Care Bill [HL]

Wednesday 3rd July 2013 Lords Chamber

Committee (4th Day) (Continued)

20:52

Amendment 78C

Moved by

[Baroness Greengross]

78C: Clause 1, page 2, line 7, after “support” insert “or need for health provision and the importance of reducing needs of either kind that already exist,”

[Baroness Greengross]

My Lords, I will also speak to my Amendments 79C, 79G and 79K.

Amendment 78C is about trying to strengthen the provisions to ensure that we have an integrated approach to care planning. This would happen if we could ensure that local authorities consider how to prevent or delay healthcare needs, as well as care and support needs, when providing or arranging the provision of services, facilities or resources for care. We have talked about this previously but I think that the Bill should require local authorities to have regard to the potential to prevent, delay or reduce health needs as well as care needs when providing or arranging care and support services. This duty would have wider benefits because it would strengthen the requirements on local authorities to prioritise integrated care services in line with Clause 3 of the Bill. It should also improve cost efficiencies for local authority budgets at a time when social care budgets are being squeezed, as we have heard, by reducing the need for more intensive and costly forms of care.

Similarly, Amendment 79K tries to enshrine the duty of prevention. We know, and have heard from other noble Lords, that many people reach a crisis point when the person for whom they are caring is critically ill, or has a fall, or the partner dies, or something else happens. There is a panic and the wrong sort of care or very expensive acute care is provided. If appropriate identification, awareness and assessment of needs could be made before people reach this point, it would be absolutely brilliant at avoiding some of these acute costs of care. Enshrining prevention in the Bill is very important. Accordingly, it is imperative to ensure that the prevention duty focuses on what a local authority must do to prevent deterioration in well-being, to underpin the imperative to prevent, delay and reduce the need for care and support.

In order to make sure that happens, Amendment 80B ensures that local authorities have regard to NICE clinical guidelines and equality standards. This came to me through chairing a committee which produced a report on autism as it now affects a lot of older people. This is a fairly new phenomenon, because fortunately people live longer—not just healthy people, not just sick people, not just frail people, but people who have conditions such as autism. We know that NICE’s remit will be extended—in fact it has been extended since April of this year—to include social care services. It has the potential for a new focus on evidence-based decision-making. For example, the NICE guidelines on adults with autism states that investing in employment support is cost-effective.

This, and similar findings, should be taken into account by local authorities when they are providing services, including preventive services. All of these together would help to provide a range of preventive care. In order to make that happen, I hope we can encourage local authorities to look at more than one-year budgeting, because preventive services need longer than that. Local authorities need to be encouraged to take a longer view. If you are running a business and invest in something, you do not expect a return immediately. If you invest in preventive services, you will not necessarily get a return in one year, you have to give things a longer time span to reap the benefits. That also applies in these cases.

Amendment 87G makes sure that local authorities assess preventable needs and look to reduce these needs as an integral part of their duties in relation to the assessment progress. Briefly, that explains this group of amendments. I beg to move.

[Lord Touhig]

My Lords, I speak in support of Amendments 79K, 80A, 80B and 87G. At the outset, I pay tribute to the noble Baroness, Lady Greengross, who did an excellent job in chairing the commission on ageing and autism. We look forward to the publication of the report very shortly. It was certainly an eye-opener for a great many of us, and the many who thought they knew a lot about support and social care learnt a great deal during that time.

21:00

Social care must no longer be the service of last resort. Under the current system, too many people become eligible for support only when their needs become acute and they require intensive high-level care and crisis management. Here, I declare an interest as a vice-president of the National Autistic Society, whose recent research shows that only 10% of people with autism said that they receive social skills training, yet 55% would like to receive it; that only 10% people with autism said that they receive employment support, but 53% would like it; and that just 17% of people with autism said that they have access to social groups, yet 42% would like to have it.

Many adults with autism would benefit greatly from low-level services such as befriending or social skills training. These would help them to avoid isolation and allow them to participate fully in society. A lack of access to these services can have a devastating impact. A third of adults responding to a previous National Autistic Society survey said that they developed serious mental health problems as a result of a lack of support. Crucially, evidence from the National Audit Office shows that providing low-level services is cost-effective and prevents people developing more complex problems—a point just made by the noble Baroness, Lady Greengross. Its report stated:

“Beside the negative impact of such crises on a person’s life, acute services are also expensive, with inpatient mental health care costing between £200 and £300 per day”.

New economic modelling by Deloitte, published earlier this month, shows that every £1 invested in support for people with autism—and any other difficulty—who have moderate needs can generate a return of £1.30. The benefit is spread across central government, local government and disabled people and their families. Services such as the National Autistic Society’s Horizons day centre, which is based in Surrey, support adults with autism to develop social and communication skills, to access the job market, to improve health outcomes and to prevent the development of further needs.

Enshrining prevention in the Bill is important also where older people are concerned—that will certainly show up when the report of the commission of the noble Baroness, Lady Greengross, is published. Many middle-aged or older people reach a “crisis point” when their parents or carers pass away. Appropriate identification, awareness and assessment of needs before this point is reached are vital. I welcome the emphasis on the principle of prevention that is already in the Bill, but for it to have a real impact on the provision of services, it must be further entrenched. I hope that the Minister will see the wisdom of the amendments proposed by the noble Baroness, Lady Greengross.

[Lord Rix]

My Lords, I wish to speak to Amendment 79D, which focuses on preventing adults at risk suffering abuse or neglect. I welcome the focus in Clause 1 on promoting well-being and the breadth of that definition, which includes protecting people from abuse and neglect. In addition, Clause 2 sets out an important duty whereby a local authority must take steps and provide services which contribute to preventing needs for care and support. However, this crucial clause on prevention makes no reference to abuse and neglect, and my amendment seeks to make this explicit.

Later in the Bill, in the safeguarding section, there is a focus on protecting people once that abuse or neglect is suspected. However, it would be hugely beneficial if local authorities and agencies were obliged and guided to prevent abuse and neglect taking place in the first instance.

Let me give you an example. Decisions were taken to send people with a learning disability and challenging behaviour far away from their homes to Winterbourne View, where they suffered the most horrific abuse. This could clearly have been prevented by local authorities and other agencies if they had taken the right decisions at the outset.

Prevention is recognised also in terms of disability-related harassment, and indeed the Equality and Human Rights Commission highlighted this in its report, Hidden in Plain Sight. It recommended that local authorities and housing providers work from the outset to reduce disability-related harassment by including safety and security measures in the design of social housing estates and facilities. In addition to good decision- making at the top, it is also important to consider how we can empower individuals to understand what abuse is and how they can protect themselves from it. This might be through providing information, advice and advocacy. Safeguarding procedures are vital in order to protect people suspected of abuse and I have tabled a number of amendments on this area under Clause 41. However, before safeguarding comes a strong commitment to preventing abuse occurring in the first place. I look forward to the Minister’s view on this matter.

[Lord Low of Dalston]

My Lords, I was waiting to see whether the noble Lord, Lord Hunt, was going to speak to his amendments in this group—

[Lord Hunt of Kings Heath]

Would the noble Lord find it helpful if I went next?

[Lord Low of Dalston]

Yes, please.

[Lord Hunt of Kings Heath]

Thank you very much. My Lords, I think this is a very interesting group of amendments and the noble Baroness, Lady Greengross, in her Amendments 78C and 79K—to which I have added my name—and her other amendments makes some very important points about the need for a preventive approach, including its health dimension. My noble friend Lord Touhig has added his powerful voice to it.

In Amendments 79K and 80A there is a real issue here about the national minimum eligibility threshold. It would provide some certainty for some adults about whether their care needs will be met, but we know there will be many people whose needs remain just below the level at which local authorities will at a minimum need to meet through the national eligibility criteria. We know the Ending the Other Care Crisis report produced by Scope with four other charities estimates that 105,000 working-aged disabled adults will in fact continue to rely on universal services. This places greater responsibility on local authorities to put in place the necessary services to help prevent, delay or reduce care needs.

There is an argument for framing Clause 2 more positively to encompass the many diverse forms of preventive support that local authorities could put in place to prevent deterioration in the well-being of adults in their area. We want local authorities to be more ambitious and to think about prevention more positively. While understanding the pressures that undoubtedly local authorities will be under, these amendments would give a very powerful voice to the need to go down the preventive route.

My Amendment 79A, to which the noble Lord, Lord Low, has added his name, continues the same theme on placing a general duty on local authorities to prevent, delay or reduce the need for care and support. We know that in Clause 2 there is a requirement on local authorities to look at how they can make the best use of community facilities to prevent, delay and reduce needs for care and support. That is very welcome indeed but the question is: to what extent are local authorities geared to put that into practice? Hence I have tabled this amendment. I think we need give a push to local authorities to take this seriously. I hope the noble Earl will be sympathetic to agreeing to some form of amendment which would reflect this in Clause 2.

The noble Lord, Lord Low, has a number of other amendments in this area which I would very much wish to support, although I have not lent my name to them. They are very well framed and important. Coming back to the issue we discussed in the debate just before the dinner break, this legislation may well stay on the statute book for many years to come, so it is really important to get it right. The emphasis that the noble Lords, Lord Low and Lord Rix, have given to these points bears careful consideration, so I am very happy to support them.

[Lord Low of Dalston]

I thank the noble Lord for his anticipatory support of my amendments, and perhaps I may return the compliment by saying that my name is on five amendments in this group and I have the most copious set of notes I have ever had in any debate. I hope that noble Lords will bear with me at this time of night, but with five amendments, there is quite a bit to go through.

As the noble Lord, Lord Hunt, said, I have put my name to his Amendment 79A and to that tabled by the noble Baroness, Lady Greengross, and in the names of the noble Lords, Lord Hunt and Lord Touhig, Amendment 79K. There are the same group of Peers on Amendment 80A, but Amendments 80C and 87F are in my name only, so I shall obviously spend a bit more time on them.

Before that, I shall say a few words on Amendments 79A, 79K and 80A. Clause 2 would be stronger if local authorities were also placed under a general duty to take prevention into account in exercising any of their functions under Part 1, not just those relating to direct provision of care. Amendment 79A would ensure that local authorities act to “prevent, delay or reduce” individual care needs across every one of their functions. Amendment 79K would ensure that the prevention duty focuses on what a local authority must do to prevent a deterioration in well-being, in addition to preventing, delaying or reducing the need for care and support. Amendment 80A would oblige authorities to have regard not just to the importance of identifying adults and carers with needs for care and support and the services available to meet those needs, but,

“the steps it could take to improve and enhance the provision of services, facilities or resources in its area”.

The idea would be to ensure that local authorities actively consider what more they could do to prevent needs for care and support above and beyond identifying existing services, facilities and resources in the authority’s area.

The Bill currently stops short of that, which is bad news for the hundreds of thousands of older and disabled people who are not deemed eligible for adult care and support. It is also bad news for the Government’s aspiration to rebalance the system away from crisis interventions in a more preventive direction. The amendments suggest a more strategic approach which, by putting in place services at the community level, not just directed at individual care, could ensure that those who did not reach the eligibility threshold were, nevertheless, not bereft of support entirely. In other words, they provide a means of enabling available resources to go further by deploying them strategically in aid of prevention.

The kind of preventive services I am thinking of might be of six types. First, there are enabling services, preventing harm before it occurs—as you might say, working well away from the cliff edge. Secondly, there are services that prevent care needs from developing: for example, reablement or specialist rehabilitation to help an adult with sensory loss or a falls prevention service for older people discharged from hospital. Thirdly, there are prompt interventions, detecting and responding to early signs of difficulty, forestalling problems which could lead to more serious consequences —as you might say, working just over the edge of the cliff. Fourthly, there are services that help to delay care needs once they have started to emerge, for example, home adaptations for those no longer independently mobile or befriending services for the recently bereaved, perhaps funded by the local authority but delivered by a local Age UK. Fifthly, there are services that reduce care needs once they have started to intensify, for example, a stroke rehabilitation service provided alongside the NHS to help adults to regain control over key activities of daily living.

Sixthly and finally, there are acute interventions reducing the impact of a situation spiralling down—working well down the cliff, you might say. Wales furnishes an example in the Social Services and Well-being (Wales) Bill, which is currently before the Welsh Assembly. I hope the Minister might be willing to take a look at that. The corresponding section of that Bill, Section 6(4), explicitly states that a local authority must, in the exercise of its other functions, have regard to this preventive services clause in the Bill.

21:15

I turn now to the amendments in my name only. Amendment 80C is a probing amendment aimed at drawing out the Government’s thinking about creating an accountability mechanism for the prevention duty. The suggestion is to use the legal framework contained in the Local Government Public Involvement in Health Act 2007. I remember it well. Local authorities have responsibilities under that Act to produce joint needs assessments and joint health and well-being strategies under Section 116 of that Act. This amendment would lay on them, in partnership with clinical commissioning groups, a duty to have regard to their duty to prevent care needs as part of discharging those responsibilities.

Successive Governments have produced ambitious plans to rebalance our care and support system away from crisis interventions in favour of preventive support. Some of these have succeeded to a degree, but what all these strategies have had in common is a desire to prevent individual care needs from developing or getting worse, providing early support that makes sense for the individual adult, their carer or family, but also makes more efficient use of public resources. Notwithstanding this, we still have a care and support system where all the legal duties and funding structures are aligned towards meeting acute or, for want of a better word, substantial care needs.

The recent ADASS survey reveals a startling lack of attention paid to preventive forms of health. Only 37 councils—that is 25% of those which responded to the survey—had formally agreed a plan on how to spend reablement money transferred from local health services as part of the 2010 spending review.

Spend on prevention of £588 million in 2013-14 represents only 4.2% of adult social care budgets. This is the consequence of the tough budget settlement for local authorities, but it is also about the inattention local authorities inevitably pay to prevention when all their legal responsibilities are focused around acute interventions—in other words, not preventing but meeting care needs.

The announcement in the Government’s latest spending review that £3.8 billion of pooled funding, including an additional £2 billion through the NHS, will be dedicated to improved and integrated care services can only be sensible at the time of rising demand. However, how certain can we be that this pooled funding will be used in the way that is clearly intended, for local authorities, their partner CCGs and other members of local health and well-being boards to redirect resources towards preventive types of care?

Clearly, there is a danger that this money and all future packages like it will be swallowed up by councils struggling with reduced budgets and be spent on care and support for people who have already reached their own personal crisis point. What we need is a legal framework that actively enables this joined-up work, not just in 2015-16 but over the longer term.

Clause 2 therefore needs to be amended so that when local authorities and their partner CCGs prepare an assessment for a health and well-being strategy under Section 116 of the Local Government and Public Involvement in Health Act, they do so with regard to local authorities’ prevention duty in this Bill. This will strengthen accountability for fulfilling the duty under Clause 2, and there will be greater clarity about whether local authorities need to do this as part of their wider role within the health and well-being board. This is not a reporting requirement or an additional burden on local authorities. Rather, it ensures that there are proper mechanisms and fora through which local authorities can discharge these responsibilities for preventing care needs: namely, joint strategic needs assessments and joint health and well-being strategies.

I turn to Amendment 87F. Clause 9(1) gives local authorities responsibility for assessing needs for care and support. This amendment would give them additional responsibility for assessing whether needs can be prevented from getting worse and how they may be reduced. The aim is to ensure that local authorities assess preventing needs and look to reducing them as an integral part of their duties on assessment. In the Government’s report in response to pre-legislative scrutiny of the draft Care and Support Bill, The Care Bill Explained, they said that,

“the Bill now requires that as part of assessments of needs … local authorities must consider whether other support is available that could contribute to the outcomes the adult wishes to achieve, and provide information on how to prevent or delay future needs”.

Clause 9(4)(d) ticks one box, placing a responsibility on local authorities to consider the other support that might be available to an adult from friends or family. However, it is not clear where Clause 9 actively enables a local authority to assess the ways in which adults’ needs for care and support could be prevented from getting worse or, indeed, how assessed needs might be reduced.

If the Bill is truly to refocus care and support on promoting individual well-being and preventive health, Clause 9(1) is a major gap that needs plugging. It needs amending to ensure that local authorities actively assess the needs that could be prevented from getting worse, or which could be reduced. Clause 9 is the critical section governing an assessment of an adult’s needs, but it would be a major omission if it did not provide some means by which a local authority is required to assess which needs are in fact capable of being reduced. In practice, not including this requirement would mean authorities inevitably concentrating on needs that have already emerged and the degree to which they could be categorised as eligible needs. Of course, a local authority must fulfil that duty but in doing so it should also consider which needs, if any, can be prevented from getting worse. Not doing so surely puts in question the Government’s ambition to refocus the system on postponing, preventing and minimising the need for care and support.

In assessing whether needs can be prevented from getting worse and how they could be reduced, an authority would in effect be making a determination on the existing impact of a need, the risk that it will deteriorate and develop into an eligible need and, crucially, what an authority and the adult themselves can do to proactively prevent a deterioration in their well-being. The idea would be to assess whether an individual’s needs could be prevented from getting worse through the provision of a structured programme of intermediate care or reablement, or some other form of preventive support—for example, a communicator guide, some intensive therapy at home, advice on suitable housing options or adaptations, mobility training or even access to a local befriending scheme. This would not only be in the interests of the individual adults, their carer or family; clearly, it would be in the authority’s interests too.

There is extensive literature which demonstrates, time and again, that preventive services deliver savings. An economic evaluation of British Red Cross services estimates that the support delivered to five typical adults created savings of between £700 and—

[Baroness Anelay of St Johns]

My Lords, I would be most grateful if the noble Lord, Lord Low, would be very kind and resume his seat for one moment. I excuse myself for being out of breath. I have been listening very carefully to the noble Lord, Lord Low, outside the Chamber, and it is my duty, as Government Chief Whip, to remind the Committee of the rules of debate in this place, rules which I know the noble Lord would never wish to transgress. Our Companion makes it clear that the House has resolved that speeches in this House should be shorter. Long speeches can create boredom and tend to kill debate. I am sure that is not the case with the noble Lord, Lord Low, but he has been speaking for more than15 minutes and is now in the 16th minute. The Companion makes it clear that speakers are expected to keep within 15 minutes. Might I therefore suggest that the noble Lord winds up his remarks at this stage? Representations have been made from all sides of the House, particularly from the Front Benches, the Chief Whips and the Convenor, to say that they wish that the Whips would intervene more often to give guidance on this matter. It has also been discussed at the Procedure Committee and I have therefore done so at the earliest opportunity. I am sure that the noble Lord, Lord Low, will be able to resume his argument but conclude fairly swiftly. Over to the noble Lord.

[Lord Low of Dalston]

I apologise to the Members of the Committee, who will understand my difficulty in that a considerable number of amendments to which I put my name have been grouped together. Five amendments in this group had my name and I had a little bit to say about all of them which I hope the Committee will have found useful. It is not my wish to try the patience of the Committee in any way so I will wind up my remarks immediately.

I echo the point made by the noble Lord, Lord Touhig, that greater concentration on prevention could actually save resources. In summary, prevention—or early intervention—matters: it works. The Bill needs to bring the Government’s White Paper vision of a genuinely preventive care system to life, but doing so relies on local authorities assessing how needs can be reduced or prevented from getting worse.

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

My Lords, it is always good when there is an outbreak of consensus across—

[Noble Lords]

Order!

[Baroness Jolly]

I will be brief. I support the amendment in the name of the noble Lord, Lord Rix, on preventing needs for care and support for those with learning disability. We need to remember that those for whom the Bill is written are all vulnerable adults: whether they are vulnerable by virtue of their age; their learning disability; mental state; physical condition, whether that is disability or frailty; whether they are living at home or in other accommodation. A local authority should take all steps it considers will contribute towards adults experiencing, or being put at risk of, abuse or neglect. We have just heard about preventive measures: these are preventive measures linking in with needs. The outcome of the amendment would be a reduction in incidents of neglect or abuse. It might mean local authority employees raising concerns about individuals or organisations providing care; making it a regular agenda item at a team meeting and not turning a blind eye; whistle-blowing where appropriate and making it part of the well-being culture.

Before I saw the regroupings, I had also intended to speak to the amendments of the noble Lord, Lord Best, which were, at one time, grouped together. Amendment 88 seems to have become an orphan amendment within this group. I support it but I will speak to it when the rest of the amendments are dealt with.

21:29

[Earl Howe]

My Lords, I apologise to my noble friend for intervening before she had a chance to speak. As the Committee will have gathered, I was observing that it is always good when there is an outbreak of consensus across the Chamber, and I think this is a case in point. It is critical that care and support work actively to promote people’s well-being and independence, rather than just waiting for people to reach crisis point. We want a system that promotes independence and reduces dependency as well as supporting those who already need care and support.

Preventing and delaying needs from arising, or reducing them where they exist, is a central part of local authorities’ modern responsibilities for care and support. Adopting preventive approaches can reduce needs in the longer term, saving public money and improving outcomes. There has never before been a clear legal duty that reflects this priority and establishes prevention as part of the core local authority responsibility. Clause 2 fills that gap, requiring local authorities to provide or arrange services to prevent, delay or reduce needs for care and support and carer’s support. This will create a legal basis for a wide range of preventive services that can help people maintain their independence for longer. The noble Lord, Lord Low, mentioned some good examples but they might also include exercise classes, which can help people maintain and increase their mobility, befriending services and hobby clubs, which can reduce loneliness and social isolation, and installing grab rails in a frail person’s home, which can prevent falls, broken bones and unnecessary stays in hospital. However, those are not the only examples. We want local authorities to be truly innovative in the services offered in their area, which is why we have not been prescriptive in the way that local authorities carry out the duties conferred by the clause. I agree with the noble Lord that these things can bring direct financial savings, and I quoted some good examples, I hope, in speaking on an earlier group of amendments.

Amendments 79A and 79K make the point that prevention should be an overarching principle of a local authority’s care and support functions, and that this should be framed in the context of well-being. This is surely right. To that end, Clause 1 sets out that in exercising care and support functions, local authorities must promote an individual’s well-being. This includes, among other things, having regard to preventing, delaying and reducing needs, as expressly stated in Clause 1(3)(c).

The noble Lord, Lord Rix, makes clear in tabling Amendment 79D the need for local authorities to be proactive in preventing, delaying and reducing needs for care and support, but also in safeguarding adults with needs for care and support from abuse or neglect. As he mentioned, Clause 41 does just that by requiring local authorities to ensure that inquiries are made when an adult with needs for care and support is at risk of abuse or neglect. Clause 42 and Schedule 2 create the legal framework for local authorities to establish safeguarding adult boards, which must devise, publish and implement annual strategic plans for adult safeguarding in their area. There will of course be the opportunity to discuss safeguarding in greater detail at a later date.

Amendment 80C, proposed by the noble Lord, Lord Low, raises the issue of prevention as part of the joint strategic needs assessment and joint health and well-being strategy under the Local Government and Public Involvement in Health Act 2007. I listened to him with care and hope that I can reassure him. The existing legislation in relation to these joint assessments and strategies is clear that where any needs can be met by the local authority exercising its functions under the prevention duty in Clause 2, these would be included as part of the joint assessments and strategies.

In Amendments 78C, 79C and 79G, the noble Baroness, Lady Greengross, highlights the importance of preventing, delaying and reducing health needs as well as needs for care and support. Again, I find myself in complete agreement with her and, as I said, I believe that the Bill achieves this laudable aim. This is where the importance of integration and co-operation can clearly be seen, a matter also raised by the noble Lord, Lord Hunt, in Amendment 79B. Clause 3 requires local authorities to promote the integration of care and support with health and health-related provision, including where this would contribute to preventing, delaying and reducing needs.

Clauses 6 and 7 require local authorities and their relevant partners to co-operate in the exercise of their care and support and carer’s support functions. Such co-operation is to be performed for the purposes of, among other things, promoting an individual’s well-being, which in turn includes having regard to the importance of prevention through Clause 1(3). Accordingly, there is a clear duty on local authorities and their relevant partners to co-operate with one another in preventing, delaying and reducing needs for care and support and carer’s support.

These duties, coupled with the return of public health responsibilities to local authorities as a result of the 2012 Act and the new prevention duty, present a unique opportunity for aligning prevention services across health and care and support. That is why local authorities will be required to ensure the co-operation of their director of public health, where relevant to care and support functions.

I turn briefly to Amendments 87F and 87G, tabled by the noble Lord, Lord Low, and the noble Baroness, Lady Greengross. The Government believe that the Care Bill allows for the assessment process fully to take account of prevention. As the well-being principle requires the local authority to have regard to the importance of preventing, reducing or delaying needs for care and support, it must also consider this when conducting an assessment.

Amendment 80A highlights that, to be able to prevent delay and reduce needs for care and support and thus promote independence and well-being, we need to improve the quality and diversity of preventive services, facilities and resources. To achieve this, Clause 5(7) makes explicit provision for local authorities to promote the diversity of services, resources and facilities which can prevent delay or reduce needs for care and support. As the noble Baroness also points out with Amendment 80B, commissioning decisions, including for preventive services, should be made on the best evidence available. In the case of preventive interventions, we know through engagement with the care and support sector that this is not yet as strong as we would like. The Government have committed to developing a library of evidence on prevention. That will enable commissioners to make decisions knowing what is proven to work and what is not. However, to be able to build this evidence base and to find the solutions to the care and support needs of the 21st century, we need to allow room for innovation in developing and testing new models of preventive interventions. Without breaking the mould of traditional care packages, pioneering solutions such as shared lives schemes, which offer an alternative model to home care or residential care using community networks, would not have been able to flourish.

The noble Baroness, Lady Greengross, observed that local authorities need more than a year to plan in terms of the budget cycle. Local authorities already have multiyear financial settlements and that gives them scope to plan services in the longer term The noble Lord, Lord Touhig, returned us to the important subject of autism. He remarked that adults with autism rely on low-level preventive services and he felt that the Bill does not do enough in this area. The reforms to care and support set out in the Bill will benefit people with disabilities, including people with autism. The provisions around prevention, personal budgets and transition between children and adult services are just some examples of new laws which will benefit many people with autism.

As local areas gain a better understanding of autism needs locally and develop autism commissioning plans, we expect them to look more at the cost benefits of more low-level and preventive services, such as befriending services or social skills training. Preventive services can be provided to prevent, delay or reduce needs for care and support, regardless of the level of need involved. I hope that I have reassured noble Lords that prevention is suitably reflected within the Bill and that the noble Baroness, Lady Greengross, will feel able to withdraw the amendment.

[Baroness Greengross]

My Lords, I was very encouraged by the words of the Minister, but I am still rather worried. It was great to hear the points made by the noble Lord, Lord Touhig, who is so knowledgeable about autism. I am also very grateful to the noble Lord, Lord Hunt, for his comments, and to the noble Lord, Lord Low, who made some very apposite points about prevention. If I were a director of adult social services and had very limited funds, I would have to concentrate on the people in the greatest need, and it would be likely that prevention would slip to a lower level of my attention. This is the danger of preventive services not getting the attention that they need. I have yet to be totally convinced that prevention will prevail in the way that the noble Earl suggested. I hope that he is right.

We need a longer timeframe. It is difficult for local authorities to budget in that way, but it is essential if we are to focus on preventive services in the long run. I hope that, as we go through the remaining parts of the Bill, we can be clearer about how to ensure that prevention is at the top of our list. That will apply to eligibility criteria, which we will look at later. In the mean time, I thank all noble Lords who supported what I said and my colleagues for their support. I beg leave to withdraw the amendment.

Amendment 78C withdrawn.

Amendments 78D and 78E not moved.

Amendment 78F

Moved by

[Baroness Pitkeathley]

78F: Clause 1, page 2, line 25, at end insert—
“( ) For the purposes of this section, “an individual” includes the parents of disabled children.”

[Baroness Pitkeathley]

My Lords, I will speak also to Amendments 79E, 79H and 88C, all of which are about parent carers, and later to Amendments 88E and 88F, which are about other aspects of carers.

The Care Bill is drafted to apply to adult carers of adults. This means that parents of disabled children are not included in the important new rights and duties introduced by the Bill. The amendments in this group seek to probe the Government’s intentions regarding parents of disabled children, and how their rights can be put on a par with those of other carers.

Under the Care Bill, a carer is an adult who provides or intends to provide care for another adult. It is therefore clear that parent carers of disabled children aged under 18 are excluded from the new entitlements. Parent carers are left with the existing statutory scheme and previous carers Acts, which are mostly Private Members’ Bills. While these Acts impose obligations on the local authority to assess parent carers’ needs, there is no statutory duty to provide services to meet carers’ needs.

In a recent report on the Children and Families Bill, published on 27 June, the Joint Committee on Human Rights acknowledged the concerns about the future of parent carers’ rights, but argued that it was a matter for the Care Bill. As these rights currently sit within children’s legislation, amendments to the Children and Families Bill are therefore needed to put the rights of parents of disabled children on the same level as those of other carers. I know that discussions are going on, and that Ministers have said that amendments will be introduced to the Children and Families Bill. However, it is important that parents caring for disabled children do not fall through the cracks, and that the Government acknowledge the need to give them parity with other carers. How will the Government ensure parity of rights for parents of disabled children, and how will they resolve the issue of whether this matter sits best within this Bill or the Children and Families Bill?

Amendment 78F includes parent carers in the well-being clause. The intention of the amendment is to include the parents of disabled children in the duty placed on local authorities by Clause 1 to promote the well-being of the adult who is carrying out functions under the Bill in relation to another adult. If anyone doubts whether this is necessary, they should remember that 72% of parent carers experience mental ill health, such as anxiety, depression or breakdown; 57% say that lack of support from statutory services means that they are isolated and not able to work as they would like; and one in five says that isolation has led to the break-up of family life.

Amendments 79E and 79H are about including parent carers in the prevention clause. Clause 2 requires local authorities to take steps, including providing or arranging services which are intended to prevent, reduce or delay the need for care and support by all local people, including adults and carers of adults. These amendments seek to include parents of disabled children —referred to here as “child carers”—in this duty so that local authorities have a duty to prevent or delay the development of the need of the parent carers for support. My apologies if any confusion has been caused by the use of the words “child carers”. We often use this term to refer to young carers, who are referred to elsewhere in amendments in this group. However, I wanted to be sure that the Government understood that this was not necessarily the parent of a child—it could be a parent, a grandparent or another relative. I hope that that has not caused any confusion.

21:45

Parent carers too often reach crisis point, leading to high-cost interventions. In addition to the negative impact on outcomes for the whole family of parental mental and physical ill health, relationship breakdown and unemployment, it can also result in substantial costs to local authorities, commissioners and the economy.

Amendment 88C includes parent carers in the duty to assess. The Bill makes it easier for adults caring for adults to receive a carer’s assessment by creating an automatic right to assessment. This is very much to be welcomed because it removes the requirement that they provide “regular and substantial care”. However, unless changes are brought forward for parents of disabled children, they will still need to request a carer’s assessment from their local authority and they will not have a right to an assessment unless they provide regular and substantial care. Therefore, this amendment seeks to include parents of disabled children in the duty on local authorities to assess carers.

Parents commonly report an inability to get support that fits the whole family. They quite often need to devote space and time to their own lives and to the lives of the other children in their family. Often, the last person whom parents consider is themselves—until it is too late. Therefore, an earlier assessment, removing the barriers and establishing the overarching principle of well-being for a group that currently misses out could improve the rights of thousands of parents in England. This is a vital role that could be played by services.

The next amendment in this group in my name is Amendment 88E, which is about clarifying the responsibility of carers under NHS continuing care. There is confusion over who is responsible for carers who provide care for somebody receiving NHS continuing care services in the community, and this can lead to carers being refused an assessment and support services from their local authority. Therefore, this amendment seeks to clarify that local authorities still have a duty of care to the carer if the disabled person is receiving NHS continuing care services in the community.

My final amendment in this group is Amendment 88F, which is about the health promotion of carers. Carers often take a long time to identify themselves as carers. They say that they are not a carer but a wife, a husband, a brother, a sister or a son. Carers UK found that 25% of carers took five years or more to recognise themselves as carers. Research from Carers UK shows that the high turnover of people taking on caring responsibilities means that as many as 2.3 million people start caring and a similar proportion cease caring. This combination of high turnover and the “hidden carer” effect may go some way to explain why an estimated £840 million in carers’ benefits alone go unclaimed every year. Once identified as carers, practical and financial support can be made available, and that can help carers to cope. Information strategies therefore need to be carefully targeted to ensure that carers do not miss out on their entitlements.

We know that care by families and friends is often provided at the cost of their own health. I think it is true to say that the NHS, in all its forms, has been slower to recognise the needs of carers than have local authorities. This amendment is about evening up that balance a little.

I end with the words of a carer:

“I have received some support and advice but only when I have asked for it. I feel that GPs and community nurses should do more to help carers. Very often carers don’t even have time to make appointments. Therefore, it would be helpful … if GPs and nurses took the initiative more often”.

I beg to move.

[Baroness Royall of Blaisdon]

My Lords, I shall speak to Amendment 79L tabled by the noble Lord, Lord Patel, who unfortunately cannot be in his place this evening. The purpose of the amendment to which I have added my name is to ensure that carers are identified and signposted to the enhanced support outlined in the Bill as early as possible and before they reach crisis point. I put my name to this amendment following a discussion with Macmillan, to which I am very grateful for its excellent briefing, about the situation of approximately 905,000 cancer carers in England, half of whom are not receiving any support despite the fact that cancer has a real impact on their lives. Of course, the impact is nowhere near as big as that on the person with cancer but nearly half of carers say that it affects their mental health and well-being; one in five says that it affects their relationships and working life; and 15% say that it affects their household finances. Almost half of cancer carers identify at least one type of support they are not currently receiving that would assist them with their caring duties. They are in real need of help but are not aware of who or where to turn for support.

As many noble Lords will know from personal experience, the real problem is that many cancer carers do not think of themselves as carers but they might well need information, advice or support. Indeed, my noble friend Lady Pitkeathley has just made the same point in general about all carers. They have no idea about things such as the local authority carers’ assessment, which is the gateway to statutory support. Consequently, the number of cancer carers who have had such an assessment is far lower than for those caring for people with other conditions and disabilities. Evidence shows that health professionals simply do not identify cancer carers as carers and do not signpost them to help or support.

Therefore, while I welcome the fact that the Care Bill enhances rights for carers, including placing a new duty on local authorities to undertake a carers’ assessment for all carers and to meet the eligible needs of carers, there is a gap which this amendment is designed to fill. Cancer carers have a lot of contact with the NHS but they seldom come into contact with local authorities. This amendment would help to ensure that all NHS bodies work with local authorities to improve the identification of all carers so that in turn they can be assessed and access appropriate support.

In the Care and Support White Paper the Government said that,

“there is still an unacceptable variation in access to tailored support for carers”.

It outlines its requirement for,

“NHS organisations to work with their local authority partners … to agree plans and budgets for identifying and supporting carers”.

This amendment would provide a vehicle for ensuring that this optimal practice of joint identification and partnership became a reality throughout England where, at the moment, the identification is at best patchy and at worst non-existent. Local authorities should take the lead but they could benefit greatly from the help of many relevant health bodies such as NHS England, CCGs, and primary care and hospital trusts which already have procedures and systems in place to identify carers. Clearly, that does not always happen.

The amendment would not lead to additional expenditure. In fact, if carers were identified as early as possible, when in most cases they just need signposting to information and advice, it could save money. Fewer carers would reach the sort of crisis point that requires NHS support for themselves and local authority support for the person for whom they are caring.

On Saturday, I was in Torbay and I talked with some people about their excellent system of integrated healthcare in which they understand that a whole-system approach is needed to support carers and that proactive identification is needed by the NHS. I was therefore interested to read a quote from Mr James Drummond, lead officer for integrated services at the Torbay and Southern Devon Health and Care NHS Trust, in which he says:

“If we wait for carers to approach us we may not engage until there is a crisis. Proactive identification is good practice, but national support is needed to spread this across the country. It should be made clear that identifying carers and signposting them to support is the responsibility of all health and social care professionals, not just local authorities”.

That says it all. I know that the Government recognise the need for the NHS and local authorities to work together on this important issue so I very much hope that the noble Earl will use this amendment and agree to look at ways of formally involving the NHS in the local authority duty to identify carers.

[Lord Hunt of Kings Heath]

My Lords, this is a very important group of amendments, and I very much support my noble friend Lady Pitkeathley in her Amendments 78F, 79E, 79H, 88C, 88E and 88F. I also support my noble friend the Leader of the Opposition in her Amendment 79L, emphasising the importance of working with the National Health Service.

My Amendments 79F, 79J and 79M to Clause 2 concern the position of young carers. They aim essentially to ensure that local authorities provide or arrange services to prevent young carers from developing needs for care and support, as well as preventing and reducing needs for adults and adult carers. The 2011 census identified 178,000 young carers who have to care for a relative in England and Wales alone. It is good that the Government have now acknowledged that, given the changes being introduced by the Care Bill for adult carers, the law must also be reviewed for young carers. However, we need a much clearer indication of what these changes will look like and particularly of how the Care Bill will ensure that adults receive sufficient care and support so that children are protected from excessive and inappropriate caring roles. We cannot have a situation where people have unmet care and support needs, which results in children and young people having to meet these needs.

I recently met a young man who had been caring for someone in his family for most of his life. He told me that it would have made a huge difference to him if his family had received support earlier. If this had happened, his caring responsibilities might not have had such a clear and serious impact on his education. He is doing well now and hopes to go to university, but it has clearly been extremely challenging for him to stay in education, and there are many thousands of other young people who have been similarly affected. That is why my amendments to Clause 2 are so important. They make clear that local authorities must take steps to prevent children from carrying out caring duties that have a detrimental effect on their health and well-being. Can the noble Earl assure me that the Care Bill will be amended to ensure that this is the case? If he can, I would welcome an indication of which parts of the Bill will be amended so that young carers are protected.

My other amendments on this issue are to Clause 12, which provides for regulations on whole-family assessment. Again, the Government have indicated that they will look at how the law might be changed for young carers in the Bill, but it is not clear how that might be done. We know that currently adult social care services and health services routinely fail to identify children who may be caring for an adult, even where the adult is assessed. That also applies to educational establishments. That means that often children can continue to undertake harmful caring roles and end up developing needs for care and support themselves.

It is very important that adult needs assessments relate to any child in the household, so that inappropriate caring by children is prevented and children's needs for support are prevented or reduced. The law must be clear that adult services need to help to identify young carers. The presence of a young carer should always constitute an appearance of need for the family and should automatically trigger an assessment of the person for whom they care. Can the noble Earl confirm that this is indeed the Government’s view? Will it be made clear, through primary care or regulations, that there should be consideration of whether a joint child and adult assessment would be appropriate and that children’s services should work together; consideration of whether any child should be assessed for support in their own right under children’s law; and consideration of whether lower-level support may be needed for the whole family, including the child?

It is a pity that we are taking this important debate at so late an hour, and no doubt we will return to this matter on Report, but I look forward to the noble Earl’s response.

21:59

[Baroness Gale]

My Lords, Amendment 88H seeks to amend Clause 12. The clause provides an excellent framework for assessments to be carried out by local authorities. However, the clause should be tightened to ensure that the framework is fully and properly implemented.

People with Parkinson’s and long-term conditions have problems in accessing NHS continuing healthcare. The APPG on Parkinson’s, which I chair, is holding an inquiry into NHS continuing care. We have been hearing about the difficulties people experience in finding out about NHS continuing care and the further difficulties in getting an assessment. Even when people are assessed, the assessment can be fraught with problems such as assessors not really understanding the condition and even assessments happening without people knowing about them.

Clause 12(1)(g) states that the regulations may,

“specify circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare”.

The Care and Support Alliance believes we must ensure that local authorities and health services work together and make people aware of NHS continuing care and that people are referred on to continuing care assessments when there is a health need.

The importance of this cannot be understated. Social care is means tested and healthcare is free, so whether someone is funded by the NHS or through means-tested social care systems has significant cost implications for that individual. The Care Bill provides a perfect opportunity for councils to ensure that people who may well be eligible for free NHS continuing care are rightly signposted to, and assessed for, it.

Clause 12 offers guidance about what may be in the regulations relating to assessing social care needs and assessments for carers under Clauses 9 and 10. It states that regulations “may” make provision on the circumstances in which the local authority must refer the adult for continuing care. This does not go far enough and the word “may” should be amended to “must”. If there is not a clear mandate placed within these regulations, the vital issue of signposting for services and systems such as continuing care could be overlooked in the drafting of these important regulations.

The regulations must make provision for the circumstances where local authorities may refer the adult on to NHS continuing healthcare. There is a lack of knowledge about who is eligible and the funding that people are potentially entitled to, so we should have certainty that these regulations will stipulate these circumstances. This should lead to a greater awareness of NHS continuing healthcare and greater access.

These attributes could ensure that all assessments are carried out in a way that supports the individual, take into account their needs and the needs of their families and carers, ensure that the appropriate professionals and experts are involved in the assessments and that people are referred on to NHS continuing healthcare as appropriate. I know that “may” and “must” are very small words, but I hope that the Minister will take note and agree to the amendment.

[Earl Howe]

My Lords, the Care Bill marks a historic step forward in improving the rights of adult carers. Although successive Governments have recognised the contribution carers make and have supported Private Member’s Bills about carers, this is the first time that the Government have included specific provision for carers’ rights to social care in their legislative programme. These provisions have been warmly welcomed.

Amendments 88E and 88F, tabled by the noble Baroness, Lady Pitkeathley, bring to the attention of the Committee the important role that the NHS can play in helping those with caring responsibilities look after their own health, identify themselves as carers and access information and advice.

Clinical commissioning groups already work with local authorities through health and well-being boards to understand and plan for identifying and supporting carers. Many clinical commissioning groups already have, or are developing, joint carer strategies. Importantly, the pooled health and care budget for 2015-16 announced last week as part of the spending round will help health and care and support to work together in supporting carers.

I quite agree that it is, of course, crucial that steps are taken to help individuals with caring responsibilities to identify themselves as carers. The Department of Health has provided over £1.5 million to the Royal College of GPs, nursing and carers’ voluntary organisations over recent years to develop training and resources to help those working in primary and community healthcare to support people with caring responsibilities. We will consider further bids to extend this work programme, including extending support to nurses working on hospital wards and outpatient departments.

I listened with care to the noble Baroness, Lady Royall, in this context and I would say that carers of people with cancer will benefit from steps which NHS England and the Department of Health are taking, some of which I have already referred to. I would also say that the current initiatives have unleashed an enormous amount of enthusiasm among frontline staff, and both nurse and GP carer champions and voluntary sector carers’ ambassadors have been recruited. They are increasing understanding about supporting carers locally at both strategic and practice levels.

In terms of identifying carers and helping them to access support, it is also critical to align assessments undertaken by other bodies, including NHS continuing healthcare assessments undertaken by clinical commissioning groups. If a carer is identified in the course of an NHS continuing healthcare assessment, the national framework for NHS continuing healthcare and NHS-funded nursing care makes clear that the clinical commissioning group should inform them about their entitlement to have their needs as a carer assessed and, where appropriate, either advise the carer to contact the local authority or, with the carer’s permission, refer them to the local authority for an assessment.

The provisions in the Care Bill provide a lower threshold for a carer’s assessment than exists now. A situation where the person whom the carer supports is being assessed for NHS continuing healthcare is highly likely to be regarded by a local authority as one where it appears the carer may have a need for support. A carer’s assessment would then be triggered. Clause 10(5) already requires a carer’s assessment to include an assessment of whether the carer is able and willing, and is likely to continue to be able, to provide care for the person needing care. Moreover, regulations under Clause 12 may make provisions for joint assessments. We will consider such particular circumstances further as we develop these regulations.

I turn now to Amendments 78F, 79E, 79H and 88C relating to disabled children. I would not wish to underestimate the challenges that families can face in supporting these young people. Policy on supporting children and families of course lies with the Department for Education. The Minister for Children and Families’ view is that there is already sufficient provision under Section 17 of the Children Act 1989 to provide for the assessment and support of children in need, including disabled children, and their parents. The Department for Education’s investment in parent carers’ forums and short breaks provision for disabled children in recent years have helped to shape family support.

In addition, the special educational needs reforms in the Children and Families Bill, which received its Second Reading in this House yesterday, are intended to give parents much more choice and control about the support they and their children receive. My noble friend Lord Nash confirmed yesterday, at Second Reading, that the Department for Education would consider how legislation for young carers might be changed. I simply ask noble Lords to be a little more patient in waiting for those proposals.

Before turning to the effect of Amendments 79F, 79J, 79M, 88H and 88K, tabled by the noble Lord, Lord Hunt, and members of the Opposition Front Bench, I would like to confirm, as I hope my words just now have, that both the Minister for Care and Support and the Minister for Children and Families are clear about the need to protect young carers from excessive and inappropriate caring by using “whole family” approaches.

Young carers should be regarded first and foremost as children and they should be assessed and supported in the context of children’s legislation. The Minister for Children and Families has confirmed that his department will look at what it can do to remove any legal barriers preventing young carers and their families from receiving the support they need under children’s legislation. We will also work to ensure that children’s legislation works with adult legislation to support the whole family in a meaningful way.

These amendments would extend the requirements on a local authority to prevent and reduce the needs of children caring for either an adult or a child. The local authority would also be required, when identifying carers in the area with needs for support, to include young carers aged under 18. One of the key principles when considering young carers is to address first what is needed to support adults in the family with care and support needs, and then see what remaining needs for support a young carer in the family has.

I hope I can reassure noble Lords that, first, through the provisions in Clause 2 to establish prevention as a core duty of local authorities, and secondly, through the provisions in Clause 12 to make regulations about a “whole family” approach to assessment of adults, we are ensuring that adult care and support makes the appropriate contribution to supporting children and young people with caring responsibilities as well.

Of course, provision of preventive services for adults would be of benefit to other family members, including children, by preventing or delaying either an adult’s needs for care and support or an adult carer’s needs for support. As it stands, without this amendment, I believe that the provisions of Clause 2 will help children and young people significantly.

Amendment 88H looks to require the Secretary of State to make regulations in all the areas listed in Clause 12(1). I reassure the noble Lord, Lord Hunt, that this is our intention, as these are essential in ensuring that the assessment is carried out in an appropriate and proportionate way. In relation to the noble Lord’s Amendment 88K, I confirm that we intend in regulations to make clear that a local authority should have regard to the needs of children in the family, and indeed we would wish to encompass other significant family relationships as well.

As I have set out, robust arrangements are in hand to ensure that carers are identified and supported by the NHS and local authorities, and that both parent carers of disabled children and young carers are adequately and appropriately supported under children’s legislation. The Department of Health and the Department for Education will continue to work closely together to ensure that children’s and adult legislation join up in respect of supporting adults with parenting responsibilities, and in the period of transition from children’s to adult services. I hope that those remarks will be sufficient to enable the noble Baroness to withdraw her amendment.

[Baroness Pitkeathley]

My Lords, I am grateful to all noble Lords who have spoken and for the recognition that all noble Lords have shown of the problems of carers, as well as the commitment to giving carers the support that they so much need. It is recognition of the fact that, however good a health and care system we put in place, the vast bulk of care will continue to be provided by our families and friends.

I know that the Minister shares this understanding and commitment and I acknowledge the attention given to carers in this Care Bill. In the history of the carers’ movement, with which I have been associated for nearly 30 years, it is truly the most significant development that we have seen.

The hour is late and I think that many more people would have wished to speak on this had we been debating it at a different time of day. I hear what the Minister says about young carers and parent carers. We need to monitor very carefully the progress of the Children and Families Bill to see how that Bill pans out and particularly how the two bits of legislation join up, as the Minister put it. In the mean time, reserving the right to come back to these issues on Report, I beg leave to withdraw the amendment.

Amendment 78F withdrawn.

Amendment 79 not moved.

Clause 1 agreed.

Clause 2 : Preventing needs for care and support

Amendments 79A to 79M not moved.

House resumed.

House adjourned at 10.16 pm.