(11 years, 11 months ago)
Lords ChamberRead Hansard Text Read Debate Ministerial Extracts
Lord Hunt of Kings Heath
My Lords, I thank the noble Earl for repeating the Statement. I know that Members on all sides of the House were appalled by the terrible incidents at Winterbourne View. I say to the noble Earl that we share a determination to ensure that all necessary steps are taken to prevent a similar tragedy happening again. Our goal must be to ensure that everyone with learning disabilities, including those with challenging behaviours, receives high-quality, decent and humane care and support; and that we finally end up with the practice of sending people with learning disabilities to long-stay institutions far away from their family and friends being a practice of the past.
The noble Earl has announced a number of welcome measures that are certainly a step in the right direction, but we remain concerned that the proposals may not be clear or strong enough to guarantee the changes that people with learning disabilities and their families urgently need. I refer the noble Earl to the NHS mandate, published only a couple of weeks ago, which says that there should be a substantial reduction in reliance on in-patient care. The noble Earl has clearly reiterated that in the Statement. Can he put a figure to that reduction? Is there not a risk that, unless the noble Earl is more precise about how and when that will be accomplished, we may not see the progress that we would wish to see?
Similarly, the Government say that they wish every local area to provide appropriate care and support. Can the noble Earl define what care is considered to be appropriate, and how it might be measured?
The noble Earl will probably know that I am somewhat dubious about the commissioning function in the National Health Service. We have, after all, had commissioning for more than 20 years under different Governments. One has to ask whether commissioning has led to enhanced outcomes. We see in what happened at Winterbourne View a catalogue of failure by commissioners. Vulnerable adults were placed in unsuitable places, often miles away from their homes. This dislocation, as a recent BMA paper pointed out, can further disturb adults who may already have had traumatic lives. These distances have made it difficult for families and carers to provide oversight and protection. As the BMA said following a round-table discussion in your Lordships’ House, commissioners need better to reflect the individual’s needs and relationships. It must be more local and less institutionalised. Containment must give way to personalised care. Would the noble Earl agree with those sentiments?
Can the noble Earl explain how the Government will ensure that all local commissioners have the necessary skills to make these changes? Clearly there was a problem with 150 primary care trusts. The question now arises: what will happen with the 212 clinical commissioning groups? Of course, they can rely on and draw on the experience of local authorities. I wonder whether the noble Earl can recollect our discussions during the passage of the Health and Social Care Act, when we on this side of the House argued that the commissioning plans of clinical commissioning groups should have to be signed off by health and well-being boards in order to draw the commissioning plans of both the local authority and the CCGs together into one cohesive approach. Would the noble Earl be willing to consider this issue again?
I am concerned that the authorisation process for CCGs does not mention learning disabilities as an area where competence is required. If this is such an urgent and important priority for the Government, can the Minister explain why this is the case?
I come back to the continued use of long-stay institutions because alternative care has not been developed in the community and at home. In a time of constrained resources, when we need to make the best use of taxpayers’ money, there should surely be one budget for people with learning disabilities, not separate funding for health and council care. How will the Minister ensure that there is a cohesive response at the local level from both the NHS and local government, with the budgetary allocation to make sure that that happens? Will the noble Earl name the specific individual leading this work within the NHS Commissioning Board so that Members of this House are clear who should be held to account?
On the regulator, the serious case review of Winterbourne View said that light-touch regulation by the Care Quality Commission was not appropriate for closed establishments, which should instead be treated as high-risk, with frequent unannounced, probing investigations. The review strongly recommends that these investigations speak to residents’ families and to patients, including those who have left the institution and who may feel more able to speak out and speak up. The Care Quality Commission has just completed a focused probe of inspections of long-stay institutions for people with learning disabilities. I think that the implication of what the noble Earl said is that that work will continue, but it would be good to have some confirmation from him.
Can the noble Earl tell me about the CQC’s capacity to undertake this work? I am one who believes that the previous leadership did the best that they could in the circumstances in which they found themselves, notwithstanding the great deal of criticism that they had to take. I have been very impressed by the approach of the new chief executive of the CQC, David Behan. However, I remain concerned that too many responsibilities may have been put on the CQC for it to be able to discharge them effectively. Clearly, in relation to places like Winterbourne View, this has to be an important priority for the CQC. Can the noble Earl reassure me that he is convinced that the CQC can take this on without being submerged by all the other responsibilities, including the whole of primary care which it has been given to address?
Whatever the shortcomings in commissioners and regulators, responsibility ultimately lies with those who provide the services; I agree with the sentiment of the Statement on that. One of the most disgraceful aspects of Winterbourne View was that vulnerable people were neglected and abused while the hospital’s owner, Castlebeck Care, charged huge fees and apparently made huge profits. The serious case review says that Castlebeck made decisions about profitability, including shareholder returns, over and above decisions about the effective and humane delivery of assessment, treatment and rehabilitation. My understanding is that the average weekly fee for residents at Winterbourne View was £3,500, rising to £10,000 for one patient.
While the hospital generated profits of almost £5 million, the review could not determine how much money went back into the hospital, and how much was creamed off for profit. The reason for that is the company’s complex financial structure, with Castlebeck itself owned by private investors based in both Jersey and Geneva. That has made it virtually impossible to hold the company to account. Can the noble Earl confirm that the company has so far failed to meet two of the serious case review’s key recommendations: that it should fund therapeutic services for all ex-patients, and pay for the cost of the review itself which has so far been entirely borne by the taxpayer? The review’s authors say that the corporate responsibility of Castlebeck remains to be addressed at the highest level.
In that regard, I very much welcome the commitment made in the Statement by the noble Earl to the Government examining how corporate bodies and their boards of directors can be better held to account, including a “fit and proper” test for the directors of those companies. Will the noble Earl consider requiring private companies to publish the names of their owners, the members of their boards and the details of their financial structure before they can be licensed and registered to provide publicly funded care? We cannot let the excuse that information is too commercially sensitive be considered acceptable, when what is at stake is the care of very vulnerable people, paid for using substantial amounts of taxpayers’ money.
Finally, perhaps I may ask the noble Earl about carers and the vulnerable adults themselves. As the BMA report says, carers and adults have important roles to play in identifying needs and helping to co-ordinate and supervise their care. Can the noble Earl confirm that the involvement of carers and the vulnerable adults concerned will come to the fore when taking forward the work of his department, the CQC, commissioners and providers?
How we care for the most vulnerable people is clearly a hallmark of a decent society. The scale of abuse at Winterbourne View was simply unacceptable in the 21st century in one of the most prosperous nations in the world. I have been encouraged by the tone of the Statement repeated by the noble Earl. There are clearly issues that we would like to see addressed and I look forward to his comments. I also look forward to the debate in your Lordships’ House on Thursday, when we will no doubt have a more detailed go at this. However, it is clear that there is considerable support for the kind of decisive actions that need to be taken to ensure that this cannot happen again.
Earl Howe
My Lords, I am very grateful to the noble Lord for his constructive comments and I welcome his commitment to a shared agenda for improving care for those with learning disabilities and autism. I agreed with a great deal of what he had to say.
As to his individual questions, he first asked whether I could articulate the number of in-patient places we expect to be reduced during the coming months and years. My answer is that we want to see a rapid reduction in the number of people with learning disabilities, autism and challenging behaviours who are in hospitals or residential care and who are away from their home areas. That is not to say that there is no role for assessment-and-treatment centres, which clearly have a role—but it is limited. It is important to ensure that everyone has a care plan built around their individual needs, rather than to say that there should be some kind of top-down national target for the number of units. We believe that plans should be in place and put into action as soon as possible. All individuals should be receiving personalised care and support in the appropriate setting for them no later than 1 June 2014, and we shall work towards that end. It is very much a case of defining the appropriate care for the individual.
To pick up the noble Lord’s final question about the involvement of carers and the vulnerable adults themselves, yes, they should indeed be involved in the planning of care. It is families, carers and the individuals themselves who know best what they need. It was one of the besetting failings of this terrible saga that families and carers were not listened to, and not only about the whistleblowing to which they wanted to alert the authorities. They also had a very good idea of what type of setting and care their loved ones would best respond to—and they were not listened to on that score, either.
The noble Lord asked about clinical commissioning groups and the extent of their expertise in commissioning appropriate treatment for those with learning disabilities. I agreed with a great deal of what he said. Commissioning expertise for this group of people is, frankly, in short supply, and that is why the department will fund the joint improvement programme being organised jointly by the NHS Commissioning Board and the Local Government Association. They will be tasked with working closely with clinical commissioning groups and their local authority partners over the next two years, to share and implement best practice. There has to be, as the noble Lord said, a cohesive approach. Joint working here is vital because we are looking at determining not only the right setting for an individual but what the right treatment for that person should be. That necessitates a joint approach. I should add that we would set an expectation that there be pooled budgeting arrangements to drive that forward.
The noble Lord asked me who on the Commissioning Board was leading in this area. Sir David Nicholson has made clear his personal commitment to take action on this. Indeed, the board is meeting people with learning disabilities this Thursday, but the lead director on the board is Bill McCarthy.
The noble Lord asked me what the Care Quality Commission intended to do by way of ongoing work. The CQC will continue to carry out unannounced inspections, which will involve people with learning disabilities and their families, as I mentioned when I repeated the Statement. That will be based on risk, and the CQC has made it plain that these particular settings are a priority for it. We expect it to take account of all the recommendations arising from the serious case review, including the views and statements of those who have left establishments of this kind.
The noble Lord asked me about Castlebeck and the liability that it should have for the ongoing costs of patients who were at Winterbourne View and, indeed, the cost of the serious case review. My reaction is that Castlebeck should give serious consideration to that suggestion. However, there are currently no powers to make that happen, and the Government are keen to ensure that in extreme cases such as this there are consequences for providers of care that is of poor quality.
As regards a requirement for companies to be more open about their board structure and corporate structure, this is something that we shall be looking at over the next two or three months, and we will come forward in the spring with our conclusions on how companies and their boards can better be held to account.
Baroness Hollins
My Lords, I welcome the report and the detailed actions that are listed in it. Indeed, it fills me with some hope after so many years of commissioning failure. The proposed change support programme is to be led by the NHS Commissioning Board and the Local Government Association. There is something ironic in responsibility for leading this change being vested in those who primarily have been responsible for the current failure. The evidence is that local authority and NHS leadership do not have the skills or knowledge to effect change. Indeed, my former colleague Jim Mansell’s first report on challenging behaviour was published 20 years ago and made similar recommendations to those in today’s report. Can the Minister confirm that the programme board will indeed be expected to engage with those from the learning disability sector, who understand the issues involved in the design and delivery of the support programme? Finally, why does the report make little or no mention of the need to provide access to the same range of mental health treatments that other citizens have access to, including psychological therapies?
Earl Howe
The noble Baroness brings us to a set of key points. She said that in her view the NHS and local government simply do not have the capacity to address these issues properly. In many respects we would agree with that, although it would be wrong to make a blanket statement about the whole country because we know that very good pockets of commissioning and provision exist. One of the tasks of the joint improvement team will be to identify those areas of best practice, and to enable those operating in those areas to go out and mentor other areas. Part of the sum of money that we set aside will be devoted to enabling those high-performing areas to backfill the places while they are engaged in that mentoring exercise. Her basic point is well taken. We think there is a job to do here but it is one of those things that the Board and the Local Government Association need to oversee on a national basis.
That is only a short extension from the function of the Commissioning Board in general, which will be to support commissions. We are grateful to the Local Government Association for its overseeing role for local authorities. I fully expect that they will engage with the learning disability sector. I commend to her the concordat, which is accessible on the department’s website, and she will see from that that the 50 organisations that have signed up to it include a number of voluntary organisations in this sector. Jointly, these bodies have committed to a programme of action. It is not just about defining what needs to be done but about how it will be done. It is an impressive set of commitments that those bodies have signed up to.
Lord Pearson of Rannoch
My Lords, the Minister spoke about the need for a fundamental change of culture but I heard nothing in the Statement about training, so I hope that he will forgive me if I ask again a question I have been asking for over 20 years about the training of our teachers, social workers and, in this case, care workers. I do so from my background in the 1980s and 1990s on the body that validated all our teacher training courses and from having taken quite a close look at the curriculum then offered by the Central Council for the Education and Training in Social Work. At the former, I was shocked to find that our mission statement was “to permeate the whole curriculum with issues of gender, race and class”.
Since then we have seen Nursing 2000 put the training of nurses away from hospital wards and into the social science departments of the former polytechnics, with results that I predicted at the time. Have the Government looked into the curricula of the training of care workers and of those responsible for this and similar disasters? What training do they get, if indeed they are trained at all? What genuine qualifications do they have before they commence training? Are they proud of what they do, or are they just in it for the money? I hope I am very out of date, but I look forward to the Minister’s reply.
Earl Howe
My Lords, the noble Lord is not out of date, because this is a key issue and I am grateful to him for raising it. It is crucial that staff who work with people with challenging behaviour are properly trained in essential skills. Contracts with learning disability and autism hospitals should be dependent on assurances that staff are signed up to the proposed code of conduct that the Department of Health has commissioned from Skills for Health and Skills for Care and that there should be minimum induction and training standards for unregistered health and social care assistants. Those standards should be met. I would say that owners, boards of directors and senior managers of organisations that provide care must take responsibility for ensuring the quality and safety of their services. There are requirements set out in law in that regard, and they include safe recruitment practices, which necessarily involve selecting the people who are suitable for working with people with learning disabilities, autism and challenging behaviour, and appropriate training for staff on how to support people with challenging behaviour.
From April next year, Health Education England, which is the new, national, multi-disciplinary education and training body, will have a duty to ensure that we have an education and training system across the piece but including a system that can supply a skilled and high-quality workforce for this sector.
Baroness Browning
My Lords, my noble friend said that families’ concerns were ignored, but would he accept that there is huge push-back across all the public services involved with this group when anyone who is a family member of someone over the age of 18 tries to make representations on their behalf? I experienced that again personally, yet again, only this week. Paragraph 3.9 of the department’s response makes reference to:
“Where an individual lacks capacity and does not have a family to support them, the procedures of the Mental Capacity Act 2005 should be followed”.
I am appalled at the way in which the Mental Capacity Act, an excellent piece of legislation, is virtually ignored by many professionals who not only do not advise people of their rights under the Act but just ignore it. If ever a piece of legislation cried out for post-legislative scrutiny, it is this Act of Parliament. It is a strong, good piece of legislation but it needs to be enforced; we need more people to know about it and to use its powers to protect the vulnerable.
Earl Howe
My Lords, my noble friend is absolutely right. Over the coming months the Department of Health will be working with the Care Quality Commission to agree how to improve the understanding of the deprivation of liberty safeguards and to ensure compliance with them. We are very clear that this work is necessary to protect individuals and their human rights. We will report the results of that work by spring 2014. During 2014 the Department of Health will update the Mental Health Act code of practice, and this will also take account of findings from the review.
Baroness Wall of New Barnet
My Lords, I also congratulate the Minister on repeating this Statement made earlier in the other place, and I welcome the report itself. I want to refer to a couple of areas and follow up his reassurance about the patient care pathway. The importance of that pathway, I am sure he knows, is not only in having it but ensuring that it is carried out with regular updates, and that the progress being made is taken into account to make sure the pathway is staying in touch. That does not always happen, so having the patient care pathway is only one part of what I hope he would ensure would happen.
The other part, and the Minister may not be surprised at this, is Part 7 where again, as my noble friend Lord Hunt has done, I urge him to think again about another area. With regard to the expectation as far as training goes—while Skills for Health and Skills for Care, as mentioned in the document, are doing a great job—it is absolutely crucial to recognise that just the induction for health care assistants in social care really is not enough. I have pleaded with the Minister on many occasions in the context of hospitals. It is equally if not more important that healthcare assistants have the confidence given to them by being registered and qualified in the way that registration ensures, so that the very difficult and important job that they do—and more of them are doing it than are working in any other area—is suitably recognised. I urge the Minister to take away that request in the context of this report, and to look again at ensuring registration for these particularly important workers.
Earl Howe
My Lords, I am grateful to the noble Baroness for what she has said. She is right to point out that the patient pathway is integral to any proper planning process for individuals, and that it should be built around the particular individual’s needs and preferences if possible. This brings us back to the role of an assessment and treatment centre: namely, as its name implies, to assess the needs of a person and to define what their care plan should be over a future period of time. As I mentioned, the care plan is best when it is drawn up with the benefit of advice from the individual, their family and their carers. Therefore, if we want more community care, we need to ensure that there is the capacity in the community to deliver good patient pathways to individuals. We are clear that some areas of the country are ill equipped to do that. Part of the task of the joint improvement programme will be to look at the facilities and resources that are required in local areas to enable commissioners to plan those patient pathways with confidence.
On the issue of the training of care assistants, I take the noble Baroness’s point. I think that it is common ground between us that those who lack a recognised qualification should nevertheless be enabled to upskill themselves and get themselves on a register to prove that they are familiar with and abiding by a code of conduct that has been recognised, with the register itself being duly accredited. Our position is that the system of voluntary registration, almost by definition, will result in an upskilling of the workforce, but it is not the whole story. There is a role for employers to ensure that there is proper supervision of care assistants, and that proper delegation takes place that does not require a person to do more than he or she is skilled to do. There is no single answer here, but I believe that voluntary registration is a good start.
Baroness Masham of Ilton
My Lords, following from the question about registration and regulation, is the Minister aware that people such as nurses and care assistants who have been sacked for dishonesty or undertaking dangerous procedures with patients can take a job anywhere as a care assistant? Without regulation, how will he control the matter? It is very dangerous for vulnerable patients because these establishments are so hard-pressed to get staff to work in their centres that they will take almost anyone, without even taking up references.
Earl Howe
My Lords, the noble Baroness raises another important point. In this country we have a list that acts as a check on those who have abused or otherwise maltreated adults or children and have been dismissed on that basis, to ensure that the scenario that she has painted in which someone who has committed such an offence is re-employed cannot occur in practice. I am not sure that I recognise the situation that she outlined because the POVA system is designed to ensure that dangerous people are not employed to look after the vulnerable. However, I will gladly drop her a line in writing to set out what we propose in this area.
Lord Willis of Knaresborough
My Lords, I echo the comments around the House that this Statement is appropriate. The fact that it has support across the House demonstrates that there is unity in terms of tackling the issue. I spent a significant part of my professional life working with young people with severe behavioural issues. As the head of a school, I, together with my governors, would be held responsible for what happened to those young people—and rightly so. The weakness in the Statement is that it does not go far enough.
The Minister was right to make clear, and I am glad he did, that it was the management and the corporate owners of the home who were principally responsible, yet it was the staff who were prosecuted and jailed. I would like to hear what steps are going to be taken with the CPS to deal with corporate responsibility, and why that is not the priority here. Without it, frankly, a lot of the things that appear in this report will not have the necessary teeth.
I respectfully but fundamentally disagree with the noble Lord, Lord Pearson, on the training of nurses and other health workers. The more that we demand of staff in terms of their education and other opportunities, the better the staff we will ultimately get. However, I agree with him and with the noble Baroness, Lady Masham, that it cannot be right that the most vulnerable people in our society are looked after by people whom we cavalierly say do not require qualifications. How unacceptable is that in the 21st century? A voluntary register of an organisation that is disreputable is utterly and totally meaningless. We need a commitment on this from the Government. I agree that this will be over a period of time; it will not happen tomorrow. However, simply stating, as recommendation 15 does, that by 2013 there will be a voluntary register will not give parents and carers of these very vulnerable adults and young people the support and comfort that they need. I plead with the Minister to make the case in the department for mandatory registration, to ensure that there is appropriate regulation and that nobody works with these young people or adults who does not have appropriate qualifications and training.
Earl Howe
My Lords, I am very happy to recognise the excellent work done by my noble friend in the report that he published and submitted to the Royal College of Nursing, which we will debate later this week. He rightly drew attention to the responsibility that lies with leaders of organisations and boards of directors. They should be fully held to account for poor quality or for creating a culture in which neglect or abuse can happen. I completely agree with that. He was right to say that despite convictions for some front-line staff, Winterbourne View has revealed weaknesses in our ability to hold to account those who were higher up. Owners, boards of directors and senior managers must take responsibility for the quality and safety of their services.
We are determined to strengthen the accountability of boards of directors and managers, but we are not yet in a position to say exactly how that should be done. It is not as easy to define a legal route as it might first appear. It is perhaps easier to do so in the area of financial irresponsibility or negligence than it is where value judgments have to be made over the quality of care delivered to a group of individuals. However, I can tell my noble friend that this is one of the priorities that we have set ourselves. I listened with respect to his suggestions on the compulsory registration of care workers. I repeat what I have said in the past: the Government’s mind is not closed to this suggestion.