children under the age of 15 with type 1 diabetes. In the home, in school and in the playground, youngsters with diabetes have my tremendous admiration: little youngsters who need to inject themselves and check exactly how many carbohydrates there are in every meal they are eating. For some youngsters, it is extremely difficult, so they need all the support we can give them.
I am trying to pronounce a word here: ketoacidosis. I am glad I have got it right. Twenty-five per cent of newly diagnosed children of all ages suffer in this way, and it is a life-threatening situation, and 35% of children under five years of age. We know the consequences. They have been mentioned: amputations, kidney failure and blindness. To tackle them early, as has already been urged upon us, is essential. When we are looking at expenditure in the NHS, in the long term, we would deeply regret doing anything to undermine this. You can reduce taxes, but not at the cost of threatening health and life. The lives of children come first.
Children with diabetes are often excluded from school trips, physical education and sports. A school can be afraid of admitting children with diabetes, although I am told that 52% of schools have such children. Only this morning, I was told of the common assessment framework, in which every child, every individual, particularly those who might have problems, is assessed and has individual concern and treatment for whatever might be their particular need. It is important that fellow pupils as well as teachers and other staff can recognise children with these conditions.
Some schools hold assemblies in which the children and staff are informed as to exactly what the situation is. Some schools also issue help cards to children, information telling them that if their diabetic classmate is showing symptoms, they should please take some action. Of course, a certain number of teachers are given courses on what they have to do if any child is in diabetic difficulties.
The recommendation of Diabetes UK is that every school should have people who are well versed in the relevant needs, and that secondary schools should have a school nurse. I have heard recently of the cuts made in school nursing levels. Is this a cut that we can really justify? Is it not time that we should assess this according to the need of the particular school? It is also suggested that there should be a nurse for a cluster of smaller schools, such as junior and infant schools: somebody who is well versed in and able to tackle these problems. In rural Wales, you could not have a nurse who would reach a school in time. That means that it is even more important that teachers and other school staff know exactly what to do when an emergency arises. We must all find the best way possible to ensure that no child suffers without somebody being there who can help them.
I will be visiting on Wednesday of next week a school with disabled and disadvantaged children; that is, those who are not able to cope quite as well as others. These are a particular problem: a child who possibly cannot read, or inject him or herself. How are we helping them? I am sure that this needs to be another of our priorities.
School meals need to be labelled in such a way that their content is easily understood. How much insulin is going to be needed in order to cope with this meal? That information is often difficult to understand. A youngster of seven, eight, nine or 10 years of age is trying to work out this complicated arithmetic to know exactly how much insulin to inject. What is the sugar level? Is it low or high? Somehow we need to signify that on every meal, wherever it is.
I am glad that some of the fast food chains, like McDonald’s, are providing the necessary information on their food tray papers. Other shops, hotels and others should follow suit. We are glad about what is happening. There is a lot more to be done. I am at least grateful for the opportunity to contribute in some way to this debate.
Viscount Falkland
My Lords, I, too, am very grateful to the noble Lord, Lord Harrison, for this debate. Particularly after the long discussions that we had about the House of Lords and its future, this debate so far has shown how it combines expertise, such as my noble friend Lord Kakkar’s expertise as a doctor, experience, such as those of us who are here as diabetics, and those like the noble Lord, Lord Roberts of Llandudno, speaking with articulate concern. It has been a wonderful debate.
A light has been shone on this subject this week. It was unfortunate for the MP for Slough, who is apparently a doctor, to imply that diabetes is a result of a poor lifestyle, and that those who indulge in a poor lifestyle and have diabetes should be deprived of the funding for their medication. That was stupid and irresponsible. What has been said so far in this debate shows that this is a complex condition that we have; I know that I have a complex condition. As I hope your Lordships can see, I am relatively well. I have had diabetes for 13 years. It was diagnosed in this House and I fully admit that I had been in denial. My wife had suggested that I might have diabetes. A good friend of mine in this House asked me to join him for lunch with his guest. After about five or 10 minutes, he noticed that I had been drinking a lot of water, which is one of the signs of a surplus amount of glucose in the bloodstream. He asked me some further questions and said, “Look, I am a diabetic and I think you are too”. He asked me whether I had a doctor. I said that I had hardly ever seen a doctor and that I belonged to a National Health Service panel. He excused himself, saying, “You wait here. I’m going to make an appointment for you this afternoon”.
My friend got me an appointment for that afternoon, which was the last appointment with that particular private doctor before Easter—I did not have a private doctor at that time. The doctor conducted a simple test and said, “You’ve certainly got diabetes and I’m going to pass you on; I don’t feel capable of dealing with it and I think you need immediate attention”. He rang a specialist diabetes clinic and I got an appointment for the following day, which, again, was the last appointment before Easter. I have been with that clinic ever since. However, I use the National Health Service and I talk to the doctor about my diabetes when we have a regular discussion about my medication. I am very thankful to the National Health Service for providing me with my medication and I am very thankful for the nurses, who have been mentioned, in my practice. They often seem to be more on top of the developments than the doctors.
Being a diabetic has been an extraordinary experience. I have had to give up certain things, and I am not talking about just Mars bars and pastry: I have had to give up playing golf; I cannot play with the same concentration that I used to because the blood sugars alter the whole time in one’s bloodstream. For six years I have been an insulin-dependent diabetic, which makes it even more difficult to do certain things, although I can drive a vehicle because I am very conscientious.
I wonder how many diabetics are conscious of the fact that they should report their condition to the DVLA. The DVLA guidelines are rather strange but basically they point in the right direction. If you are an insulin-dependent diabetic, you should check your blood sugar every time you go anywhere near a vehicle. If you are caught in an accident with a low level, you are committing an offence and will pay a penalty.
Generally speaking, my life is pretty good. When I first saw the specialist, he said, “You are in a very bad condition, aren’t you? Do you realise what your blood sugar level is?”. I will not mention the technical term for it but for the average person—for those in this Chamber even—whose pancreas is working properly, the blood sugar level would be about 5.5 or 5.7. Mine was 29 and the specialist said, “You are one Coca-Cola away from a coma”. I said, “I feel perfectly all right”. He said, “That is odd. I have people with a quarter of your level who are almost crawling in through my door”. It is curious because I have a reasonable feeling of well-being most of the time, although not all the time. I think that diabetics can feel like that.
However, I am not convinced that the NHS generally, as has been mentioned today, gives the kind of service that allows people to have the lucky break that I had when my diabetes was spotted. The number of people who are undiagnosed has been mentioned. I think that the noble Lord, Lord Rennard, mentioned the cost and ramifications of that. If you have nearly 1 million people with diabetes all wandering around the streets not feeling 100%, they are likely to have complications without having had the original diabetes diagnosed. Finally, something may bring them to realise it, but it will be a serious business and they may not have long to live. The cost of dealing with that emergency to the NHS is out of all proportion to what would have to be spent on medication on a daily basis.
I do not want to decry the NHS—I am the first person to praise it—but diabetes is an extremely odd, and serious, condition; one’s requirements change the whole time. One very important thing that the noble Lord, Lord Rennard, mentioned, and which saved my life, is the specialist diabetic nurses. It is all that they do, and they are absolutely essential; if you have any stress or worry, they talk you through it and get you to make the necessary adjustments, such as going to see your doctor or changing your medication. So it is quite extraordinary what can be done on a personal level. That is where the NHS is in trouble, because it is really not equipped to deal on a personal level with all the people who have diabetes.
There must be a better interface between the NHS and the private sector. Education and training is essential and can be provided to the NHS, if it cannot handle the problem, by the private sector, and not expensively. In any case, even if it is expensive, it is going to save a lot of money in the long run by preventing the kind of complications that cost all the money. We have already mentioned amputations and heart disease, and all the rest.
That is my first suggestion and question to the Minister. Why can we not work towards closer co-operation on these services with the NHS? When I go to my NHS people, they are sent everything from the private clinic but they do not have a compatible computer, which seems strange. That would seem to me the first step. They get the written stuff, which goes into a file. So when I go in, nobody ever knows what has happened the previous year. I have taken to having just a brief summary of what happened at my last inspection. I go regularly and have all the things that have been mentioned—a carotid examination, a foot examination, everything. I am thankful for that and for the course that my condition has taken. Whether I shall be standing here much longer in this condition, I do not know; I shall not say that I do not care about it, but I am optimistic. I think that I will probably have a pump, in the long run; they have been mentioned for type 1 diabetes but I think that in the end, most people like me, with type 2, will also have pumps. Then perhaps I will be able to go back to the golf tee and play golf again. Who knows?
How can we reduce the number of people who do not realise that they have this condition? As long as it remains at this level, we are in trouble.
Lord Brooke of Alverthorpe
My Lords, I thank my noble friend Lord Harrison for putting this debate before us. I suspect that I come under the category that was just described as “articulate concern”. I am certainly concerned; whether I am articulate remains to be seen.
I was drawn to the report by the Public Accounts Committee. In particular, I want to address the recommendation where it talked about the projected increase in the diabetic population having a significant impact on NHS resources. It said:
“The Department and Public Health England should set out the steps they will take to minimise the growth in numbers through well-resourced public health campaigns and action on the risk factors for diabetes, such as the link with obesity, and the complications they can cause”.
It is to those that I wish to address my remarks. Before doing so, I offer the Minister, at the end of rather a hard day for him, with quite a battering, some words of encouragement and thanks. I thank the Government for announcing yesterday in a Written Statement that they will consult on the proposal to introduce a 45p minimum unit price for alcohol. That is a brave step forward, on which they are to be congratulated. The figure is different from that in Scotland, but that is the lesser of the issues. I hope that all will come together, including the BMA and the rest of the medical profession, and work with the Government to move forward on this front.
This process will not be easy. It has taken time to get to the consultation stage and plenty of people will try to prevent this new policy being put in place. I have recently spent some time with the drinks and retail industry looking at the Government’s strategic policy on alcohol, and have encountered little enthusiasm for this change. Indeed, we have already seen one legal challenge against the Scottish proposal. I understand that the Bulgarians have a great interest in this matter and will raise question marks and seek a legal challenge. I suspect that there will also be a legal challenge against the Government’s proposal.
As I say, the Government’s action is a step in the right direction. In the past, the important link between alcohol consumption and diabetes has in many respects not been addressed to the extent that I would have hoped. I shall speak primarily about type 2 diabetes, and alcohol consumption causes difficulties in that respect as well as the consumption of high-fat and sugary foods. Drinks, particularly alcoholic drinks, contain a significant amount of sugar, of which nobody who consumes them is aware. Although food and fizzy drink labels show fat and calorific content, alcoholic drinks are totally exempt from any requirement to show energy or calorific factors. This means that people who drink excessively are not only harming themselves in other areas but are particularly at risk of raising their sugar levels, which may lead to type 2 diabetes.
The Minister seemed surprised to hear about what has been going on at the other end of the Corridor, but Dr Phillip Lee MP has said this week that, as a doctor, he believes that type 2 diabetes is self-inflicted in many respects and that, due to cost factors, the department should stop providing free prescriptions for people with this type of diabetes. Like my noble friend Lord Harrison, I hope that the Minister will state very clearly this afternoon where the Government stand on this issue and will refute Dr Lee’s proposition. That is not to say that there may not be some fundamental issues behind Dr Lee’s comments regarding costs in the NHS that we need to address, and I will come to that.
I see a link between drinking, obesity, diabetes and alcohol abuse. I hope that the Government will be prepared to stick to their objectives on that front and resist any challenges that may arise in Europe. I have taken soundings, as that is what we can do in this amazing Chamber, from some of my learned counsel friends who tell me that, if we are challenged in Europe, there is an opportunity for us to fight that very vigorously indeed on the basis of our having a margin of appreciation—that is, because of the scale of the problem with diabetes in the UK, we should have the freedom to act differently on this issue from other countries in Europe, even though the Commission may initially oppose such action.
Similarly, with regard to alcohol labelling, which the Minister knows I have raised previously, I have been encouraged to wait until the Commission comes back to this issue in 2014 because we cannot move unilaterally. Again, noble counsel here tells me that we could use the exemption that I referred to as a means to press the industry to move quickly and require it to move forward and introduce labelling on alcohol products that would show the number of calories in them. We should also think about the energy side of that.
Opportunities are there for us to keep pressing ahead on this front. This links to where we stand on public education, on which I will spend a few moments. Last night I had the good fortune to go to a celebration that was held in the River Room by the Terrence Higgins Trust to celebrate its 30 years of existence and the work that it has done. We were addressed by the noble Lord, Lord Fowler. He is a former Health Secretary who is remembered particularly—this was discussed at some length last night—for the very effective and world-leading public campaign on HIV that he raised in the 1980s and 1990s, and which had such a great impact on public health in this country.
After seeing reference to the emergence of a strategy on obesity, I look to see what the Government will do on that front, too. There have been plenty of other campaigns in addition to the one on HIV. There were campaigns on alcohol and drinking and driving and a range of campaigns on smoking, and they have been very effective. However, we await a national programme to highlight the problems that arise from eating and drinking too much. When can we anticipate something moving on this front? Given the evidence that we face with obesity and type 2 diabetes, such a campaign should be on the kind of scale that we had in the past. In particular, I look to see a Government that will address some of these issues in relation to children. A phenomenal number of young children are now classed as obese, and a growing number in turn will be likely to fall into the group of the 7 million possible candidates for type 2 diabetes.
We must be honest and straightforward in such a campaign. We must recognise that not only must the food and drinks industry be socially responsible but we must seek to persuade people in all the ways we can to accept responsibility for their own health. That means letting people—particularly young people—see that if they do not care for their health in the way that is best for them, there is a distinct possibility that their lives will be shortened, their health diminished and their opportunities greatly reduced. We need to highlight some of the topics that we have been talking about today, such as the risks of amputation, blindness and so on. We should not run away from presenting them to the public at large in a wide-scale programme of action. I hope that the Minister will tell us when we can expect a campaign of major proportions to come forward.
Lord Collins of Highbury
My Lords, I, too, thank my noble friend Lord Harrison for initiating this very timely debate. Five years ago I stopped smoking and subsequently put on weight. I stress that this was not through drink; I had a weakness for sweets. I thank my noble friend for reminding me of that. I had an eye infection and had taken on a very stressful job. My infection got worse and, after using all the available creams from the local chemist, I was finally persuaded to drop into the walk-in centre in Victoria Street, which unfortunately, as we heard recently in a debate, has since closed. The centre nurses helped me with my eye and also gave me a quick check-up that covered blood pressure and heart rate. The result was an urgent referral to my GP for very high blood pressure. The GP undertook a series of tests that led to an early diagnosis of diabetes type 2. I am therefore acutely aware of the need to raise awareness of diabetes, not only to help prevent the condition but to promote early diagnosis.
My early diagnosis and the excellent response of the NHS have meant that I have a chance of avoiding the worst consequences of diabetes. Early preventive action saves not only lives but money. As my noble friend Lord Harrison was right to point out, there is a worrying tendency to put the onus on the individual—it was the Tory Back-Bench MP for Bracknell, not Slough, I must add to the noble Viscount, Lord Falkland. Instead, as other noble Lords have indicated, we should focus more on the food industry that since the war has pumped out high-salt, high-fat and high-sugar products without any proper warnings.
However, as we have heard in today’s debate, there is a genuine fear that, at a time when the priority of diabetes should be enhanced, the new NHS arrangements seem to be removing diabetes-specific leadership, dedicated staff and specific plans. Many noble Lords have referred to the National Audit Office investigation into diabetes care, which found that:
“Diabetes care in the NHS is poor, with low achievement of treatment standards, high numbers of avoidable deaths and annual spending reaching an estimated £3.9 billion”.
In its response, the Public Accounts Committee highlighted how barely half of people with diabetes get the nine basic checks they need to manage their condition, and fewer than one in five has the recommended levels of blood glucose, blood pressure and cholesterol, leaving an unacceptably high number at risk of developing complications, being admitted to hospital and costing the NHS more money. As we have heard from the noble Lord, Lord Kakkar, the Public Accounts Committee also criticised NHS accountability structures for failing to hold commissioners of diabetes services to account for poor performance. He expressed optimism about the future, but I wonder how the new structures will stand up to the challenge of diabetes.
As the noble Lord, Lord Rennard, said, both type 1 and type 2 diabetes can lead to costly and life-shattering complications, including kidney failure, blindness and amputations, which my noble friend Lady Thornton focused on. Amputation is not only devastating, it is expensive. In England between £500 million and £600 million is spent each year on foot ulcers and amputations. I am lucky to see a podiatrist at regular six-monthly intervals. Speaking to my podiatrist, I discovered that as a consequence of the service being moved from the PCT to the local hospital trust, recruitment was frozen. His concern, as he was looking at my feet, was that without sufficient staff regular check-ups would not be carried out, so that instead of preventive treatment, he would be dealing with an increasing number of ulcers and other serious infections.
My noble and learned friend Lord Morris also pointed out that although the major rise is in type 2 diabetes, type 1 is also rising. As was referenced in a Question I put down, the first ever report into mortality from the national diabetes audit was published just under 12 months ago. It found that up to 24,000 people with diabetes are dying in England each year from causes that could be avoided through better management of their condition. About three-quarters of those are aged 65 and over. However, the gap in the death rate between those who have and those who do not have diabetes becomes more extreme when comparing those who are younger. It was truly shocking to learn that so many young people are dying from diabetes. Type 1 is a particularly difficult condition to live with, as my noble friend pointed out, and we need to raise awareness in schools and workplaces. At the end of the day, we need a huge public awareness campaign to help both to prevent and to detect diabetes.
The focus of today’s debate has been on the need for action. As I said at the beginning of my contribution, early diagnosis is key to both saving lives and saving money. We have heard about the NHS Health Check programme, which can help to detect and prevent the onset of type 2 diabetes. As my noble friend Lord Harrison said, implementation of the programme has been poor, and patchy at best. A number of PCTs failed to offer a single person an NHS health check last year, and so far this year the poor performance has continued, with two PCTs having offered no health checks to date. There is considerable variation in the way that PCTs have delivered the programme, and overall its implementation has been poor.
As the noble Baroness, Lady Masham, said, in April next year the responsibility for commissioning the NHS Health Check programme will shift to local authorities as part of their new public health duties. She is right to be concerned about the impact of this transfer on the future sustainability of the programme and the potential for further variation in its implementation.
This morning, I said in my Oral Question on HIV services that supporting self-management is critical. This approach helps people to gain the confidence, skills and knowledge to manage their own health, with resulting improvements in quality of life and even independence. My personal experience of the DESMOND programme has taught me how important this resource can be. Proper care planning, structured education and access to psychological and emotional support are essential if we are to deal with the challenge of diabetes.
In conclusion, I have a number of specific points, many of which have been raised by noble Lords today, but there is one that I want to focus on in particular. Will the Minister ensure that diabetes is given sufficient priority? There is an absolute need for a clinical lead in, and function for, diabetes within the national Commissioning Board. As we have heard, multidisciplinary networks working across all aspects of diabetes care are vital, and local commissioning work is going well for diabetes care.
My final point concerns the health checks. Will the Minister ensure that there is national delivery and national promotion of this vital work to prevent people developing diabetes? Unless there is urgent action on diabetes, thousands more people a year will be condemned to debilitating complications and early death. The time for action is now.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank noble Lords and, in particular, the noble Lord, Lord Harrison, for an extremely interesting and knowledgeable debate. Given the range of comments and issues raised, if I do not cover all the substantive issues, I hope that noble Lords will allow me to write to them.
I do not need to repeat all the statistics. It is abundantly clear that diabetes is a major current and future challenge for this country. It has to be a priority for the National Health Service. Diabetes is a priority for the Government and, as a long-term condition, it has been prioritised in the mandate for the NHS Commissioning Board. It is also a key marker of improvements in the NHS. Diabetes affects every system in the body. There should be no hiding place for this condition, but as the noble Viscount, Lord Falkland, reminded us, it frequently remains hidden from the patient who does not realise he or she has it, and from healthcare services that treat the complications of diabetes without managing their cause.
This year, the National Audit Office reviewed the management of adult diabetes services in the NHS. This highlighted the progress that has been made over the past 10 years, but also the significant challenges that we face over the next 10 years. As a number of noble Lords have pointed out, there is unwarranted variation in diabetes care. The management of people with diabetes has not been optimised. There is no excuse for poor diabetes care. No one with diabetes should lose their leg or their vision if this could have been prevented. We know what needs to be done and we have to ensure we meet this challenge head on.
A Public Accounts Committee hearing followed the publication of the NAO report, and the PAC has recently published its report. The Government are currently considering the PAC’s recommendations and will prepare a Treasury minute in response, which will be published in the new year. The noble Lords, Lord Harrison and Lord Kakkar, stressed the importance of integration of the patient pathway. The NHS has clear statements of good-quality care, with the publication of the NICE quality standards and a range of NICE clinical guidelines. These were informed by the national service framework for diabetes published in 2001, which sets out the key areas of development required for diabetes services in the NHS. The NICE quality standards require integrated care. They will be used by the NHS Commissioning Board as a basis for describing what good-quality care looks like.
The Quality and Outcomes Framework—QOF—introduced in 2003-04 has incentivised primary care to perform the nine care processes for people with diabetes, even though the percentage of people diagnosed with diabetes has more than doubled since 2004. NICE has been asked to review the quality and outcomes framework and we await its response and findings. We have a wealth of information and data on the provision of services and where we need to improve. The national diabetes audit started in 2004 and is now the world’s largest published clinical audit. There has been a year-on-year improvement in a number of areas. The audit shows that 54% of people with diabetes receive all nine care processes; 76% of people with diabetes had eight of the nine, which equates to 1.4 million people. However, I agree with the noble Lord, Lord Kakkar, that much more needs to be done. We need to ensure that everyone with diabetes for whom it is appropriate receives these essential care processes annually. We aim to achieve nine processes for as many people with diabetes as possible. However, each person needs individual care and it may not be clinically appropriate to do the tests in everyone. Some patients decline blood tests or other procedures. Nevertheless, I take the noble Lord’s point that the variation in the number of people with type 2 diabetes receiving all nine care processes is completely unacceptable.
A lot of work is being undertaken to drive up improvements in care and outcomes for people with diabetes, and I must now commend the work of Diabetes UK in driving change and raising awareness of issues for people with diabetes. I part company, very respectfully, with my honourable friend Dr Lee in another place on this issue. We know what needs to be done. We have the data and the guidelines to support this, and we must ensure that in the future structure clinicians and commissioners come together to commission services that meet the needs of people with this condition.
I went to Huddersfield last week to visit a general practice which is doing just that. The Grange Group practice, which provides a one-stop clinic for people with diabetes, impressed me a lot. It has developed an integrated and multidisciplinary team approach to the management of people with diabetes. It is a great example of a CCG taking the lead on improving the management of diabetes. It is not a one-off: there are examples of this up and down the country and it should become the norm.
The prime objective of the NHS Commissioning Board will be driving improvement in the quality of NHS services and we will hold it to account for this through the NHS mandate. Following the reforms to the NHS, the NHS Commissioning Board will use accredited evidence, such as NICE quality standards for diabetes, to guide local commissioners to improve outcomes for people with the condition. Commissioners can use the Atlas of Variation to identify the areas in their community that need improving and there is a wealth of clinical guidance and commissioning support for diabetes services. All this means that people with diabetes can expect to see a better service, with improved outcomes, and an end to unwarranted variation.
In addition, through the NHS outcomes framework we will be able to track the overall progress of the NHS in delivering improved health and outcomes. For people with long-term conditions such as diabetes, this will be measured by whether patients are in good health and are able to live active, fulfilling lives. Diabetes is relevant to all five domains in the outcomes framework, so it is important that when work programmes are developed they consider diabetes and how optimising care can help to deliver improvements.
We face substantial challenges in the next five to 10 years due to the changing age and ethnicity structure of the population, increased numbers of people with multi-morbidities and the challenges allied with obesity and activity. In 2020, it is estimated that 8.5% of people over 16 years of age will have diabetes—that is 3.8 million people in England. While type 1 diabetes is not currently preventable—I will say more about that in a moment—we must ensure that those with this form of the disease have access to appropriate services and have the knowledge and support to self-manage their condition.
We are fully committed to the prevention of type 2 diabetes. All our work on promoting an active lifestyle and tackling obesity will support this aim. The NHS Health Check programme has real potential to prevent many cases of type 2 diabetes and to identify thousands earlier. The Government have an ambitious programme to improve public health through strengthening local action, supporting self-esteem and behavioural changes, promoting healthy choices and changing the environment to support healthier lives. The Change for Life national campaign is raising awareness around eating healthily and increasing activity. The National Child Measurement Programme is giving people the information they need to make informed decisions about their child’s risk of becoming overweight.
We launched a new national ambition in January this year for a year-on-year increase in the number of adults doing 150 minutes of exercise a week. The public health outcomes framework was published in early 2012 and has key indicators for Public Health England, including diet, excess weight and physical activity.
The NHS Health Check programme, which I mentioned a moment ago, is a universal and systematic programme for everyone between the ages of 40 and 74. It assesses people’s risk of heart disease, stroke, kidney disease and diabetes, and it then supports people to reduce or manage that risk through individually tailored advice. I can reassure the noble Lord, Lord Collins, that the NHS Health Check programme is a key performance measure in the NHS operating framework this year, and take-up of the NHS health checks by the eligible population is another indicator in the public health outcomes framework. Local authorities will be mandated to offer risk assessments to their eligible populations from April next year—and I stress the word “mandated”.
The noble Lord, Lord Collins, referred to the NHS reforms and what these will mean for diabetes commissioning and care. He particularly stressed the importance of clinical leadership in the NHS Commissioning Board. I agree that clinical leadership has been key in driving improvements in care in recent years. Diabetes is a very high priority for the domain directors of the NHS Commissioning Board, both from the perspective of reducing premature mortality and improving the quality of life.
The noble Lord, Lord Kakkar, was right to remind us of the costs of diabetes care. These costs are hard to pin down—he is correct—because people with diabetes can be found in every part of the NHS. The thing to remember is that the greatest cost of diabetes is to the person with diabetes himself or herself in terms of the distress, disability and premature death that can ensue.
The noble Lord, Lord Harrison, spoke about the risk of short-termism and he was concerned that annual checks might be cut and replaced with online advice. He rightly asked about those people who are computer-averse. Annual checks are required by NICE and the Quality and Outcomes Framework and they must be face to face. Online advice does not replace them and, when it occurs, it is an additional option for patients who might find it helpful.
A number of noble Lords, including the noble Lords, Lord Harrison, Lord Kakkar and Lord Collins, referred to the importance of self-management, and I agree with what they said on this subject. The department is working to promote self-management in the care of diabetes through patient education and support from appropriately trained service providers, including the DAFNE and DESMOND programmes. The NHS reforms present an opportunity for stronger and closer partnership working between GPs and specialists, ensuring that the right care is commissioned and that it is focused on the needs of each individual patient and carer.
The noble Lord, Lord Brooke of Alverthorpe, brought us to the subject of alcohol, and particularly calorie counts in labelling. People with diabetes most certainly should have access to dietary advice, and that should include advice on alcoholic drinks. It is a subject that he raises regularly and he is right to do so. Around a quarter of adult men and a fifth of women report drinking at levels that are above the NHS guidelines, and in fact some 2.2 million people have said that they drink more than twice the amount set in the guidelines. That puts them at most risk of illness and death from alcohol. The noble Viscount, Lord Falkland, talked about safe driving with diabetes. I welcome the reminder he gave us that people with diabetes should follow DVLA guidance, and that includes the need for blood glucose testing if the driver is on insulin.
The noble Lord, Lord Harrison, spoke about transitional care, and particularly about children with diabetes in schools, an issue also referred to by the noble Lord, Lord Brooke. There has been long-standing work between the national clinical directors for diabetes and children and young people on improving diabetes care in children and those in the younger age groups. There is now a best practice tariff for children’s diabetes care. NHS Diabetes has been supporting work with young people on transitional care and there are regional paediatric diabetes networks. My noble friend Lord Roberts of Llandudno rightly drew attention to the late diagnosis of diabetes and diabetic ketoacidosis. I agree that it is important that all parents, teachers and healthcare professionals should be aware of the symptoms of diabetes, and I particularly welcome the “Four Ts” campaign from Diabetes UK. He referred to hypoglycaemia and the awareness of diabetes and its consequences. Again, I agree how important it is that children, young people and their families are taught how to avoid unduly low blood glucose levels. Friends, schoolmates and especially teachers should learn about this. An example is the work being done in Essex by the local authority with schools and parents as well as children.
The noble Baroness, Lady Masham, referred to specialist nurses. The Government consider that diabetes specialist nurses are an essential part of the diabetes specialist team. They have a valuable part to play in supporting people with diabetes. It is local healthcare organisations, with their knowledge of the healthcare needs of their populations, that are best placed to determine the workforce required to deliver safe patient care within their available resources, but the reforms once again present an opportunity for stronger, closer partnership working between the new primary care commissioners and secondary care specialists so that evidence-based, multidisciplinary care is focused on the needs of the individual patient. Once again, I saw this for myself last week when I visited Yorkshire. The noble Baroness also drew attention to high-fructose corn syrup, which is used as a food additive. I will write to her on that very important subject, on which a lot of work has been done.
A number of noble Lords, including the noble Baronesses, Lady Masham and Lady Thornton, focused on the very grave issue of amputation of limbs among those with diabetes. The National Diabetes Audit and the Atlas of Variation have both shown that there are unacceptable levels of variation in the care received by people with diabetes, and the noble Lord, Lord Kakkar, gave eminently sensible and important advice. It is important that clinicians review data relevant to their practice and make improvements to the care that they provide to reduce variation. We have plenty of examples of excellent patient-centred services that have improved outcomes and provided value for money. NICE guidance was published in January 2004. The guidelines include recommendations for primary and secondary care settings.
The incidence of amputation among people with diabetes has been declining over time, but the absolute number of diabetes-related amputations is rising as the prevalence of type 2 diabetes increases, and I agree fully with the noble Baroness, Lady Thornton, that the numbers need to come down. Diabetic foot disease accounts for more hospital bed days than all other diabetes complications put together. In the UK, 100 people a week lose a lower limb because of complications from diabetes. One in 20 people with diabetes will develop a foot ulcer in one year, and up to 70% of people die within five years of having an amputation. That shows how important an issue this is, but once again there is evidence that rapid access to multidisciplinary foot care teams can lead to faster healing, fewer amputations and improved survival. Savings to the NHS can substantially exceed the cost of the team. The noble Baroness spoke extremely powerfully on this subject. We join her in supporting the Putting Feet First campaign by Diabetes UK and NHS Diabetes and good patient education. The ambitions for the NHS are set out in the NHS outcomes framework and of course include improving the quality of life. Good care costs less for everyone.
The noble and learned Lord, Lord Morris, and the noble Lord, Lord Collins, spoke about type 1 diabetes. I agree that it is important to provide high standards of care for the 250,000 with type 1 diabetes, and that it would be helpful to improve the costing data around that. The noble and learned Lord, Lord Morris, was right to mention insulin pumps in this context. NICE recommend pump therapy as an option for adults and children over the age of 12 with type 1 diabetes if multiple daily insulin therapy has failed. In May this year, NHS Diabetes launched an insulin pump network to ensure an effective two-way sharing of the most up-to-date guidance, tools, best practice and resources. An insulin pump audit, the first to be undertaken nationally, is currently under way, and provisional unpublished data suggest that 11,985 adults and 4,447 children are currently on insulin pump therapy. Some 8% of people with type 1 diabetes now have insulin pumps. That is an increase, but we still need to go further to achieve the 12% to 15% advised by NICE.
As regards research, the department is currently supporting more than 60 studies into type 1 diabetes through the diabetes clinical research network. The Juvenile Diabetes Research Foundation has spent £1 billion on research around the world into treatments and prevention of the condition. I also acknowledge the major contribution of Diabetes UK to type 1 diabetes research.
Time prevents my replying to the points made about in-patient care, HIV/AIDS and diabetes, and the points made very powerfully about ethnic minorities. The noble Lord, Lord Harrison, asked me about the European Union and sharing ideas. I will write on those topics but will just say that progress has been made. It has been good progress, but we are not there yet. It is encouraging to see that many of the building blocks for making real progress are there and that, in the new NHS structure, there will be renewed awareness and mandated responsibility to improve care and services for all those at risk of this devastating condition.
Lord Harrison
My Lords, I thank the noble Earl for his repudiation of the intemperate remarks made at the other end about type 2 diabetes. I share his acknowledgement of the width and the depth of this debate, in which so many interesting individual contributions were made. I thank colleagues who have joined us in the Chamber to hear my last words on this important day. As the warm-up act for the Leveson inquiry, perhaps I may just identify the point made by the noble Lord, Lord Roberts of Llandudno, that diabetes is not properly represented on radio and TV. If the press have nothing better to do in the future after Leveson, perhaps they could explore and investigate some of the problems that we have identified today in the care given to diabetics, and many of the exhilarating stories of diabetics who have resisted their disease and who should be celebrated in the press and the highest organs of the state.
Leveson Inquiry
(12 years ago)
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The Chancellor of the Duchy of Lancaster (Lord Strathclyde)
My Lords, as I said earlier on today, I thought that I should repeat the Statement made by the Prime Minister immediately after this debate and I should now like to do exactly that. The Statement was made by the Prime Minister a few minutes ago in the House of Commons and is as follows:
“With permission, Mr Speaker, I should like to make a statement on today’s report from Lord Justice Leveson. As we consider this report, we should consider the victims. We should remember how the parents of Milly Dowler, at their most vulnerable moment, had their daughter’s phone hacked and were followed and photographed; how Christopher Jefferies’s reputation was destroyed by false accusations; and how the mother of Madeleine McCann, Kate, had her private diary printed without her permission and how she and her husband were falsely accused of keeping their daughter’s body in their freezer. These victims, and many other innocent people who have never sought the limelight, have suffered in a way that we can barely begin to imagine. That is why, last summer, I asked Lord Justice Leveson to lead an independent inquiry.
The inquiry had the power to see any document and summon any witness under oath to be examined by a barrister in public. It has been, as Lord Justice Leveson says,
‘the most public and the most concentrated look at the press that this country has seen’.
I thank Lord Justice Leveson and his entire team for the work that they have undertaken.
Lord Justice Leveson makes findings and recommendations in three areas: on the relationship between the press and the police; on the relationship between the press and politicians; and on the relationship between the press and the public. Let me take each in turn—first, the press and the police. Lord Justice Leveson makes it clear that he does not find a basis for challenging the integrity of the police, but he raises a number of areas which he felt were a cause for public concern, such as tip-offs, off-the-record briefings and, more broadly, “excessive proximity” between the press and the police. He makes a number of recommendations, including national guidance on appropriate gifts and hospitality, record-keeping of contact between very senior police officers and journalists and a 12-month “cooling-off” period for senior police officers being employed by the press. These are designed to break the perception of an excessively cosy relationship between the press and the police, and we support these recommendations.
When I set up this inquiry, I also said there would be a second part, to investigate wrongdoing in the press and the police, including the conduct of the first police investigation. This second stage cannot go ahead until the current criminal proceedings have concluded, but we remain committed to the inquiry as it was first established.
The next area is the relationship between politicians and the media. As Lord Justice Leveson has found,
‘over the last 30-35 years and probably much longer, the political parties of UK national Government and of UK official Opposition, have had or developed too close a relationship with the press in a way which has not been in the public interest’.
I made this point last summer when I set up this inquiry, and at the same time I set in train reforms to improve transparency.
This is the first Government ever to publish details of meetings between senior politicians and proprietors, editors or senior executives, as Lord Justice Leveson recommends in his report. He also recommends disclosing further information on the overall level of interaction between politicians and the press. This would apply to all parties and on the Government’s behalf I can say we accept the recommendation.
During the course of the inquiry, a number of serious allegations were made. I want to deal with them directly. First was that my party struck a deal with News International. This allegation was repeated again and again on the Floor of the House and at the inquiry itself. Lord Justice Leveson looked at this in detail and rejects the allegation emphatically. Let me read his conclusion:
‘The evidence does not, of course, establish anything resembling a ‘deal’ whereby News International’s support was traded for the expectation of policy favours’.
Those who repeatedly made these allegations—including Members of this House and, I have to say, the former Prime Minister—should now acknowledge they were wrong.
Secondly, it was alleged that I gave my right honourable friend, the then Culture Secretary and now the Health Secretary, the responsibility of handling the BSkyB bid in order to fix the outcome. Lord Justice Leveson states clearly that,
‘the evidence does not begin to support a conclusion that the choice of Mr Hunt was the product of improper media pressure, still less an attempt to guarantee a particular outcome to the process’.
That is another allegation repeatedly made again and shown to be wrong.
Thirdly, there was the criticism that the then Culture Secretary had rigged the handling of the BSkyB bid. Again, today’s report rejects that as well. My right honourable friend,
‘put in place robust systems to ensure that the remaining stages of the bid would be handled with fairness, impartiality and transparency’.
Indeed Lord Justice Leveson goes further, concluding that my right honourable friend’s,
‘extensive reliance on external advice … was a wise and effective means of helping him to keep to the statutory test’.
He concludes that,
‘there is no credible evidence of actual bias’.
Of course, as my right honourable friend has said himself, there are lessons to learn about how quasi-judicial decisions are made and we must learn those lessons. But let me say this: my right honourable friend, now the Health Secretary, has endured a stream of allegations with great dignity. The report confirms something that we on this side of the House knew all along: we were right to stand by him. Let me also say this: Lord Justice Leveson finds in respect to my right honourable friend the Business Secretary that he,
‘acted with scrupulous care and impartiality’.
Next—and most important of all—let me turn to what Lord Justice Leveson says about the relationship between the press and the public. As he says very clearly, even after 16 months of this inquiry, he remains,
‘firmly of the belief that the British press—all of it—serves the country very well for the vast majority of the time’.
But on the culture, practices and ethics of some in the press, his words are very stark. He finds that,
‘there have been too many times when, chasing the story, parts of the press have acted as if its own code, which it wrote, simply did not exist’.
He cites,
‘press behaviour that, at times, can only be described as outrageous’.
He catalogues a number of examples of such behaviour, going wider than phone hacking. He refers to,
‘a recklessness in prioritising sensational stories, almost irrespective of the harm that the stories may cause and the rights of those who would be affected’.
He finds that,
‘when the story is just too big and the public appetite too great, there has been significant and reckless disregard for accuracy’.
And he reports,
‘a cultural tendency within parts of the press vigorously to resist or dismiss complainants almost as a matter of course’.
In a free society, the press is subject to criminal law, civil law and requirements for data protection. But there should be a proper regulatory system as well to ensure that standards are upheld, complaints are heard and there is proper redress for those who have been wronged. That is what the current system should have delivered. It has not. As Lord Justice Leveson says, the Press Complaints Commission is,
‘neither a regulator, nor fit for purpose to fulfil that responsibility’.
That is why changes are urgently needed.
We welcome the fact that the press industry has put forward its own proposals for a new system of regulation, but we agree with Lord Justice Leveson that those proposals do not yet go far enough.
In Volume IV of the report, Lord Justice Leveson sets out proposals for independent self-regulation organised by the media. He details the key requirements that an independent self-regulatory body should meet, including: independence of appointments and funding; a standards code; an arbitration service; and a speedy complaint-handling mechanism. Crucially, it must have the power to demand upfront apologies and impose million-pound fines.
These are the Leveson principles. They are the central recommendations of the report. If they can be put in place, we truly will have a regulatory system that delivers public confidence, justice for the victims, and a step-change in the way the press is regulated in our country. I accept these principles and I hope the whole House will come behind them. The onus should now be on the press to implement them, and to implement them radically.
In support of this, Lord Justice Leveson makes some important proposals. First, he proposes some changes to the Data Protection Act that would reduce the special treatment that journalists are afforded when dealing with personal data. We must consider that very carefully—particularly the impact that it could have on investigative journalism. While I have been able to make only preliminary investigations about that since reading the report, I am instinctively concerned about that proposal.
Secondly, he proposes changes to establish a system of incentives for each newspaper to take part in the system of independent regulation. I agree that there should be incentives and believe that those he sets out, such as the award of costs and exemplary damages in litigation, could be effective.
Lord Justice Leveson goes on to propose legislation that would help deliver those incentives but that would also, crucially, provide,
‘an independent process to recognise the new self-regulatory body’.
This would, he says,
‘reassure the public that the basic requirements of independence and effectiveness were met and continue to be met’.
I have some serious concerns and misgivings about this recommendation. They break down into issues of principle, practicality and necessity.
The issue of principle is that, for the first time, we would have crossed the Rubicon by writing elements of press regulation into the law of the land. We should be wary of any legislation that has the potential to infringe free speech and a free press. In this House, which has been the bulwark of democracy for centuries, we should think very carefully before crossing this line.
On the grounds of practicality, no matter how simple the intention of the new law, the legislation required to underpin the regulatory body would, I believe, become more complicated. Paragraphs 71 and 72 of the executive summary begin to set out what would be needed in the legislation. For example, it refers to validating the standards code and recognising the powers of the new body.
If you turn to page 1772 in Volume IV of the full report, it says this about the new law. It must,
‘identify those legitimate requirements and provide a mechanism to recognise and certify that a new body meets them’.
The danger is that that would create a vehicle for politicians, whether today or at some time in future, to impose regulations and obligations on the press—something that Lord Justice Leveson himself wishes to avoid.
Thirdly, on the grounds of necessity, I am not convinced at this stage that statute is necessary to achieve Lord Justice Leveson’s objectives. I believe that there may be alternative options for putting in place incentives, providing reassurance to the public and ensuring that the Leveson principles are put in place, and that these options should be explored.
These questions, including those about data protection, are fundamental questions that we must resolve. I have therefore invited the Deputy Prime Minister and the leader of the Opposition to join me in cross-party talks, starting immediately after this Statement. But let me be clear: a regulatory system that complies with the Leveson principles should be put in place rapidly. I favour giving the press a limited period of time in which to do this. It does not need to wait for all the other elements of Lord Justice Leveson’s report to be implemented. While no one wants to see full statutory regulation, let me stress: the status quo is not an option. Be in no doubt; we should be determined to see Lord Justice Leveson’s principles implemented.
Mr Speaker, there is much that we in this country can be proud of—the oldest democracy in the world, freedom of speech, a free press, and frank and healthy public debate—but this report lays bare that the system of press regulation we have is badly broken and has let down victims badly. Our responsibility is to fix this. The task for us now is to build this new system of press regulation that supports our great traditions of investigative journalism and free speech but protects the rights of the vulnerable and the innocent, and commands the confidence of the whole country. I commend this Statement to the House.”
My Lords, that concludes the Statement.
Lord Hunt of Kings Heath
My Lords, I am grateful to the noble Lord the Leader of the House for repeating a Statement given in the other place by the Prime Minister on the report published today of the inquiry carried out by Lord Justice Leveson. I also say to the noble Lord that I welcome the opportunity for cross-party discussions. For our part, we will seek to convince the Government—or indeed, the noble Lord’s part of the Government—to put their faith in all the recommendations of the report.
I start by echoing the tribute that the noble Lord has paid to Lord Justice Leveson and his team. In particular, I thank them for the painstaking, impartial and comprehensive way in which they have conducted this inquiry. I thank the Lord Justice for the clarity with which he has explained his report today. Most of all, we on these Benches want to pay tribute to the innocent victims who gave evidence to the inquiry—people who did not seek to be in the public eye, who suffered deep loss and grief and who then faced further trauma at the hands of sections of the press. We pay tribute to Bob and Sally Dowler—it is easy to forget now that without their revelations last July about what happened to them and their daughter, and their courage in speaking out, we would not be here today—and to Gerry and Kate McCann, who suffered so much and showed such courage. Kate McCann, whose daughter remains missing, saw her private diary published by the News of the World for the sake of a story. They gave evidence to the inquiry to serve the wider public interest and I pay tribute to them. It is they who should be at the forefront of our minds today.
A free press is essential to a functioning democracy. The press must be able to hold the powerful, especially politicians, to account without fear or favour. That is part of the character of our country. At the same time, we do not want to live in a country where innocent families such as the McCanns and the Dowlers can see their lives torn apart simply for the sake of profit and where powerful interests in the press know that they will not be held to account. This is also about the character of our country. There never was just one rogue reporter. Lord Justice Leveson concludes that a whole range of practices from phone hacking to covert surveillance, harassment and other wrongful behaviour were widespread—all in breach of the code by which the press was supposed to abide.
We on these Benches recognise that many decent people work in our country’s newspapers and that not every newspaper did wrong. However, Lord Justice Leveson concludes:
“it is argued that these are aberrations and do not reflect on the culture, practices or ethics of the press as a whole. I wholly reject this analysis”.
That will not come as a surprise to many people but, as Lord Justice Leveson also concludes:
“there has been a persistent failure”,
by politicians,
“to respond … to public concern about the culture, practices and ethics of the press”.
All politicians must take responsibility for that.
The publication of this report is the moment when we must put that right, upholding the freedom of the press and guaranteeing protection and redress for the citizen. As the Prime Minister himself said at the Leveson inquiry:
“If the families like the Dowlers feel this has really changed the way they would have been treated, we would have done our job properly”.
The Opposition agree very much with that statement.
We should be clear about Lord Justice Leveson’s proposals and why they are different from the present system. He proposes a genuinely independent regulator with effective powers to protect and provide redress for the victims of abuse. He gives responsibility for establishing the system to the press, as now, but he provides a crucial new guarantee which we have never had before. He builds in a role for the media regulator, Ofcom, to ensure that the system that is established passes the test we would all want to see applied to it—that is, that it is truly independent and provides effective protection for people such as the McCanns and the Dowlers. To make this guarantee real, he recommends that both Ofcom’s power and these criteria of independence and effectiveness should be set out in statute, a law of this Parliament, with truly independent regulation of the press guaranteed by law.
Lord Justice Leveson’s proposals are measured, reasonable and proportionate. We on this side unequivocally endorse both the principles set out and his central recommendations. We support this new system of regulation. We support the Lord Justice’s view that Ofcom is the right body to carry out the task of recognition of the new regulator. We support his proposal that Parliament should lay down in statute the role of Ofcom. We endorse Lord Justice Leveson’s proposal that the criteria any new regulatory body must meet should be set out in statute.
Does the noble Lord the Leader of the House accept Lord Justice Leveson’s analysis that his recommendations cannot be characterised as statutory regulation of the press? He argues that what is proposed is independent regulation of the press, organised by the press, with a statutory verification process to ensure that the required levels of independence and effectiveness are met by the system “in order”, as he says,
“for publishers to take advantage of the benefits arising as a result of membership”.
Does the noble Lord accept that analysis? Does the noble Lord, Lord Strathclyde, also not follow the point made by Lord Justice Leveson that it is essential that there should be legislation to underpin the independent self-regulatory system and to facilitate its recognition in legal processes?
Lord Justice Leveson has, I believe, made every effort to meet the concerns of the industry. There are some who will say that this will not work because the press will not co-operate. Does the noble Lord the Leader agree that this arrangement, as Lord Justice Leveson says, will work, but only if the press now come forward to sign up to it with genuine commitment? If we cannot achieve a comprehensive system involving all major newspapers then Lord Justice Leveson has set out the necessary alternative—essentially, direct statutory regulation. Do the Government agree that if the newspapers refuse to adopt the system proposed, this will be necessary and will need to be implemented?
Lord Justice Leveson has genuinely listened. He has acted with the utmost responsibility. Surely newspaper editors and proprietors should now do the same. He also reaches important conclusions on the need to prevent too much media influence ending up in one pair of hands. He proposes that there should be continuous scrutiny of the degree of media plurality and a lower cap than that provided by competition law. Will the noble Lord the Leader say that the Government will now take this forward? Lord Justice Leveson also makes specific suggestions about greater transparency about meetings and contacts between politicians and the press. He says that they should be considered as an immediate need. We agree, and we hope that they can be taken forward too.
As I said earlier, we welcome the Prime Minister’s offer of immediate cross-party talks on the implementation of the recommendations on press regulation, but those talks must be about implementing these recommendations, not whether we implement them. These talks must agree a swift timetable for implementation. They must agree to legislate in the next Session of Parliament with a new system up and running at the very latest by 2015. By the end of January next year, we should have an opportunity for Parliament to endorse and proceed with the Leveson proposals. Does the noble Lord the Leader of the House agree?
We should move forward together. After 70 years, seven reports and many last-chance saloons which have gone absolutely nowhere, now is the time to act. The case is compelling and the evidence is overwhelming. This is a once-in-a-generation opportunity to make change that the public can trust. In doing so, we ought to remember the words of Bob and Sally Dowler at the Leveson inquiry. They said:
“there is nothing that can be done to rectify the damage that has been done to our family… All that we can hope for is a positive outcome from this inquiry so that other families are not affected in the way that we have been”.
Surely, on behalf of every decent British citizen who wants protection for people like the Dowler family, and who wants a truly free press that can expose abuse of power without abusing its own power, we must act.
Lord Strathclyde
My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, very much for his response. He has made a similar analysis to that of the Prime Minister on the virtues of the Leveson report, come to many similar conclusions and, indeed, accepted many of the same recommendations as the Prime Minister has done on behalf of the Government. The noble Lord was right to reiterate his thanks to Lord Justice Leveson and to remind us that the reason why all this came to a head was that the disgraceful way in which so many innocent victims had been affected by the press’s behaviour over a great deal of time came to light. It is right that Parliament and politicians should be part of the responsibility for allowing that to happen over many decades. The noble Lord talked about cross-party talks, and I am glad that the Labour Party will play its full part.
The report that has been published stands almost six inches high. It is an extremely authoritative document. It will take time to read and to digest. I am glad to be able to announce to the House that we will have an opportunity for a full debate on the report on Tuesday 18 December, which will give us time to digest the report and its implications before coming back to the House and making, no doubt, substantive speeches on its conclusions.
The noble Lord said that we should try to deal with this as quickly as possible. Our view, with which I hope the noble Lord will agree, is that there is much here that the press can get on with immediately. They do not need any more encouragement from Parliament or from Lord Justice Leveson to put the changes into effect, and they should do so. The noble Lord asked about the role of Ofcom. That is one of the things that we need to discuss in the cross-party discussions.
As to whether or not this is statutory regulation, I agree with the analysis of Lord Justice Leveson, as the noble Lord invited me to do. In fact, Lord Justice Leveson argued strongly that his model is not statutory regulation. He says in his report:
“Despite what will be said about these recommendations by those who oppose them, this is not, and cannot be characterised as, statutory regulation of the press”.
It is a statement of belief in independent self-regulation. However, there are aspects of statutory regulation that are required in all of this. We are not convinced that statutory regulation would be the best way of providing for these things. There needs to be some further discussion, and that is what we will continue to have in the cross-party talks.
I hope that the talks will be businesslike; there is no reason why they should not be. They will be carried on as well by my right honourable friend the Secretary of State for Culture, Media and Sport. I hope that we will be able to conclude those discussions as soon as possible.
Lord Fowler
My Lords, are there not two major points on which we can all agree? First, the campaign organised by the big newspapers before the report was even published to say that Leveson was backing a state-regulated press has been shown to be utterly false, and the newspaper advertisements suggesting that he was about to side with Mugabe, Castro and all kinds of other dictators should be condemned in the strongest possible terms.
Secondly, I think that I was the first parliamentarian to call for an inquiry. Can we also agree that Lord Justice Leveson has done the country an enormous service by exposing the corruption that has taken place in some parts of the press and by criticising the inadequacy of the Press Complaints Commission? Lord Justice Leveson has proposed a new, absolutely independent complaints body with the very minimum of statutory underpinning, which, in my view, is good for the public and good for the press. I urge the Government to take the opportunity of the inquiry that they set up and to implement these eminently sensible proposals. If we falter now, I think that we will live to regret it.
Lord Strathclyde
My Lords, I very much welcome what my noble friend Lord Fowler has said. He is right that there has been an extraordinary mood of hysteria in recent days and weeks about what the Leveson report would come out with. Many people will regard what my noble friend said about the report to be right. He was right to call for an inquiry and my right honourable friend the Prime Minister was right to set it up. That decision has been vindicated: the report has exposed corruption and the inadequacy of the current press regulatory system, and has pointed us in the right direction to go forward from here.
Baroness Hollins
My Lords, I gave evidence to the Leveson inquiry and I am very pleased to see his report. I have read only the executive summary. I gave evidence because, after my daughter was attacked, my family and I were subject to sustained harassment, press intrusion and misinformation, which continued for about five years. The coverage usually was sensational but usually kindly in tone. However, its main purpose was commercial. Will the noble Lord the Leader of the House reassure us that the Government will act swiftly to implement the recommendations made by Lord Justice Leveson? Victims of abuse deserve nothing less. Will he also tell us what steps the Government will take to prevent a decisive response being derailed by vociferous elements of the industry—those parts of the industry that have been thoroughly disgraced and remain remorseless?
Lord Strathclyde
My Lords, the noble Baroness’s words are particularly poignant because of what she and her family went through some years ago. I am sure that I speak for the whole House in saying that there is no place in ethical journalism for what happened to her; it was outrageous. It is one of the issues that have brought the reasons for this report to a head.
I confirm that we will act swiftly. We have acted swiftly already today by announcing the areas on which we comprehensively agree and in announcing cross-party talks. Perhaps I may reiterate what I said a moment ago: there is no reason why the press cannot start in this new direction as quickly as possible, providing a system of independent and transparent regulation with very firm criteria, along the lines proposed in the report from Lord Justice Leveson.
Baroness Bonham-Carter of Yarnbury
Lord Justice Leveson said today that the Black-Hunt proposal for a reformed PCC does not come close to delivering regulation that is genuinely free and independent both of the industry and political control, and has called for an independent verifier established by statute. Twenty years ago, David Calcutt QC came to virtually the same conclusion and was ignored. Are we not in danger here of repeating the mistake of 1992 of asking for advice and then ignoring it?
Lord Strathclyde
My Lords, the overwhelming majority of the recommendations, suggestions and thought process that Lord Justice Leveson has gone through have been accepted by us and, no doubt, by the press. I say “no doubt”—I very much hope that that applies to the press. There are issues that we believe need to be explored more thoroughly, particularly about the role that legislation should play. My right honourable friend the Prime Minister said this afternoon that he had issues on the principle, the practicality and the necessity of that. These are issues that we can explore in the near future.
Lord Prescott
My Lords, I speak as a victim of our free press. The failure of the PCC and the Metropolitan Police is well recorded in this excellent report by Lord Justice Leveson, who has given us solutions to that failure. I welcome the report, as it recommends change and accepts the recommendations that I made for change, including the voluntary and statutory framework, when he invited me to do so in giving evidence to his inquiry. Does the Minister accept that Lord Justice Leveson was well aware that there could be a failure, as there has been in the past six inquiries into the press, as to whether they would carry out their promises and make the change? In those circumstances, is the Minister prepared to consider in the legislation that will come before this House a sunset clause that makes it clear that, if the press fail to carry out their promises, we have the authority in the Bill to bring forward a statutory framework, which Lord Justice Leveson said was the only alternative?
Lord Strathclyde
The noble Lord was clearly wronged by elements of the press. He is right to say that Lord Justice Leveson has comprehensively exposed a failure in the PCC, which cannot continue any more. He largely absolves the police from blame, although he has made some important recommendations on certain changes relating to the relationship between the police and the press.
I know that there are a lot of speakers. I shall try not to make my answers too long so as to get in as many as we possibly can, but I remind noble Lords that there will be another Statement along in a minute.
Lord Mackay of Clashfern
My Lords, I shall try to follow that good example. When Lord Justice Leveson was appointed, I knew that we had an excellent judge to undertake this task. I knew from a certain amount of experience of being in Government in the past that he was dealing with an extremely difficult problem. We had the “last chance saloon” and so on over the time when I was in Government, so I know how difficult it is. Surely we have a unique opportunity at this time to go ahead with an extremely well thought-out system for giving the press the right of self-regulation that is seen to work in the public interest. The only purpose of the statutory arrangement is to ensure that that self-regulation will be properly independent in the sense that Lord Justice Leveson explained. I would have thought that the sooner we can get all-party consent to this, the better. There will be a certain amount of discussion about detail, but the principles and essentials of the legislation can surely be put in place very quickly. We owe it to people like those who have been referred to to do it as quickly as possible to prevent that kind of thing happening again.
Lord Strathclyde
My noble and learned friend has a great deal of experience and knowledge on this subject, and I agree with him that what we asked Lord Justice Leveson to do was extremely difficult—yet what he has done is to bring his intellect to bear and publish an extremely impressive report and analysis. I agree with much of what my noble friend said; there is an opportunity for us to work together on a cross-party basis to bring about some extremely good results as quickly and effectively as possible.
Lord Mandelson
My Lords, the Prime Minister said at the beginning of his Statement that above all we should put the interests of the victims first. I am afraid that in his response to Leveson he is doing the very opposite of that: he is putting politics and the perceived power of certain sections of the press before the interests of the victims. Let us be honest, he is not the first Prime Minister to be in that position.
The Leveson report is a very moderate and realistic set of proposals that seeks to achieve two things. First, it seeks to achieve high standards of journalism in this country and the untrammelled ability of journalists to pursue those high standards, while at the same time putting in place a rudimentary protection of the rights and freedoms of individuals. It is perfectly clear that what certain sections of the press—they are by no means unified—want to put forward instead is a variation of the PCC, which, as we know, is and always has been a plaything of the Daily Mail and News International—nothing more or less than that.
Leveson is right: we need a statutory longstop to a genuinely independent system of regulation—a statute that should give privileges to the press because of the unique role that they play in our society, but should make absolutely clear that while they enjoy those unique privileges, they are none the less not above the law in how they behave.
Lord Strathclyde
My Lords, it is truly astonishing to hear the noble Lord complain about politicians being political. I cannot join him in his accusation that my right honourable friend is afraid of the power of the press; in fact, I think that my right honourable friend has accepted most of the criteria set out in this report. Where I agree with the noble Lord is that we should have uppermost in our minds the interests of the victims, and should judge the criteria and the new system of regulation against that. The new regulatory system, unlike the current one, will be devoid of editors and members of the Government on its governing board. That is an enormous strength to ensure that it can never again become a plaything of any newspaper group.
The Lord Bishop of Liverpool
My Lords, in the public debate there is sometimes an assumption that the problem with the press is that of a rogue reporter distorting a story. When I chaired the Hillsborough independent panel, we became aware of the way that one news agency failed not just one national newspaper but several, which between them became cumulatively responsible for misrepresenting the events of Hillsborough for a generation. Will the Government ensure that the regulatory body is sufficiently equipped to deal with complaints against such complex and enormous misrepresentation?
Lord Strathclyde
My Lords, the right reverend Prelate brings a very particular experience of abuses of the press that have recently come to light. Again, it will be a test of the new regulatory system whether or not it will have the resources that he mentioned. At first reading of the executive summary, I am bound to say that I think the intention is that it will. However, that is precisely the kind of thing that we will be able to discuss in great detail.
Lord Soley
My Lords, some people have been quick to demand that the powerful be held to account. Now is the time to hold the press to account because they have avoided that for too many years and we have all ducked the problem for too long. What troubles me about the Statement repeated by the Leader of the House today is that it calls on the press to make these changes, with which I agree, but if that means that they then do not proceed to legislate on the Leveson proposal, I will tell him exactly what will happen: in about two or three years’ time, when the spotlight of Leveson has dimmed, they will go back to their old ways. We must have Leveson.
Lord Strathclyde
My Lords, I agree with the noble Lord. Lord Justice Leveson has created a new, self-regulatory system. We expect the press to put it into effect as quickly as possible. We should all be guardians to make sure that the press sticks to the new regulatory system.
Lord Elystan-Morgan
My Lords, I join in with the well deserved congratulations tendered in respect of Lord Justice Leveson, but does the Minister agree that a great deal of irrelevant nonsense has been spoken on the issue of freedom of the press? The press is subject to the law of sedition, defamation, treason, contempt and dozens of other fundamental legal principles, yet remains free. In Leveson we have nothing more than a statutory framework for spelling out certain principles of human decency that should have been abided by all along.
Lord Strathclyde
My Lords, I do not entirely agree with the noble Lord that there has been a lot of nonsense spoken, but I do agree that there are statutes designed specifically to deal with excesses not just of the press but of other people as well. There are also instances—for example data protection—where the press has a privileged position and is excluded from the law. This is one area we need to examine.
Lord Hattersley
My Lords, in another place the Prime Minister was less than precise about how a regulatory authority that was not statutorily backed would be constituted. Does the Leader of the House agree that were the regulatory authority to be financed and nominated by the press itself, it would no longer be independent?
Lord Strathclyde
My Lords, there is perhaps a small misunderstanding. The authority will not be nominated by the press. It will be a truly independent body that will not have editors on it, as the current body has.
Lord Black of Brentwood
My Lords, I agree with my noble friend on the need to get on with establishing a new system of tough, independent regulation. The Prime Minister has laid down a tough challenge to the newspaper industry to proceed quickly. I reassure him that the industry will rise energetically to the challenge, starting tomorrow. There is much in the Leveson principles that he referred to that the industry can agree with. The proposals can be fully deployed in the proposals set out by my noble friend Lord Hunt. As the report says on page 1769, there is no reason why the industry model should not be capable of adaptation to meet the requirements set down. I concur, and we can look at the various points raised.
Finally, I echo the great caution expressed about the role in the new system of the statutory regulator Ofcom. I should have prefaced my remarks by declaring my interest as executive director of the Telegraph Media Group. I draw the Leader’s attention to paragraph 6.16 in volume 4 of the report, which states that the recognition body would be required to determine whether the standards code met statutory requirements. That would put a state regulator at the very heart of the newsroom. Does he agree that if the industry can make rapid progress in the task of establishing a new system, such a move would be not just profoundly dangerous but completely unnecessary?
Lord Strathclyde
My Lords, I very much welcome what my noble friend said about the press welcoming this report as much as we do. It is for the press to come up with a very firm timetable for how quickly they will put this into effect. The issue of Ofcom is one that we will discuss over the next few weeks.
Lord McConnell of Glenscorrodale
My Lords, I discovered towards the end of the Leveson inquiry that my daughter’s mobile phone had been hacked 10 years ago. Her intimate conversations were used in a story published in the News of the World and other publications. Will the Government and the leaders of all parties bear in mind that it is not just those in the public eye but the families of those in the public eye, including the wider families—the brothers, sisters, nieces, nephews, aunts, uncles, mothers and fathers—who suffer from press intrusion even though they have never volunteered to be in public life. Will the Government also consider, in the discussions that are about to take place about the importance of the media outwith London, the culture of the media across the whole of the United Kingdom, particularly in Scotland and Northern Ireland, where the national media operate in just as influential a way as they do in London for the rest of the UK?
Lord Strathclyde
My Lords, I agree entirely with what the noble Lord said. He is also right about the rest of the United Kingdom, and we shall need to take into account the devolved Administrations to make sure that they are fully on board with some of these changes.
Leveson Inquiry
(12 years ago)
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The Minister of State, Ministry of Justice (Lord McNally)
My Lords, I would like to repeat a Statement on the Leveson inquiry made earlier in the House of Commons by the Deputy Prime Minister. The Statement is as follows:
“Mr Speaker, I am grateful for the opportunity to address the House. I know it is unusual, but this is an unusual debate. The terms of reference for Lord Justice Leveson’s inquiry were agreed on a cross-party basis. As the House has heard, we intend to proceed on a cross-party basis. So I think it is right that Parliament is clear on the initial views of the Government—across the coalition.
First, let me say that I agree with a huge amount that has already been said by the Prime Minister and the Leader of the Opposition, which bodes well for the cross-party talks taking place later this afternoon.
I would like to thank Lord Justice Leveson for his extremely thorough report. In my view, there are two big liberal principles at play in this debate: on the one hand, the belief that a raucous and vigorous press is the lifeblood of a healthy democracy; on the other, the belief that the vulnerable, the innocent and the weak should be protected from powerful vested interests.
A free press does not mean a press that is free to bully innocent people or to abuse grieving families. What I want now is for us to strike a better balance between those two liberal principles, so that our media can scrutinise the powers that be, but cannot destroy innocent lives; so that the journalists up in the Press Gallery can hold us, the politicians, to account, but we can look up to the individuals and families in the Public Gallery knowing they have the right protections in place.
I have always said that I would support Lord Justice Leveson’s reforms, providing they are proportionate and workable. I will come on to why, at first glance, I believe that to be the case for the report’s core proposal for a tougher system of self-regulation, supported by new, independent checks, recognised in law.
However, I do not want to disguise the fact that I have some specific concerns about some specific recommendations; for example, on data protection rules, and any changes to the way in which journalists can use personal information when reporting in the public interest; and on the suggestion that it should be Ofcom that independently verifies the new press watchdog. Ofcom has a key role in regulating the content of broadcast media, but I am yet to be convinced that it is best placed to take on this new, light-touch function with the print media as well. Lord Justice Leveson has himself said this function could be fulfilled by a new body.
However, on the basic model, of a new, self-regulatory body, established with a change to the law, in principle, I believe this can be done in a proportionate and workable way. I understand the entirely legitimate reasons why some Members of this House are wary of using legislation. I myself have thought long and hard about this. I am a liberal; I do not make laws for the sake of it—and certainly not when it comes to the press. Indeed, when I gave my own evidence to the inquiry, I made the point that, if we could create a rigorous, independent, system of regulation that covers all the major players, without any changes to the law, of course we should. But no one has yet come up with a way of doing that.
Lord Justice Leveson has considered these issues at length. He has found that changing the law is the only way to guarantee a system of self-regulation that seeks to cover all of the press, and he explains why the system of sticks and carrots he proposes has to be recognised in statute in order to be properly implemented by the courts.
What is more, changing the law is the only way to give us all the assurance that the new regulator is not just independent for a few months or years but independent for good. Someone will need to check, periodically, that the independence of the regulator has not been weakened over time. The report explains why that needs to be set out in law. As Lord Justice Leveson himself says:
‘This is not, and cannot be characterised as, statutory regulation of the press’.
This is a voluntary system, based on incentives, with a guarantee of proper standards. It is not illiberal state regulation.
It is worth dwelling on that point for a moment because, while there has, rightly, been a lot of discussion about the risks of legislating, there have, so far, been key arguments missing from this debate. First, the press does not operate in some kind of lawless vacuum; it has to abide by the law. In many instances it is already protected by the law, and I agree with the report that we should actually go further in enshrining the freedom of the press in statute.
Secondly, it has been suggested that using the law will blur the line between politicians and the media, but we must not ignore the extent to which that line has already been blurred under the current system of self-regulation. It is the status quo which has allowed such cosy relationships between political and media elites to arise in the first place. And let us not forget that, of the five PCC chairs, three were serving parliamentarians who took a party whip. Far from allowing greater overlap, the laws that have been proposed give us a chance to create a hard wall between politics and the press.
Thirdly, as the report notes, there is already an example of statutory underpinning in the Press Council of Ireland, which has been accepted by a number of UK newspapers. The Daily Mail, the Daily Mirror, the Daily Star, the Sun, the Sunday Times, the Mail on Sunday and the Sunday Mirror are all members; they all publish Irish editions. I have not yet heard these papers complain of a deeply illiberal press environment across the Irish Sea.
Of course, neither I nor anyone can be certain of exactly how these proposals will look until we have worked up the detail. The two tests I have set—that any reforms must be workable and proportionate—will need to be met in practice as much as in principle, and if they are not I will be the first to sound the alarm. In that event, we would then need to consider alternatives.
Absolutely the worst outcome in all this would be for nothing to happen at all, but we must not now prevaricate. I, like many people, am impatient for reform. Bluntly, nothing I have seen so far in this debate suggests to me that we will find a better solution than the one which has been proposed. Nor do I draw any hope from the repeated failure of pure self-regulation that we have seen over the past 60 years. We need to get on with this, without delay. We owe it to the victims of these scandals, who have already waited too long for us to do the right thing—too long for an independent press watchdog, in which they can put their trust. I am determined we do not make them wait any more”.
I commend this Statement to the House.
Lord Hunt of Kings Heath
My Lords, I am very grateful to the noble Lord, Lord McNally, for repeating the Statement of his right honourable friend the Deputy Prime Minister in the other place. It is a bit like the No. 11 bus: we have been waiting a long time for a Statement on press regulation and two come along at the same time. The House has shown remarkable sympathy to accommodate the strains and stresses of the coalition Government and allow this to happen. Perhaps it will be equally accommodating when we are dealing with the Electoral Registration and Administration Bill, which we hope will come along at some point.
I found myself largely in agreement with much of what the noble Lord, Lord McNally, said. I also pay tribute to his long-standing and consistent work in this area. Of course, the reason why the Deputy Prime Minister found it necessary to make a statement separate from that of the Prime Minister is now clear: there is a fundamental difference between the Prime Minister and the Deputy Prime Minister. The Prime Minister is extremely reluctant that statute should be involved in any way in a system of independent regulation of the press, whereas the Deputy Prime Minister is clearly convinced that a new system of independent regulation must be supported by statute. I invite the noble Lord, Lord McNally, to reiterate that Lord Justice Leveson could not have been clearer about why statutory underpinning of his proposed system of independent self-regulation is required. Paragraph 70 of the executive summary of the Leveson report says plainly that,
“it is essential that there should be legislation to underpin the independent self-regulatory system and facilitate its recognition in legal processes”.
Does the noble Lord, Lord McNally, accept that Lord Justice Leveson absolutely rejects as inadequate the proposals put forward by the noble Lord, Lord Black? In paragraph 53 of the executive summary, Lord Leveson says that,
“the new body must represent the interests of the public as well as the press and the proposed model”—
the Black model—
“does not go anything like far enough to demonstrate sufficient independence from the industry (and in particular, serving editors) or sufficient security of high and unalienable standards for the public; neither does it appear to have sufficient support from all the major participants within the industry”.
Surely that is persuasive in the need for action to provide the statutory underpinning that Lord Justice Leveson puts forward.
In his response, the Prime Minister seems to be setting himself against a fundamental point of what Lord Justice Leveson proposes. He is setting himself against where the public are and he is certainly setting himself against where victims of the media want politicians to be. Of course, legislating on the press is a difficult and complex area but we believe that the Prime Minister is making a misjudgment on this issue. He should put his faith in what Lord Justice Leveson is proposing and enact it.
We welcome the Statement from the noble Lord, Lord McNally, and look forward to working in cross-party talks with him and his party on this point. It is very simple: we should not allow the press to have another lock-in at the last chance saloon, which has lasted for so many decades. Our democracy needs a free press, but a clean press, too. We will work very hard to achieve that.
Lord McNally
My Lords, I am grateful for the kind, personal remarks of the noble Lord, Lord Hunt. The noble Lord, Lord Prescott, called out from a sedentary position, “What’s the difference?”. The noble Lord, Lord Hunt, tries to find differences. One of the things that I found most encouraging about the two Statements—indeed, the three Statements made in the other place today—is the broad level of common ground. I hope that everyone will take the opportunity, including my noble friend Lord Black, to read the Leveson report and then match the statements that they made before reading it in the light of it. In some ways it is an insult to someone who has spent as long as Lord Justice Leveson has, whether it was a year or nine months—I am never quite sure, but it was a very long time—to produce a four-volume 2,000-page report, and then to announce, “I agree with this; I agree with this; I agree with this”. Let us read the report and think about how to go forward. I am pleased that, as far as I am aware, those cross-party talks have already been in place for the past 55 minutes, which bodes well.
Baroness Kennedy of The Shaws
My Lords, clearly Lord Justice Leveson’s report managed to answer the tests that he was set, which were basically how to reconcile freedom of the press with concern for the many victims who have suffered terrible mistreatment at the hands of the media. I think there is consensus in this House and in the other place that he has managed to do that with great aplomb, skill and proportionality.
I listened with care to what the noble Lord, Lord Black, said, and it filled me with concern. Here we are with a report that recommends regulation with the lightest of touch—it really only creates backstop oversight and allows the press themselves to create the independent regulatory system that we would all like to see—yet there is still a sense that somehow the media will not be satisfied and that the press barons and their supporters will rally to prevent anything happening.
There was a wonderful moment in the Leveson inquiry when Stephen Dorrell—who is not much remembered anymore but he was a Minister in the early 1990s in what was then the Department of National Heritage, now the Department for Culture—told how someone working on his team had produced a memo. Calcutt had just reported and the memo said, “We can’t do anything; we’re not going to do anything; we can’t say we are not going to do anything; we therefore have to find something to say that sounds as though we’re not going to be doing nothing”. That is the terrible thing that I feel could easily happen here again. We must not descend again. I would like the Minister—who, as everyone has said, has a great track record on this—to reassure us that he is not going to allow this to become the purview yet again of those masters of the universe who happen to run some sections of our press.
Lord McNally
My Lords, there will be a test tomorrow. If tomorrow’s newspapers and editorials follow the lines suggested by the noble Baroness, I—and, I hope, the noble Lord, Lord Black, and anyone who has influence on it—will say that our media have misjudged horrendously the public mood and the public disgust at their behaviour. It is simply not good enough to wave the flag that it will be a state-controlled press and Russia and Turkey will be pleased at what we are doing, when manifestly that is not the case. That would be really sad.
There is also a responsibility on us. I do not mind the odd bit of knockabout, and I might remind the other side of its record in this area at some points in this questioning, but the responsibility of the three parties that have had experience of government is immense. This is our chance, a chance that may not come again, and it would be a betrayal if we did not take it.
Lord Ashdown of Norton-sub-Hamdon
My Lords, in that precise context, does my noble friend agree that those in the press who have so overplayed their hand in their pre-emptive bombardment of Leveson, in the hope that we would somehow put it aside, have woefully misjudged both the public mood and the seriousness of the problem that confronts them, to which Lord Justice Leveson has provided such a balanced reply?
Lord McNally
After long experience, I always agree with the noble Lord, Lord Ashdown.
Lord Clinton-Davis
My Lords, the Minister spoke about the vulnerable, the innocent and poor people. Undoubtedly the issues that such people face will be complex and they will need help. Will the noble Lord undertake that, in suitable cases, legal aid will be available to them?
Lord McNally
I suspect that legal aid would be available. However, this is not the evening to discuss that issue.
Baroness Hollins
My Lords, can the Minister suggest an appropriate and achievable timetable to scrutinise Lord Justice Leveson’s proposals for legislative action? Can he reassure the House that the case for legislation to underpin independent self-regulation will not simply be referred to another committee?
Lord McNally
I most sincerely hope not. As I said earlier, all-party talks started, as I understand it, at five o’clock. When I had the pleasure earlier today of sitting in on a meeting between the Prime Minister and the Deputy Prime Minister, they were both clearly determined that this issue would be pressed with all possible urgency. It will not run into the sand or go into the long grass, and the sooner that the press understand that and respond with a sense of urgency and reality, the better.
Lord Inglewood
My Lords, I should declare an interest as chairman of the Cumbrian Newspaper Group, not that that makes me much of a press baron. Will my noble friend confirm that the Government accept Lord Justice Leveson’s findings of fact in his report?
Lord McNally
I would assume so, although I am not sure whether there is an elephant trap in that. One of the things that have been said by all those who have responded is that they pay tribute to the absolute thoroughness of the work done by Lord Justice Leveson.
The Lord Bishop of Chester
My Lords, I welcome the report. Perhaps I may follow up the aside of the previous speaker and ask where do the press begin and where they end. It is not clear how much printed media there will be in the coming 20 years; increasingly they are going to be in the blogosphere, twittering and whatever, and it seems that, whatever the Government do, they must weigh that very carefully. The problems of the press are increasingly going to be the problems of the paperless media. I would like a reassurance that, in swiftly implementing what the inquiry says, the matter will be given careful thought.
Lord McNally
My Lords, we are most certainly moving into a new age, but let us be clear: newspapers that publish online are already subject to the same disciplines as the printed versions of those newspapers. As I think we discovered in the Lord McAlpine case, electronic tweeting, e-mails and so on are not protected from the other laws of this land.
The Chancellor of the Duchy of Lancaster (Lord Strathclyde)
My Lords, I think we should hear from the noble Lord, Lord Whitty.
Lord Whitty
My Lords, there seems to be one dimension that the discussion in this House so far has missed. A truly free press requires diversity of opinion and therefore diversity of ownership. A whole chunk of the recommendations in the report relate to that plurality point. The Government have a great chance. There is a Bill already before this House, the Enterprise and Regulatory Reform Bill, in which the recommendations made here on media ownership, competition and plurality could be introduced at this stage. Will the noble Lord and, indeed, the Leader of the House prevail upon their colleagues to consider putting them into the Bill?
Lord McNally
I will certainly take that suggestion back, and I think that the noble Lord is quite right. Although the Leveson report devotes a relatively small amount of attention to plurality, it throws on our respective Houses and on the Government the responsibility of looking at, monitoring and, if necessary, responding to questions of plurality. I hope that we will take up the challenge posed in the report because, as has been said, this is an industry in technical change and we may find that there are very rapid concentrations of power. We may well need to be able to respond to such concentrations, but whether or not that is done through the noble Lord’s suggestions is above my pay grade.
Lord Steel of Aikwood
My Lords, I hope I am not alone in expressing my deep sympathies for my noble friend and for the Leader of the House at having to repeat these two Statements in the House because it is surely not the right way to proceed. What really matters are the all-party talks, and I am delighted to hear from my noble friend that they have already started. The danger about these Statements is that they overemphasise the differences within the coalition before the talks have started. That is not the right way. Lord Justice Leveson took a long time to produce a weighty report, so we should treat it seriously and see that it is properly implemented.
Lord McNally
I hear what my noble friend said, but this is one of those dilemmas. In each House, my right honourable friend and I could have sat silently while a Conservative made the points, or we could have done what I think is the sensible thing, which is to set out clearly the attitudes of the three major parties that are going to have responsibility for seeing this through. I think we took the right decision and do not agree with my noble friend.
Lord Foulkes of Cumnock
On the specific point made by the noble Lord, Lord McNally, this is a different House from the House of Commons and very different in its procedures. I have agreed with everything that the noble Lord has said so I hope he will forgive me if I ask him: in what capacity was he speaking from the Dispatch Box? Why could he not have done what has been done on a number of previous occasions—the noble Lords, Lord Alderdice, and Lord Dholakia, have done it—and expressed a point of view from the Liberal Democrat Benches? That is what is done in this House, which is different from the other place.
Lord McNally
This House would not then have had the benefit of hearing what my right honourable friend the Deputy Prime Minister said in the other place. I was trying to work out how long the noble Lord and I have known each other. I think it is—
Lord McNally
So he knows the affection in which I hold him. However, I do not think that this is an issue for the barrack-room lawyers. It is a time for statesmanship in all three parties.
Lord Elystan-Morgan
My Lords, I resist completely any temptation to embarrass the noble Lord in relation to the issue of legal aid, something that I have assiduously sought to do over the past six months, but does the Minister accept that Lord Justice Leveson says in his report that any complaint should be made,
“without cost to the complainant”?
Therefore it does not matter whether that comes from legal aid or some other public purse—there should be that complete freedom and guarantee in this regard.
Lord McNally
As with other parts of the Leveson report, we will have to look at this. However, one of the things that I know is in the report is the suggestion that, rather than a purely legalistic solution, there should be a road for settling complaints against the press that is cost-free.
Lord Strathclyde
We have only had one Conservative speak so I think it should be my noble friend Lord Elton.
Lord Elton
My Lords, I come back to the involvement of statute. I was 12 years old when the first of the succession of reports on the misconduct of the press was published. I was not old enough to take much interest in it, but I have taken an increasing level of interest in the successive ones. Every report has concluded that the press has undertaken to behave better. I was greatly impressed by the proposals from my noble friends Lord Hunt and Lord Black but it comes down to the fact that if their working is dependent on the press fulfilling its undertakings to behave differently, then I hope my noble friend and his right honourable friend will look at the record before deciding how much weight to put on those undertakings.
Lord McNally
My noble friend makes a very sound point, and it is extremely good that it comes from someone on the Conservative Benches with such long experience of these matters.
Baroness Symons of Vernham Dean
My Lords, the Deputy Prime Minister’s Statement makes the very important point that the statutory underpinning of the Press Council of Ireland is accepted by those very newspapers that have become so hysterical about the possibility of statutory underpinning in this country. Will the Deputy Leader of the House assure the House that this crucially important point will not be lost in the cross-party discussions that will take place and that the Deputy Prime Minister will stick to his guns on this point?
Lord Clement-Jones
My Lords, Lord Justice Leveson makes clear recommendations about changes to the framework of the Data Protection Act in terms of eliminating some of the exceptions that currently apply to the media. I note in the Statement repeated by my noble friend that my right honourable friend has certain reservations about that set of recommendations. Is the abuse of personal information not one of the root problems that we have seen during the past few years? Should we not proceed with those changes, particularly in light of the fact that his department would be responsible for making them?
Lord McNally
No, my Lords, we should not proceed with those changes but we should certainly move with speed to see how such changes could and should be implemented. The recommendations on data protection came slightly from left field; I am not sure that anyone was fully aware that Lord Justice Leveson would make suggestions in this area. It is an area where we are discussing matters in a European context, in terms of revising the European data directive and our own legislation. My right honourable friend the Secretary of State for Justice and I have already commissioned work within our own department to respond to the Leveson suggestions. As with other parts of the report, we will move forward with all due purpose.
Baroness Farrington of Ribbleton
My Lords, while joining all the speakers who have condemned the attacks on people who are particularly vulnerable at times in their lives, such as the McCanns, and noting the Leveson report’s reference to a second inquiry, which cannot be discussed at this stage, will the Minister please confirm that not only the weak and vulnerable but everyone who has the sought the limelight or is in public life should be exempt from anything that is found to be an illegal action?
Lord McNally
Yes, my Lords, I am sure that that is broadly the case. I have just been asked to remind the House, in relation to the question asked by my noble friend Lord Clement-Jones, that the illegal use of data is already against the criminal law. I say in response to the noble Baroness that what we want is a press that respects us all, and for us all to respect that press.
Baroness Rawlings
My Lords, Lord Justice Leveson recommends that there should be a new a regulatory body for the press, that it should not be made up of the press, as was the PCC, and that it should not be made up of parliamentarians or Ministers. Who would make up this new independent body? Who would appoint the members? Would they be elected and what role would the judiciary play?
Lord McNally
These matters will be looked at because they are not prescribed in the report. Although the judiciary must be feeling a little overworked these days because of the number of times we ask them to pick up hot potatoes for us, it is an interesting thought that there may be some judicial role in setting up the body.
The key thing is to emphasise that there is a broad measure of support for this and, I suspect, a broad measure of political determination. There have been views from different places this evening. Although I have occasionally thought that this House could be reformed, I have never been in any doubt that there is a collective wisdom in the House that Governments should draw on, particularly at times like this. On 18 December, we will have a debate on this in the House. The other place contains faster readers and they will have their debate on Monday. The debate on 18 December could—and, knowing this House as I do, will—contain a great detail of experience and wisdom, which will carry us forward on this issue.
Violence Against Women
(12 years ago)
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Baroness Jenkin of Kennington
To ask Her Majesty’s Government what action they are taking to prevent violence against women.
Baroness Jenkin of Kennington
My Lords, I am grateful for this opportunity to open this timely debate on violence against women. As noble Lords will appreciate, it is timed to coincide with the annual International Day for the Elimination of Violence against Women on 25 November, designated by the UN General Assembly to raise awareness of the fact that women around the world are subject to rape, domestic violence and other forms of violence, the scale and true nature of which is often hidden. Each year, this creates an opportunity for individuals, groups and NGOs such as Women for Women International, UN Women, UNICEF, ActionAid and of course DfID—to name but a few—to promote 16 days of activism, joining together to speak out against and raise awareness of the need to end violence against women. Over the past few days, I have found the tweets of these various organisations extremely illuminating. I am delighted that this debate falls within the 16-day campaign period which ends on 10 December. I hope that it, too, will serve to highlight and draw attention to some of the issues both domestically and internationally which so many others around the world are also currently discussing.
I am far from an expert in this area and look forward to hearing from noble Lords across the Chamber who speak with great experience and authority. I pay tribute to the noble Baroness, Lady Rendell, who, along with my honourable friend Jane Ellison in the other place, has been a leading campaigner on the issue of female genital mutilation. I look forward to her contribution to the debate. I look forward to hearing from the noble Baroness, Lady Stern, whose review into the treatment of rape complaints by public authorities has had such a significant impact.
I am also delighted that we will hear from three noble Lords. As in so many areas of policy, we need the support of men for things to change and for progress to be made. Here, I take the opportunity to pay tribute to two men of vision who have by their actions proved this point. Andrew Mitchell, when Secretary of State at DfID, ensured that women and girls are at the heart of every DfID programme—that includes 16 programmes in this area alone. As he said on International Women’s Day earlier this year,
“Discrimination and violence destroys the potential of girls and women in developing countries and prevents them from pulling themselves out of poverty”.
Also, the announcement of our Foreign Secretary, William Hague, earlier this month on preventing sexual violence in conflict and post-conflict situations was groundbreaking. I will return to that later in my remarks.
Before preparing for this debate, I was of course aware of the basic facts and statistics with regard to domestic violence, many of which have been raised in this Chamber during Questions or in debates, and will I am sure be raised again today. But looking through the briefings which we will all have been sent, I confess to being utterly shocked by the extent of what is going on under our own eyes. A friend of mine was recently hospitalised with broken ribs. It turned out that her husband had been beating her for years and neither her friends nor her family had any idea. She is one of the fewer than one in four victims who, suffering abuse at the hands of their partner, report it to the police. That means we have to do more to help victims feel confident about reporting these crimes and overcome the feelings of guilt they have about the consequences of doing so. As a society, we are failing to remedy the tragedy of gendered violence. In the UK alone, two women every week are killed by a partner or ex-partner, and every year 60,000 women are raped. Sexual harassment in schools, communities and workplaces is routine.
However, the hour is late and the time is tight. I shall focus my comments on the global situation. I hope that my noble friend in her closing remarks will expand on recent changes domestically which are addressing many of the challenges that we will discuss today. They include the new anti-stalking legislation, the Home Office’s call to end violence against women and girls and the fact that forcing a girl to marry against her will is to become a criminal offence in England and Wales.
I am sure that all of us in this Chamber welcome the Government’s new cross-governmental definition of domestic violence, which will be implemented next March. That definition will reduce the age at which domestic violence can be recognised from 18 to 16—something that is necessary given that the British Crime Survey in 2010 found that 16 to 19 year-olds are the most likely to suffer abuse from a partner. It affects more than one in 10 girls in that age group.
Violence against women and girls is the most widespread form of abuse world wide, affecting one-third of all women in their lifetime. Addressing violence against women and girls is a central development goal in its own right and key to achieving other development outcomes for individual women and their families, communities and nations. Globally, 603 million women live in countries where domestic violence is not yet considered a crime.
To mention a few specific issues, more than 60 million girls are child brides. I recommend the report of the APPG on Population, Development and Reproductive Health, A Childhood Lost, published earlier this week, which is packed with detailed information spelling out the consequences of child marriage, as well as some utterly tragic case histories.
Yesterday’s horrifying news of the beheading of a 15 year-old in northern Afghanistan because her father thought she was too young to marry, is the latest in an alarming trend of similar violence in the area. About 100 million to 140 million girls and women have experienced FGM. More than 600,000 women and girls are trafficked across borders each year, the vast majority for sexual exploitation. In a survey in India, 50% of men and women agree that wife beating is justified if the woman disrespects her in-laws or neglects the house. When violence against women is justified and attributed to the victim, change is very unlikely to occur.
In the South Kivu Province of the Democratic Republic of the Congo, reportedly the worst place in the world to be a woman or a child, there is an epidemic of rape—according to UNFPA, an average of 40 women every day. Given how difficult it is to get news out from some of those remote places, we can only assume that these dreadful stories are merely the tip of the iceberg.
As mentioned earlier, in his speech on 14 November about the use of violence and rape in war, William Hague said that we must shatter the culture of impunity for those who use rape and sexual violence as a weapon of war and shift the balance of shame away from survivors to the perpetrators of that crime. The Foreign Secretary is right to address what is a common view in some parts of the world that it is the victims who should feel ashamed. We need a cultural change through education and media so that women are empowered and gender relations can be built that sustain respect, harmony and non-violence. Those are all issues which need to be addressed both for the victims’ sake and for development reasons
Violence against women has its roots deeply embedded in the inequality between men and women. Violence is used as a tool to maintain subordination of and control over women. Gender inequalities and discrimination are exacerbated during crisis and social breakdown, meaning that already vulnerable girls and women are increasingly less likely to be able to defend themselves, or to break the cycle.
As I mentioned, violence against females impacts negatively on economic growth—indeed, the cost to society is billions of dollars in lost opportunities from education and employment as well as more direct costs for policing, healthcare and the justice system. Violence against girls has a direct correlation to poor performance in school, lower enrolment and high dropout rates. Females are often forced into pregnancy, and abuse can have serious repercussions for their physical and psychological ability to gain employment and participate in what we would consider to be normal lives.
I end by looking back briefly to the origins of this particular day. The international recognition that women have a right to a life free from violence is recent. Historically, their struggle with violence, and with the impunity that often protects the perpetrators, has been linked with their fight to overcome discrimination. Since its founding, the United Nations has concerned itself with the advancement of women's rights, but it was not until 1993 that it specifically targeted the high rates of violence against women. One of the aims of the resolution which adopted the Declaration on the Elimination of Violence Against Women was to overturn the prevailing governmental stance that violence against women was a private, domestic matter, not requiring state intervention.
Next March, Governments, NGOs and civil society leaders will again meet at the UN in New York for the 57th session of the Commission on the Status of Women. The priority theme is the elimination and prevention of all forms of violence against women and girls. As they meet, and as we continue our deliberations today, I hope that they and we bear in mind the remarks made at that meeting nearly 20 years ago by Boutros Boutros-Ghali, when he issued a statement in preparation of the declaration. He said:
“The struggle for women’s rights, and the task of creating a new United Nations, able to promote peace and the values which nurture and sustain it, are one and the same. Today—more than ever—the cause of women is the cause of all humanity”.
Baroness Rendell of Babergh
My Lords, I thank the noble Baroness, Lady Jenkin, for introducing this debate on a subject that, sadly, is always with us. It comes at an apposite time for a new development that is taking place in the campaign against a particularly horrible type of violence against women. I speak, of course, about female genital mutilation.
Almost a decade has gone by since the passing of the Female Genital Mutilation Act 2003, which makes it an offence to take a child abroad for mutilation and carries a maximum penalty of 14 years’ imprisonment. All of us associated with the Bill that became that Act hoped confidently for prosecutions but none has been brought. Three cases have been referred to the Crown Prosecution Service but none has made it to court. The police have tried, but a major objection has been and is that the young girls—it is usually children under 12 who are cut—are unwilling to give evidence against their parents. Another is that Horn of Africa communities maintain silence, even among themselves, on FGM issues.
Now, however, the Director of Public Prosecutions, Keir Starmer, has spoken out on the criminality of this practice and published an action plan. The 10 provisions in the plan include: gathering more robust data on allegations of FGM, so that the scale of the problem can be gauged; identifying case studies from the data to examine emerging issues as to why the police officer or doctor did not proceed; investigating what has hindered investigations and prosecutions; raising with Ministers what the existing reporting duties are for medical professionals, social care professionals and teachers in referring possible FGM cases to the police; exploring how other jurisdictions prosecute this crime; examining how these have prosecuted cases of FGM; and asking what evidence is required to support charges of conspiracy to commit, or to aid and abet, the offence.
The plan proposes that the Director of Public Prosecutions should raise with Justice Ministers whether current legislation should be reviewed. Other police tactical options might operate and the question asked as to what intelligence could be collated to support evidence-gathering for a prosecution. The police and the Crown Prosecution Service should develop a protocol for the police to refer all cases of FGM to the CPS for early advice on lines of inquiry and evidential issues, so that the police can build a strong case. Discussions will take place with the Department for Education on whether guidance on Working Together to Safeguard Children requires updating for further clarity about FGM. A steering group has been established to oversee the progress on the action points ahead of the DPP’s next FGM prosecution round table in summer 2013.
I cannot stress too strongly the pleasure and hope that learning of this action plan will bring to the many who have supported campaigns against FGM and suffered continual disappointment during the past years. In the past decade, it has appeared that whatever might be happening in other EU countries—France, Italy and Sweden, among others—the UK was to remain a safe haven for those who practised with impunity the excision of young children’s genitalia. If this action plan can set in train a real advance in prosecution and therefore a warning to those contemplating FGM, it will be a step forward that should have happened 10 years ago, but now that such a decisive plan has been formulated, it must not be allowed to founder. Its progress will be watched avidly by the dozens, by now hundreds, of groups and organisations across the United Kingdom set up over the years to oppose this particular type of child abuse.
Baroness Hussein-Ece
My Lords, I, too, thank the noble Baroness, Lady Jenkin, for securing this important debate. I, too, woke up this morning to the horrifying headline news of the 14 year-old Afghan child who was beheaded by members of her family because her father had refused a marriage proposal for her. As we debate how we have a responsibility to lend our weight to end violence against women around the world, this terrible tragedy comes as a stark reminder of the urgency of this issue.
Michelle Bachelet, director of UN Women, in her message for the International Day for the Elimination of Violence against Women, called for bold action and decisive leadership to galvanise efforts to end the pandemic of violence against women and girls. Today, we know that 125 countries have laws that penalise domestic violence, which is a huge step forward from a decade ago, but that is not enough as 603 million women live in countries where domestic violence is still not a crime. Recently, a high-profile, educated woman from the Indian subcontinent told me of an incident where a senior official casually in conversation talked of how when he beat his wife, she knew what she had done wrong. This is by no means an unusual attitude and is not necessarily confined to poorer communities. I experienced threats of violence myself some years ago, when I set up the first project and centre to support Turkish and Kurdish women who experienced violence in the UK, from the very men who perpetrated that violence against women and their family behind closed doors, or who, often in the name of their so-called honour, which, as we all know, is dishonour, tried to control women by using violent methods.
Having laws in place is not enough. We need those laws to be properly implemented. We know that legislatures and enforcement authorities are usually dominated by men who often do not see this issue as a priority. We must do better to protect women and prevent this pervasive human rights violation. Governments and leaders must lead by example. Many Governments, such as the Afghan authorities, make promises, but it is time for Governments to translate international promises into concrete action. We need an increased number of women in politics, law enforcement and peacekeeping forces as well as economic opportunities for women. We also need educational campaigns, both here in the UK and elsewhere, that teach human rights and advocate mutual respect that will inspire young people so that the next generation can show leadership on ending violence against women.
Here in the UK, we are still working hard to eliminate and educate people in our society to change behaviour and attitudes, but according to the NSPCC sadly one in three teenage girls experience sexual violence from their boyfriends. We need to look at how women are being portrayed in some sections of the media, particularly in online sites.
In showing leadership and using our influence to progress this work internationally, will the Minister consider whether the UK will lend its support to the recommendations that Oxfam, among others, has put forward on human rights featuring prominently in UK diplomacy at international and country level with specific attention to gender-based violence, including sexual violence, and also on championing a place at the table for women in peace negotiations, in line with UN Security Council Resolution 1325, to help to ensure that gender-based violence is recognised as part of any peace process and that women’s rights are sustained over the long term?
As the noble Baroness, Lady Jenkin, said, the 57th session of the Commission on the Status of Women will be held next March and will be on this theme. It is important that the UK Government show leadership at this event and support the call from UN Women and its expert group for the development of an international implementation plan to end violence against women. Will the Minister say whether this will be the case?
Baroness Stern
My Lords, I thank the noble Baroness, Lady Jenkin, for initiating this important debate during the 16 days. I shall concentrate my remarks on what needs to be done to prevent rape and serious sexual assault in this country; I am talking particularly about the rape of those over the age of 13, not young children.
Great progress in dealing with rape and serious sexual assault has been made in recent years, both under the previous Government and under the coalition Government. The Government have made clear in a number of policy documents what they see as the right approach, with which I agree wholeheartedly. First, the victim must be central to the response, and help and services should be provided regardless of the possible criminal justice outcome. Secondly, good specialist law enforcement is essential. Thirdly, prevention must always be accorded time and resources.
Those three aspects are interconnected. If victims are at the centre and given the support and help they need, they are more likely to stick with the legal process and more likely to give information that might help prevention efforts. I will illustrate this with one small example. Sexual assault referral centres are key to an approach that puts the victim first. These are places that are run ideally by the NHS and commissioned jointly by the police and the NHS, where victims reporting rape go straight away for forensic testing and attention to any other immediate needs. In the London sexual assault referral centres, of which I am patron, a nurse reads all the reports of all the cases that they deal with: those reported to the police and those of people who come to be tested but do not want to report to the police. The nurse puts stickers on a map which identify the clubs and nightspots which seem to be producing a number of cases. Where there is a cluster which suggests a particular nightspot is attracting those who prey on vulnerable women, the nurse talks to the management of the club and offers training to the staff to understand what is going on on their premises and work to prevent women being harmed.
That is one small example of how prevention should be woven into the thinking of every agency that sees and deals with the victim. Of course, spreading understanding of the law about rape, particularly to young people, must also be done. The London sexual assault referral centres have produced an interactive video, aimed at young men, called “Where is your line?”, aiming to make it clear that sex without consent is rape. I also congratulate the Home Office for its online educational campaign about rape and sexual assault, targeting 13 to 18 year-olds.
Dealing with rape and sexual exploitation is not a simple matter of a victim making a report, a suspect being charged, a court case and a conviction. Success is not that easy to measure. It is a complex matter involving a strategic approach in every area, with the police ideally having a specialist rape unit working in an integrated way with health and with the involvement of the range of organisations that care for the many vulnerable groups that are especially at risk.
Success cannot be measured by any one indicator on its own. I first ask the Minister therefore, how are the Government going to try and get this complex message across to the police and crime commissioners, who will now be in charge of policy in their areas? Secondly, is the Home Office anticipating a phase two of the online educational campaign that was so successful the first time around?
The Lord Bishop of Liverpool
My Lords, in thanking the noble Baroness for this debate, I must also apologise to the House that there are no women on these Benches to contribute to this important debate today. The fact that they are excluded from the Bench of Bishops is not unrelated to how women are treated generally throughout the world. Although religion can be a liberating force, history shows that it also can be used to confine and to constrain, and to reinforce prejudice against women.
One reason why I believe that women should be bishops in the Church of England is that in the history of my faith you can trace the liberation of women. I would go as far as to say that the cursive script of the hand of God in the course of history is seen through the development of the leadership of women: namely, in the Bible; in the early church; on the mission field; in the fact that the Supreme Governor of the Church of England is a woman; in that women serve on the General Synod; and in the exercise of leadership of women in our parishes where one-third of all clergy in the Church of England are now women. Indeed, if women did not serve in leadership in our parishes, the parish network of the Church of England would collapse today if they withdrew the gifts that they bring to the church and to the world.
I believe that the time has come in this historic development to open the door of the House of Bishops to the spirit of God and to the women of God. Not to do so reinforces prejudice and discrimination on the grounds of gender, and defies the biblical understanding that women, as well as men, equally bear the image of God.
In my capacity as Bishop to Prisons, I am particularly aware of the issues surrounding women in prison and on probation. Last January, I explored some of these themes in a BBC Radio 4 series, “The Bishop and the Prisoner”. At the risk of generalisation, and without exonerating perpetrators of crime, it is clear that the context in which many women offend is coloured by them being victims of abuse and violence. In 2002, according to the Ministry of Justice, more than 50% of women in prison reported suffering domestic violence and one in three reported sexual abuse.
The diocese of Liverpool sponsors a bail hostel, Adelaide House, for women who have come out of prison or are on probation. On one visit I met a number of women and in each case her story of offending was linked with her being the victim of physical abuse. They were not trying to excuse their behaviour but simply giving an account of their actions and reactions to being the victims of violence.
I should like the Minister to respond to two points. First, what progress are the Government making on implementing the proposals brought forward through the Corston report, especially in relation to female offenders who are the victims of violence? Secondly, on the point with which I began, will the Minister for Equality be seeking a formal meeting with the Archbishop of Canterbury to explore how the Church of England might, with equity and justice, serve all the people of England?
Baroness Bottomley of Nettlestone
My Lords, I am honoured to follow the right reverend Prelate. I warmly commend his approach, and that of many of his colleagues, of taking every opportunity available, whatever the topic of debate, to reinforce the arguments for women on the Bishops’ Benches. Many of us should follow that example. If we could extend it to the Roman Catholic Church we might really be making progress. I entirely am with him on that issue.
I believe that many of these issues are deeply and profoundly cultural. We know that there was legislation to protect animals 20 years before legislation to protect children. The idea that a woman is somehow a chattel is very recent in our lives. For some years I, with my noble friend Lady Howe, was particularly involved in Brixton and Peckham, working with the Child Poverty Action Group. I remember an evening when a woman was screaming out at about one o’clock in the morning near where I lived. We went out and took her in, and had her for the night. The following morning she went home. No police came and there was no support for her. Only 20 years ago, there was the idea that culturally these issues were taboo and unacceptable, and that somehow it was the individual’s own fault.
More shockingly and more recently, we all have personal examples where we have been taken aback by the horror of the situation. A woman who worked with us for 25 years in Surrey suddenly arrived with bruises in her early 80s. Her husband suffered from pathological jealousy and, when he had his walking stick, all the way through his marriage, he would trip her up and then beat her with it—and this in a respectable Surrey village, with the shame and humiliation. That happened four years ago.
We talk about progress, as the noble Baroness, Lady Stern, did—and there has been great progress. The humiliation of being treated following rape by, I am sorry to say, some of the police and other forces, was almost as bad as the rape itself. Some of the agencies have been deeply unhelpful and humiliating, and have hurtfully said that women had brought it on themselves. I am delighted that the Home Secretary and the Minister for Equality, Maria Miller, have taken this seriously, with the 100 step action plan—and there is not only that but, as has been said, the work being done at DfID and the Foreign Office.
I can recall the British Council visiting a women’s group in Kenya, where the women were beaten and left in the back kitchen. When they could finally bear it no more they went back to their homes and the parents said, “You have brought shame on us—you must go back to your husband”. The British Council introduced legal rights and education policies to try to make progress.
People have talked about the subcontinent. India is a country where seven chief executives of banks are women but somehow there is still this massive group of women who have no rights and no dignity. I like practical projects. I know of a man called Vineet Nayar who has introduced 400 teachers in communities. They have the teacher only if they have 100% attendance by the girl children.
I know that I am encroaching on what the following speaker is going to discuss, but I have been very struck not only by what government can do and what charitable agencies can do—Oxfam, refuges, Women’s Aid—but also by what employers can do. My great good news at the moment is that there is a new charity, the Corporate Alliance Against Domestic Violence. What do we do at work about domestic violence? Who at work ever thinks that people are late or delayed or fearful about domestic violence spreading into the workplace? This is an organisation that reaches out to people in HR and business, which can do a huge amount of good. I hand over to the noble Baroness.
Baroness Scotland of Asthal
My Lords, I commend the noble Baroness, Lady Jenkin, for bringing forward this wonderful and important debate—and, indeed, the noble Baroness, Lady Bottomley, for introducing so generously a subject that I shall touch on. Noble Lords will know that I have to declare my interest as patron of the Corporate Alliance Against Domestic Violence, the Global Foundation for the Elimination of Domestic Violence, and chair of the All-Party Parliamentary Group on Domestic and Sexual Violence.
This debate is timely, because we still live in a world where one in three women will suffer from domestic violence at some stage in their lives. It is still the greatest cause of morbidity in women and girls worldwide. Some 75% of those victims suffer abuse while at work and 56% of victims do not go to work at least five times a month. It was for that reason that we created the Corporate Alliance Against Domestic Violence in 2005, when I left government, to assist businesses to do what they could to reduce the impact of domestic violence on the workforce.
This issue can be tackled, but it needs us to tackle it together. In this country, we have moved from serial dysfunction to function by coming together in partnership to make a difference. Noble Lords will know that we managed together, with all parties working with the third sector and business, to reduce domestic violence in our country by 64% and reduce the economic cost of domestic violence by more than £7 billion.
However, it is not just in this country that we can do that. We worked with Spanish Ministers in 2006. As a result of that joint work and initiative, our Spanish colleagues took the matter further and reduced domestic violence homicide in Spain in 2006-10 by 25%. This is something we can do worldwide. For that reason I created the Global Foundation for the Elimination of Domestic Violence in 2011. I was proud to hear the noble Baroness, Lady Hussein-Ece, talk about the work of UN Women, because the global foundation joined its expert panel and assisted in drafting the UN policy in December 2011. We are now working in a number of countries, not least Turkey, where we have done a full in-country assessment. We launched EDV India in February this year. We have also formed a coalition of more than 200 organisations in 85 countries—the largest coalition to combat domestic violence—along with the Global Truce 2012 campaign. In doing that, we have, together with Peace One Day, reached 280 million people, and we hope to reach 3 billion people by 2015, so there is a great deal we can do.
However, there is concern here in our country that our focus hitherto has not been as good as it could be. Wearing my various hats, I am constantly being contacted by a number of our voluntary organisations, which are very concerned about this issue. Yesterday I was contacted by the Changing Lives project, which said that many female participants with whom it deals have overcome significant barriers around domestic violence, sexual abuse and forced marriages. The Changing Lives project provides advice and counselling to ensure that victims get support from local services. It trains staff and offers an advanced certificate in systemic family therapy. It also offers a brand of systemic family intervention that combines therapeutic support with parenting skills, and does so in community languages to bridge the gap. However, with the changes in funding, the level of support available to those affected by domestic violence has gone down significantly. As a significant number of community advice services have lost their funding and are no longer available to provide legal advice to these women, and they are not entitled to legal aid, many of these women and their children are experiencing a cycle of stress, physical health problems and mental distress.
All of us in this House, together with those outside, have fought very hard to change that paradigm. Have Her Majesty’s Government assessed, or do they intend to monitor, the effect that the cuts in public funding to legal aid, the provision of Sure Start places and parenting skills programmes, such as those provided in Bengali, Urdu and Somali, is having on vulnerable and hard-to-reach families? Will the Government help us to better address these issues in future?
Baroness Brinton
My Lords, the threat of violence remains a shocking part of everyday life for too many people. Noble Lords have spoken movingly of that in this important debate. I thank the noble Baroness, Lady Jenkin of Kennington, for securing this debate.
Some noble Lords will be aware of my own experience of being stalked—thankfully, it was never actually violent. I want to focus on how the new law that came into effect last Sunday will begin to transform the lives of victims of stalkers, the vast majority of whom are women. The independent stalking inquiry chaired by Elfyn Llwyd MP, on which I was privileged to sit, heard evidence last year which shows that stalkers are frequently very bright, extremely manipulative and seek to control the lives of those whom they stalk in every way, every hour of every day. Problems have arisen in the past when the police and criminal justice system have not recognised the threat of violence, resulting in tragic consequences. For example, at the inquest of Clare Bernal, murdered by a former admirer in Harvey Nichols in 2006, the coroner said that the police could not have prevented her murder. However, this ignored the many signs which the police and others ignored. These included his threats to kill her and the fact that he had approached colleagues for advice on how to buy a gun and on the jail sentence for murder—all at a time when he had been arrested for harassment, stalking and threatening to kill, had been rearrested for breaking bail conditions, had talked of suicide and had lost his job. But no one thought to assess the risk he posed to Clare.
It did not have to be like this. The examples of Australia and the United States, which legislated some time before us, prove that comprehensive anti-stalking legislation can be highly effective. The Australian legislation, which first separated stalking from harassment and domestic violence, as we have now done, has led to a substantial decrease in stalking. Key to the legislation are police protocols to assist victims through their ordeal, including the allocation of a trained police officer as primary liaison and the training of all—yes, all—police officers to recognise stalking and its dangers.
Sadly, prosecution alone is often not enough to help a victim overcome the complex consequences of their ordeal. In America, stalking survivors have explained which measures undertaken by their local police department made the biggest difference in their cases and, ultimately, their lives. These included the speed of the officers’ response, putting safety first, the use of technology in recording evidence, and help for victims to understand the risks to themselves.
The new stalking law in England and Wales makes stalking a criminal offence in its own right and no longer just part of harassment. It gives courts the ability to sentence stalkers threatening violence to up to five years in prison. Unlike the Scottish law introduced two years ago, the legislation here goes further by stating that training and support is necessary for the entire criminal justice system. The victims of stalking also need expert help to protect themselves from the perpetrators.
I give my personal thanks to all Ministers who supported this legislation as it progressed through Parliament, and particularly to Lynne Featherstone, who made it a priority to champion the fight against violence against women in any form. It remains essential that we hear the voices of the victims and assess the risks to them. An anti-stalking law is only as effective as those who enforce it. The culture change proposed in the new law may take a while to implement, but I am sure that now we have a tool that can give women peace of mind and safety from the persistent nightmare of stalkers.
Lord McColl of Dulwich
My Lords, I, too, thank the noble Baroness, Lady Jenkin, for initiating this debate. What I am about to say may sound rather detached and clinical, because I shall draw on my experience as a surgeon. I will give your Lordships an example of this terrible problem. One evening a man started attacking his partner at home. He put her up against a wall and beat her for three hours, smashing her face with his fist, his foot and then with an instrument. Throughout the night he beat her intermittently and finally he raped her. She thought she was dying. The surgery to repair the terrible damage took five hours and cost thousands of pounds. Further operations had to be carried out over the ensuing six months. Such was the skill of the surgeon that the physical result was perfect, but the psychological damage continues. In half of victims, it remains all their life.
There are three aspects to this that need to be emphasised. First, physical violence is a sign of an abusive relationship. Such are the complexities of human make-up that the abused person—as has been said—may blame herself for her injuries. This is one of the reasons why I commend to the House charities that are working together to transform abusive relationships and address the root of the problem. Among them is Restored, an umbrella organisation working in this country and overseas to end violence against women.
This violence usually escalates. It may start as a slap, go on to a punch in the abdomen, perhaps next time to a smash in the face and eventually to death. The problem often goes undetected. On the first occasion the attacker may be forgiven by the victim, and when they go together to the casualty department the story is that she fell against a wall or a door. The woman will deny that she was attacked. After the next assault they go to a different hospital; after the third attack they visit yet another one, so the problem is not picked up. When the doctor in the casualty department suspects what is going on, there is a reluctance to report the case for many reasons, including lack of proof.
To try to solve this problem, Professor lain Hutchison of the Royal London Hospital has established the National Facial, Oral and Oculoplastic Research Centre in Leeds to collect data to help identify victims early on. His scheme is as follows: when one suspects such a victim, a note is made that this may be an example of potential domestic violence—PDV—and it is recorded at the national centre in Leeds. Two notifications will alert the authorities and three will trigger an investigation.
Another possible solution that might reduce this appalling scourge is to make facial injury caused by personal violence a notifiable disease or condition. This was suggested by a surgeon who spends most of his time operating on these victims to repair the damage. Nowadays these injuries are more violent and destructive than ever and the facial bones are so severely smashed to pieces, making reconstructive surgery a lengthy and complicated process, to say nothing of the suffering and cost. The majority of cases go unreported for a variety of reasons, including lack of understanding by the authorities, fear of reprisal and further suffering. The police are often not informed. If the condition were made a notifiable disease, this would bring to light the huge extent and severity of the problem and ultimately reduce the number of cases. Will the Minister kindly consider this suggestion?
Finally, it is essential to have an integrated multiagency response that includes medical professionals, police, judiciary, social services and others. It is vital that perpetrators are held to account for their appalling crimes. I also stress the importance of debates such as this to raise awareness, encourage disclosure and make the abuse of women, in any form, socially unacceptable.
Lord Brooke of Alverthorpe
My Lords, I, too, am grateful to the noble Baroness, Lady Jenkin of Kennington, for sponsoring this debate, and for her introductory speech, which set the tone for us.
I declare an interest as a joint patron of the Everyman Project, which is a small London-based charity that provides training for men who are violent in family relationships but who want to stop it. Last Thursday I tried to get in a question and had I done so I would have been putting this question to the Minister—today I get the opportunity to ask her just how much money is being spent on men who are prepared to undergo training to alter their behaviour.
I know very well that if you get yourself into the criminal justice system and you end up in prison or on probation, there is an opportunity for anger management training and for individuals to try to change their practices. But for those who do not get to that stage but who want to change, I suspect that the amount of money that is available to assist them is very small indeed, and this really ought to be changed.
The vast bulk of money that is spent in this area comes from the charitable and voluntary sector. Of course, at the moment, it is extraordinarily difficult to raise cash. For example, the Everyman Project does not get a penny piece from the public purse yet it provides a 13-week training course for men who want to change. Unfortunately, we have to turn away far more men than we are able to offer training to because we simply do not have the resources to accommodate them all.
If the Government are really serious about trying to help in this area, I hope—even though I have made this plea previously, unsuccessfully—that they will be prepared to look again at the possibility of going into partnership with a number of charities, where perhaps matched funding arrangements could be made, to try to ensure that we get far more men going on these training courses. Ultimately, that is going to be a far more effective way of utilising money than the cost that is accrued when people end up in the courts and go to jail, although at the end of it they have an opportunity to get training if they are prepared to embark on it. I make an open, unabashed approach to the Minister to see whether she is prepared to take this away and give some consideration to it. I ask that question against a background of rumours that more women were killed in violent incidents in domestic disputes last year than in the previous year. I hope I am wrong on that but there are stories that that is the case. Can the Minister provide some clarity on that?
I should also like to pick up on the point made by my noble and learned friend Lady Scotland about the Corporate Alliance Against Domestic Violence, and again this goes back to government departments. I understand that the NHS has signed up to this organisation and fully supports it, but I also understand that a number of government departments have declined to do so or have not indicated a willingness to join up so far. Can the Minister say whether that is the case, which departments they are and whether she will bring pressure to bear to ensure that they go along with it?
Baroness Bakewell
My Lords, I add my thanks to the noble Baroness, Lady Jenkin, for bringing forward this debate and I thank all the other speakers for such an informed session. In recent days I have read many thousands of words about the initiatives that people are taking and I am really impressed. There are initiatives from the Home Office, from Europe, from the police and from the UN. I read that 125 countries now have laws that penalise domestic violence. This is a positive demonstration of the will of civilised legislators to bring an end to what they all agree is pernicious behaviour, yet I have noticed a distinct lag between all these good intentions and what is actually happening on the ground. Changes are intended and many are coming, but they are happening too slowly and, so far, on too modest a scale. I shall give some examples.
Forced marriage is currently a civil offence in Britain. Government proposals will make it a criminal offence and that will go before Parliament in 2013. That is all well and good. In 2002—10 years ago—the Government created the Forced Marriage Unit. In 2008, forced marriage protection orders came into being and a statutory duty was placed on public bodies to protect both children and adults. However, in 2011 the Forced Marriage Unit helpline received 1,400 calls and, in 2012, some 600 by the time this excellent report that we have all had—A Childhood Lost—was compiled. Yet it is estimated that each year around 5,000 women are at risk of being forced into marriage against their will. If that is an annual estimate, then 50,000 women are being threatened. With 1,400 calls but 50,000 women at risk, it is clear that the message is not getting right through. The people who need the help are not being reached.
In the matter of honour-related violence, according to the Iranian and Kurdish Women’s Rights Organisation, more than 2,800 honour-related cases were reported in the UK in 2010, and police say that that was an increase of 47%. However, in 2011-12, only 172 cases of honour-related violence were prosecuted and, of those, only 50%—some 80—were successful. That number was down from the figure of 52% for successes in the previous year. Therefore, these modest achievements—positive gains in the face of intolerable violence—are no match for the scale of the problem.
This is indeed a global and cultural problem of huge dimensions. It is well established in many cultures that men have the right to exercise control, which often means violence, over their women. That cultural belief is often rooted in the fundamental religion that prevails in the country. I suggest that the religious leaders of the world should perhaps be invited to examine the texts on which these acts of violence are justified. The enlightened leaders of religion know that violence against women is not a moral activity. It would be good if they were to examine the texts, just as the leaders of the anti-slavery trade campaign examined the texts in the Bible that supported slavery. They examined the texts and revised the attitude of their followers.
I have two further suggestions for the Minister. Britain sends trade delegations around the world. The delegations speak up for human rights and plead the case of prisoners wrongfully detained. Could not violence against women be specifically noted in their agendas? Could not a woman be included in delegations, specifically with the idea in mind to meet up with women in other countries and bring the issue into arenas of debate at a high level, with ambassadors, consular officials, and so on, being properly briefed to meet the people who are now speaking out in often very backward countries with little support?
Secondly, the treatment of women fleeing violence who seek asylum in this country is far from satisfactory. The organisation, Women for Asylum Women, has charted many cases where women are summarily turned away by the UK Border Agency and sent back to face the abuse that they were fleeing. The Home Office must instruct the interrogating staff about the nature and scale of violence that such women are fleeing, and allow those women asylum. We are not short of suggestions in this Chamber; we want to see them activated.
Baroness Howe of Idlicote
My Lords, I join other noble Lords in thanking the noble Baroness, Lady Jenkin of Kennington, for this debate. Yes, indeed, let us have plenty more on this subject. As we know, violence against women has been with us for far longer than any of us can imagine, and probably since the world began. Indeed, in this country in the past, such violence was regarded almost as acceptable family behaviour; it was seldom discussed openly, and certainly not if it happened in a middle-class family because of the shame felt by the woman concerned. Thankfully, those issues are now slightly more of a priority for open discussion and solution.
I want to concentrate my comments on three areas in which I hope the Government have active plans to support and encourage. First, midwives and health visitors are those who have the earliest contact with mothers and their babies and they may well have reason to suspect that there is a history of violence in a particular family. Can the Minister assure the House that there will be enough trained and aware staff—albeit working with skilled volunteers, such as those from Home Start—to provide the family with the support needed in such circumstances?
Secondly, given the views of Schools Safe 4 Girls and the End Violence Against Women Coalition, and many others, that sexual bullying and harassment are routine in UK schools, will the Government encourage all schools to run compulsory parenting classes? I mean not just classes that teach children how to cope with their parents but classes that concentrate on ensuring that all girls, and indeed boys, know the essential skills and loving relationships needed to bring up their own children as responsible, well-adjusted citizens. Thirdly, as preventing bullying at school could set the tone for acceptable behaviour across all lifetime relationships, including employment, will the Government consider encouraging the successful practice employed by some schools where a slightly older child mentor is provided for each new school entrant and that mentor gets brownie points on the quality and success of that pupil’s integration?
Some progress has been made and we should acknowledge it. For example, and as we have already heard, the new law against stalking is an important first step in coping with a number of problems that the internet world has created for us. I have to say that I think that many more steps will be needed but that one is important.
I remain worried about the effect of the increasing volume and escalation of violent and explicitly sexual activities shown on all forms of media. Of course, my own Online Safety Bill is relevant for child protection and I hope that, ultimately, the Government will support it. However, my unease grows that there is a growing appetite for the explicit sexual violence that is being created, with its obvious implications for increased violence against women.
Baroness Crawley
My Lords, I say, “Hear, hear” to the right reverend Prelate the Bishop of Liverpool on his commitment to women bishops—and that is from a collapsed Catholic. I also thank the noble Baroness, Lady Jenkin of Kennington, for raising this vital area of concern to all of us.
I welcome the work that the Government have achieved so far in combating violence against women and girls. Their plan of 88 actions has been set out clearly and their work on encouraging prosecutions and on stalking, in which my noble friend Lady Royall played so vital a role, is to be rightly acknowledged. However, I, too, wish to sound a note of caution about the notorious nature of the under-reporting of this area of crime, as many noble Lords have said. That has been acknowledged clearly by the CPS in its most recent report. We still have a long way to go before we can claim that we are having a positive effect on the majority of the lives of vulnerable women and girls in the UK.
The recession has been bad for everyone but it has been a total disaster for vulnerable women and their families. Tensions within households that can lead to violence and breakdown are exacerbated by unemployment, lack of certainty over permanent housing, lack of food, lack of heating, an increase in consumer debt—the list goes on and on.
These are desperate times for many vulnerable women and their children, who need the safety, the calm and the specialist advice of local refuges. Yet that safety from violence is being sought at a time of unprecedented cutbacks in the funding of women’s refuges. The executive director of the Colchester and Tendring Women’s Refuge says in its latest annual report:
“The ever present threat of cuts to statutory funding and the uncertainty around future commissioning of refuge services in Essex, means that we are constantly looking for additional avenues of income”.
She goes on to say:
“Last year, cuts to our Supporting People grant forced us to make difficult staffing decisions, and we are waiting to see what impact the Welfare Reform Bill will have on the Housing Benefit we receive on behalf of our residents, a significant part of our income for front line services”.
What action are the Government taking to ensure that the safeguarding and the survival of the women’s refuge network carries on at local level?
While it is right and proper to acknowledge the work that the Government are undertaking on behalf of vulnerable women, it is also only fair to point out that they did not start with a blank sheet. I am pleased to see my noble and learned friend Lady Scotland in her place. I am reminded of her own tireless work, and the work of the noble Baroness, Lady Stern, in tackling the victimisation of women. Convictions for rape increased by 45% under my noble and learned friend’s watch and I, for one, am proud of the way in which the previous Labour Government put women and children at the heart of their policy-making legislation.
I end by asking the Minister if she would bring the House up to date on those actions set out in the Government’s action plan which have a completion date of December 2012. If time is short, obviously the noble Baroness can do this in writing. I refer to points 10, 11, 14, 15, 17, 45 and 61. She will know what I am talking about. The Government’s work so far on the vital issue of violence against women will be eroded unless local government cutbacks are revised and economic growth is urgently achieved.
Baroness Thornton
My Lords, I start by thanking the noble Baroness, Lady Jenkin of Kennington, for initiating this very important debate. I have only a few minutes in which to speak and the hour is late. I am also feeling extremely cold, so if anyone notices a colleague falling asleep they had better wake them up, because I have been in this Chamber for about five hours and I am now very chilled. I shall limit my speech to putting to the Minister a few questions about the problems we face in the UK. We have had an extremely good debate that has covered both the world and many of the issues, and I congratulate noble Lords on doing that.
Like my noble friend Lady Crawley, I read with interest the latest report from the Home Secretary, A Call to End Violence Against Women and Girls: Taking Action—The Next Chapter, that was published in March this year. It sets out progress on the 88 recommendations in the action plan. It is indeed a comprehensive round-up of what the Government are doing and what they want to do. It reads well and in some parts it is very good. However, it may ring hollow in places because the broader policies being implemented by the Government will undermine many of the aspirations set out in the document. For example, on page 17 the Government want to achieve outcomes that include that:
“VAWG victims receive a good and consistent level of service across England and Wales”.
I wonder how this will be possible given what is happening on the ground.
I turn first to intelligence and information. In 2007 and 2009 the End Violence Against Women coalition was funded to provide what were called the Map of Gaps reports. Both of them were very important documents, and I shall highlight the main points. The first pointed to the fact that a third of local authorities provided no services at all for women suffering domestic violence, while the second report published in 2009 similarly reported gaps in services, pointing in particular to the problems faced by ethnic minority women. Of course, the funding for this ended in 2010. My question for the Minister is therefore about how information and intelligence is being gathered now. How accurate will the Government’s picture be of refuges and the services that are available in 2012? Who is collating the information and where and when will it be published?
What we know is that the cuts of 27% to local authority budgets appear to have been translated into cuts of 31% to the services that protect women who are experiencing violence. For example, Eaves, a local charity that supports vulnerable women, has reported that demand for its services has increased from 366 referrals for advice and support in 2009-10 to 548 in 2010-11, a 50% rise on the previous year. The 31% funding cut in the domestic violence and sexual abuse sector means a reduction from £7.8 million to £5.4 million. According to a Women’s Aid survey, on a typical day some 3,410 women and 2,502 children were living in refuge accommodation, but that 230 women seeking refuge—around 9%—were turned away due to lack of space. The number of independent domestic violence advisers, who we regarded as crucial, has been reduced. In 2011 eight major IVDA service providers supported 13,180 clients, but two of them faced cuts. This means that those services are not being provided.
I have two other issues that I wish to highlight because I think that they will have a terrible effect on services for abused women. One of them has already been mentioned by my noble friend. Refuges are going to be particularly hard hit by the changes being made to housing benefit. Are the Government monitoring the effect that this is going to have on abused women?
The second issue concerns changes to the legal aid structure that will make it more difficult for women to get legal aid when they need it. I recommend a briefing that has just been produced by Gingerbread, Resolution and Women’s Aid, which explains the problems that there are going to be for the domestic violence gateway criteria. Will the Minister assure the House that she and the Equalities Minister will be monitoring this issue and the effect that it is going to have, and will take action if what we think will happen happens?
I congratulate all noble Lords who have spoken. We have had a good and hard discussion but clearly there is much more to do.
Baroness Stowell of Beeston
My Lords, this has been a very powerful and timely debate, coming as it does within the 16 days of action following last Sunday’s UN International Day for the Elimination of Violence against Women. I congratulate my noble friend Lady Jenkin on securing this debate and on setting out so comprehensively the massive problem that we are trying to combat and its effects. I also pay tribute to all noble Lords who have contributed today. I know that this is an opportunity for me to respond, and lots of questions have been put to me, but I also consider it an opportunity to listen and learn, which I have certainly done.
We have covered a wide range of issues. In responding, I will talk briefly about international issues later on but will concentrate on the domestic—by which I mean national—front. I will write to all noble Lords if I fail to cover any of their points, which I know I will do. I know for sure that I am not going to be able to respond to the questions from the noble Baroness, Lady Crawley, about the action plan.
I think it was the noble Baroness, Lady Bakewell, who said that the scale of the problem was not being matched in global terms by action. In global terms, that is evident and it is why we continue to raise this issue and put it right at the top of all agendas. I will respond right at the start to the noble Lord, Lord Brooke, who asked a specific question about the number of domestic homicides and whether that has increased recently. I am not aware of any increase in those numbers, and certainly not in the last published crime statistics.
Violence against women is not a political issue; it is too important for that. Combating it for good is a real ambition that we all share. This Government’s strategy, which we first published in 2010 and which has been referred to by many noble Lords today, has that as its clear purpose. It can be explained quite simply in three parts: it seeks to help prevent violence against women happening in the first place; to provide adequate levels of support where that violence, regrettably, occurs; and to bring perpetrators to justice. All our work in these areas is in partnership with many other agencies and voluntary organisations, some of which noble Lords have referred to today.
Our strategy and our commitment to it is underpinned by the guaranteed funding of £40 million, which we have allocated until 2015, for specialist local domestic and sexual violence support services, a range of national phone lines, existing rape centres and developing some new centres, where there are gaps in provision.
While I am talking about funding it is probably the right moment to answer some of the points that the noble Baronesses, Lady Thornton and Lady Crawley, made about funding. Of course I understand people’s concerns about potential cuts to any kind of local authority funding. I can absolutely see why people would raise that. However, we do not recognise the 31% figure that has just been quoted. Many local authorities are not making cuts and indeed some are increasing their funding. I point to Westminster as one example, which is putting its funding for outreach work up from £440,000 to £760,000. All that said, to try to understand the situation around local funding further, the Home Office is holding a round-table meeting with the Local Government Association in January.
While we are talking about local services and local provision, I make it clear that it dismays me as much as everyone else to hear of any woman who is turned away if they are seeking refuge. I do not want to hear that; none of us does. I would like to think that provision exists to meet everybody’s needs. While some women may be turned away from some of the refuges designated as local authority refuges, they are not the only place where women seek refuge. If refuge is not available to them there, it is often available elsewhere. We fund a database delivered by Women’s Aid which enables those working with victims to identify appropriate services and refuge vacancies.
If I have misunderstood the point on refuges and housing benefit, I shall come back to it in the letter with which I shall follow up the debate. The concern expressed by women and women’s groups about women in refuges who are in receipt of housing benefit has now been addressed. It was a legitimate concern and it is my understanding that it no longer remains a problem.
The noble Baroness, Lady Stern, asked about the future of SARCs—sexual assault referral centres. These have been locally commissioned up till now on a collaborative basis by police and NHS primary care trusts. We have decided that, for the future—at least in the short to medium term—responsibility for them will rest with the NHS Commissioning Board.
The noble Baroness also asked what role PCCs would play in tackling violence against women. I shall not go into great detail about this, because I answered a Question on it recently. The best way in which I can respond is to point to what Boris Johnson has done here in London, because he has been the nearest example that we have had to a PCC before those who were recently elected. It has been striking how, in working with London women’s groups, he has diverted some of his own funding alongside national funding to increase the number of rape centres in London. He shows us that there is real potential for violence to be tackled through the new police and crime commissioner structure.
If we are to end violence against women and girls, we need to challenge attitudes—that has been made clear by many noble Lords today—and raise awareness of abuse and educate young people. There is always more that we can do in this area and we have to keep looking for new opportunities to do so. One of the things that we are doing in the 16 days of action is to restart this very weekend the teenage rape prevention advertising campaign. Its target audience is 13 to 18 year-olds and it will run until the end of January. The noble Baroness asked about the website alongside that. That will be available and be part of that campaign.
My noble friend Lady Bottomley raised questions about awareness of domestic violence in the workplace and the noble Lord, Lord Brooke, said that it was important that we debate domestic violence. I hope that we can encourage employers to do this in the workplace and encourage women who may be feeling isolated to come forward. I have taken on board that point.
The noble Baroness, Lady Howe, and my noble friend Lady Hussein-Ece referred to sexualisation of women and children. This is of course a matter of great concern. Since the controls on online pornography recently introduced by ISPs, the Government have reconsulted on online controls. Fairly soon we should be making public some new thoughts on the way forward to build on what has already announced. We are very aware that this is something that continues to concern all parents. With regard to child sexualisation, one useful initiative was the launch of ParentPort—a single website for complaints and feedback to regulators if parents see any inappropriate advertising located where children might see it.
Obviously we can use the law and strengthen it to prevent violence against women and girls. My noble friend Lady Brinton referred to the new stalking offences. I share with her and those others who commented on this the fact that we as a Government are proud to have introduced these new laws but we recognise the contribution made by so many people to make that happen, including Members of this House.
I will skip along because I am running out of time. We are introducing lots of new measures in terms of new laws. One of the most important ones is about extending the definition of domestic violence to include 16 and 17 year-olds, and another is for the definition to include coercive control—or mental cruelty, as other people might recognise it.
My noble friend Lord McColl made a very interesting proposal about the collection of data on potential domestic violence. I have already asked my colleagues in the Home Office to raise that with the Department of Health because my noble friend was kind enough to give me advance notice of it. I will certainly come back and write to him about that.
The noble Baroness, Lady Rendell, spoke in great detail about female genital mutilation so I will not go over that in any detail myself. I am so pleased that she welcomed what Keir Starmer announced at the weekend; we very much share her view that this is absolutely vital. Having that law in place is not enough. We need prosecutions, and action to bring prosecutions to bear.
On the international agenda, my noble friend Lady Jenkin trailed the Commission on the Status of Women next year, the focus being on the elimination and prevention of all forms of violence against women and girls. I hope it will give some comfort to the noble Baroness, Lady Bakewell, and my noble friend Lady Hussein-Ece that my officials have already started preliminary work to ensure that this agenda moves on next year and is not just something that we have ambitions for that are not fulfilled.
Also in the international arena next year, the UK will take the presidency of the G8. As my noble friend mentioned, the Foreign Secretary is using the profile of that forum—the world’s richest countries—to promote the UK’s initiative on preventing rape as a weapon of war. I am so pleased that someone of that rank in the Cabinet has taken this on board and will take it forward. If noble Lords have not yet had the opportunity, I urge them to read the speech that he gave about that earlier this month.
Lots of questions have been asked; I have a pile here of things that I need to come back on. Forgive me that I am not able to cover them all now. In closing, we are committed to maintaining our strong lead on both the national and the international stages. Ending violence against women and girls is not possible for Government alone. The progress that we have made would not have been possible without the hard work of so many people, including Members of this House. The challenge now is to sustain that collective commitment, to challenge the inequalities and attitudes that can encourage violence against women and to drive improved service for those victims. I believe that we are on the right path to creating a society where no women or girl need live in fear, but we are clearly far away from actually getting there.