House of Lords
Global Partnership for Aid Effectiveness
(10 years, 9 months ago)
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Lord Chidgey
To ask Her Majesty’s Government what progress they have made, as part of the Global Partnership for Aid Effectiveness, in developing and specifying the aid effectiveness indicators outlined in the global agreement reached at the High Level Forum in Busan.
Baroness Northover
My Lords, 10 indicators and associated targets for a framework to track global development effectiveness were agreed internationally in June 2012. The UK has provided detailed feedback on proposed data to be used for each indicator. These data will be collected until mid-September and published in time for a major meeting on development effectiveness in early 2014.
Lord Chidgey
My Lords, I thank my noble friend for that reply. The Busan agreement includes the commitment to strengthen the role of Parliaments in the oversight of the development process by monitoring to ensure that aid is on budget lines that are subject to parliamentary scrutiny. What measures are the Government taking to ensure that the Busan parliamentary scrutiny includes democratic accountability, challenging the view of some that there is no relationship between democracy and development? What plans do the Government have to compensate for the drain on parliamentary capacity in developing countries caused by the high percentage of parliamentary staff trained under aid programmes leaving for more attractive posts elsewhere?
Baroness Northover
As my noble friend will know, parliamentarians are represented in the global partnership steering committee meetings, and DfID certainly believes that democratic government helps to promote sustainable development in the way which he has indicated. That is why we are supporting democratic elections through various programmes and other work, which we will be supporting in 13 countries by 2015. As for his point about the drain in staff, between 2011 and 2012 DfID invested £181 million in public sector reform, which includes improvement of staff performance and retention. We very much understand my noble friend’s point.
Lord Judd
My Lords, is it not very important to realise that if development is to be sustained, it is necessary to have stability and security? Can the Minister give us an assurance that, whatever happens, we will continue to give priority to the security sector reform programme, which tries to ensure that there are effective security arrangements that are also based on transparency and human rights?
Baroness Northover
I can give the noble Lord that assurance. He will note that it is a crucial part of the arrangements in the new deal for fragile states, and it also underlies and is an extremely important part of our principles regarding where we are willing to give budget support.
Baroness Hayman
My Lords, although I fully support the development of technical indicators for aid effectiveness, will the Minister confirm that there is manifold evidence that the most effective form of aid is that which concentrates on the social, economic and educational development of women?
Baroness Northover
The noble Baroness is absolutely right, which is why we have put women and girls very much at the centre of what DfID does. Education is part of that. As for the stages of development of various countries, I note that the countries that are most developed have the highest levels of educational enrolment and adult literacy.
Baroness Jenkin of Kennington
My Lords, does my noble friend agree that many of the aid-effectiveness indicators agreed at Busan—for example, the governance indicator which features so heavily at the G8—are already part of the Government’s development strategy?
Baroness Northover
My noble friend is quite right, and if she looks—as I am sure she has—at the recent DfID annual report, she will see that evidence there. It is extremely important that both aid givers, such as the United Kingdom, and aid recipients make sure that they address the requirements laid down in Busan. Only by doing so will we ensure that aid is most effectively delivered and has its greatest effect.
Lord Anderson of Swansea
My Lords, on the drain of staff, how does one seek to resolve the problem of staff of talent being attracted into the private sector, and also into the international organisation sector, with salaries that are perhaps four or five times more than they can get in their own Administrations? That only encourages corruption.
Baroness Northover
The noble Lord might look at the United Kingdom, too, and wonder whether that is a challenge that we also face. Of course it is a challenge, and it is one that we are well aware of. It is encouraging to see that there are very talented people working within, for example, the sovereign wealth funds, which can be useful instruments in the economic development of some of those countries.
Baroness Tonge
My Lords, have the Government made an assessment of the effectiveness of aid to the Palestinians? Can the Minister also tell us whether the Government have made any attempt to recoup the cost of that aid from the Government of Israel, who are, after all, responsible under Geneva conventions for the welfare of the people whose land they occupy?
Baroness Northover
The noble Baroness has made this point before. We constantly monitor the situation with the Palestinians. We are very concerned about their situation and frequently make the case about it to the Government of Israel. I would also point out, as I have before, that we need to see peacebuilding measures between the Israelis and the Palestinians, which will be in the interests of both sides.
Lord Ashdown of Norton-sub-Hamdon
My Lords, my driver in Bosnia and Herzegovina earned more than the local Prime Minister. Does my noble friend not realise that unless something serious is done about this problem of the internal brain drain to the international organisations, steps to try to help failed states recover after conflict will be seriously hog-tied?
Baroness Northover
My noble friend has enormous experience, of course. It is lessons such as those which he derives from Bosnia that we carry over when trying to rebuild in fragile states elsewhere, for example in Afghanistan. We are aware of these challenges, which is why the United Nations and the international bodies seek to address them.
The Earl of Sandwich
My Lords, when the Government have discovered which of their programmes are effective, will they make more effort to communicate this to the general public, who are still largely in ignorance of the aid programme?
Baroness Northover
There is sometimes a disconnect between what comes over in Comic Relief programmes, which people sign up to and understand—for example, linking back to the question from the noble Baroness, Lady Hayman, the importance of education and its transformative effect, especially for girls—and the news that sometimes comes out via some of our newspapers. We all need to continue to emphasise how effective and transformative aid can be.
Housing: Rent Levels
Baroness Turner of Camden
To ask Her Majesty’s Government what steps they are taking to deal with the level of rents being charged by private landlords, particularly in London, and their impact on housing benefit.
Lord Ahmad of Wimbledon
My Lords, across England, increases in private sector rents in recent years have been modest and below inflation. Over the 12 months to May 2013 private rents increased by 1.3%; this compares with the CPI of 2.7%. We are also encouraging the supply of new homes with a £1 billion build-to-rent fund which will help to keep rent levels down.
Baroness Turner of Camden
I thank the Minister for that response. Is he not aware that we are facing a bit of a housing crisis at the moment, particularly in London? Younger people cannot afford the deposit to buy a place and cannot afford the rents because they are far too high. Is the Minister aware that following the last war there was also a housing crisis and that the Government then dealt with it by building lots of small houses—the famous prefabs—and also introduced a system of rent controls through the rent tribunals so that people were not pushed into poverty by trying to pay for a roof over their heads? Can we not sometimes learn something from our predecessors?
Lord Ahmad of Wimbledon
The Government are fully aware of the housing challenges. In London the mayor’s housing covenant contains detailed proposals for improving London’s private rental sector. The housing guarantee schemes are intended to help expand the provision of large-scale, professionally managed rented housing and to support economic growth. Of course, as was recently announced, the Government have allocated an additional £3 billion to a housebuilding programme. We are embarked on the biggest housebuilding programme of the past 20 years, and that should be appreciated and commended.
Baroness Maddock
My Lords, my noble friend indicated that one of the problems with high rents in the private sector is lack of supply. Did he see something interesting in the newspaper this week: that in many towns with a high student population the students occupy houses that could be lived in by families if we were to build more proper student accommodation there? Will the Government see if there is any mileage in that?
Lord Ahmad of Wimbledon
My noble friend raises an important point. The Government are forever looking at ways that we can help address the housing challenges in particular cities, and if there are good practices I will take them back and share them across the country.
Baroness Hollis of Heigham
My Lords, is the Minister aware that the highly respected Chartered Institute of Housing reported last week that, because there are so few vacant smaller properties in the social sector, four-fifths of underoccupying tenants who need to move will have to go into the private rented sector where, as my noble friend said, rents are higher and so the housing benefit bill will soar. Does the Minister accept that as a result, 660,000 families will have their lives turned upside down and at the end of it there will be no savings but instead an increase in public expenditure?
Lord Ahmad of Wimbledon
As I said in answer to a previous question, the Government are embarked on one of the biggest ever housebuilding programmes, both for the rental sector and for affordable housing. There are challenges ahead with the housing crisis. I am sorry that noble Lords opposite do not appreciate that. We took on one of the biggest challenges with the housing crisis and, unlike the party opposite, are addressing it head on.
The Lord Bishop of Leicester
My Lords, more than one-third of privately renting households are families with children, yet typical tenancies remain short-term with little assurance about when rents may rise or how long they will be able to stay in their home. Uncertainty of this kind is particularly damaging for families trying to give their children stability. Will the Government give serious consideration to Shelter’s proposal to develop and promote stable rental contracts that would offer renters a five-year tenancy agreement and tie rent increases to inflation?
Lord Ahmad of Wimbledon
The right reverend Prelate makes an important point. I have seen the Shelter policy. Security of tenure has increased. Recent figures from the English Housing Survey show that only 9% of tenancies are ended by the landlord. We have seen an increasing percentage of people staying in their accommodation for more than two years. That is to be appreciated. We are looking at Shelter’s proposition, which came out in its September 2012 report.
Lord McKenzie of Luton
My Lords, is not the reality that the Government have created a vicious cycle where those deemed to underoccupy cannot move in the social rented sector because of the lack of appropriate smaller accommodation, cannot afford the extra rent payable to stay put because of the bedroom tax and, at a time when rents are planned to rise by CPI plus 1% for the next 10 years, cannot afford to move to the private rented sector where rents are soaring while housing support, the local housing allowance, is to be restricted to a 1% uprating? Is this not bound to lead to greater homelessness, more misery for families and more cost to the taxpayer? Which genius invented these policies?
Lord Ahmad of Wimbledon
I suppose I should ask the noble Lord which genius created these problems. Part of the challenge for this Government is to look at the current crisis. As I indicated, we have embarked on the biggest housebuilding programme both in the private rented sector and in affordable housing. The noble Lord raised housing benefit. The Government have looked at it. It is being raised by CPI, and it will be raised by another 1%, but generally the party opposite should not look at a picture of gloom. There is a picture of optimism emerging in terms of housing for the long term. That will be seen over the next few years.
Baroness Farrington of Ribbleton
Will the Minister explain why, if the Government’s policy of building more houses is so good, it is not starting now?
Lord Ahmad of Wimbledon
It is starting now. We have already committed to build 170,000 new homes by 2015 and a further 30,000 by 2017. As recent announcements have indicated, another 10,000 homes will be on line as well. Over the next four years, 200,000 homes will be coming on line by 2018. That is putting the record straight.
NHS: Foundation Trusts
(10 years, 9 months ago)
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Lord Warner
To ask Her Majesty’s Government what progress the NHS Trust Development Authority will have made by April 2014 with NHS Trusts becoming NHS Foundation Trusts; and when they forecast that the Authority will have completed its work.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in the light of Robert Francis’s recent report, we have allowed the NHS Trust Development Authority to agree trajectories for NHS trusts to reach foundation trust status that go beyond 2014 on a case-by-case basis. In doing so, we will ensure that the primary focus of the NHS Trust Development Authority and of NHS trusts themselves is on improving the quality and sustainability of services for patients.
Lord Warner
My Lords, I thank the Minister for that reply. Does he recall that in a recent Written Answer to me he identified 26 acute hospitals under the stewardship of the TDA which have cumulative deficits running into hundreds of millions of pounds? Does he agree that many of them are unsustainable and potentially unsafe and need their services reconfigured? Will he tell the House why the Government refuse to publish the review by Sir Ian Carruthers on the procedures for service reconfiguration and why they resist publication by declining FOI requests?
Earl Howe
My Lords, there is no doubt—and we have never denied this—that there will be a hard core of organisations which will be very difficult, if not impossible, to bring to foundation trust status. For those trusts, it is necessary to look at other options, including, for example, mergers. That work is being taken forward. Although some trusts are in deficit, the NHS TDA is working very hard to mitigate those deficits in-year and when the first quarter board papers are published in September we will know what its predictions are for all trusts for the current year. I will come back to the noble Lord on the report of Sir Ian Carruthers because all FOI decisions are reviewed at regular intervals to make sure they are current. I want to make sure that there is a plan to release that information in due course. I am sure that there is.
Baroness Knight of Collingtree
My Lords, following yesterday’s Written Statement, in which the Government indicated total support for the review carried out so expertly by the noble Baroness, Lady Neuberger, on the Liverpool Care Pathway, can my noble friend the Minister confirm that the trusts will take immediate action to implement its recommendations?
Earl Howe
My Lords, I hope my noble friend will allow that that is a little wide of the Question on the Order Paper, which is about bringing trusts to foundation trust status. Nevertheless, I refer my noble friend to the Written Answer which was published in Hansard yesterday and which sets out the immediate steps we have taken to instruct all hospitals to review all patients currently on the Liverpool Care Pathway and to make sure that there is a named, responsible clinician for every patient at the end of life.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. Is the failure to publish the reconfiguration paper by Sir Ian Carruthers due to the intervention of the Competition Commission in proposed mergers and reconfiguration of services in the NHS? Is the noble Earl aware that it was reported in the other place this morning that the intervention of the Competition Commission in the Dorset merger will cost £6 million which should have been spent on patient services? When will the Government start to ensure that the foolish intervention by the Competition Commission which is not needed in the health service stops and money that could be spent on patient services is actually spent on them?
Earl Howe
My Lords, I am sure the noble Lord is aware that the provision for reviewing NHS mergers on competition grounds is not at all new. Responsibility for reviewing NHS mergers has moved from one independent body—the Co-operation and Competition Panel—to another, the OFT. This is a continuation of the approach that has been in place since 2009. In all these decisions what matters is what is in the interests of patients. The competition authorities will continue to review whether the potential benefits of a merger outweigh the potential costs to patients.
Baroness Jolly
My Lords, would my noble friend confirm whether any of those trusts yet to achieve foundation trust status were planning to merge with any on today’s Bruce Keogh list?
Baroness Cumberlege
My Lords, my interests are declared in the Register of Lords’ Interests. Complicated organisations, such as hospitals of every sort, need outstanding, in-depth leadership from all quarters. Does my noble friend agree that clinicians should provide that leadership but that if there is an overwhelming culture of retribution there is no incentive for them to take on these very demanding roles? What incentives can the Government introduce to ensure that the most talented doctors and nurses are attracted to lead the NHS and take on these very high risk jobs?
Earl Howe
My noble friend makes a vital point. If we are to strive for excellence in the health service, leadership is essential. That is the reason why the NHS Leadership Academy has been established—to encourage not only managers but clinicians and nurses to take leadership roles in the health service for the very reasons that my noble friend states.
Lord Brooke of Alverthorpe
My Lords, given the Government’s commitment to the duty of candour in the NHS, can the Minister give us an indication of some of the reasons why there has been a long delay in the production of Sir Ian Carruthers’s report?
Earl Howe
My Lords, I am not aware of the underlying reasons why Sir Ian Carruthers’s report has not been released. As far as I am aware, that is a matter for NHS England. However, if I can enlighten the noble Lord, I will be happy to write to him. I can say that the programme for bringing trusts to foundation trust status has to be taken slightly more slowly than we thought was appropriate perhaps a couple of years ago. That is because of the Francis report. I make no apology for that, because it is right for trusts to take a longer and harder look at the issues that Robert Francis flagged up.
Smoking: Cigarette Packaging
(10 years, 9 months ago)
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Baroness Finlay of Llandaff
To ask Her Majesty’s Government what is the basis for the decision not to proceed with standardised packaging of cigarettes.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
Standardised packaging remains a policy under active consideration. The Government have not ruled out its introduction. However, we want to spend more time assimilating information about the likely effect of such a policy in this country and learning from experience abroad. Let me be clear: we are not going soft on tobacco, which is a leading cause of premature death. We have an ambitious tobacco control plan and will press ahead with tobacco control policies, including removing tobacco from displays in shops.
Baroness Finlay of Llandaff
I declare my interest as president-elect of the BMA. As 200,000 11 to 15 year- olds start smoking each year in the UK, what are the criteria and time frames that the Government will use to judge the outcomes of standardised packaging in Australia? The high mortality rate does not appear until about 25 years after these youngsters start smoking. As this is fundamentally a child protection issue, how will the Government now prevent vulnerable children—particularly those in local authority care—from starting smoking, given that the Department of Health’s own systematic review showed that current packs are particularly attractive to youngsters and that they mislead them into thinking that some brands are less harmful than others?
Earl Howe
My Lords, we want to keep a close eye on what is happening around the world before making a decision. We are keeping standardised packaging under active consideration. It has been newly introduced in Australia, and other countries are intending to follow suit, so it is sensible for us to see what we can learn from other countries’ experience. The impacts could be several. They could include, for example, health benefits, as well as impacts on businesses such as retailers and tobacco manufacturers, and could possibly bring about a change in attitude to smoking.
On the risk to children, the noble Baroness is of course absolutely right. Evidence suggests that action needs to be taken to reshape social norms around smoking so that tobacco becomes less desirable, less acceptable and less accessible, particularly to the young. That is why we are committed to ending tobacco displays in shops. We have a TV-led marketing campaign to encourage smokers not to smoke at home or in cars and we have banned the sale of tobacco in vending machines, which has removed a source of cigarettes that underage smokers could access as often as they liked. There is a range of work going on.
The Chancellor of the Duchy of Lancaster (Lord Hill of Oareford)
We will briefly hear from my noble friend and then go over to the other side.
Lord Naseby
I congratulate my noble friend on not rushing in to another unproven restriction on the consumption of alcohol, particularly one which has legal dimensions that affect intellectual property rights. Can he confirm that consumption of cigarettes is already falling, and that we are already spending something like over £50 million on tobacco control? Is not the greatest problem at the moment illegal smuggling of cigarettes into this country, which costs the Revenue a huge amount of money—close on £200 million—and is consumed principally by young people?
Earl Howe
My Lords, smoking rates in the UK are lower than those in many comparable western societies, but our reductions in prevalence still lag behind those in countries such as Canada and the United States, and in some Australian states. Overall prevalence is gradually coming down, but we still need to worry about smoking take-up by the young. There is no doubt that smoking is a significant cause of health inequalities in the UK.
On illicit trade, the story is quite positive. In 2000 around 21% of the UK’s cigarette market was illicit, whereas the latest estimate from HMRC for 2010-11 is that around 9% of the cigarette market is illicit. That is too much; nevertheless, we are heading in the right direction.
Lord Foulkes of Cumnock
Does the Minister recall that when he was a shadow Minister opposing our legislation, he regularly met Gardant Communications on behalf of Philip Morris International? May I ask him very gently: who does he think had the greatest influence on this U-turn—his friends at Gardant or Lynton Crosby?
Earl Howe
My Lords, I have never adopted a personal position on plain packaging; the noble Lord is wrong about that. As an opposition spokesman, yes, I did make it my business to talk to all sectors—to the tobacco companies, to ASH and to other lobby groups—to make sure that the picture I presented from the Benches on which he now sits was a balanced one. I took no personal position, nor, indeed, a position on behalf of the Conservative Party; I need to make that very clear. The decision that the Government have taken has been in no way influenced by Mr Crosby.
Lord Taverne
My Lords, will the Government take into account the effect of postponing a decision, in the light of the very strong evidence cited by the Public Health Research Consortium in coming to the conclusion that such a measure would help to deter smoking? That seemed to be confirmed by the statement by the brand director of Imperial Tobacco that now that advertising was banned, the company should look at the design of packaging. Is it not unwise for the Prime Minister, after the Coulson disaster, the decision on alcohol pricing and the postponement of a register of lobbyists, to have appointed as special adviser to the Government someone who has turned out to be a lobbyist for the alcohol and tobacco industries?
Earl Howe
I emphasise that the Government have by no means a closed mind on the issue of plain packaging of tobacco—quite the reverse. We want to take the time needed to consider fully the many relevant issues around standardised packaging, before making any decision. My noble friend’s last comment might have had greater force if I had been announcing that we would not be proceeding with plain packaging, but that is not the case.
European Union (Approvals) Bill [HL]
Natural Resources Body for Wales (Consequential Provision) Order 2013
(10 years, 9 months ago)
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Baroness Randerson
That the draft order laid before the House on 3 June be approved.
Relevant document: 3rd Report from the Joint Committee on Statutory Instruments, considered in Grand Committee on 8 July.
Alternative Investment Fund Managers Regulations 2013
(10 years, 9 months ago)
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Lord Newby
That the draft regulations laid before the House on 10 June be approved.
Relevant document: 4th Report from the Joint Committee on Statutory Instruments, considered in Grand Committee on 10 July.
National Health Service (Licensing and Pricing) Regulations 2013
(10 years, 9 months ago)
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Renewable Heat Incentive Scheme (Amendment) (No. 2) Regulations 2013
Baroness Verma
That the draft regulations laid before the House on 10 June be approved.
Relevant document: 4th Report from the Joint Committee on Statutory Instruments, considered in Grand Committee on 10 July.
Motion agreed.
Northern Ireland
(10 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Wales Office (Baroness Randerson)
My Lords, with the permission of the House, I will repeat a Statement made by the Secretary of State for Northern Ireland in the other place. The Statement is as follows:
“I am sure the whole House will join me in condemning this shameful violence and in expressing our profound sympathy and support for the police officers who have been injured. It is also a matter of the gravest concern that the right honourable Member for Belfast North was knocked unconscious as he tried to calm the situation on the streets of his constituency. I am certain that I speak for everyone here in wishing him well.
On Friday evening, following the annual 12 July parades, around 5,000 people gathered to protest against the Parades Commission determination not to allow three Orange Lodges to return home past the nationalist Ardoyne area. This has been the scene of serious disorder in recent years, including shots fired at police by dissident republicans. Violence erupted as the crowd reached the police line on Woodvale Road preventing access to the route past the Ardoyne shop fronts. This has been followed by further disturbances and rioting on each night since then, mainly in the Woodvale Parade/Twaddell Avenue area, but also in the Newtownards Road in east Belfast, Mount Vernon in north Belfast, Rathcoole in Newtownabbey, Portadown and Ballyclare.
During these disturbances, the police have come under attack from a variety of weapons including fireworks, petrol bombs, bottles, stones, bits of masonry, iron bars and ceremonial swords. Last night, four blast bombs were thrown at police officers in east Belfast and a pipe bomb from Brompton Park in the Ardoyne. Water cannon and AEP plastic bullet rounds have been discharged on four successive nights, and 71 police officers have been injured.
I am well aware of the anger felt by many people over the Parades Commission determination in relation to Ardoyne but, however strongly people feel, there can be no justification, or excuse, for the behaviour we have seen in recent days. Attacks on the police are wholly unacceptable and I condemn them without hesitation or reservation. It is also utterly disgraceful that the right honourable Member for Belfast North found himself the victim of this violence, too.
There has been talk of attacks on British identity and culture in Northern Ireland. Well, the sort of behaviour that has been taking place in north Belfast does nothing to promote Britishness or the pro-Union cause; rather, it undermines it in the eyes of the overwhelming majority of people in Northern Ireland and the rest of the United Kingdom. In fact, it is hard to think of anything less British and less patriotic than wrapping yourself in a union flag and going out to attack the people who are there to maintain the rule of law and protect the whole community.
So now it is the responsibility of everyone with influence, including the Orange Order, community leaders and politicians, to do what we can to defuse tensions and calm the situation. We need temperate language over the coming days, and I am afraid that the Orange Order needs to reflect carefully on its role in encouraging mass protests on Friday, in a highly volatile situation, without the careful planning, stewarding and engagement with the police that is so important for keeping people safe when big crowds gather together. While the Orange Order’s announcement of the suspension of its protests was welcome, it is now time for it to call them off completely.
I would like to pay tribute to the outstanding work of the Police Service of Northern Ireland over recent days. Its officers have demonstrated fortitude, determination and courage in defending the rule of law. They have put their own safety on the line in the face of violent attacks and deserve our utmost praise, support and thanks, as do the police officers from Great Britain who provided mutual aid support. I would like to commend the leadership of chief constable Matt Baggott and Justice Minister David Ford. I know that meticulous planning took place to ensure that everything possible was done to try to keep people safe over the weekend of 12 July, including bringing approximately 1,000 mutual aid officers from Great Britain.
Of the 4,000 or so parades that take place annually in Northern Ireland, the vast majority pass off without major problems, including hundreds on 12 July. But any rioting is unacceptable, not least because it undermines efforts to secure economic recovery for Northern Ireland and because it makes competing in the global race for jobs and investment that much more difficult. The way forward has to be through dialogue to find sustainable local solutions to contentious parades, as has been the case in, for example, Derry/Londonderry.
I welcomed the talks that took place between members of the Orange Order and Ardoyne residents before the Parades Commission determination. I know how difficult this will be after what has happened, but I believe that it is vital that local dialogue continues. I also welcome inclusion of parading in the remit of the Executive’s all-party working group and the appointment of the distinguished US former envoy to Northern Ireland, Richard Haass, to chair it. The Government have always made it clear that we are open to a devolved solution on parading if one can be found but, in the mean time, we will not tolerate lawlessness on the streets of Belfast any more than we would in any other UK city.
Last week in this Chamber, issues were raised regarding my powers in relation to Parades Commission determinations. They are set out in the Public Processions (Northern Ireland) Act 1998. Section 9 states that the Secretary of State can only review a determination made by the Parades Commission following a request by the chief constable. The reason why he has not made such a request is because at all times he has been confident that the officers under his command can police the situation, and I fully share that confidence.
So to those on the streets over recent days taking part in this violence I say this. So far, 60 arrests have been made and emergency courts were sitting on Sunday to accelerate the criminal justice process. But that is just the start. No stone will be left unturned in building the case needed for more arrests and more criminal convictions. Those who engage in so-called recreational rioting and attacks on police officers can expect to face the full force of the law. I am confident that for some that will mean that the next 12 July holiday will be spent not in the sunshine following the parades, but locked up in prison living with the consequences of the crimes that they have committed”.
My Lords, I commend this Statement to the House.
Lord McAvoy
My Lords, I thank the Minister for repeating the Statement made by the Secretary of State in the House of Commons. I assure her of the full support of the Opposition Front Bench for the position outlined. I will now repeat the statement by my honourable friend Vernon Coaker, the shadow Secretary of State for Northern Ireland.
“I thank the Secretary of State for her usual courtesy in giving me advance sight of her Statement. I also thank her and her officials for keeping me and my office updated over the course of the weekend. It was very much appreciated and in the best traditions of bipartisanship.
I welcome her Statement. It is right that this House has the opportunity to discuss these important matters. I unequivocally condemn the violence that has taken place in Belfast over the last number of days and nights. There is no justification for it. The disgraceful attacks on the police have resulted in dozens of injuries, and a very deliberate attempt to murder officers by throwing blast bombs at them last night was shameful.
I pay tribute to the PSNI and colleagues from other UK forces for their bravery and determination in upholding the law. Can the Minister update us on the status of injured officers? Are any still receiving treatment? How many have returned to duty? How many are PSNI officers and how many are from other forces? How many mutual aid officers are still undertaking duties in Northern Ireland, and how long is that expected to continue?
We know that policing these large-scale public order incidents is costly. Does the Secretary of State have an estimate of how much the policing operations have cost to date? Who will meet this cost? Will it be her department, the Department of Justice or a combination of the two? There is always a concern about the involvement of paramilitaries in or on the margins of contentious parades and protests. Has she looked at who is involved and who is being arrested? Is there any indication that loyalist paramilitaries or dissident republicans have organised, or taken part in, the violence?
The origins of the appalling scenes we have witnessed lie in the dispute around parading. We have been here before. Does the Secretary of State agree with me that meaningful dialogue and working towards local agreement is the key to finding a solution? It has worked well in other places. The Orange Order held a peaceful, enjoyable and colourful celebration on the 12th in the UK City of Culture, Derry-Londonderry. It was a huge success, attended by thousands of people, and was able to happen because of years of dialogue and communication between neighbours in an atmosphere of respect and good will. Will the Secretary of State update the House on what discussions she has had with the First and Deputy First Ministers, the Orange Order, residents’ associations and local political and civic representatives over the weekend? Does she agree that she has an important role to play in having further discussions over the coming days and weeks in north and east Belfast? As well as condemning the violence that has taken place, we need to work to ensure that it ends and does not recur in the future.
My view is that the British and Irish Governments still have a hugely significant role to play in helping to resolve all these issues. They should both be involved in the talks convened by the First Minister and Deputy First Minister, which are being facilitated by Richard Haass. Does the Minister agree? Will she confirm that the Northern Ireland Office is working with the OFMDFM on this? It is crucial to bring people together to look at what needs to happen now to prevent a repeat of what happened over the weekend, when a disagreement that was not addressed led to significant tensions between communities and ended in unacceptable violence. That is the main message I wish to send out today. I encourage all those working to find a solution to these matters to keep going and not give up, and to keep talking. I say to those involved in parading and protesting—unionist and nationalist—that respecting the law, your neighbour and the wishes of people right across a community to live in peace is the only way forward. It has been done and can be done”.
Baroness Randerson
I thank the noble Lord for his comments, and particularly welcome his condemnation of the violence and the stress he laid on the importance of respect in the situation in which Northern Ireland finds itself. I also thank him for his support for those so closely involved in controlling the violence. They have had a very difficult job in the past few days.
The noble Lord asked a number of questions. Seventy-one police have been injured and we believe that six have been hospitalised, of whom two were police serving under the mutual aid scheme. There were more than 1,000 mutual aid officers in Northern Ireland at the weekend and yesterday.
The noble Lord asked about the cost of the problem and who bears it. This is where the real tragedy lies financially, because the Department of Justice in Northern Ireland bears that cost. That puts even greater stress and pressure on the police budget. The economic implications are very serious because of the impact it has on Northern Ireland, but it has immediately a massive financial impact on the Department of Justice.
The noble Lord asked about paramilitary involvement. That is something that will be very carefully investigated. He also asked about the Secretary of State’s discussions. She has had a whole range of conversations and meetings, both prior to and over the weekend. She was, of course, in Northern Ireland throughout this period. She is very supportive of the work that will be done by Richard Haass and the work that is being done by the Executive, the First Minister and Deputy First Minister, to bring a more peaceful situation back into play.
Baroness Stowell of Beeston
My Lords, before the clerk starts the Clock, in the interests of all noble Lords with an interest in this matter, may I remind the House that the Companion guides us that all Statements are an opportunity for brief questions only?
Lord Shutt of Greetland
My Lords, I, too, thank my noble friend for repeating this Statement. I am happy to endorse her condemnation of shameful violence and to express sympathy. But can we also do some encouraging? There is still one gap from the Belfast agreement which was toyed with for a period and then put aside. That is the engagement of a civic forum, so that there can be genuine discussion with so many people about the shared future that Northern Ireland needs.
I have one further point and a question. It is one thing having these anniversaries and annual events—we worry about what is going to happen on the 12th—but we are moving to a period when we are going to be celebrating centenaries. These centenaries will be coming up very shortly. They are opportunities to celebrate, but some might see them as opportunities to be violent. Will my noble friend confirm that there are real plans and thought-through initiatives with this Government and the Government of Ireland and the devolved Assembly, to see that when the centenaries are celebrated, they really are celebrated and do not provide a further opportunity for violence?
Baroness Randerson
I thank the noble Lord for his questions. In relation to his comments about a civic forum, the situation in Northern Ireland is such that this process is worth reconsidering. In view of the recent A Shared Future document, issued by the Executive, and the recent Cardiff conference, which addressed issues of concern from the past and dealt with facing the decade of anniversaries and centenaries to which the noble Lord referred, this is an interesting concept which I am sure will be raised again and again. It would obviously help to engage a wider spectrum of the community in dealing with these problems. I have used his name already, but Richard Haass has, of course, the issue of the anniversaries that are coming up within his remit of reviewing of the past and how it should be dealt with. It will undoubtedly be something which is of interest to him in his work.
Lord Kilclooney
My Lords, the riots must of course be condemned without any reservation whatever. However, it is important to analyse their cause, is it not? Unless we understand the cause, we will never get the solution. Can the noble Baroness confirm that many Members of our House approached her last week to warn her that there could well be violence as a result of the determination made by the Northern Ireland Parades Commission? The violence was predictable and predicted. Can she confirm that the chief constable concluded that he could not police the decision of the Parades Commission: that the PSNI would be incapable of doing so? As a result, 16% of police officers on the streets of Northern Ireland are now from England, Wales and Scotland. That is the kind of situation that the Parades Commission has led us into in Northern Ireland. Would it not be better if we had a Parades Commission that had widespread consent in Northern Ireland and attracted support? At the moment, it does not. Would it not be better to have an independent chairman of the commission who is not tainted by party politics, has not been involved in an elected position against unionism but is totally impartial and independent?
Baroness Randerson
The noble Lord referred to an informal meeting held last week. It is indeed the case that the Parades Commission’s determination was discussed at that meeting and a number of views were put. I have to say to the noble Lord that the chief constable was confident that he could police the parades but felt that it was important to have additional support under the mutual aid scheme. It is indeed the purpose of that scheme that events such as this should be dealt with in that way. The noble Lord referred to the status of the Parades Commission. It is of course a lawfully constituted authority that is independent of government. Its determinations must be obeyed. It is not a devolved authority and was set up by an Act of Parliament. It is essential that its determinations are duly obeyed on all sides in Northern Ireland. It is important to note also that the decisions of the PSNI, the chief constable and the Parades Commission, and the way in which they acted, were based on the experience of previous years and the problems that had previously been experienced at this time of year.
Lord Dubs
My Lords, many of us will feel utterly dismayed, saddened and angry at the events in Belfast when, yet again, the PSNI bravely had to bear the burden of this violence unleashed at it. Does the Minister agree that one of the tragedies is that there seems to be very little political leadership for the loyalist community? There was such leadership at the time of the Good Friday agreement, and it gave the loyalist community a sense that they had a stake in what was happening. I ask the Minister and her colleague the Secretary of State to engage in discussions with the First Minister, the Deputy First Minister and David Ford to examine what the problems are in parts of Belfast where members of the loyalist community seem to have the sense that there is nothing for them in the peace process. They are then too easily persuaded that the only way out is violence against the police. Real problems need to be addressed in the loyalist community in terms of lack of jobs and hope for the future. Will the Minister and the Secretary of State take an initiative with the people in Northern Ireland to deal with that?
Baroness Randerson
The noble Lord makes some extremely important points, and there is the issue of there having been a process of change in loyalist politics and its leadership—but that is now devolved in large part, and the leadership in the Assembly has to develop from within and cannot be dictated from outside. I agree with the noble Lord about the significance of poverty among many in the loyalist communities in Belfast. It is therefore all the more important that Northern Ireland makes the most of the economic package which was agreed recently between my right honourable friend the Secretary of State and the Executive, the First Minister and the Deputy First Minister. That economic package had a specific purpose of reinvigorating the economy in the poorest parts of Belfast.
Baroness Stowell of Beeston
Perhaps we can hear from my noble friend Lord Tebbit first.
Lord Tebbit
Is it not the case that violence begets violence? The Parades Commission gave in to the violence of the republican community against these parades. Now, of course, they are faced with the violence of the unionist community against the surrender to the republicans’ violence. How do you break out of that?
Baroness Randerson
The Parades Commission makes its decisions based on the evidence before it and according to the protocols it follows. As I have said, the Parades Commission is independent, it is at arm’s length from Government and it is the duly constituted authority undertaking an extraordinarily difficult, problematic task. It has to deal with that to the best of its understanding. I hope that noble Lords will accept that the work of the Parades Commission is very difficult indeed. I thank the noble Lord for his question.
Lord Rogan
My Lords, I, too, join in condemning the widespread violence, and in expressing my sympathy and support for the police officers of Northern Ireland. I should like to pay tribute to the valiant work of the Police Service of Northern Ireland over recent days and weeks. Its officers have shown their professionalism and personal courage in defending the rule of law and protecting society. I come from a police family. I have many relatives who served in the RUC. I personally served as a special constable for many years, and today, I have a son and daughter-in-law who stood on the streets of Belfast hour after hour over the past few days. So let us also recognise the support and the encouragement these officers receive from their families at home, wondering night by night in what condition their loved ones will return.
Since assuming office, the Secretary of State has been less than visible. The noble Lord, Lord Dubs, made a very interesting contribution. Can the Minister emphasise to the Secretary of State how crucial it is that she engage with, and be seen to engage with, the authorities in Northern Ireland to help alleviate the social, economic and cultural problems which contribute to the volatile situation in unionist working class areas?
Baroness Randerson
I thank the noble Lord for his moving tribute to the police. That tribute to their bravery, from first-hand experience, is very significant and says far more than anything that I could say standing here today.
The noble Lord referred to the significance of the leadership provided by the Secretary of State. It is important to remember that many of the levers that used to be within the hands of the Secretary of State no longer are, as policing and justice are devolved. However, the Secretary of State retains the ability to intervene if, following the determination of the Parades Commission, the chief constable of the PSNI had believed that he could not cope with the situation. However, he never felt that.
Perhaps I may make a very important point. The Secretary of State had the Justice Minister, the PSNI and the Parades Commission around the table for discussions prior to 12 July. Those were significant discussions and very important leadership was shown. The Secretary of State was there throughout the weekend and she is there on a very regular basis. There is no question of her lacking active engagement in this issue.
Baroness O'Loan
My Lords, is the Minister aware of the widespread community support for the Parades Commission and of the fact that there are now very few contentious parades that remain to be resolved? The situation in respect of those contentious parades can be resolved only by discussion. Is she also aware of the extent of the work that was done, for example, in Derry to achieve the level of harmony which existed on 12 July this year?
Baroness Randerson
The noble Baroness makes a really important point—that is, to refer us to the past and indirectly to point out the terrible situation that existed prior to the existence of the Parades Commission. It is important to bear in mind that there are many hundreds—thousands—of parades at this time of year in Northern Ireland. The city of Derry/Londonderry, for example, has done a superb job in making sure that its parades are successful and enjoyable and that they do not cause trouble. I had an extremely interesting meeting with the mayor of Derry/Londonderry, in which he pointed out the very simple and straightforward ways in which the sting has been taken out of the situation in that important city. I absolutely agree with the noble Baroness when she says that the Parades Commission has widespread support. The vast majority of the public in Northern Ireland are not interested in a return to the problems of the past.
Lord Morgan
My Lords, Griffith observed that Irish history was trapped between the dead past and the prophetic future. Is this not a particularly tragic and all-too-familiar example of it? This is exploiting a battle that happened well over 300 years ago for sectarian provocative purposes. It seems to me that the problems lie far deeper than simply the social and economic circumstances of Northern Ireland. Could there not be a totally different way of celebrating the cultural and historic traditions of unionism? By definition, these events are going to be violent and produce casualties. We know that they are—it happens every year. They are as much a part of the calendar of our country as, let us say, Remembrance Sunday, and they have equally sad connotations. Is there not some peaceful historic or cultural way of celebrating unionism rather than these provocative battles? If not then frankly it is not worth celebrating.
Baroness Randerson
The noble Lord, coming from the same part of the world as I do, is well aware of the importance of history to us all. It is of course extremely sad when history becomes so embroiled in violence. I say to him that it is important that as the years go by the people of Northern Ireland are able to embrace the future, and to let go of the past while not ignoring or neglecting it. They should be able to celebrate it in a positive way. I point to the importance of the Derry/Londonderry City of Culture in that transition process, because it does not shy away from the traditions and problems of the past. It embraces them and makes them part of a cultural experience.
Lord Browne of Belmont
I join the Minister in condemning unreservedly the recent street violence in Belfast, and in paying tribute to the bravery and strength of the police men and women from all parts of the United Kingdom who formed the front line in protecting the rule of law. However, does the Minister agree with me that the remit of the proposed all-party talks, under the chairmanship of Richard Haass, should include consideration of a change in the law to make the default position an unrestricted right to parade peacefully anywhere in Northern Ireland, unfettered by the arbitrary edicts of an unelected quango? Surely this is the only acceptable legal model for the mature and tolerant society which we are all trying to create in Northern Ireland.
Baroness Randerson
I join the noble Lord in the hope that in future years it will be possible to hold parades that are entirely peaceful. Unfortunately, the events of this year have made his hopes even further off than they were before.
NHS: Keogh Review
(10 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, with the leave of the House I shall now repeat a Statement made in another place earlier today by my right honourable friend the Secretary of State for Health on the Sir Bruce Keogh review. The Statement is as follows.
“Mr Speaker, I would like to make a Statement about Professor Sir Bruce Keogh’s review of hospitals with high mortality rates, which is being published today.
Let me start by saying that in the health service’s 65th year, this Government are deeply proud of our NHS. We salute the doctors, nurses and other professionals who have never worked harder to look after each and every one of us at our most vulnerable. We recognise that the problems identified today are not typical of the whole NHS, nor of the care given by many wonderful NHS staff; but those staff are the ones who are most betrayed when we ignore or pass over poor care. The last Government left the NHS with a system that covered up weak hospital leadership and failed to prioritise compassionate care. The system’s reputation mattered more than individual patients; targets mattered more than people.
We owe it to the 3 million people who use the NHS every week to tackle and confront abuse, incompetence and weak leadership head-on. Following the Francis report into the tragedy at Mid Staffs, the Prime Minister asked Professor Sir Bruce Keogh, the NHS medical director, to conduct a series of ‘deep-dive’ reviews into other hospitals with worrying mortality rates. No statistics are perfect, but mortality rates suggest that since 2005 thousands more people may have died than would normally be expected at the 14 trusts reviewed by Sir Bruce.
Worryingly, in half of those trusts, the CQC—the regulator specifically responsible for patient safety and care—failed to spot any real cause for concern, rating them as ‘compliant’ with basic standards. Each of the trusts has seen substantial changes to its management since 2010, including a new chief executive or chair at nine of the 14. However, while some have improved, failure or mediocrity is so deeply entrenched at others that they have continued to decline, making the additional measures I announce today necessary.
This time, the process was thorough, expert-led and consisted of planned, unannounced and out-of-hours visits, placing particular weight on the views of staff and patients. Where failures were found that presented an immediate risk to patients, they were confronted straight away rather than waiting until the report was finished. We will be publishing all those reports today, alongside unedited video footage of the review panel’s conclusions, all of which I am placing in the Library. I shall also today set out the actions the Government are taking to deal with the issues raised. I would also like to record my sincere thanks to Sir Bruce and his team for doing an extremely difficult job very thoroughly and rapidly.
Sir Bruce judged that none of the 14 hospitals is providing consistently high-quality care to patients, with some very concerning examples of poor practice. He identified patterns across many of them, including professional and geographic isolation; failure to act on data or information that showed cause for concern; the absence of a culture of openness; a lack of willingness to learn from mistakes; a lack of ambition; and ineffectual governance and assurance processes. In some cases, trust boards were shockingly unaware of problems discovered by the review teams. So today I can announce that 11 of the 14 hospitals will be placed into special measures for fundamental breaches of care. In addition, the NHS Trust Development Authority and Monitor have today placed all 14 trusts on notice to fulfil all the recommendations made by the review. All will be inspected again within the next 12 months by the new Chief Inspector of Hospitals, Professor Sir Mike Richards, who starts work today.
The hospitals in special measures are as follows: Tameside Hospital NHS Foundation Trust, where patients spoke of being left on unmonitored trolleys for excessive periods and where the panel found a general culture of ‘accepting sub-optimal care’; North Cumbria University Hospitals NHS Trust, where the panel found evidence of poor maintenance in two operating theatres, which were immediately closed; Burton Hospitals NHS Foundation Trust, where the panel found evidence of staff working for 12 days in a row without a break; North Lincolnshire and Goole NHS Foundation Trust, where the panel identified serious concerns in relation to out-of-hours stroke services at Diana, Princess of Wales hospital. The panel also witnessed a patient who was inappropriately exposed where there were both male and female patients present.
The list continues: United Lincolnshire Hospitals NHS Trust, where there were a staggering 12 ‘never events’ in just three years, and the panel had serious concerns about the way ‘Do not attempt resuscitation’ forms were being completed; Sherwood Forest Hospitals NHS Foundation Trust, where patients told of being unaware of who was caring for them, of buzzers going unanswered and poor attention being paid to oral hygiene; East Lancashire NHS Trust, where the panel highlighted issues of poor governance, inadequate staffing levels and high mortality rates at weekends. Patients and their families complained of a lack of compassion and being talked down to by medical staff whenever they expressed concerns.
The list continues: Basildon and Thurrock University Hospitals NHS Foundation Trust, where there were seven ‘never events’ in three years and concerns over infection control and overnight staffing levels; George Eliot Hospital NHS Trust, where the panel identified low levels of clinical cover, especially out of hours, a growing incidence of bed sores and too many unnecessary shifting of patients between wards; Medway NHS Foundation Trust, where a public consultation heard stories of poor communication with patients, poor management of deteriorating patients, inappropriate referrals and medical interventions, delayed discharges and long A&E waiting times; and Buckinghamshire Healthcare NHS Trust, where the panel found significant shortcomings in the quality of nursing care relating to patient medication, nutrition and observations, and heard complaints from families about the way patients with dementia were treated.
For these 11 trusts, special measures will mean that each hospital will be required to implement the recommendations of the Keogh review, with external teams sent in to help them do this. Their progress will be tracked and made public. The TDA or Monitor will assess the quality of leadership at each hospital, requiring the removal of any senior managers unable to lead the improvements required. Each hospital will be partnered with high-performing NHS organisations to provide mentorship and guidance in improving the quality and safety of care.
Three of the 14 hospitals are not going into special measures. They are Colchester Hospital University NHS Foundation Trust, the Dudley Group NHS Foundation Trust and Blackpool Teaching Hospitals NHS Foundation Trust. While there were still concerns about the quality of care provided, Monitor has confidence that the leadership teams in place can deliver the recommendations of the Keogh review and will hold them to account for doing so.
This is a proportionate response in line with the findings of the review. Inevitably, there will be widespread public concern not just about these hospitals but about any NHS hospital, and some have chosen to criticise me for pointing out where there are failures in care, but the best way to restore trust in our NHS is transparency and honesty about problems, followed by decisiveness in sorting them out. The public need to know that we will stop at nothing to give patients the high-quality care they deserve for themselves and their loved ones. Today’s review and the rigorous actions that we are taking demonstrate the progress that this Government are making in response to the Francis report. I shall update the House in the autumn on all of the wide-ranging measures that we are implementing, when the House will be given a chance to debate this in government time.
The NHS exists to provide patients with safe, compassionate and effective care. In the vast majority of places it does just this—and we should remember that there continues to be much good care, even in the hospitals reviewed today. Just as we cannot tolerate mediocre or weak leadership, we must not tolerate any attempts to cover up such failings. It is never acceptable for government Ministers to put pressure on the NHS to suppress bad news, because in doing so, they make it less likely that poor care will be tackled.
We have today begun a journey to change this culture. These 14 failing hospital trusts are not the end of the story. Where there are other examples of unacceptable care, we will find them and we will root them out. Under the new rigorous inspection regime led by the Chief Inspector of Hospitals, if a hospital is not performing as it should, the public will be told. If a hospital is failing, it will be put into special measures with a limited time period to sort out its problems. There will be accountability, too: failure in the NHS should never be a consequence-free zone, so we will stop unjustified pay-offs and ensure it will no longer be possible for failed managers to get new positions elsewhere in the system.
Hand in hand with greater accountability will be greater support. Drawing inspiration from education, where super-heads have helped to turn around failing schools, I have asked the NHS Leadership Academy to develop a programme that will identify, support and train outstanding leaders. We have many extraordinary managers such as David Dalton in Salford Royal and Dame Julie Moore of University Hospital Birmingham, but we need many more to provide the leadership required in our weaker hospitals.
At all times the Government will stand up for hard-working NHS staff and patients, who know poor care and weak leadership have no place in our NHS. It was set up 65 years ago with a pledge to provide us all with the best available care, and I am determined that the NHS will stand by that pledge. We owe its patients nothing less. I commend this Statement to the House”.
My Lords, that concludes the Statement.
Lord Hunt of Kings Heath
My Lords, before responding, I declare an interest as president-elect of GS1, chair of an NHS trust and a consultant trainer with Cumberlege Connections. First, I thank Sir Bruce Keogh and his team for this important review. I know Sir Bruce and have the utmost respect for him. His review presents a challenging but accurate picture of care standards and failings at the 14 trusts. As with both Francis reports, the Opposition accept the findings of this report in full.
At Health Questions earlier today in the other place, the Health Secretary claimed that this was a historical report, going back to 2005. However, it is not. These trusts were identified on the basis of mortality data for 2011 and 2012—this report is about this Government’s failings, happening on this Government’s watch. Anyone who supports the NHS must always be prepared to shine a spotlight on its failings so that it can face up to them and improve. However, in doing so, we must be fair to staff and to the NHS as a whole. In his report, Sir Bruce puts the failings at the 14 trusts in their proper context, by concluding that,
“mortality in all NHS hospitals has been falling over the last decade … by about 30%”.
He rightly reminds us of decades of neglect in the NHS in the 1980s and 1990s, when the noble Earl’s Government were in charge. Of the challenge facing the previous Government in their early days, he says:
“The key issue was not whether people were dying in our hospitals avoidably, but that they were dying whilst waiting for treatment”.
The noble Earl spoke about targets. The disgraceful record of his Government, with a target that they had in the patient’s charter of a maximum 18 months’ wait for treatment as an in-patient, was brought down by the targets that he decries to a maximum of 18 weeks. That is why we had targets.
In fact, the balanced picture in this report bears no resemblance to the Government’s leaking of the report over the weekend but it exposes one of the most cynical spin operations ever seen in this country. Nowhere in this report does a claim of 13,000 avoidable deaths appear. Indeed, Sir Bruce is absolutely clear. He says:
“However tempting it may be, it is clinically meaningless and academically reckless to use such statistical measures to quantify actual numbers of avoidable deaths”.
Yet that is precisely what this Government chose to do in advance of this report.
In the past few minutes, details have emerged of an e-mail that Sir Bruce Keogh has sent. He is clearly very angry about the report’s leak by the Government to the press, and specifically about the 13,000 lives allegedly lost. The noble Earl talked about accountability, so will his Secretary of State be accountable for the disgraceful actions that occurred over the weekend in his department? Will the Secretary of State consider his position? He should certainly do so.
On mortality rates, does the noble Earl recognise that Robert Francis himself said that,
“it is in my view misleading and a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers of deaths were caused or contributed to by inadequate care”?
Does he also accept the comment of the Liberal Democrat MP Andrew George that the leaks by the Tories on the Keogh report were obviously designed to mislead the media?
The result has been that these unfounded claims, spun out by the Government, will have alarmed people in the 14 areas affected. They have questioned the integrity of the staff working in those hospitals in difficult circumstances, all for their own self-serving political ends. This is unworthy of any responsible Government. On reading this review, the diversionary spin now makes sense as it is clear that those 14 hospitals have all shown signs of deterioration on this Government’s watch.
The noble Earl suggested that pressure had been put on the regulator to tone down criticisms. Does he accept the word of the noble Baroness, Lady Young, the former chair of CQC? She has written that CQC was not pressured by the previous Government to tone down its regulatory judgments or to hide quality failures.
Let me turn to staffing. One of the report’s central findings is that staffing is a major concern in all these trusts. The review states that,
“when the review teams visited the hospitals, they found frequent examples of inadequate numbers of nursing staff in some ward areas”.
The review team has already had to intervene in three areas on staffing to protect patient safety. Five of those trusts had warnings left in place by the previous Government. Does the noble Earl accept that it is shocking that they have been allowed to cut front-line staff to unsafe levels on his watch? The great sadness is that it appears that Ministers are in danger of forgetting the lessons of Stafford, where Robert Francis identified dangerous cuts to front-line staff as a primary cause of care failure.
Like Robert Francis, Sir Bruce makes recommendations on appropriate staffing levels. Can the noble Earl ignore this authoritative call any longer? What action is he going to take to ensure safe staffing levels in these 14 trusts and across the NHS? We accept that the loss of more than 4,000 nurses during the lifetime of this Government has now been laid bare as a monumental error. Will he intervene to stop those job cuts? Will he apologise for the fact that seven out of the 14 trusts investigated by Keogh have cut more than 1,000 nursing jobs since the election?
The noble Earl tells us that of the 11 trusts going into special measures, each hospital will be partnered with high-performing NHS organisations to provide mentorship and guidance in improving the quality and safety of care. That is to be welcomed but can he guarantee that this will not be deemed to be collusive action by the competition authorities?
I turn now to A&E performance, which is the barometer of the health service and the wider indicator of problems across the health and social care system. The report highlights major failings in A&E at many of the trusts. Of course, we know we have come through just about the worst winter we have had for a decade. At the end of last year, all 14 were in breach of the Government’s A&E target. Sir Bruce is clear that urgent action is needed to improve A&E, saying:
“We have established that one of the primary causes of high mortality in these 14 hospitals are found primarily in urgent and emergency care, and particularly in care for frail and elderly patients … all trusts were functioning at high levels of capacity in the urgent care pathway. This frequently led to challenges in A&E and, as a consequence, cancellations of operations due to bed shortages and difficulty meeting waiting time targets”.
Will the Government take immediate steps to work with the whole health economy to bring the 14 back up to national standards?
Even given the appalling way the Government have handled the Francis review, people will want solutions rather than politics so surely the right response is to accept the Francis recommendations in full, including the one on staffing levels. I can assure the noble Earl that if he were to do so the Opposition would work with him to ensure their swift passage through Parliament.
In conclusion, it is a sad fact that mistakes will be made in any walk of life, even in the National Health Service. The only real answer to all of these problems is for both sides of the House to recommit to full openness and transparency in the National Health Service. People who have been let down deserve nothing less.
Earl Howe
My Lords, I am disappointed that the noble Lord should have chosen to turn this occasion into a rather poorly directed political tirade. I can assure him that I am perfectly capable of trading party political debating points with him; I have a great deal of material in my brief which I will not hesitate to use if he pushes me. However, I choose not to because I think this is an occasion for reflecting in a mature and considered way, as befits this House, on a very important report. Therefore I begin with a welcome—I am glad that the noble Lord and his party accept the veracity of the report. It is a fine piece of work. It was done very thoroughly and very rapidly and we are grateful to Sir Bruce.
The noble Lord said a lot about mortality data with which I agree. At a national level, mortality has improved; however, the 14 trusts selected for these deep-dives had long-standing performance issues on mortality rates, some going back to 2005 or even earlier. Therefore, it is only partially true to say that this is a problem that happened on our watch. We want to make sure that we are lifting the lid on any failures of care that need to be tackled and we are not afraid of doing that. Again, the noble Lord was right to say that while higher mortality rates do not always point to deaths that could have been avoided, they indicate that there could be issues with the quality of care. That is why we decided to ask Sir Bruce Keogh to carry out these inspections and to give us his findings.
The rationale for the review was that the 14 trusts were outliers for at least two consecutive years on one or other measure of mortality. I agree with the noble Lord that it is pointless to bandy figures around, and I am not going to do that. He rightly quoted Bruce Keogh saying that it is clinically meaningless and academically reckless to use mortality formulae to quantify actual numbers of avoidable deaths. That reflects Robert Francis’s view, but we now have clear evidence that those mortality data were indicative of more deep-seated problems. That has been the value of this exercise, I suggest. I cannot comment on the letter written by the noble Baroness, Lady Young; I have not seen it. However I am sure the House will agree that the report by Sir Bruce has challenged us all to look again at why poor care persists in some hospitals.
As regards staffing levels, the number of front-line staff has gone up since May 2010. There are 6,000 more doctors and 1,000 more midwives, for example. On staffing, one can be too simplistic. It is not simply about the crude numbers. It is not simply about nurses. The number of staff on the wards will vary according to skill mix, clinical practice and local factors. It is right that nurse leaders have the freedom to agree their own staff profiles. That gives flexibility to respond dynamically to changes in patient demand and workforce supply. I do not in the least dismiss the potential concern that staff may in some instances have been stretched, but I do not think we can make generalisations of the kind that the noble Lord was suggesting that we did.
On A&E, as the noble Lord knows, urgent care boards have been working flat out since May with local A&E departments to develop individual plans in order to improve A&E performance in all areas where targets have not been met, and that includes the 14 trusts considered by the Keogh review. However, this is not only about A&E; it is about how the NHS works as a whole, how it works with other areas, such as social care, and how it deals with an ageing population and more people with long-term conditions. Dealing with these pressures means looking at the underlying causes. That is why, together with NHS England, we are putting together a strategy that focuses on the people who are the heaviest users of the NHS: vulnerable older people and those with multiple long-term conditions.
There is no doubt that people are right to focus on the funding of social care. That is exactly why we in the Department of Health have allocated significant additional funding to local authorities, including a transfer from the NHS that is worth £1.1 billion a year by 2014-15. We have also announced as part of the spending round that has just concluded a local integration fund of £3.8 billion across health and social care in 2015-16. Pooling budgets in that way will help drive down the costs to the acute sector by tackling the acute and expensive pressure points in the system, such as A&E, by improving prevention, reducing unplanned hospital admissions and allowing people to stay in their own homes and live independently.
I agree with the noble Lord that many of the messages in Sir Bruce’s report—in fact, all of them—are urgent. As he knows, in the Care Bill, we are looking at the whole question of openness and candour in a number of respects. Although the duty of candour is not one that we plan to build into the Care Bill, it is very relevant to it. It will be introduced by secondary legislation. The key challenge is a change in behaviour rather than the law. That is why the legislative changes arising out of Francis are targeted and carefully designed to support a culture of openness.
I hope that I have answered most of the noble Lord’s questions; those that I have not answered, I will write to him about.
Lord Warner
My Lords, I want to ask the Minister about the Government’s future intent. Are he and his colleagues now satisfied that Sir Bruce has found an indicator or indicators which require constant attention, year on year? Can we expect to see, either by Sir Bruce or by the new Chief Inspector of Hospitals, an annual look at the outliers on mortality rates and a regular report to Parliament about the findings of the exercise? Is this going to be institutionalised as part of the performance management of the NHS?
Earl Howe
We will see the Chief Inspector of Hospitals picking up the baton, as it were, from Sir Bruce Keogh, whose way of working in this exercise has been very instructive. His judgments were based on talking, not just to a few people in the trust, but to patients, a wide range of staff and, in some instances, people outside the trust. I am sure that Sir Mike Richards, the new chief inspector, will want to learn from that. It will be up to the CQC to decide whether this will be institutionalised. Its methodology is evolving. The hospital aggregate rating system will have a role to play in systematising the evaluation of performance and in any future instances of very poor care we will no doubt see a level of transparency from the CQC which we have, perhaps, not had before. However, I would not want to commit the CQC to reporting annually to Parliament in a particular way. It will report annually to Parliament but it is largely up to it how it does it.
Baroness Jolly
My Lords, we welcome the drive to improve quality in these trusts and across the NHS, based on the eight ambitions for improvement held in the report. In the Statement read by the Minister, the Secretary of State said:
“In some cases, trust boards were shockingly unaware of problems discovered by the review teams”.
Surely the boards were in receipt of data on quality. If not, why not? If so, why was action not taken? What attention is being paid to issues of trust board governance and its support and development?
Earl Howe
We will now see follow-up action by the CQC, not least in the area of trust governance where the quality of that governance has been called into question by Sir Bruce. That will be done rapidly. It is by no means the case that governance is defective in every trust, but question marks have been placed on some and it is important that assessments are made, not just by the CQC, but by the Trust Development Authority and Monitor as the two bodies responsible for overseeing the provider section. It may be that the CQC will be asked to carry out further work, but we are looking, for the time being, to the TDA and Monitor to do that.
Baroness Emerton
My Lords, how did Bruce Keogh’s team determine whether staffing levels were short, inadequate or low, as was mentioned in the Statement, when we have not actually got a base against which to measure staffing levels? We raised this all the way through the passage of the Health and Social Care Bill and we have been raising it during the passage of the Care Bill. What was the evidence for low staffing?
Earl Howe
I know that this is a concern of the noble Baroness and I understand that. She will know that work is going on to try to frame better rules of thumb and guidance on staffing numbers. When Sir Bruce looked at this area he had very closely in mind the precept that Robert Francis gave in his report when he said:
“To lay down in a regulation, ‘Thou shalt have N number of nurses per patient’ is not the answer. The answer is, ‘How many patients do I need today in this ward to treat these patients?’ You need to start, frankly, from the patient, as you do with everything”.
That was the basis of Sir Bruce’s assessment on that issue.
Baroness Armstrong of Hill Top
My Lords, will the Minister acknowledge that Sir Bruce Keogh made it absolutely clear that over the past decade there has been significant improvement in mortality rates across the National Health Service? He said that, because of the increasing complexity of the patient, that improvement is probably greater than the 30% that is measurable. Will he therefore congratulate those hospitals—the vast majority—that have led the improvement? At the same time, of course, we must tackle poor performance and make it clear that that is unacceptable. However, in doing so we have also to acknowledge the significant improvement that has happened over the past decade.
Earl Howe
I applaud that and we should all celebrate the success of outstanding hospitals—there are many in the health service—which have led the way in improving mortality rates over the past few years. The noble Baroness is quite right. Indeed, Sir Bruce suggests that those hospitals should now be asked to partner with some of the hospitals that are struggling in certain respects to show the way, whether that is on governance, on systems in A&E, on quality of surgical outcomes or whatever it happens to be. That is an appropriate idea, and we should undoubtedly ensure that it is taken forward. However, as the Statement itself reflects, the 14 hospitals that are under the microscope at the moment are not representative of the quality of care that the NHS delivers day in and day out, which is of a very high standard by any benchmark.
Lord Cormack
My Lords, I accept what my noble friend has just said, but he will understand that there will be concern throughout the country at this very disturbing indictment—because that is what the report is. Will he talk to the new chief inspector to consider whether we can have a form of assessment of hospitals—the noble Lord, Lord Warner, effectively referred to this—so that patients throughout the country know whether their local hospital is graded as being excellent or not? Will he also ensure that there is a debate on the Floor of this House, as there will be on the Floor of the other House?
Earl Howe
I can certainly use my best endeavours through the usual channels with regard to my noble friend’s latter question. On his first point, he is absolutely right. That is what led us to believe that aggregate hospital ratings, provided that they are produced in a sophisticated and careful way, will be very informative to the general public and to patients in a local area, and to professional staff within the health service. The Healthcare Commission, of old, used to produce aggregate ratings. They fell into disuse and, I have to say, into some disrepute, because they were so broad brush as to be meaningless. When we asked the Nuffield Trust to look at this area, it told us very clearly that, as long as we adopted a nuanced and sophisticated approach so that what was assessed was not just a hospital trust or an individual hospital within that trust but rather the performance of individual medical teams and units within a hospital, we would provide useful information to the public. However, that information needs to be accessible.
Baroness Masham of Ilton
If the chief inspector, when visiting failing hospitals, finds a lack of senior sisters on the wards and a shortage of doctors working in emergency medicine, what is he going to do about it? Does the Minister realise that there is a serious shortage of emergency medicine doctors?
Earl Howe
The noble Baroness is right. There is a serious shortage in certain specialties, and emergency medicine is one of them. Work is currently going on in Health Education England to ensure that we boost the numbers in that specialty. As for what the CQC can do, there are a range of actions available to the chief inspector. In most such instances he would draw the attention of the chief executive and the hospital board to whatever problem he had found, and it would then be incumbent on the trust to put its own house in order within a reasonable space of time. That would be the norm. We should not forget that commissioners of care, too, will be encouraged to join in that conversation, to ensure that providers are properly held to account through the NHS contract. There are a range of actions that could be appropriate, and only in the most extreme cases will warning letters have to be issued or more drastic action taken.
Baroness Smith of Basildon
Despite the rather alarmist —and, as it turns out, inaccurate—briefing over the weekend, this is, as we have heard, not a historical report; it is about what is happening here and now in 14 hospitals in the NHS. I was sorry that the Minister skirted round the problems of staffing in the NHS. My local hospital, in Basildon and Thurrock University Hospitals NHS Foundation Trust, is named in the report as one of the 14 hospitals. Yet since the general election it has lost 345 nursing staff. The report found,
“inadequate numbers of nursing staff … compounded by an over-reliance on unregistered support staff and temporary staff”.
The noble Earl himself referred to this when repeating Jeremy Hunt’s Statement. May I tell him that that hospital is now recruiting 200 staff this week? That is welcome, but it can be no coincidence that, after the report, it is recruiting the staff that it needs. Does he now really believe that the £3 billion spent on reorganising the NHS was the best value for money, when staffing levels are so low?
Earl Howe
It was not £3 billion that was spent on reorganising the health service. As the noble Baroness knows, it was probably less than half that figure. The important point is that the saving in this Parliament will be at least £5.5 billion, with a £1.5 billion saving every year thereafter. I therefore suggest to her that it is meaningless to bandy that figure around. I am very glad that Basildon hospital is taking the action that it is. It has recently undergone significant leadership changes. A transformation programme is under way, and that is part of it.
Lord Elystan-Morgan
The Statement repeated by the noble Earl makes the point that the story does not end with the 14 failed trusts. Does he agree that there is clear evidence of the acceptance of standards that are not worthy of our community or of the National Health Service, and that, very probably, such a situation is not unassociated with the lack of a hierarchy of discipline in nursing? Will the Government therefore give an undertaking that, by way of an agonising reappraisal of the situation, they will concentrate on establishing whether the institution of the hospital matron could be considered again, as a post that was effective and seemed to operate well? Many people the length and breadth of this land believe that to some extent we should revert to that system, rather than worshipping at the altars of accountancy and management.
Earl Howe
The noble Lord makes an extremely important point. Those hospitals that I have visited where the standard of care is manifestly excellent have all had nurse leaders at board level whose responsibility it is to make the quality of nursing care absolutely centre stage at every board meeting and to transmit to every nurse in that hospital what good quality care looks like. Whether we call that person a matron or not is perhaps a matter that we can discuss at leisure—but the point that the noble Lord makes is extremely valid.
Lord Black of Brentwood
My Lords, I agree with my noble friend very strongly that failure should never be a consequence-free zone. But would he agree that, for far too long, the bitter truth is that it was a consequence-free zone? My late mother was treated in the Basildon and Thurrock University Hospitals NHS Foundation Trust in 2008 and 2009, on two occasions. On the first occasion, she sustained an injury after being left on the toilet for 40 minutes, from which she never recovered. On the second occasion, having been admitted suffering from a heart attack, she was shifted between wards three times in 24 hours. I wrote to the chief executive and he wrote back to me with 11 separate apologies. I wrote back to him saying that apologies were no good unless something happened.
I agree with the noble Baroness, Lady Jolly, that boards must have responsibility. Would my noble friend agree that they must have responsibility for scrutinising data and, above all, looking at complaints, otherwise nothing will ever change?
Earl Howe
My Lords, the historical culture of that particular trust has been focused on financial targets, and the tone from the top now needs to focus on improving quality and long-term sustainability. There is a string of issues identified in Sir Bruce’s review, all of them urgent. The good news is that I know that the current management is addressing those issues. I am naturally sorry to hear of the personal experiences of my noble friend’s family.
Baroness Jay of Paddington
My Lords, I wonder whether I can assist the noble Earl, and indeed the House, by quoting directly from the letter from the noble Baroness, Lady Young of Old Scone. The noble Earl referred to it earlier and said that he was not aware of the details. This is a letter to the Prime Minister from the noble Baroness, dated yesterday, in which she says that he has been “misled” in the response that he gave in Prime Minister’s Questions. She says that the CQC, of which she is a former chair,
“was not pressurised by the previous Government to tone down its regulatory judgments or to hide quality failures”.
She goes on to say:
“So I am afraid neither my evidence to the Francis Inquiry nor my current recollection … can be interpreted to support the view that, in the words of your answer at PMQs ‘there was a culture under the previous Government of not revealing problems in the NHS’”.
She finishes the letter by asking:
“How can this misapprehension best be corrected for the record?”.
Perhaps the noble Earl can suggest that.
Earl Howe
I am rather sorry that the noble Baroness should have raised that, as I was rather keen to protect the noble Baroness, Lady Young, from any embarrassment, because I think that the whole House respects her. All I can say is that the substance of the letter to which the noble Baroness refers is diametrically opposite in content to the evidence that the noble Baroness, Lady Young, gave to the Mid Staffs public inquiry.
Lord Cotter
In the report there are, quite rightly, robust words about poor management. However, I refer the Minister to a point that I and others have raised in the past. There is a great concern in the health service about untrained, or poorly trained, healthcare assistants. Nurses have said to me that they are held responsible for the work done, often by untrained or inadequately trained people. I have raised this before. Can I ask the Minister to look at it again as a very serious issue?
Lord Sutherland of Houndwood
My Lords, one thing that is very positive in the Minister’s Statement, and in the way in which he responds to questions, is that he clearly understands that this is a multifaceted problem and that there is no single way in which to deal with the whole set of issues. That being said, there is, of course, a “but”. The “but” is that one element of the government response—already referred to at least twice—is the role of the future Chief Inspector of Hospitals. The view taken, and reiterated again today, is that the inspector should be within the umbrella of the CQC. For some of us, at the moment, the CQC is part of the problem. It has not solved all our problems. I share the hopes of the Government that the CQC will remove itself from its current difficulties. However, in the mean time at least—or, in my view, in the longer term—a chief inspector should have both the responsibility and the authority of reporting directly to Parliament, as does the Chief Inspector of Schools. That would be a helpful element of transparency.
Earl Howe
I would have agreed with the noble Lord had he made those comments 18 months or two years ago. However, the CQC has turned a very important corner. It has new leadership and has articulated new ways of working. The leadership of the CQC commands high levels of confidence in every quarter of Parliament. I am encouraged by that. However, the point that the noble Lord makes about transparency is vital. The CQC is very clear that it is not its function to gloss over poor care when it is found, nor indeed to fail to celebrate good care when that is found.
Arrangement of Business
Baroness Anelay of St Johns
My Lords, before my noble friend Lord Howe begs to move that the House resolves itself into a Committee on the Care Bill again today, I will say a brief word about progress on the Bill.
I hope that it might help the House if I indicate that the usual channels have agreed that the Committee stage of the Bill will definitely complete before we rise for the Summer Recess on 30 July. The usual channels have further agreed that in order to facilitate that result, the Committee should continue to sit on each of our three remaining days until we have reached the advertised target. The usual channels are confident that, with the help of all involved, it need not take us beyond 10 pm on any night, although of course both sides of the House are willing to sit later if that is what it takes to conclude the Committee stage before the recess.
I draw the attention of the House to the fact that today’s target is slightly more modest than would have been expected, going by the calendar. Today’s target is the group beginning with Amendment 92ZZV. That is a little less than would have appeared from last week’s calendar. I give the House an assurance that we will still reach the target next Monday, as advertised in the calendar. There are a lot of Zs and Vs in this, but it means that noble Lords taking part in debates on this Bill can have certainty about the business on Monday 22 July and Monday 29 July, as well as having the certainty that tonight we will rise after we have considered government Amendment 92ZZAA. That means that next Monday, we will begin with some amendments on portability from the noble Baroness, Lady Campbell of Surbiton.
Care Bill [HL]
(10 years, 9 months ago)
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Lord Low of Dalston
Lord Low of Dalston
My Lords, in moving Amendment 88M, I will speak also to Amendment 92ZZN, both of which are in my name. These amendments would ensure that regulations specify in what circumstances a specially trained person must carry out an assessment or reassessment. A number of groups of disabled people may need a specialist assessment. For a deafblind person, for example, the ability to access a specialist assessment carried out by someone who understands the impact of deafblindness is a critical first step in the process of getting adequate and appropriate care and support. Assessors who do not have these specialist skills—for example, a generic assessor who assesses older people or a single sensory assessor who knows about visual impairment but not about deafness and blindness and how they interact—often offer deafblind people inappropriate mainstream or single-sensory services which are inaccessible and do not meet their needs.
Similarly, community care assessors can easily misunderstand the needs of someone on the autistic spectrum if they do not have experience and knowledge of how to communicate with someone with autism, or of the impact of the condition of autism on someone’s day-to-day life. People with autism can lack insight into their own condition and may struggle to define their needs. For example, if a person with autism is asked, “Are you able to wash yourself on your own?” they may reply, “Yes”, but omit to mention that this is with verbal prompting at every stage. I hesitate to venture on to this ground with the noble Baroness, Lady Browning, in the Chamber. Perhaps she will intervene in the debate later to supplement or, indeed, possibly correct what I am saying. However, what I have said so far is a fair reflection of the situation as it has been explained to me.
In addition, some people with autism may be non-verbal or have limited capacity to communicate or take part in the process unless substantial adjustments are made. People with profound and multiple learning difficulties and people who display challenging behaviour are two further groups where it is vital that they have a specialist assessment undertaken by an expert. People with PMLD do not use formal communication such as words, signs or symbols and may rely on others to speak up for their needs. Staff carrying out the assessments will need to have skills to ensure that people with PMLD can be meaningfully involved in the assessment process and have the opportunity to influence decisions made about their lives. It is also important that people with PMLD have advocates who are trained in non-instructed advocacy techniques.
Councils in England and Wales have to follow statutory guidance on how to provide care services for deafblind people. This guidance, Social Care for Deafblind Children and Adults, requires local authorities, when assessing the needs of a deafblind person, to ensure that an assessment is,
“carried out by a specifically trained person or team, equipped to assess the needs of a deafblind person—in particular to assess their need for one-to-one human contact, assistive technology and rehabilitation”.
In the five years following the introduction of the Social Care for Deafblind Children and Adults guidance in 2001, we saw the number of deafblind people provided with appropriate specialist support increase by 60%, which says a lot about the importance and value of specialist assessments of the kind I am talking about. The RNIB has obtained figures from the National Adult Social Care Intelligence Service showing that the numbers of blind and partially sighted people in receipt of local authority-funded care and support dropped by 35% between 2005-06 and 2011-12. This compared with a drop of only 16% for all adults with care needs. This is worrying and could indicate that generic needs assessments inadequately capture the needs of blind and partially sighted people and reduce their chances of being judged eligible for social care.
Lord Touhig
My Lords, I support Amendments 88M and 92ZZM in the name of the noble Lord, Lord Low of Dalston, and myself. Assessments must be carried out by assessors with the necessary training and expertise to understand the needs they are assessing. This point has been made time and again in this Chamber. The noble Lord, Lord Low, also referred to the Autism Act. The Department of Health has provided clear direction that autism training is essential for community assessors to ensure that the needs of adults with autism are fairly assessed. Here I declare an interest as a vice-president of the National Autistic Society. The noble Lord, Lord Low, also told us of the too few local authorities that have awareness training in place— 70 out of 152 local authorities have still not got a proper awareness training in place as part of their equality and diversity training.
Crucially, a National Autistic Society survey found that one in three social workers did not have a good understanding of autism. This is, in part, because adults with high-functioning autism or Asperger’s syndrome can have less obvious, hidden needs that can be hard to pick up in any assessment. That is why the assessor must have the necessary training and expertise. Failure to assess needs can mean that autistic people and others with disabilities are denied the support they need to live independently. As we all know, this makes it much more likely that in later life they will have a significantly greater need for support.
We are simply asking in these amendments to ensure that the needs of people with autism and other conditions are expertly and properly assessed. In that way, one can ensure that people will have a good quality of life—the sort that we in this Chamber take for granted. We are not asking for much and I hope that the Minister will agree with that.
Baroness Wilkins
My Lords, I strongly support this group of amendments. The consolidation of the care and support legislation into one Bill is very welcome but not if it lessens existing essential provision. As both noble Lords have clearly described, the initial assessment of someone’s needs is critical and must be carried out by someone who is appropriately qualified and understands the impact of the impairment and the types of support that are needed. As we have heard, the Bill does not provide the same requirement as the current statutory guidance. I therefore hope that the noble Earl will recognise the critical importance of specialist assessment for people in these groups and allay the concerns of organisations such as Sense and the RNIB.
Baroness Wheeler
My Lords, I do not have a great deal further to add on this issue, given that we fully supported this approach in the earlier debate on our amendment. The noble Lord, Lord Low, and my noble friend Lord Touhig have made their case powerfully for the need for specialist expertise in assessing people with complex care and support needs—for example, deafblind people, people with autism and those with profound and multiple learning difficulties.
As the noble Lord, Lord Low, pointed out, the draft Bill originally provided for the regulations to specify the circumstances in which a person with expertise in a specialised matter must carry out the assessment on behalf of the authority. However, this was altered in the published Bill, with the only requirement being consultation with a specialist. Noble Lords are right to consider this to be a retrograde step and I look forward to the explanation from the Minister on this and an undertaking to reinstate in Clauses 12 and 27 the current approach, as the amendments propose.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I thank the noble Lords, Lord Low and Lord Touhig, for bringing forward these amendments. I say straight away that I fully support the intention of Amendment 88M, which is to ensure that local authorities engage a suitable expert when carrying out complex assessments. The assessment will remain an integral part of the process of determining a person’s care and support needs and whether these meet the national eligibility criteria. To ensure that this is done correctly, it is essential that the person carrying out the assessment has the right knowledge, skills and competence. We heard from users of care and support during the engagement on the draft Bill about the importance of the assessor having knowledge of the condition that the person may have, whether they are, for example, a frail older person, a person with mental health problems or a person with autism.
Care managers and social workers are trained to carry out assessments. Their skills and experience will allow them to assess people with various conditions such as physical disability. There are, however, certain complex conditions where these skills are not sufficient to allow assessments to be carried out effectively. I am particularly thinking about a person who is deafblind—the example, given by the noble Lord, Lord Low. In those circumstances, most care managers would find it very difficult, if not impossible, to communicate with the person. It takes someone with expertise to carry out an assessment properly and identify the person’s needs and the outcomes they wish to achieve.
I agree with the noble Lords that, in such circumstances, the local authority must engage a person with the relevant expertise to carry out the assessment. That continues to be our policy. I also accept that if the adult’s condition is so complex at the assessment stage as to require the services of an expert in the field to provide advice, then it makes perfect sense for this to be repeated when the plan is to be reviewed. I should like to reassure the Committee that the Bill already has provisions in place to allow this joined-up approach to occur if an adult’s circumstances have changed in a way that affects the care plan. Clause 27(4) states that the local authority must, to the extent it considers appropriate, carry out a fresh needs assessment. In doing so, it would have to follow the requirements of regulations to consult a person with expertise. I hope I have reassured noble Lords of our agreement to the principles that they raise. In the light of what they have said in support of the amendment, I will look again at Clause 12 to ensure that we are giving ourselves the relevant powers to achieve our aims. I hope that the noble Lord, Lord Low, will find that undertaking welcome.
Baroness Barker
In Clause 27 it appears that it is only the local authority that has the power to ask for there to be a reassessment, not the individual. Is there a provision somewhere in the Bill that enables an individual to trigger a reassessment, or does that power lie with the local authority alone? If the Minister does not have an answer to hand, perhaps he might write to me.
Earl Howe
I shall do my best to answer my noble friend in a moment or two, but I am aware that I did not answer a specific question raised by the noble Lord, Lord Low, as to why we changed the wording in Clause 12(1)(c) of the draft Bill. We widened the scope of the powers following consultation—for example, to add a power to specify when an expert must be consulted —and in widening the powers the wording was slightly amended. We are happy to look at this again in order to make sure that it continues to meet the policy intention. In answer to my noble friend Lady Barker, I would refer her to Clause 27(1)(b), which refers to the right of an individual to request a review.
Lord Low of Dalston
My Lords, I am grateful to all those who have spoken in support of these amendments. I am also grateful to the noble Earl for his response. I thought we were going to be in the position where we had to say that we welcomed his support for our principle but we were disappointed that he was not willing to review the legislation to make sure that it put the principle into effect on the same basis as our amendment seeks to achieve. However, lo and behold, the noble Earl, not uncharacteristically, has come more than half way to meet us by saying that he is willing to look at the Bill again just to make sure that the policy intent, which he shares with us, is carried into effect. I welcome that very much. If it would assist the achievement of a consensus on this for us to meet, I would welcome that. I am very conscious of the calls on the Minister’s time as a Bill such as this goes through the House, so it may be that a meeting with officials would suffice. If further dialogue with the department would help to establish that we were fully on the same page on all this, I would welcome that very much. However, for now, with the very full assurances that the Minister has given us, I beg leave to withdraw the amendment.
Baroness Grey-Thompson
“(7) Needs meet the eligibility criteria when—
(a) there is, or will be, an inability to carry out several personal care or domestic routines, and/or (b) the individual will be unable to maintain control over several aspects of their day-to-day life, or(c) involvement in several aspects of work, education, training or recreation cannot or will not be sustained, and/or(d) several domestic, family and personal relationships cannot or will not be sustained, and/or(e) there is a risk of abuse or neglect; they form part of a combination of needs described in paragraph (a).”
Baroness Grey-Thompson
My Lords, Amendment 88Q relates to the eligibility for social care. This is a probing amendment in order for the Committee to debate the most critical area of social care reform for working-age disabled people—that is, whether they are eligible to receive the care and support that they need to lead independent lives.
The Government’s regulations have now confirmed that the Care Bill will be nothing more than an unachievable aspiration for more than 100,000 working-age disabled people and more than 150,000 older people who have significant care needs but will not be eligible for support. It is not my intention to debate the nuances of the regulations that have been published in draft, and the Minister would, rightly, tell me that this is not the time or the place to do so. However, it is my intention to focus on the policy principle concerning who should be eligible for social care and support. I also thank the Minister in another place for taking the time to meet me yesterday to discuss my amendment.
The difference that good-quality social care can make cannot be underestimated. It is the difference between being isolated, living locked up and staring at the same four walls or being set on the path to living a full and independent life. The recent Time to Invest in Care publication described the situation faced by David, a 23 year-old man with autism and schizophrenia who currently lives with his parents. David needs support to engage in activities and look for suitable jobs. He needs guidance to gain a better understanding of social rules and to develop his awareness of dangers in the community. He also has difficulty in understanding boundaries in regard to friendships. As a result of receiving the right social care and support, David has a volunteering job and is now working towards moving into supported living and leading an independent life. This is the difference that the right social care support can make.
However, under the current eligibility system David has been assessed as having only moderate care needs. This means that, under the eligibility regulations set out alongside the Care Bill, David would not be entitled to support and his future would therefore be far less positive. Essentially, the Government’s regulations mean that David should not receive this formal social care support.
That brings me to the policy intention of the regulations. I very much welcome the pause in the proceedings of the Care Bill in this House so that time has been allowed for us to look over the regulations that have now been published in draft. I have read them with interest and there is much in the direction of them that is to be welcomed. They represent a real improvement on the current system. Particularly positive is the focus on well-being and, specifically, the inclusion of shopping and managing household finances in the definition of basic household activities. This appears to be a very progressive step which joins up the regulations with the very first clause of the Bill, which has been widely praised, and I congratulate the Government on that. It is also a very brave and positive step to end the postcode lottery in care provision.
However, I have very real concerns about the Government’s intention—as stated by the Minister in another place in his foreword to the draft regulations—that in terms of practical outcome the regulations will be equivalent to “substantial” under the current system. This will be devastating news to the hundreds of thousands of disabled and older people with significant care needs who will be excluded from receiving formal social care.
The Minister is aware that historic underfunding of the social care system, the pressures of an ageing population and a 33% reduction in local council budgets by 2014-15 have led to many local authorities raising the threshold at which disabled and older people become eligible. In 2005, 50% of local authorities set their eligibility criteria at “moderate”. By 2012, 84% had set the eligibility criteria at the higher level of “substantial” needs. The result is that since 2008 90,000 people have fallen out of the care system.
The excellent report, The Other Care Crisis, illustrates the impact that this has had. Four in 10 disabled people who receive social care support say that it does not meet their basic needs, such as washing, dressing and getting out of the house—all things that we take for granted. The Care Bill will not resolve this crisis in care if the regulations are set at the level currently proposed. In fact, by setting a national minimum threshold at a level which maintains this crisis, the Government appear to be reducing their ambition for their social care reforms.
One point which has not been picked up is that the Government also appear to be reducing their ambition for the cap on care costs. While it is a welcome and important measure to attempt to cap the catastrophic costs of care that some people face, particularly in their old age, the Government have made it clear that the cap will only be triggered once an individual has been deemed eligible for care. Setting the bar for eligibility too high effectively means that there will be hundreds of thousands of people who think that they will not have to sell their homes to pay for care in their old age, yet will not be eligible for the cap itself. They will still have to pay for the cost of their care, even well above the £72,000 threshold, unless they are deemed eligible by their local authority.
For working-age disabled people the cap on care costs is irrelevant. The recent joint parliamentary inquiry, co-chaired by my noble friend Lady Campbell of Surbiton, highlighted the fact that the introduction of the cap was never designed to answer the care crisis for disabled people under 65. The inquiry was clear that the most crucial aspect of reform for working-age disabled people is where the eligibility for care is set. For them, this is the difference between living an independent life and spiralling into crisis.
I also have very real concerns that those disabled people who are set to lose out as a result of the Government’s welfare reforms will be the same people who will lose out on social care. It is highly likely that an individual who has significant care needs, but who falls just short of the current threshold, will be one of the half a million disabled people who will not get the personal independence payment under the new system. This means that not only will the social care that enables them to live independent lives be beyond their reach, but their financial independence will also be threatened further.
It appears to me that there is a clear group of disabled people whom the Government deem not quite disabled enough to receive support. Providing them with just enough support to remain independent will prevent them spiralling into crisis, costing local authorities much more money in crisis emergency care. I also believe that there is a clear economic argument to be made here. Economic modelling, carried out by Deloitte and published in the Ending the Other Care Crisis report, found that an investment of £1.2 billion in a lower eligibility threshold, equivalent to the current “moderate” level, would lead to substantial returns across government. This would include a £70 million saving to central government through increased taxes and reduced welfare spending. There would also be a £570 million saving to the NHS and local government through the avoidance of expensive crisis care.
The Government made a very welcome investment of an additional £2 billion at the recent spending review. I urge the Minister to use this money to invest in a lower national eligibility threshold, not just to ensure that his ambition for a care-based system on well-being becomes a reality, but for the savings it could generate as well.
In conclusion, as Members from across the House have repeatedly made clear, the Care Bill is a very good piece of legislation, and is welcome. However, we must make sure that disabled and older people who have significant care needs do not fall out of the social care system. If the eligibility threshold continues to be set at the level the Government have proposed, hundreds of thousands of disabled and older people will be shut out of the care system. There will be real concerns that the Government’s admirable focus on well-being will be far from reality for these people. I beg to move.
Lord Low of Dalston
My Lords, I am glad to support Amendment 88Q, put forward by the noble Baroness, Lady Grey-Thompson. As she has explained, the amendment seeks to ensure that the national eligibility threshold, a welcome feature of the Bill, is set at a level which will not exclude this group of more than 100,000 disabled people with significant needs from the social care system.
I would like to focus particularly on the role of the eligibility threshold in creating a truly preventive care system. While I welcome the explicit duty on local authorities actively to take steps to prevent delay or reduce the need for care and support, I fear that the regulations published last week on the national eligibility threshold will impede the realisation of this vision. In confirming their intention to set the threshold at a level equivalent to “substantial” under the current criteria for fair access to services, the Government would exclude more than 100,000 disabled people with moderate care needs from the care system. These are people who need support to get out of bed in the morning, wash, eat, get out of the house and participate in the community—the most basic of tasks that you need to be able to do in order to live a fulfilling life.
Moreover, denying disabled people with moderate needs the care and support they need is a false economy. If their needs are not met in the care system there is a real risk that they will escalate to a point where they have to be dealt with further down the line once they reach crisis point. This does not come cheap. It could lead to longer hospital stays, frequent readmissions, even the need for residential support, not to mention the lost tax revenue resulting from disabled people having to give up work as a result of losing social care support. This happens in one in three cases of working-age disabled people who need care.
Take, for example, the case of Elizabeth, of which I have been made aware. She used to have seven hours of key worker support a week to help with managing her bills and shopping. Following a letter from her council she was told, with no consideration of the impact it would have on her independence, that her hours would be reduced to three per week. As a consequence of losing this support she fell into a crisis. As she said, “I did have a job—I was working with disabled people—but I left because I couldn’t cope. I thought it wasn’t fair on the clients. I was going through a bad time, overdosing a lot”.
This case illustrates how only a small amount of timely support can pay real dividends. Support with shopping and managing her bills helped Elizabeth maintain an independent life. However, as a consequence of losing her support she was left in crisis, resulting in her making several suicide attempts and becoming reliant on more expensive medical services.
Under the current draft regulations Elizabeth would be shut out of the care system. I have real fears that cases such as hers will be replicated up and down the country. Indeed, despite the Government’s supportive words about prevention I am concerned that they are effectively regulating for prevention to be taken out of the care system. The consultation document published last week on the draft minimum eligibility threshold states that for those people who are not eligible for care— namely, the 100,000 disabled people with moderate care needs—local authorities will make available universal support, including information, advice and preventive services.
However, this implies that coverage of such services is comprehensive, consistent and of adequate quality when we know that this is not the case. The reality is that many such services have already been axed or are at risk of closure. Indeed, research by the Red Cross has found that nearly two-thirds—64%—of councillors said that their local authority had cut or frozen funding for prevention and lower level social care since the last local elections. This means that universal services will simply not have the capacity to provide the adequate preventive support that the Government intend. People who are not eligible for care will continue to face a postcode lottery of support and will be allowed to fall through the gap between the care system and universal services.
I end by emphasising that setting eligibility at a lower level is the essence of prevention. We cannot have a system where you have to reach crisis point before you can get the support you need. Early intervention and preventive support can also have significant financial benefits. Research undertaken by Deloitte on behalf of disability charities found that investing in people with lower levels of need provides a net positive return of at least 30% to the Government. I therefore hope that the Government will be prepared to take these points on board and ensure that the regulations on eligibility underpin rather than undermine the vision of a truly preventive care system, glimpsed in Clause 2 but, sadly, not yet fully followed through in later clauses.
Baroness Wilkins
My Lords, I strongly support this amendment. If the Government do not agree with the intention behind the amendment, it is clear that they accept, no doubt at the Treasury’s insistence, that the social care crisis should continue for years to come. As we have already heard, the social care system is currently failing to support four out of every 10 disabled people of working age to do the basic things in life such as washing, dressing, eating and getting out of the house. The proposed national eligibility threshold will do nothing to change this. The cap on care costs for these people will be a fiction; unless their needs are assessed to be at the equivalent of “substantial” under the current FACS criteria, they could well spend a small fortune paying for care, none of which would count towards the overall cap.
The public would be shocked to learn that the level of needs spelled out in the amendment in the name of the noble Baroness, Lady Grey-Thompson, is not covered by the cap on care costs. The Government envisage that people whose needs are below the proposed national eligibility threshold will be helped by the universal preventive services covered in Clause 2. However, as the Care and Support Alliance points out, many of these services have already been axed in the cuts or are at risk of closure. The £2 billion funding is very welcome, but we need the Government to be clear with the public that they are endorsing the continuation of the social care crisis unless a major shift of resources takes place.
Baroness Jolly
My Lords, I, too, am delighted that these amendments have given us the opportunity to debate the eligibility criteria and I echo the comments of noble Lords who know better than I do how this will affect them. Eligibility is a critical issue, which affects both disabled people and older people with care needs—disabled people account for one-third of the people affected by the Bill and elderly people the other two-thirds.
The Joint Committee warmly recommended the introduction of a national minimum eligibility threshold as a key way of resolving the current postcode lottery in social care. The new eligibility framework and national threshold proposed in the Bill will go a huge way to alleviate the lottery of care and will be vital in ensuring that there is more clarity and consistency in the provision of care for disabled people and the elderly in England.
The focus on well-being in the Bill was hugely welcomed by the committee. This principle is the thread that runs through the Bill and will ensure that the care system not only delivers basic support but promotes older and disabled people’s independence, allowing them to realise their potential through participating more fully in their communities. This is a bold vision for the future and one that could truly revolutionise the care system. It is therefore key that these two elements of the Bill work seamlessly together so that the well-being principle is at the forefront of the Government’s mind when considering who will be eligible for care, something that the committee explicitly recommended in its report on the Bill.
However, as the Government have rightly recognised, social care is not merely about allowing people to “survive” but about enabling them to live full and independent lives. The Bill explicitly places a duty on local authorities to provide care that promotes the well-being of individuals. In a conversation yesterday with the Minister for Care and the noble Baroness, Lady Grey-Thompson, it was acknowledged that the draft regulations, which have already been referred to in this debate, were just that—draft. Much more can and needs to be done to make them asset or strength-based. Can my noble friend ensure that the work on the draft regulations proceeds at pace so that they are fit for purpose and meet the needs and requirements of all within the scope of the Bill? Can he also ensure that any work involves those from the sector and expert Members of this House?
Lord Rix
My Lords, the Minister knows perfectly well where I stand because I already talked about eligibility at Second Reading and in the debate last week on the future funding of health and social care, led by my noble friend Lord Patel. I was backed in that part of the debate on the question of someone having to reach a level of substantial disability before becoming eligible for care. It should be the right of all people with a disability at least to be assessed properly, from the lowest level of disability to the highest. A level may be set where tens of thousands of people are excluded, such as people with a learning disability. Many are already being excluded by local authorities and being denied the use of day centres, or whatever. I can only plead with the Minister to say something which would give a glow of optimism to all of us who are totally and utterly opposed to the level which the Government are likely to set.
Lord Touhig
My Lords, I support Amendment 88Q, which was so powerfully moved by the noble Baroness, Lady Grey-Thompson. I certainly welcome the Government’s intention to establish national eligibility criteria, so that local councils across the country will be required to provide care for all those with a minimum level of need. However, I share the concerns which were so well articulated by the noble Baroness and the noble Lord, Lord Low of Dalston, that setting the fair access to care services criteria at “substantial” is simply plain wrong. It is wrong because it will exclude many people who I know with autism, and who have a low-level need of support. They will no longer be able to live independently if the level is set at substantial.
Setting the threshold at this level also seems to be running counter to the Government’s stated intention in the Bill, which is to focus on prevention. The requirement for people to have a physical or mental impairment to qualify for support could mean that those without a diagnosis will be excluded and miss out altogether. A great many people with autism do not get a diagnosis. I have been dealing with a case recently where people have been waiting four years to get their daughter diagnosed. I join the National Autistic Society—again, I declare an interest as a vice-president—in urging the Government to reconsider this and set the threshold at something equivalent to “moderate”. That is by far the fairest and best way to do it.
I make no apology for saying something which I think I have said about three times in this Committee: there is substantial evidence from the National Audit Office and NICE to indicate that investing in services for those with a moderate need is cost-effective. New economic modelling by Deloitte, published recently, shows that every £1 invested in support for people with autism and other disabilities who have moderate needs, generates a return across the piece of £1.30. That is not to be ignored and should be part of our consideration. There is much merit in this and I rather feel that the Minister, who is a decent and honourable man, will see that there is. I am sure he is going to give us some good news; at least, I hope he will.
Baroness Hollins
My Lords, I would have added my name to this amendment because it is excellent and necessary. I, too, hope that the noble Earl will see the sense of it. Certainly, people’s fears that the Government would propose to set the national eligibility threshold too high have been confirmed. Rather than celebrating the achievements of councils that have been able to provide highly valued, innovative and low-cost services to people with low and moderate needs, we are instead to fall in line with the majority of local authorities, with the false hope of avoiding financial strain. Failing to provide services to people with moderate care needs is, at best, a missed opportunity to encourage preventive care and significantly improve the quality of life for a highly disadvantaged group of people. At worst, we are leaving a considerable proportion of people with a lifelong disability to fend for themselves.
Case reports of those recently excluded from receiving support are extremely troubling. We have heard some examples already today with some people losing all daycare provision and facing an isolated life at home. Other case reports demonstrate the importance of lower levels of support. I want briefly to give the example of Frances, a middle-aged woman with a mild to moderate learning disability who has always struggled to understand and manage bills. Since receiving a few hours support a week she has finally had relief from receiving constant threats and eviction notices. How long will her support survive before she is declared ineligible? Clearly the resources of the state are limited but they need to be used wisely, and I believe that our care system must encourage and incentivise local authorities to provide lower intensity interventions that can make a difference to the quality of life for many people.
On the face of it, opting for a moderate national eligibility threshold may sound as if it would require considerable additional funding, but providing these services to a group who by definition are often highly vulnerable and disadvantaged could result in great savings by avoiding more costly acute care later. I hope that the Government will rethink this amendment.
Baroness Greengross
There are vast numbers of older people—for whom this Bill is designed, in terms of quantity—who we know want to stay in their own homes in their community. Early intervention can make that possible. If we delay, the alternative is crisis-driven. It leads to many older people going into expensive care homes where they do not want to be and from which they do not emerge again or into hospitals, adding to the problems we know about with frail elderly people. I very much hope the noble Earl will reconsider and enable people with moderate needs to have access to services.
Lord Warner
My Lords, I hesitate to intervene in the debate on Amendment 88Q but I feel under some obligation to share with the Committee some of the thinking of the Dilnot commission where we went into this issue and set out our views in our report. I declare my interest as a member of that commission. I suspect that what I am going to say may be thought of more advantageously by the Minister than by those who tabled the amendment; however, it is important that we consider these factors.
First, we made it very clear in the report that,
“we believe that those who develop a care and support need during their working life should be assessed in broadly the same way as an older person”.
We tried to create an architecture that was reasonably consistent between the needs of those of working age and older citizens. Secondly, when we were asked to undertake this assignment we were asked to consider the feasibility of introducing this and the affordability of the changes. We wrestled with this quite a lot in our deliberations but we concluded in recommendation 6 of the report:
“In the short term, we think it is reasonable for a minimum eligibility threshold to be set nationally at ‘substantial’ under the current system”.
Our concern in doing that was not just that we were mealy-mouthed stooges of the Treasury but the overwhelming amount of evidence given to us about underfunding of the adult social care system over a long period. We considered that and said in the report that it was seriously underfunded and that funding had failed to keep pace with demographic changes in people of working age and those who were not. We thought that the deficit had to be made good but that that was a matter for the Government of the day and would need cross-party consensus if improved funding for social care was to be maintained.
Lord Warner
I do not think we want to have a debate on our report, but I suggest that the noble Lord reads Chapter 2 which sets out the arguments why we should have consistency between the two age groups and why there was a fairness issue about that. If you distinguish between the two age groups, we favoured not being over-elaborate in means-testing working age people. If the noble Lord reads Chapter 2, he will see that we have in many ways discriminated in favour of working-age people in the treatment of them under a means-tested system. We were not being hard-nosed about it; we were saying that there was a general equity issue about treating people of working age and non-working age under the same architecture in this system. I do not want to detain the Committee with the Warner standard lecture on the Dilnot commission, but I recommend to the noble Lord that he refreshes his memory on Chapter 2, which sets out our arguments.
Lord Warner
I do not think that we said that they should fund the deficit. We said how they should be treated under the architecture of a new system for funding care and support in the future.
Lord Lipsey
My Lords, I rise to make two brief points. First, this argument is not really about eligibility criteria but about money. It would be highly desirable to extend eligibility to people with only moderate needs, but we will find it extremely hard simply to cater for people with substantial needs unless the pot of money is substantially expanded. That is the elephant in the room. In all the discussions here, we are describing a marvellous new system, but we have not yet said how it will be paid for.
Secondly, I think that eligibility criteria are, to a degree, a bit of a phantom. We know that there is variation between authorities across the country: some accept people with moderate needs and some accept them with substantial needs. Quite aside from that, there is overwhelming evidence of enormous variety not between local authorities but within local authorities depending on who is assessing you and their state of mind. I quote in support of this a report from the National Care Standards Commission in 2005-06 and an excellent report by the PSSRU last year which tells you what actually goes on when people are being assessed. You might have a social worker who is terribly sympathetic to the older or disabled people she is assessing, and her boss who is, no doubt, sympathetic but who knows what budget he has to meet each month. In those cases, you simply get a wrestling match.
Thirdly, and to me most worryingly, once the cap comes in, people and their families will have a huge economic interest in demonstrating that they have substantial needs because that is when the meter starts ticking for them getting help. The danger is that those with, in some cases, the biggest needs will not be very good at gaming the system. Somebody with autism may be told by their parents to seem as bad as possible so they can get the meter ticking. They are not going to be very skilled at that, but the mums and dads of articulate middle-class people will have a different set of instructions to go on. There will always be a tendency to exaggerate—play up to the full may be a better way of putting it—their needs to get them graded as substantial.
I make these points, not to draw any firm conclusion, not even on the question of whether those with moderate needs should be catered for, but to say that more fundamental thinking has to go into deciding how eligibility criteria should be set and operated. This has not yet been apparent, even in the Government’s improved scheme which is encapsulated in the Bill.
Lord Hunt of Kings Heath
My Lords, my Amendments 88R and 88S take us back to the amendments which I moved last week on eligibility criteria, inspired by the noble Baroness, Lady Campbell. Promoting individuals’ well-being, assessing their needs and those of carers, deciding on eligibility and the priority for needs to be met, developing them with an appropriate care and support plan, enabling the best use of a personal budget and/or direct payments and ensuring continuity of capacity during and after a move, such as a house move, are all processes or stages in which the active engagement of NHS professionals or services could have a positive effect on the outcome for individuals and carers.
In his response, the noble Earl said that he agreed and that the Care Bill already allowed for that kind of co-operation from the NHS through Clauses 1 and 3. He also pointed out that Clause 12(1)(f) sets out regulations where a local authority must consult with someone with expertise before undertaking an assessment. He went on to say:
“Regulations may also set out conditions around co-operation with the NHS, by specifying the circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare”. —[Official Report, 3/7/13; col. 1272.]
That is helpful but I wonder if we should go further and place an explicit responsibility on the NHS so that we know it plays its part in full.
Amendment 88Q, tabled by the noble Baroness, Lady Grey-Thompson, and my Amendment 88T focus on the eligibility criteria in the draft regulations. We support national eligibility criteria. As the consultation paper says,
“the needs which are determined to be ‘eligible’ vary from one area to another”,
at the moment, with local authorities,
“able to set their own ‘eligibility threshold’ or ‘criteria’…This approach has led to perceived wide distances between areas and inconsistency in the offer made to local people, confusion and legal challenge. Because local authorities are able to vary the threshold over time, it also leads to the fear that people may lose their care and support if ‘eligible needs’ are reclassified locally”.
It is also very helpful to have the draft regulations available for debate and I have been able to discuss them with a number of stakeholders in the last few days. The noble Baroness is absolutely right that there is concern among many stakeholders about the level at which the criteria are set. This is reflected in the amendment in her name and those of the noble Lord, Lord Low, and my noble friend Lord Touhig. However, we must also take account of the points raised by my noble friends Lord Warner and Lord Lipsey because this is, in the end, an issue of funding. I hope that, when she winds up, the noble Baroness will address the issue of affordability. This may be a technical point, but this might be a matter of supply, since the Commons might well assert their own position in this regard. The noble Earl, Lord Howe, will, no doubt, advise us on that matter.
The guidance is very important and my noble friend Lord Warner said that it was a good first shot. I agree with him and it is certainly something to work on. However, could it warrant more parliamentary scrutiny than is normally given to regulations? We usually have a debate of about one hour; the conventions allow us to defeat a statutory instrument on very few occasions, and there is no opportunity to amend those regulations. We have benefited enormously from having a Joint Select Committee to advise us on the draft Bill: might it be right to have a similar process in relation to the regulations? I hope the noble Earl might be sympathetic to my Amendment 88T, which asks for a joint parliamentary committee process to look at the regulations before they are laid before Parliament.
Earl Howe
My Lords, this has been an excellent and very important debate and I thank all noble Lords who have contributed. I will, if I may, begin by picking up the remarks of the noble Lord, Lord Warner. He put his finger on a number of very important points. The system of locally determined eligibility for care and support has been confusing to people for too long. It has been seen as an unfair system under which different levels of needs are met on the basis of where somebody lives. The changes we are bringing forward will mean that people’s entitlements to care and support will be much clearer and fairer and will reduce variation in access between local authorities.
That is our starting point and, once this legislation comes into effect, local authorities will not be able to reduce eligibility below the level set out in regulations. They will be able to meet other needs which do not meet the national eligibility criteria through the power in Clause 19, but they will be required to follow a consistent approach to determining eligible needs. That is a big step forward. We must not view these national criteria in isolation. The Bill does a great deal for people with lower levels of need, including through provisions on prevention, information and advice. One of the key aims in relation to assessment is to ensure that this is effective in identifying needs and support options for all people, in particular to help those who do not have eligible needs and to prevent deterioration.
Clause 13 provides for regulations which will set out the eligibility criteria according to which local authorities must meet an adult’s needs for care and support or a carer’s needs for support. Amendment 88Q seeks to add this detail to the Bill. I understand why the noble Baroness would like to see the eligibility criteria set out in this way. Some noble Lords have questioned the number of important provisions being introduced through secondary legislation. However, in this case I believe that it is necessary. It is important that we get the eligibility criteria right, otherwise there is a danger that we will put in place a system that is more confusing than the one that we are replacing.
There is advantage in having the flexibility of setting the criteria in regulations; once again the noble Lord, Lord Warner, gave a helpful pointer to this in his remarks. We are not proposing to amend the national eligibility criteria on a regular basis. However, we need the ability to amend the regulations if it is shown that the criteria need to change at some point in the future. Of course, we would consult fully before making any such change.
To help inform debate on this area, and as noble Lords have mentioned, on 28 June we published draft regulations for discussion which set out the proposed national eligibility criteria. I emphasise that these are intended to set a national minimum equivalent to the level operated by the vast majority of local authorities in the current system. As part of the spending round announced recently we have committed to provide funding that will maintain the same level of services when authorities move to the new system in April 2015. This is the beginning of engagement with stakeholders before we formally consult on draft regulations next spring.
Amendment 88T is concerned with parliamentary scrutiny of the eligibility regulations. The power to set the eligibility criteria in regulations is one of the most important in the Bill and is central to the new care and support system. For this reason the Bill requires the regulations to be made under the affirmative procedure. That will ensure that Parliament will consider the regulations before they are introduced and that it will also consider any future changes. As a matter of course the regulations will also be considered by the Secondary Legislation Scrutiny Committee and the Joint Committee on Statutory Instruments. Therefore we do not believe that the regulations need further scrutiny by a Joint Committee of both Houses.
Amendments 88R and 88S in the name of the noble Lord, Lord Hunt, refer to matters that the Secretary of State should have regard to when making the regulations. Amendment 88R clarifies that the regulations may describe a person’s care and support needs by reference to the effect of needs arising from a physical or mental condition. The well-being principle at Clause 1(2)(a) includes physical and mental health, and this is reflected in the draft regulations. Regulation 2, which sets out the eligibility criteria, explains that needs are eligible needs if they have a significant impact on a person’s well-being and are as a result of a physical or mental impairment or illness. Amendment 88S proposes that a person should be eligible for care and support if they are in receipt of health services. As we debated earlier, a person can expect to receive an integrated service, but the determination of eligibility for care and support must be based on care needs only, rather than what health services a person is receiving.
A number of noble Lords suggested that the eligibility criteria should be set at moderate. As I have already said, this threshold is about establishing a minimum standard, not about taking away councils’ discretion to go further. Local authorities will remain able to meet lower needs locally if they choose to do so. Once again I was grateful to the noble Lord, Lord Warner, for his realistic assessment, and to the noble Lord, Lord Lipsey, for his comments. The eligibility criteria are intended to be equivalent to the level operated by the vast majority of local authorities in the current system. Independent research suggests that it would cost an additional £1.2 billion to set the threshold at moderate for younger disabled people and those with mental health needs, and a further £1.5 billion for older people. The combined total is £2.7 billion, which is a large amount to find in the current financial climate.
The pooled funding that we are proposing is important to factor in here. The noble Baroness, Lady Grey-Thompson, suggested that setting the criteria at moderate would save money. It is important to understand what the pooled funding is designed to do. Once again, the eligibility criteria should be seen as part of the overall system that we are putting in place. The pooled funding that we have announced will support better integration between local authorities in the NHS to improve outcomes for the local population. Part of this funding will be used to support local authorities and the NHS if they need to intervene earlier to prevent people’s health or care needs worsening. That will include many of the people with low or moderate needs.
The noble Lord, Lord Low, suggested that universal services do not have the capacity or resources to meet the aspirations that the Government have set out. As we have debated, the Bill sets out new duties on local authorities to provide universal services such as preventive services. These will also be supported by statutory guidance to make clear the expectations that we are placing on local authorities. Moreover, as I have mentioned, the pooled funding is relevant here. Among other things, that will enable preventive and integrated services, which also benefit the NHS.
The noble Baroness, Lady Grey-Thompson, said that it was not fair that the cap applies only to eligible needs. We will debate the Government’s proposals for the capped cost system in due course. However, access to the cap needs to be consistent in order for the system to be fair. Using national eligibility criteria will ensure that the cap applies on an equivalent basis in every area. The noble Lord, Lord Lipsey, commented that the eligibility criteria will not solve the huge variation within local authority areas due to variable assessments. First, the eligibility assessments will set a minimum threshold, which is important. Some differentiation in local implementation will remain, but as referred to previously, we will require that local authorities appropriately train assessors to ensure that assessments are carried out properly, and we will publish guidance that will help to reduce variation.
My noble friend Lady Jolly asked whether we can ensure that the regulations become more asset-based and that that work involves experts. I can reassure her that the Bill already allows for the individual’s strengths to be taken into account in the assessment. In relation to the draft eligibility regulations I can assure her that we will engage widely with stakeholders to make sure that they deliver our policy.
Baroness Browning
As far as the eligibility criteria are concerned there is another indicator, which I have not heard mentioned in this debate, and that is the number of people who challenge their local authority through the courts. Currently—from my own experience of case work, particularly with those on the autistic spectrum and with learning disabilities—many local authorities, when challenged legally on this, will settle before it goes to court. It is difficult to quantify what that number is, and I do not know whether what I am asking my noble friend is practical. However, in monitoring whether the eligibility threshold is correct, particularly for those with low to medium needs, would the Government be prepared to use the number of applications for legal challenge and, if possible, of those who settle out of court before it goes to court? That is a very clear indication of where local authorities refuse because the current eligibility criteria have not been properly constructed. When challenged, they usually pay up pretty quickly.
Earl Howe
My noble friend raises an important point, and I will take her suggestion away with me. As I mentioned earlier, however, a great deal of what this Bill will deliver is, so to speak, invisible to the naked eye, because it will ensure that those with lower needs will also be catered for in some way or another. I would like to hope that, for that reason, there will be less scope for challenge. I will write to my noble friend if I can supply her with our further thinking on that important topic.
I hope that what I have said will have reassured the Committee on these important matters. This has been a well informed debate. Our continued approach to engagement and consultation on the draft regulations will obviously allow us to consider many of these issues further, and on that basis I hope that noble Lords will not press their amendments.
Lord Touhig
Have the Government looked at the Deloitte economic modelling, which shows that support for moderate needs actually gives a greater return on the money invested? If not, will the Minister undertake to look at it before Report stage, so that we can discuss the savings that could be achieved?
Earl Howe
I know that my officials have looked closely at that modelling. I have not yet had an opportunity to look at it but undertake to do so. However, in all such matters a judgment is needed as to how money is best spent. No doubt there are good arguments for the Deloitte point of view, but, as I have already outlined, we think that if one has to spend money of that order, it is better spent in the way that we propose. Nevertheless, this is a debate that we can usefully continue, and I shall be happy to do that between now and Report, and also at Report stage itself.
Baroness Grey-Thompson
My Lords, I thank all noble Lords who have taken part in the debate, and also the Minister for his response. My amendment, which is about who is eligible and who is not, addresses the main crux of the Bill. I shall respond to a few points that noble Lords have raised.
I agree with the noble Lord, Lord Warner, when he says that we need to be realistic. However, my view still is that a small amount of support for working-age disabled people or older people—to keep them active, to keep them in their own homes and to support them in the best way—will actually save us money in the long term. Moreover, expectations have been raised about what older people can expect.
There is still a lot of work to do on the draft regulations to encompass the needs of working-age disabled people and older people, and to ensure that we keep the consistency. As things stand, giving someone the ability to have an assessment of the care that they can expect, but no actual support, does not help them; it just raises their expectations in a slightly misleading way. Again, disabled people and older people are paying the price of the economic downturn. Although this is not the right time for it, I would welcome a really honest debate on what the Bill is about. Is it about saving money, or is it about the well-being of certain groups of people? As ever, disabled people and older people seem to be at the bottom of the priority list.
I welcome the fact that the Minister has said that he will go away and look at Deloitte’s economic modelling. I think that we would probably agree to disagree about where that is at the moment, but it would be beneficial to try to find the best way forward in that context.
The noble Baroness, Lady Jolly, raised two very important points, the first of which was about the seamless transition. That is incredibly important. This is about not just who makes it to the support level, but what we do with people who are just outside that category. It is crucial that we get the advice and the signposting and all the support absolutely right, to make sure that people are not falling through the cracks. Her second point was that the regulations are still in draft. The Minister in the other place has offered me the opportunity to continue this discussion on the eligibility criteria, and I very much welcome that, because it is a recognition that the draft regulations can be improved.
It is also important that we have a constructive continued discussion on what the draft regulations mean in reality. There is lots of expertise both inside and outside your Lordships’ Chamber, and we must use those people to get to the best place, and use the time we will have in the summer leading up to the formal consultation. I do not see all this as just a negative discussion. There is much work to be done, but I see that as a huge opportunity to improve the regulations and get them into a much better form for everybody. At this stage, however, I beg leave to withdraw the amendment.
Baroness Pitkeathley
“( ) Services of an intimate nature can only be provided to the disabled person and not to meet a carer’s need for support and regulations may make provision about what is, or is not, of an intimate nature for the purposes of subsection (3).”
Baroness Pitkeathley
My Lords, I wish to speak to Amendment 89B as well as Amendment 89A, as they are both amendments about the circumstances in which a carer can be charged for services. Carers UK—I declare an interest as its vice-president—has estimated that carers save the UK economy £119 billion per year. That is a statistic that I never tire of giving your Lordships. Local authorities recognise the value and cost-effectiveness of supporting carers. As a result, very few local authorities charge for services provided to carers. The Government’s impact assessment for the Bill sets out current evidence on the cost-effectiveness of supporting carers, and refers to the benefits received from doing so: for example, preventing or delaying hospital or residential care admissions; sustaining the caring role; improving the health and well-being of carers; and, crucially, assisting carers to remain in or return to work.
The Bill includes a power to charge carers for services, and a power to charge for arranging services for carers. Given the benefits of providing support for carers, I shall argue that it would be counterproductive to charge carers and thereby reduce the take-up of support.
The current legislation under which support is provided is the Carers and Disabled Children Act 2000, which started as a Private Member’s Bill. Under the Act, services provided to a disabled person in order to meet the needs of the carer cannot include services for the disabled person that are “of an intimate nature”. It is for that reason that that same wording is used in Amendment 89A.
Interpretation varies concerning to whom, and by whom, services are provided, but the definition legally prevents carers being charged for a respite care service that includes personal care provided to the person whom the carer cares for. As I have said, very few local authorities now charge for carers services. However, given the difficulties with local authority funding, about which we hear constantly, I am concerned that more local authorities may consider charging carers in the future.
Following a recommendation by the Joint Committee scrutinising the draft Care Bill—on which I, together with several other Members of your Lordships’ House, served—the Government have sought to protect carers from being wrongly charged, by introducing the following wording in Clause 14:
“The power to make a charge under subsection (1) for meeting a carer’s needs for support under section 20 by providing care and support to the adult needing care may not be exercised so as to charge the carer”.
Although the intention of this wording is welcome, it does not provide any definition of what is a service for the carer and what is a service for the adult. So it does not prevent local authorities charging carers for services such as replacement care and other things that help them.
It is important that any potential conflict is resolved so that carers and disabled people have clarity about their personal budgets. Independent personal budgets can be useful in relation to managing options and direct payments. Whose budget is this to come out of? It will also be important when the carer count is introduced that we have clarity, so that the disabled person knows whether the cost of care is starting to accrue to their account.
Decision-making on whether services are designed to give carers a break or result in them having a break from caring is very variable at the moment. Some local carers’ services, for example, have experienced variations in approach from their local authority. I cite a particular example in which a local carers’ organisation that provides a sitting service—that is, replacement care, so that carers can take a break—operates with two neighbouring local authorities. One regards replacement care as a service for the cared-for person, including sitting services. The next-door authority allows carers to purchase a sitting service, as long as it does not include intimate care, with their direct payment. Varying interpretations mean that there is a disparity for carers in the same area. Some can access breaks, while some cannot. This creates difficulties for the service provider and for those who want to support carers.
In the current legislation, the Carers and Disabled Children Act 2000, services provided to the disabled person to meet the needs of the carer cannot include services for the disabled person that are of an intimate nature. My Amendment 89A seeks to reproduce that wording in the Bill to probe the distinction made in the Bill between carer services and services for a disabled person and to clarify how the current wording would prevent a carer being charged for respite or replacement care provided to the carer. Without a clearer definition of whose service is whose, negative consequences for the carer will inevitably result. Carers may be prevented from having a break; they may find that they are subject to charges for services that should be allocated to the disabled person; and social workers and others assessors’ time will be taken up in trying to allocate services to people.
I hope that the Minister, who I know to be totally committed to supporting carers, as are the Government, will accept this amendment to clarify the position with regard to charging carers. I beg to move.
Lord Lipsey
My Lords, I rise briefly—I fear that that will be the last time that I will use the word “briefly” tonight—to speak to Amendment 104ZB in my name in this group. This is another bits and pieces group; my amendment does not relate to the excellent speech just made by my noble friend Lady Pitkeathley.
Clause 64 enables a local authority to recover money owed to it in connection with the provision of care and support. A person’s failure to disclose any material fact would make them liable to recovery proceedings. However—and this is the nub—it would do so even if they had done so inadvertently. This seems terribly draconian and might well deter people from taking steps, such as asking for a direct payment, which they might perceive as carrying the risk of legal proceedings. This clause should refer only to misrepresentation, and the deliberate failure to disclose information, rather than incorporating, as it does, accidental failure.
These decisions of where to apply for help are taken at time of acute stress in many families. There may have been an incident, such as a fall or a stroke, which has changed the picture for that family entirely. At that stage, the last thing that people want to worry about is whether they have inadvertently failed to disclose some piece of information and will have legal proceedings taken as a result.
I cite an example given to me by Age UK, which was contacted by a husband whose wife has dementia. She has a private bank account that she will not let her family have access to, and discussions of financial arrangements upset her terribly, so he has not yet gained a power of attorney over her affairs. Despite knowing that his wife has assets, her husband is paying for everything relating to her care with his benefits and pensions. He feels that he could not make an accurate disclosure of her assets that would be necessary to get the benefits to which he is entitled. Imagine how that person would feel when faced with this clause and the danger that an inadvertent failure to disclose fully would lead to the local authority taking him to court.
Baroness Browning
In the case that the noble Lord has just mentioned, would there be any question of the lady concerned being assessed as not having capacity?
Lord Lipsey
That could arise, I suppose, but it has not arisen in this case. I am not even sure—it is very difficult with these cases, and I do not know if it is even known—whether the man I am referring to has attempted to find that way around it. This lady gets distressed at the mere mention of financial affairs, so it is not surprising that he is ducking away from that. As the noble Baroness says, there could be capacity issues. In certain circumstances, clearly, there could be a court decision that she no longer has capacity to exercise discretion, but that is a long and difficult route to go down in the situation of this poor old man and his poor wife. That is the sort of situation that I am trying to avoid. I am not trying to open the door so that everybody can get away with claiming everything. I am simply saying that if people have inadvertently misled the local authority, the authority should not go after them in the courts to get its money back. It seems a moderate proposal, and I hope that the Minister will be able to respond positively to it.
Lord Low of Dalston
I shall speak to Amendments 89BA and 92ZZM. I very much welcomed the comments of the Minister at Second Reading, when he stated that the Government,
“intend to use regulations to ensure that services ... currently … provided free, including … minor aids or adaptations, remain provided free of charge”.—[Official Report, 21/5/13; col. 826.]
That seems only right, since minor aids and adaptations are qualifying services under the Community Care (Delayed Discharges etc) Act (Qualifying Services) (England) Regulations 2003.
The Government do not want to see local authorities charging for services that they are not permitted to charge for today. Clauses 2(3)(b) and 14(6) hint at this, explaining that regulations may prohibit local authorities from charging for particular types of support. However, the Bill should be explicit about what local authorities are prohibited from charging for.
I shall take the amendments in reverse order. Amendment 92ZZM relates specifically to personal budgets and would ensure that anyone needing care and support and requiring equipment or adaptations costing under £1,000 would not be financially assessed as part of a personal budget, which would effectively impose a charge for those items. In considering the amendment, will the Minister clarify how equipment and adaptations will be provided for in personal budgets? Will he ensure that regulations are unambiguously clear on the need for equipment and adaptations to remain free and for there to be no variations at a local level? The College of Occupational Therapists has some concerns about this.
I know that the Minister understands how important these provisions are to ensure effective preventive services that reduce both the demands on care services and the cost to local councils. In many instances, occupational therapists assist those requiring care and support by recommending the provision of equipment, minor adaptations and assistive technology, often resulting in recommendations, disabled facilities grants for safe management of progressive conditions and the moving and handling of people.
Equipment and adaptations are critically important, as they reduce the need for escalating care, protecting the individual and saving the resources of cash-strapped local authorities. Any reference to the provision of equipment and adaptations is notably absent from the legislation. However, these aids are critical for many people, and it is important that the Government are clear about how equipment and adaptations will be treated under the Bill. I hope that the Minister will agree not only that they should remain freely available but that they should not attract a charge by the back door when made the subject of a personal budget.
Amendment 89BA is a probing amendment to seek an assurance from the Minister that the provision in the Community Care (Delayed Discharges etc) Act (Qualifying Services) (England) Regulations 2003, preventing local authorities charging for minor aids and adaptations under £1,000, will be maintained and to ask whether the £1,000 threshold, set 10 years ago, will be kept up to date.
Baroness Barker
My Lords, I support all the amendments in this group. On these Benches one of our great hopes for a national system of criteria is that it will lessen the frequency with which people in different parts of the country are wrongly charged for services that should be free. It has always been the case that older people, and carers in particular, can find themselves being charged by a local authority for things that are in fact free under various different pieces of legislation, notably the Community Care (Delayed Discharges etc) Act.
All of these amendments have things to commend them. I will start in reverse order, with the amendment of the noble Lord, Lord Lipsey. He has hit on something that is a bigger issue than perhaps has been realised yet. When we were debating the pension credit legislation in this House, the noble Baroness, Lady Hollis, talked about the fact that she had taken over the affairs of an elderly relative. She was probably the one person in the whole of Britain who at that time knew exactly what the regulations were. Yet it was only after the person died that she discovered that they had a little account about which she had known absolutely nothing. Why? Because many older people put money aside to cover their funeral. That is the truth. It is something that is very important to them. They probably do not tell people about it. I am sure that they also have other reasons, but that is a very common one. It is not uncommon for relatives to discover such accounts, although they are not vast amounts of money. The noble Lord, Lord Lipsey, is absolutely right that if, in a circumstance like that, somebody was deemed to have transgressed the law, it would be unfair and unjust.
I also add support to Amendment 89BA, an amendment of the noble Lord, Lord Low of Dalston. I was lucky to serve with the noble Lord, Lord Best, last year on an inquiry into the availability of aids and adaptations for older people who need help to remain in their own homes. We discovered extraordinary variations across the country and heartrending stories of elderly ladies having to carry their very elderly husbands up and down flights of stairs on their back, in a way that was simply unsustainable.
I commend to noble Lords the policy that was adopted by the local authority in Hull. It occurred to officials one day that, truth be known, nobody really wants a ramp outside their door. So they abandoned their assessment procedure; they stopped sending social workers out to discover whether or not this was necessary. They saved a lot of money that went instead into direct services. That is a commendable approach, and one that probably saved the city of Hull a lot of money in immediate and direct costs. Would that that spirit could go into the implementation of this Bill.
Lord Warner
My Lords, I rise briefly to support the amendment of my noble friend Lady Pitkeathley. As someone who has spent six years in the local authority salt mines, I say that one should never underestimate the capacity of any local authority, when times are hard, to scratch around for things by which they can raise some money—I say this with affection. If there is a scintilla of doubt in this legislation about the ability to charge carers for services, we should remove it immediately. Otherwise I would be willing to bet a reasonable sum of money that when there is a financial crisis in some part of the country at some point in the future, a bright spark in a local authority will light upon the chargeability of carers for particular services. I am not sure whether my noble friend’s wording is the right way of doing this, but her intention is absolutely right. I hope that the Government will take this issue away and make sure that this particular piece of legislation is totally fireproof in terms of the ability of local authorities to charge carers for services.
I also support the amendment of my noble friend, Lord Lipsey. Evidence was given repeatedly to the Dilnot commission about the distressed state that many people were in when they made key decisions about their family’s circumstances. I suspect that he is on to something important that affects quite a lot of people.
Baroness Wheeler
My Lords, these amendments under Clause 14 deal with the difficult area of charging for the care and support that we have established is required through assessment. The historic settlement of charging for social care but not for healthcare is being increasingly challenged and the obviously linked issue of funding for social care is ever present, as we have been reminded in today’s debates.
The common agreement about charges is that they should be fair and that the process for means testing should be as simple and as unintrusive as we can make it. Fairness in the eyes of the public means no postcode lottery, but the excellent work by my colleague Liz Kendall, our shadow Care Minister, has shown just how stark the variations are across local authorities today. This is something that we need this Bill to address. Why should charges for the same service be allowed to vary so much? This is seen as unfair and it is. I will be interested to hear from the Minister about this variability of charges and what actions the Government are taking to address it.
For many older people, claiming for any kind of help is hard. We need a system that is easy to use and we could do far more to integrate the various bureaucracies to minimise form filling and document checking and having to repeat the same information over and over again. We could use income information from the Inland Revenue, for example, and we could unify all assessment frameworks and use passporting of entitlement to minimise bureaucracy and administration costs. Much of the detail is for the future in the regulations, but this is our opportunity to remind ourselves of key principles, such as fairness and simplicity, that should shape those regulations. Can the Minister tell us when the draft regulations relating to Clause 14 and charging will be published?
When they are published, the regulations themselves will inevitably be complex and disputes are likely. Dispute through judicial review or the courts is not the way. Will the Minister explain why there appears to be no response to appeal or conflict resolution processes contained in this part of the Bill? Why do many of the decisions made under provisions in Part 1 seem not to have some mechanism of appeal attached to them? The appeals system should be fair, easy to access and independent. Does the Minister acknowledge that this is needed?
On the specific amendments in the group, my noble friend Lady Pitkeathley has provided an excellent explanation of the importance of her two amendments, Amendments 89A and 89B. As usual, it is very hard to find anything additional to say when it comes to carers and carers’ rights after she has spoken. It is right always to underline our support for the provisions in the Bill providing statutory rights for carers, but there are still areas of concern that need to be addressed relating to means testing and local authority care charges, and the widespread fear among carers about charges as local authorities become increasingly strapped for cash.
Earl Howe
My Lords, not for the first time, I find myself in sympathy with the noble Baroness, Lady Pitkeathley, and the concerns she has raised about the Bill’s practical implementation. I am sure it is a shared view across the Committee that people should be supported to remain independent within their own homes for as long as possible. As the Bill recognises, supporting carers and preventing or delaying the need for care and support are both vital to achieving this goal.
On the specific amendments tabled by the noble Baroness, our previous debate shows the value and importance which noble Lords place on carers and the need to support them. I thank the noble Baroness for her recognition of the significant improvement that this Bill will make. I reassure her that the Bill makes it clear that local authorities cannot charge carers for services provided to the person being cared for. Our clear view is that Clause 14(3) puts this matter beyond doubt, and this would include services of an intimate nature provided to the person being cared for.
Local authorities need to retain the flexibility to meet the needs of carers in the most appropriate way. This might include providing services to the adult needing care such as feeding them or taking them to the toilet. Providing these services is necessary to allow carers of people with the greatest needs to take a well earned break from their responsibilities. However, Amendment 89A would create a legal barrier which may hinder the provision of support to carers. For that reason, I do not warm to it.
Amendment 89B would ensure that services provided to carers were provided free of charge by the NHS. Local authorities currently do not usually charge carers, as they recognise the vital work that they do. In some cases, however, local authorities may charge a fee for services provided directly to carers, such as when the local authority arranges a trip for them. We want to continue to give local authorities this flexibility.
The noble Baroness expressed a worry about the scope for different interpretation about who is the beneficiary of a particular service. In most cases, I suggest that it will be clear what is being provided to the adult needing care and support as opposed to the carer. However, statutory guidance will be provided to help to promote national consistency on that point. I hope that that reassurance will provide the noble Baroness with the wherewithal to withdraw the amendment for the time being although I will, of course, reflect further on what she has said.
On Amendments 89BA and 92ZZM, I reassure the noble Lord, Lord Low, that we intend to maintain the existing entitlements to aids, minor adaptations and intermediate care in regulations. Aids and minor adaptations costing up to £1,000 will continue to be provided free and without the need for a financial assessment. We will shortly be consulting on the implementation of our reforms to care and support funding, which will inform the future regulations. In designing the new regulations, we will consider whether we should update the list of services which must be provided free of charge. However, we must bear in mind that further limitations on the ability of local authorities to charge would reduce the resources available to support people with the greatest needs. The draft regulations will be subject to a further public consultation to ensure the final regulations are based on the best available evidence.
As I indicated earlier, we are introducing a fairer system, including a cap on care costs. It is right that people who can afford to do so should continue to contribute a fair amount towards their care costs, and when they do not, Clause 64 allows local authorities to recover these costs as a debt. I understand the desire to protect people who make mistakes or accidentally fail to disclose relevant information. However, I fear that Amendment 104ZB, which would require local authorities to prove intent, would result in complex and expensive legal cases. Intent is not always easy to prove. Local authorities will not be able to charge people more than their due debt and the costs incurred in recovering that debt, and we think it is right that they should be able to do so even if someone has made a genuine mistake. This is not about instituting recriminations but about correcting mistakes. We should surely allow local authorities to take action in such a case if we believe in protecting public money.
Lord Lipsey
I am a bit bemused. I cannot see where my amendment states that local authorities have to prove intent, nor do I see in the noble Earl’s argument any reason why the person who makes a mistake should have to pay not only the extra money they have received but the cost to the local authority of retrieving that money. That seems to me a punishment too far.
Earl Howe
I had rather assumed, perhaps wrongly, that if, for whatever reason, there has been a discrepancy in the declaration made by a person, it either has to be a genuine error, or something more deliberate, in which case there is intent involved. I am not sure what other explanation there could be. That was why I read into the noble Lord’s amendment what I did.
I think that the ability of a local authority to recover costs ought to act as a disincentive to people to be careless about what they are doing. They should make sure that what they declare is accurate and should be made aware that if they make a mistake, it might prove a little more costly to them than just rectifying the error. This is not about imposing recriminations on people. It is right for local authorities not to be out of pocket when other people out there could be benefiting from the public money that is available.
Lord Lipsey
The noble Lord has interpreted my amendment one way; I have interpreted it in another way. It may be that the Bill, either as it is or as amended, is not quite right. Can the noble Lord agree that we have further discussions to see if we can find a way forward that satisfies us both?
Earl Howe
I am more than happy to discuss this with the noble Lord and I apologise if I have misunderstood his amendment. I certainly would not wish to do that.
The noble Lord, Lord Low, asked me how equipment and adaptations will be addressed in a personal budget. Those costs that are intended to meet eligible needs will be included in the personal budget, or the independent personal budget, and will count towards the cap. We intend that aids and minor adaptations will be provided free of charge however they are funded, including by way of direct payments.
The noble Baroness, Lady Wheeler, asked me when the regulations under Clause 14 will be published. We intend to publish the draft regulations after the forthcoming consultation on funding reform. This consultation will enable the regulations to be based on the best available evidence. She asked where are the provisions about complaints and redress in relation to charging and, indeed, all of Part 1. Existing complaints provision for adult social care is through regulations. The provisions of the regulations mean that anyone who is dissatisfied with the decision made by the local authority about their assessment or eligibility would be able to complain to the local authority and have that complaint handled by the local authority. The local authority must make its own arrangements for dealing with complaints in accordance with the 2009 regulations.
The Government recognise that the existing framework allows local authorities flexibility in the development of the process for dealing with appeals and challenges. There are options for local authorities to introduce independent elements to the complaints process through a range of formal and informal measures. Each local authority will therefore have a different process and we appreciate that local variation will result in varying user experiences. If a complainant is not satisfied with the response from the local authority, they can refer the case to the independent Local Government Ombudsman.
I hope that those remarks will be helpful and that the noble Baroness, Lady Pitkeathley, will for now be able to withdraw her amendments.
Lord Warner
Can the Minister clarify his response to my noble friend’s amendment that there would be statutory guidance? I know that I have been away for a few weeks, but before I left, the Government had turned their back on a statutory code of guidance, as I understood it. Has there been a change of heart in my absence?
Earl Howe
My advice is that the guidance that we will issue on this topic will be binding on local authorities. It will not be the type of guidance which merely points to best practice, which local authorities are free to ignore. The last thing I wish to do is to mislead the noble Lord and if I have done so, I apologise in advance and I will clarify that point to him and to the entire Committee.
Baroness Pitkeathley
My Lords, I thank all noble Lords who have spoken in what my noble friend Lord Lipsey called this “bits and pieces” group, although charging and access was the theme that linked the amendments. I am naturally disappointed that the Minister cannot accept my amendments, but reassured by his restating his intention so far as carers and charges are concerned, and by the statement that he has now given twice about the guidance being binding on local authorities with regard to charging. I am also grateful for his offer to reflect on my concerns, because I am not entirely certain that we have totally removed what my noble friend Lord Warner called “the scintilla of doubt” which might allow local authorities at some point in the future to charge carers. For the time being, I beg leave to withdraw the amendment.
Lord Lipsey
Lord Lipsey
Now for something completely different. These amendments hardly deserve the epithet “probing”—more a light examination by the doctor’s fingers. What they do is, in essence, simple. They substitute for the monetary cap proposed by the Government a cap based on the number of years a person has been receiving care at a substantial level.
The origins of my amendment were in a proposal floated in the minority report to the 1999 royal commission on the funding of long-term care. As I was the author, I remember this quite well. It did not even gain the support of a majority of the minorities, as the noble Lord, Lord Joffe, declined to sign up to it. Nevertheless, it has had a life after death and I think it can claim paternity —the noble Lord, Lord Warner, knows better than I—for the cap proposal in the Dilnot report, because it shares precisely the same objective as the cap: to limit the costs of care to those unlucky enough to require it for a long time as it costs a lot of money. That is the aim of the proposal.
When I first saw the Dilnot proposal, I thought that it was clearly superior to the one in the minority report—everyone would spend the same before the state kicked in. But as time has gone on I have become much less sure of this as two defects of the Dilnot version have become more apparent. The first is that it is extremely complex for local authorities to administer. There have been figures of between £300 million and £500 million floating about for the cost of administration, before money is handed out to people. That is because, to implement the Dilnot report, it is necessary to track each individual from the time the meter starts ticking to see exactly what they are spending on care or, rather worse, to see exactly what a local authority thinks it should be providing in spending on care for each individual—a sort of abstract concept that has to be turned into a concrete figure.
As will be apparent from other amendments I have tabled, I am not even confident that local authorities will have their systems sufficiently sorted to manage it by the proposed start date of April 2016. There is a non-negligible risk that this will prove to be universal benefit mark 2, a scheme that will in practice prove impossible to operate. I hope I am wrong but the fact is that, putting the best face on it, it will cost a lot of money to implement without any of that money going to better care, and not a penny of it going to the people who should be helped. In the Government’s ghastly jargon, it will be money spent on bureaucracy, not front-line services. That is my first query about the Dilnot way of doing things.
My second point is equally worrying. The Dilnot system is terribly difficult for anyone normal to understand. When do you start to get it? How much is assessed as being the cost of the care that you may get from the council? How much have I spent? How much of that counts towards the cap? People may say, “My care costs differ because my condition goes up and down”. All those factors are crucial if people are to know what they spend out of their own pockets. I am sure that better-off people who are in full possession of their faculties will work it out, but we know that 40% of people over 80 have some degree of dementia and are therefore not in full possession. Certainly, those with computer-literate families and sons or daughters who happen to be independent financial advisers will crack it all right. Their claims for substantial care needs will be there on day one in a large pile on the local authority’s desk. They will know every penny that has been spent, but are we confident that everyone else will? Just explaining the system and the process of communication, to which we shall come later, will be jolly difficult. It should be remembered that more than half the people think that the state at the moment pays their entire care costs without deductions. There is a long way to go from there to understanding Dilnot.
By comparison, a time-based system is simplicity itself. You have an assessment, and if it shows that you need substantial care or its equivalent under the new system, the clock starts ticking. Five years later, you no longer have to pay the cost of your care. That is very simple. Five years is what you have to find. In my variant, the council would then pick up the whole cost, not some notional cost, as under the Dilnot cap, and you would simply have to find your hotel costs where applicable. That is simplicity itself and, incidentally, it makes it much easier for you to insure privately. Private insurance companies are going to struggle to know how much their liability will be under the Dilnot system. Under a time-based system, they will know that they have a liability. If you live more than five years the state will pick up the bill and the only bit that they will have to cover is the first five years.
How does that compare in generosity with Dilnot? It will probably be about the same. The Dilnot cap would be reached by someone in residential care rather more quickly than the five years but, on the other hand, as you are going to be paid only in part if you reach the cap, you may not be any better off. I suspect that for those receiving care in their own homes my proposal will prove to be more generous than Dilnot’s £72,000 cap. In most cases, people will take more than five years to reach the £72,000 and it may therefore be slightly more generous to people who live at home, which is no dreadful thing.
Sunny optimist though I am, I do not expect the Minister to go snap on my scheme today. I am not even sure that I do. He and his colleagues had enough trouble getting the Government to sign up to Dilnot, and they will not want to execute any unnecessary U-turns now. However, I suggest that he puts this proposal in his bottom drawer because it may become apparent in six, 12 or 18 months’ time that Dilnot, as encapsulated in the Bill, is simply impossible to administer on any realistic timetable. When that day dawns— I hope it does not—my scheme may come in handy. I beg to move.
Lord Warner
My Lords, my noble friend will not be surprised if I gently defend the Dilnot commission’s recommendations on a cap. His final suggestion of putting his proposal in the bottom drawer was actually rather good. I remind the House that as a young civil servant I was once the recipient of a Health Minister’s regular manuscript notes asking me about progress on various matters. They ended up in my bottom drawer because he had usually forgotten about them. Putting this recommendation in the bottom drawer may be the best thing to do.
I think that my noble friend has forgotten the task that the Dilnot commission was set. It was not the case that we just brought a cap out of the ether and projected it on to an unsuspecting world. We were trying to fulfil the task that we were given, which was to make recommendations on how,
“to achieve an affordable and sustainable funding system … for care and support for all adults in England, both in the home and in other settings”.
In particular, we were asked to examine,
“how best to meet the costs of care and support as a partnership between individuals and the state … how people could choose to protect their assets, especially their homes, against the costs”,
and,
“how both now and in the future public funding for the care and support system can be best used to meet care and support needs”.
I suggest that to fulfil those requirements it is probably better to concentrate on money and try to achieve a credible system than to concentrate on time. One of our main purposes was to project the idea that if we could get citizens to be more engaged with the realities of a means-tested adult social care system, they would plan for the future in a better way than at present. Money is the currency in which they would be thinking, to all intents and purposes. That is why we came up with the idea of a cap.
My noble friend is right to ask how well prepared local government is to introduce this system. There are some genuine concerns about that, which we will debate later. However, he is a little pessimistic about our ability to develop, perhaps over a longer period than the Government might like, a taxi-meter system that works for the Dilnot proposals. They are essentially a taxi-meter system. You need to clock up the costs that are being spent over time until you reach the cap. There is a thing called IT; it is not always well used in the public sector but it is possible to take the pain out of all this. We as a commission did not envisage a new pencil-and-paper system that 152 local authorities would reinvent in individual and separate ways. It is a complex system but it is actually not that difficult to manage, once you get into the swing of it.
I say very gently to the Minister and to my noble friend that we sweated blood for about a year to try to get a very large number of people to agree on a way forward. This is not the time to go back to square one and think of another way of doing it.
Lord Campbell-Savours
My Lords, I totally dissent from the case that my noble friend Lord Warner makes. I have opposed Dilnot since the first day that it was made public as a report. My view is very simple. It will simply transfer money from those without to those with, and it has been introduced to appease—I repeat: to appease—the demands of those who insist on passing on inherited wealth from one generation to another, a most ignoble way of proceeding.
I think that my noble friend’s amendment is utterly brilliant—it deals with exactly the concerns that I have, and I hope that it does not end up in the department’s bottom drawer. I hope that when the Government begin to realise that the whole complicated process they are imposing on local authorities will inevitably lead to mistakes and errors and congestion and arguments between carers and people being cared for and their relatives and local authorities, they will sit down, have a rethink, and turn back Dilnot.
The Dilnot report is unjust as far as I am concerned in that it simply transfers wealth from one generation to another. I totally oppose it, and I think that my noble friend’s amendment should be enshrined in the legislation. My noble friend Lord Warner set out the remit as if members of the commission were somehow imprisoned in it so that they could not even consider this proposal. As I understand it, my noble friend’s amendments and the idea behind them were not considered by Dilnot. Sad to say, that is the case. I hope that in the near future this proposal will be resurrected—I hope by my own Labour Party.
Lord Hunt of Kings Heath
My Lords, I hesitate to come between my noble friends Lord Warner, Lord Lipsey and Lord Campbell-Savours, and indeed knowing what is good for me I am not intending to do so. I say to my noble friend Lord Campbell-Savours that I understand the point that he is making and I agree that Dilnot is not the answer to many of the really pressing problems that we are talking about.
I want to tempt the noble Earl to say a little bit more on two areas which have been referred to by noble Lords. The first is the complexity for local authorities of what they have to administer. The noble Earl has not really responded in detail on this matter so far. Indeed, it is noticeable that local authorities have not responded. We have received a huge amount of evidence, but not very much from local authorities and the local authority associations. This worries me. I understand why local authorities would be keen to play a prime part in the administration of this new system, but these are genuine concerns about whether there is capacity to make changes of this complexity happen. Nothing would be worse than the new system coming into being and collapsing almost on day one. At the moment, that is my view on what is going to happen. I do not know what the Government intend in terms of testing out the robustness of the system for when it is due to come in. I hope that at some point during our debate the noble Earl will be able to tell us.
Secondly, the next group of amendments deals with the public understanding the complexity of the system being considered, but it seems to me that this issue relates to the point about insurance raised by my noble friend Lord Lipsey. My understanding is that one benefit of full implementation of Dilnot—although I am not sure that the Government have gone down that path—would be that, if the public knew that their liabilities would be capped, there would be likely to be a ready insurance market. A number of us have looked with interest at the comments of the Association of British Insurers and other parts of the insurance industry. I have to say there does not at the moment seem to be much optimism about whether there is going to be a market and whether packages are going to be developed. This may come up in later amendments, but at some point I hope that the noble Earl will give a little more information about the Government’s view of the potential of the insurance market to develop products which the public can understand and will be willing to invest in.
Earl Howe
My Lords, as the noble Lord, Lord Lipsey, explained very clearly, these amendments would mean that the capped system counted time rather than costs. I agree that there are advantages to this approach. The Dilnot commission, in considering this option, said that using years instead of costs would be easier to administer and simpler to understand, and I appreciate those arguments. However, the commission also made the case that to adopt this approach would disadvantage those with more intensive care needs, who over a given period of time could spend significantly more on care than those with less intensive needs, so that what we might gain in simplicity we should lose in fairness. I am sure that we all want to see a fair care and support system giving the most support to those in the greatest need. Using time instead of costs would undermine that goal.
We are committed to using notional spend—in other words, the equivalent of what the local authority would pay to meet an adult’s eligible care needs. As with using time, it is in fact relatively simple to administer because it fits in with the current system of needs assessment. It also ensures that people with more intensive needs are not disadvantaged. That is why the Government agree with the Dilnot Commission, which said,
“the only suitable way of deciding when a person has reached the cap is to meter notional spend.”
The noble Lord, Lord Lipsey, pointed to the understandable fear that Dilnot will mean spending money on administration rather than on meeting people’s needs. I accept that times are challenging for councils, but we are committed to funding these reforms. Critically, we are also committed to co-producing the implementation of the reforms to minimise the bureaucracy that accompanies them and maximise the benefits that they bring. The noble Lord suggested that local authorities might not be ready to implement Dilnot in 2016, and the noble Lord, Lord Hunt, also asked about this, and whether we were intending to test the robustness of the system. We shall be coming to the issue of readiness in the next group, but I agree with the noble Lord, Lord Warner, that there is sufficient time to develop what he referred to as a taxi-meter system.
The noble Lord, Lord Campbell-Savours, took us to a point that he has made in this Chamber before about Dilnot, and his view that it is fundamentally unfair. I simply say to him that the vast majority of state support, under the Dilnot system, will be provided to the roughly 40% of older people with the lowest income and the lowest wealth. The cap, and the extended means test, provide the most reassurance to that particular group. Our view is that we need a system that protects people with the greatest lifetime care needs. It is not about protecting people with the greatest wealth.
To clarify the question that the noble Lord, Lord Warner, raised in the previous group of amendments about the guidance under Clause 71, this will indeed be statutory guidance, and it will look and feel like a code of practice. Importantly, it will have the same legal status. However, we do not think that guidance should be subject to parliamentary scrutiny every time it is updated, as with a code of practice Statutory guidance under this Bill will have the same status as the current guidance issued under Section 7 of the Local Authority Social Services Act 1970. I hope that this is helpful.
In a later group of amendments we will come to what local authorities think about the new system and indeed the whole area of financial services. However, I was reassured that the Local Government Association said that it fully supports and welcomes the inclusion of a cap on what an individual will pay. The Association of British Insurers has welcomed the announcement that we have made as a positive step forward in tackling the challenges of an ageing society. Arising out of that is a sector-led review that is working constructively with government to understand how the market will develop and create the right environments for products to succeed. That review will be completed over the summer.
I hope that with those comments the noble Lord, Lord Lipsey, will for now be content to withdraw his amendment. I hope that he found my comments, if not ones that he can agree with immediately, at least ones that he will put into the context of the Bill in, I hope, a manner that he will understand.
Lord Lipsey
My Lords, I thank the Minister for his reply, which was a miracle of putting very well the point that has come out of the debate. I thank all those who have participated. We have here a trade-off between simplicity and fairness—it is as simple as that. The Government—unusually, my party might think—have opted for fairness, and my party might not be surprised that in this case I have opted for simplicity. However, the matter will rest. Of course, if this system goes absolutely swimmingly, I shall forget that I asked the Minister to put it in his bottom drawer, but if it all goes wrong I shall tell the world that “I told you so”. With that, I beg leave to withdraw the amendment.
Lord Sharkey
“( ) The Secretary of State has a duty to ensure that there is, through national public awareness campaigns, a high level of public awareness and understanding of the terms and implications of the cap on the cost of care.”
Lord Sharkey
My Lords, my Amendment 89E covers the same ground as, and is very similar to, Amendment 90 in this group standing in the name of the noble Baroness, Lady Greengross. I entirely agree with the spirit of the noble Baroness’s amendment except that I do not think that it goes quite far enough.
The question of public awareness of the terms of the cap on care costs is obviously critically important. However, as I said at Second Reading, the Dilnot report views communication to be central to the success of the entire scheme. Dilnot makes two recommendations in this area. The first is:
“To encourage people to plan ahead for their later life we recommend that the Government invests in an awareness campaign”.
The second is:
“The Government should develop a major new information and advice strategy to help when care needs arise”.
In his reply at Second Reading, the Minister said:
“Legislation is not required for that but the Government agree on the need to raise public awareness. The Government will adopt a strategic approach to maximising the public’s understanding of the new care and support system, and that is a crucial part of our plans to implement Dilnot”.—[Official Report, 21/5/13; col. 827.]
I was very glad to hear that the Government plan to maximise public understanding of the new system. Maximisation is a strong word and this is a very strong and very welcome commitment. I agree that legislation is not necessary in order to implement an awareness campaign. However, while legislation may not be necessary, I think that in this case it is highly desirable and probably even essential.
I believe that it is highly desirable for four reasons. First, it is a binding and unambiguous commitment; secondly, it allows for a national campaign, so that there should be no unsatisfactory variations in achievement by local authority area; thirdly, only central government is really likely to spend the amount of money needed to truly maximise public understanding; and, fourthly, it is the only efficient way of holding someone to account for failure to achieve maximisation. As I mentioned, where I slightly part company with the noble Baroness, Lady Greengross, is over whether her amendment goes far enough.
I have had a great deal of experience of devising and running very large-scale information and advice campaigns, some of the largest being for government departments, and I know that successfully providing information and advice is never enough. It is critical that this information is understood but it is also critical that there is awareness and understanding of the implications of that information and advice. Awareness of facts is not in itself worth very much if we do not understand what those facts mean or what their implications are for you. That is why my amendment is slightly stronger than Amendment 90. It imposes a duty on the Secretary of State not only to run a national awareness campaign but to ensure that there is a high level of public awareness and understanding of the terms and implications of the cap on the cost of care.
Baroness Greengross
My Lords, I support the noble Lord, Lord Sharkey. A similar amendment in my name is not as strong as his amendment. I think that his would do the job that needs to be done remarkably well and I hope that it will be agreed by the Minister.
Lord Lipsey
My Lords, I will speak to the amendments in this group standing in my name but, before I do so, I should like to offer the strongest possible support for the noble Lord, Lord Sharkey, and particularly for the words that he said at the beginning about the information task that we face here. This is not just a question of advising individuals when they go to their councils, although that is important and we have had a debate on that. It is a question of making the whole of our society aware of what is going on against a background of very great ignorance and misinformation. It is crucial that something is done on a real scale to turn that around and that the best communication skills are used in doing so. We have to move from the language that we use in this Chamber as aficionados or geeks studying the detail of the Bill to the general public out there, and that is a hell of a task.
As I said, I will speak to my Amendments 90D, 92ZZB, 92ZZC and 104ZC. Amendments 90D and 92ZZC relate to a topic that we touched on in the debate on the previous amendment—namely, the costs and administrative difficulties for local authorities of introducing the cap in the scheme. The Local Government Association has expanded on the numerics in the briefings for this debate, as has London Councils. I think that the local authorities have a slight tendency to underplay what is going on for fear that the Government will take the whole thing away from them, and they want to be shown as “can do” rather than “can’t do”. When you get into the detail, and look below the politicians in local government at the fine detail of those who have to implement it, you find that it is quite difficult.
The Government have in principle accepted the burdens doctrine, namely that if they make local government do something they will pay for it. They have provided around £335 million to pay for that. None of this extra money is coming now, by the way. The contributions will not start until 2016. Bad though the administrative mess may be, if local government does nothing to prepare for this scheme until 2016 it will certainly fail. Already it is doubtful whether the burdens scheme is really being met. Many of the costings put forward are fingers in the air stuff. The detail has yet to be grappled with. Details crucial to costing the implementation of the scheme, such as the eligibility requirements, are only emerging bit by bit. We do not even know what the government money is supposed to cover. Does it fund in full the cost of additional self-assessments, when the self-funders and people who will potentially benefit from Dilnot queue up for assessments? I really do not think that we know the detail of duties around advice and information, on which we spoke earlier, or on the funding for setting up new deferred payment schemes.
My change is designed to write into the Bill what is in effect the burdens doctrine. Whatever the cost, the Government must pick it up. It is not as if local authorities have got large chunks of money in their pocket at the moment to reach in and pay for all this stuff. They do not. They cannot afford basic care services at the moment, so this is a huge task. There is a huge task, too, in training the local authority workforce to do assessment and implementation on this scale, and indeed in creating the workforce.
These facts lead me to believe—and I am very glad that my noble friend Lord Warner, with whom I agree on nearly everything, agrees—that it was a terrible mistake to bring forward the start of the scheme from 2017 to 2016. We know why it happened, do we not? The Government found that they had a few spare quid in their pocket, and wanted to be able to tell the electorate that Dilnot was nigh, and so without proper consideration of any kind they brought the date forward. It was a U-turn, and my amendment U-turns on the U-turn to get back to the right place where they were to begin with, namely that the scheme will come in in 2017. This would give it a good chance to work.
I turn now to my other amendments in this group. I hope that we might finally get an actual concession from the Minister, instead of words of great sincerity and great sympathy and not much change. My other amendments in this group refer to the setting up of a ministerial advisory group on the cap and the means test. They insist that this group should be consulted in the planned five-year review of how all of this is working. This is not a criticism of the Department of Health. I have been impressed by how effective officials have been in grasping this scheme, particularly as for most of the time that Dilnot was under consideration they probably thought that it was never going to happen. They are a first-class team, but I do not think that they possess a monopoly on wisdom, and indeed they do not think so, either. The Minister just referred to the working parties with the financial services sectors that have been set up to give advice. I applaud that.
I think that there are complexities in all of this that even the most literate advisers have barely grasped. I will come to some of them, for example when we come to the detail of the proposals on the means test. It would be helpful if Ministers had to hand a helpful advisory group comprising academic experts, local authority representatives, representatives of the financial sector and someone from Dilnot. Maybe the noble Lord, Lord Warner, would like to volunteer. A group of that kind would not second-guess Ministers on every detail, but would offer its general advice on how things are progressing and how they may be set right if there are departures from the course on the way forward.
Lord Warner
My Lords, I support the comments made by my noble friend Lord Lipsey. There is a case for setting up some sensible monitoring arrangements. This is not just to check up on the Government, but to make sure that this system is working in the way that everybody wants it to. It is a big change, and we are starting from a position which means we have to grasp the nettle, as the noble Lord, Lord Sharkey, said. I strongly support his amendments.
I want to refresh the House’s memory of what we said in the Dilnot commission report. I will briefly detain noble Lords with a quote:
“There is very poor understanding of how the adult social care system currently works and how much it can potentially cost. Many people live under the false impression that social care will be free if they need it. If people are confused over how the system works and the costs that they potentially face, they will not prepare appropriately for the future”.
That setting was why two of our 10 recommendations were that the Government should develop a major new information and advice strategy to help when care needs arise. To encourage people to plan ahead for their later life, we recommended that the Government should invest in an awareness campaign. We deliberately put those responsibilities on the Government. We did not put them on local authorities. We did this because we thought that unless the Government of the day—and this would apply to a Labour Government as much as a coalition Government—took a grip on this awareness campaign and planned the information and advice strategy, we would end up with a badly informed public and a mishmash of different local authority systems up and down the country.
We are not going to make this system work well or deliver the changes in the Bill and in the Dilnot commission report, unless there is investment. In our report we put the price tag of this as being a massive public awareness campaign. The public do not start from a position of being well informed about how they prepare for the future care and support needs that they will have in later life. The only way to start to change that is for the Government to grasp the nettle. I strongly support the proposals of the noble Lord, Lord Sharkey, to put this in the Bill. We should put a clear responsibility on the Secretary of State to run with the ball on this issue and, in effect, to monitor progress, not on a five-year basis but on a regular, annual basis. If we do not do something like this, we will live to regret it. We will see failure of implementation and failure to take the public with us on this major set of changes.
Lord Campbell-Savours
My Lords, my noble friend refers to the exhortations in the report to require the Government to carry out an awareness exercise. However, the reality is that there has been a huge spin on the whole Dilnot proposal. Many people, even those in care, believe that as of the starting date, 2016, everyone who has already spent something like £70,000 will suddenly receive free care. Of course, that is not true. It only affects people who enter the care system after a particular date. That is all part of the spin which has now led to a gross misrepresentation of what Dilnot proposes. Dilnot, while I oppose it, is offering a lot less than the spin suggests.
I want to talk about the reference in the amendment to the,
“implications of the cap on the cost of care”.
The implications of the cap on the cost of care are that there will be far greater transparency in the system, which was what the Minister told us in the debate that took place last week, when we debated the question of transparency. I argue that that transparency will lead to a lot of conflict between self-funders and people who are in receipt of support from their local authorities.
There is a group of people who will be over the means-test threshold but will pay the full cost under the cap. They will suddenly be confronted with information in this new regime of transparency which will give them far more information about what other people are paying in the home, what the local authority is prepared to pay and what the local authority believes to be a reasonable fee for care. That could lead to conflict within individual care homes and I wonder to what extent Ministers have taken it into account.
An amendment such as this is absolutely necessary because, before people are confronted with this decision when it comes later in this decade, it will at least give them some indication of where the truth lies and will perhaps bring an end to the misrepresentation that is taking place.
Lord Hunt of Kings Heath
My Lords, my Amendment 90ZA requires the Secretary of State to report to Parliament,
“in advance of this section coming into force with the Government’s assessment of the likely impact of the cap on care costs; and … annually once the section is in effect, with the Government’s assessment of the impact of the cap, in particular its distributional impact across the income spectrum”.
I echo some of the points already made. The operation of the cap ought to be, and continue to be, subject to ministerial oversight. The opportunity to report to Parliament and for us to have an annual debate should not be missed. This links into the amendment of my noble friend Lord Lipsey, Amendment 92ZZB, because it would enable a ministerial advisory group to feed into an annual report on how the scheme is being implemented and whether changes need to be made.
It is important to bear in mind the concern of my noble friend Lord Campbell-Savours that simply operating Dilnot will favour the better off at the expense of the worse off. We must keep an eye on how it impacts on the distributional spectrum in this regard. That is why I have the second part of my amendment.
Like other noble Lords, I agree with Amendment 89E in the name of the noble Lord, Lord Sharkey, and Amendment 90 in the name of the noble Baroness, Lady Greengross. I have learnt over the past few months how complex this issue is, and if noble Lords do not understand the full complexity of the scheme—and I gladly hold my hand up that I have yet to believe that I have full mastery of how it will operate—how can members of the public be expected to understand its full consequences?
In our debate on Clause 2, we discussed the responsibilities of local authorities in providing advice and we debated the need for independent financial advice to be made available. The consequences for a person making the wrong decision on funding could be catastrophic. It is therefore important that advice is readily available, and I agree with those noble Lords who think that it ought to be a national responsibility. Whether I would give it to the current Secretary of State, I am not quite so sure.
I remember how the Government spun this Bill in the Queen’s Speech and the Prime Minister giving the impression that no one would for ever more have to sell their home and that the £72,000 cap was the limit. However, as we have gone through the Bill has become quite clear that neither is the case. I agree with my noble friend Lord Campbell-Savours that the Government have not thought through the implications of what the noble Earl said last week about the issue of transparency.
The point is that most people have to spend more than £72,000 because self-funders do not pay local authority rates. In his sophisticated response last week, the noble Earl suggested that local authorities took advantage of procurement at scale, which is why they were able to get a rate lower than self-funders. That was a remarkable argument. Most people see this as a case where local authorities underpay and that if homes only existed under local authority rates many of them would not be viable. It is therefore not surprising that many homes are on a cliff edge of viability on the one hand and at risk of being put out of business because of CQC inspections on the other. There is no doubt that it is generally thought that self-funders subsidise the people in those homes who are paid for by the local authority.
However, most people do not know that. Only an inside circle is aware of the issue. However, come the new implementation, everyone will know—as the noble Earl said last week, it will be transparent—and people will not put up with it. That is why, first, it is essential that more thought is given to implementation. I am not sure whether my noble friend Lord Lipsey is right to want to delay it by a year, but I am sure that he is right to say to the Government that they need to look carefully at the practicalities of implementation.
Secondly, it is important that self-funders are in future fully aware of the consequences of any decisions they take. At the moment, I and many other noble Lords are not convinced that the public are aware. That is why it is so important that a duty is laid on Ministers to fund, and continue to fund, a national campaign of information and that we come back to our debates on Clause 2 in relation to independent advice being made available.
Thirdly, I hope that the noble Earl will readily accept the amendment of my noble friend Lord Lipsey about the need for a ministerial advisory committee, which could then enable the Secretary of State to report to Parliament annually in relation to the implementation of the Dilnot proposals.
The noble Earl will be aware that, in general—my noble friend Lord Campbell-Savours aside—the Care Bill enjoys support. However, there is a risk of our disagreeing on implementation. If he can reassure us on the readiness of local authorities, on the willingness to provide independent advice and on the willingness to establish some kind of independent mechanism to report on a regular basis, it would provide a great deal of comfort.
Earl Howe
My Lords, the clauses on the capped-costs system represent a significant step forward, ending decades of uncertainty, with the introduction of a clear system that fairly shares costs. For the first time, people will be protected from spiralling costs and will no longer have to fear that their home will be sold while they are in a care home. In response to Amendment 90ZA, I can confirm that we published an impact assessment of the reforms which includes the distributional impact by income.
The current system exposes those with little savings or modest housing wealth to the greatest risk of losing everything to pay for their care and support. We will enable people to keep more of their capital and still receive a contribution from the local authority towards their residential care costs. Under new regulations, those with capital assets of less than £118,000 will see the local authority pay a proportion of their residential care costs rather than only those with assets of under £23,250.
As I mentioned earlier, the vast majority of state support will be provided to the 40% of older people with the lowest income and wealth. The cap and extension to means-tested support provides the most reassurance to this group. This is about protecting people with the greatest lifetime care needs and not people with the greatest wealth. The reforms must be sustainable and affordable for the long term, which is why we have accepted the Dilnot commission’s recommendation that the level of the cap should be adjusted annually in line with inflation. It is an approach used in taxes, pensions and benefits, ensuring they remain equally fair year after year.
I turn to amendments 92ZZB, 92ZZC and 104ZC. The noble Lord, Lord Lipsey, shares our aim in drawing up the Care Bill of ensuring the system can respond to changing circumstances. However, that dynamism must be balanced with some certainty about the basis for changes. That is why Clause 16 requires annual adjustments to be made to the cap and to an adult’s accrued costs, so that they keep pace with inflation. Clause 66 provides some certainty that changes are likely to occur only as a result of the annual adjustment or five-yearly review. In reviewing the level of the cap and the means-test threshold, the Government will want to involve a range of experts in assessing how external factors such as demographic change and healthy life expectancy are affecting affordability and the benefits of the capped costs system. A standing independent committee is therefore unnecessary and could suggest that the system is subject to constant change—which may, perversely, result in fewer people planning and preparing on the basis of these reforms.
Amendments 90A, 90B and 90C would require the annual adjustment to be made in line with average care costs. The first point to make is that there is no nationally recognised measure for care costs inflation. Linking the annual adjustment to a care costs inflation measure that has no national benchmark would not give people, or the financial services industry, certainty or confidence in the system. It would of course be possible to develop such a measure, but we feel it is unnecessary, as a robust proxy already exists. Average earnings is one element of the measures used to determine the state pension and therefore represent changes in people’s ability to pay. Earnings is a national statistic certified as compliant with the code of practice for official statistics. In addition, care costs and average earnings are related since labour is a substantial proportion of the cost of care. The latest Laing & Buisson market survey states that,
“in the longer term, fees are inevitably driven by costs … the major cost item is payroll”.
Turning to Amendments 89E, 90 and 104ZD, which is where my noble friend Lord Sharkey began this debate, I fully agree that it is critical that people are made aware of the reforms and what they will mean. The Dilnot commission rightly recommended that there should be an exercise in raising awareness alongside implementation of the reforms. Many people do not realise that they may have to pay for their care and support, which acts as a significant barrier to effective planning and prevention. The Committee will be aware from the debate on Clause 4 that we know that easier access to good quality, trusted information and advice is a critical enabler. The Bill places a duty on local authorities to provide information and advice, including on the capped cost system.
I assure the noble Lord, Lord Campbell-Savours, that we have absolutely no intention to or interest in allowing spin to replace clear and balanced information for the public. In improving awareness and advice, national and local must work together. It will be in the interests of local authorities, the public, government and the financial services industry to make sure that people are aware of the reforms and have access to the right information and advice at the right time so that they can plan and prepare to meet their care and support needs. We will seek views in the forthcoming consultation on the design and technical implementation of the funding reforms, which will include addressing the best way to raise awareness of these reforms nationally and locally.
My noble friend Lord Sharkey made the good point that awareness and understanding of the Dilnot reforms has to be evaluated and measured over time. As with any other policy, we will seek to evaluate the effectiveness of this particular policy, but we believe that to require an annual report in the Bill would incur a potentially high and unnecessary cost. There are other ways of delivering the same aim.
Lord Campbell-Savours
If someone is below the £70,000 figure and funding their own care, why would they bring in the local authority? What business is it of the local authority?
Earl Howe
My Lords, potentially, everyone in need of care and support may benefit from these reforms. We want to make it as widely known and as apparent as possible that planning is an important matter, whatever a person’s means. If I have misunderstood the noble Lord’s question, I will review that answer and write to him, but that is the main point.
I come back to the point I made earlier: this is just the beginning and it is why we will shortly be consulting on all these implementation issues. With those comments, I hope that my noble friend will feel able to withdraw his amendment and that other noble Lords will not press theirs.
Lord Sharkey
My Lords, I thank all noble Lords who have spoken in favour of a comprehensive, national and centrally funded information and advice campaign under the direct control of the Secretary of State. I am sorry that my noble friend the Minister did not seem entirely convinced by that. I was very puzzled by one thing that the Minister said about the cost of an annual report on how well we were making progress in generating awareness of the terms and implications of Dilnot. I cannot see that the cost could be anything but essentially trivial. I may be wrong about that, but I should be very grateful if the Minister would clarify, perhaps in writing later, why he thinks that the cost would be substantial at all.
I continue to feel that the whole issue of providing information and understanding is much too important to be left to local authorities and for the Secretary of State not to have direct responsibility for it. The task facing any information campaign in this area is enormous. The last survey that I saw showed, for example, that only 17% of UK adults understand what a percentage is—even that may be an overstatement—and Dilnot’s implications are much more complicated than that. We need the best communication with the most money and we need obvious accountability. That means central government and the Secretary of State having responsibility.
Given the opinions expressed around the Chamber today, we may well want to return to this issue on Report. I beg leave to withdraw the amendment.
Democratic Republic of the Congo
(10 years, 9 months ago)
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Lord McConnell of Glenscorrodale
To ask Her Majesty’s Government what is their assessment of recent developments designed to halt the conflict in the eastern Democratic Republic of the Congo.
Lord McConnell of Glenscorrodale
My Lords, I am grateful for the opportunity this evening to lead this short debate and to pose some questions to the Government about the situation in the eastern DRC. I am also particularly grateful, on such a sunny summer’s evening, to the Minister and other noble Lords for volunteering to speak on this topic. I should record my role as the chair of the All-Party Parliamentary Group on the Great Lakes Region of Africa, partly because it was in that role that I recently had the opportunity to visit both the Democratic Republic of Congo and Rwanda as part of a parliamentary delegation from the United Kingdom.
When requesting this debate, I thought that it would be timely, partly as a result of that delegation visit, which took place at the end of May, and partly because I spent last week in Burundi at the regional conference on women, peace, security and development in the Great Lakes region at the invitation of the new UN special envoy, Mary Robinson. However, this debate has become even more timely with the events of the last 48, or perhaps 72, hours. There has been renewed fighting in the eastern DRC, not just in one area but across much of the region and involving, it appears, many different groups. Publicity this week will no doubt focus on the clashes between the M23 and the FARDC—the Congolese army—which now appear to be battling outside Goma, yet again, for control of parts of that area. Fighting appears to have begun at the weekend, involving a group called the ADF, which is at least alleged to be made up mainly of Ugandan-based rebels and which appears to have some links with Islamist extremists from elsewhere in the continent.
There has been a growing trend over recent weeks, which again appears to have been shown over the weekend, for the FDLR—a former Rwandan rebel group—and other smaller groups to use the fact that the main focus appears to be on the M23 around Goma to execute all kinds of attacks on local villages. There have been kidnaps and in some cases rapes and deaths. Yet again today we see an outbreak of accusation and counter-accusation from the Democratic Republic of Congo and Rwandan Governments, which will no doubt heighten tensions in the area and in the region as a whole. I have received a series of e-mails over recent days documenting the horrors that this means on the ground for local people who are living in small communities. To be honest, they are too painful to read out tonight.
The Great Lakes region has, as a whole, seen incredible conflict over the past 20 to 25 years. The eastern DRC is not the only area affected. There is the Central African Republic and the long-standing campaign for independence in South Sudan, with conflict continuing even after that independence has been achieved. There is the terrible civil war in Burundi and the horrific genocides in Rwanda, the 20th anniversary of which is next year. In and around the DRC itself, there is what has been described as Africa’s world war, in which over 5 million people have died in the past 15 years or so. The whole region is affected by each of these conflicts in turn, but tonight I want to concentrate on the situation in the eastern DRC.
This area, and indeed the whole country and the region, is populated by wonderful people. It has incredible resources and a beautiful landscape, but the poverty, violence and hopelessness at its core have been debilitating, as anybody who has visited or studied the region over recent years knows, while other parts of the continent have grown and prospered. Lives have been ruined and opportunities are being wasted on an incredible scale. That is why we, as the United Kingdom, need to continue to be interested in what is happening there.
Last year, a group called the M23 broke off, as we know, from the official Congolese army and eventually overtook the capital of the area, Goma. There are allegations against that group, the Congolese army and others for the way in which the conflict in 2012 was conducted. The UN failed to protect Goma. More than £8 billion has been spent on the UN peacekeeping force over the past 14 years, yet it has continually failed to contain and deal with these conflicts at the local level.
In 2013, however, there have been what might be seen in the context of the region as quite dramatic developments. On 24 February, a peace, security and development framework for the whole region was signed by all 11 heads of state in the Great Lakes region and by four supporting multilateral institutions: the International Conference on the Great Lakes Region, the African Union, the United Nations and the Southern African Development Community. Subsequent to that, on 28 March the UN Security Council passed Resolution 2098, which updated the mandate of MONUSCO in the region but also called for and started to put in place a regional intervention brigade, which for the first time in UN history will have the specific job of dealing with combatants at local level to try to secure peace for local people. It also bravely appointed the first ever woman special envoy in this area for the United Nations, Mrs Mary Robinson, the former President of Ireland. She has begun her work and, as I said, I was with her in Burundi last week.
During our APPG visit focused on this area, we met President Kabila and senior Ministers from both Rwanda and the DRC. We met human rights campaigners, parliamentarians and senior officials in the UN. We also met a significant number of former combatants from the M23. This visit has indicated a number of things to me. First, the anger and suspicion in the area continue on all sides and are deep-rooted, but there is, perhaps for the first time, some hope that this regional framework can make a difference. There are at least public, formal commitments from everybody involved to work with the new framework. The President of Burundi reinforced that when I met him last week in Bujumbura.
Progress has been slow in implementing the details of the new framework, perhaps especially in relation to the peace talks presided over by President Museveni in Kampala. However, the UN has put in place the regional intervention brigade and Mary Robinson is in place and being very active. Her appointment has been welcomed by almost everybody in the region as someone whom they can trust. She has said that it is time to do things differently, by trying to implement a bottom-up approach to peace as well as a top-down approach, and in particular by trying to involve women in a way that is so needed, as was of course highlighted by UN Security Council Resolution 1325.
The DRC Government have at long last started to pursue, in a more determined fashion, security sector reform and genuine dialogue between different groups. Oversight mechanisms are starting to be put in place and improvements in governance are at least promised. However, this peace, security and development framework has not just national recommendations and commitments but regional and international ones, and it is to them I want to turn in my questions.
This is a very complex series of conflicts involving identity, land, fear, greed and power. These different emotions and elements of history cross borders in this region perhaps more than anywhere else in the world. We need to see implementation and determination on national, regional and international commitments. Inside the DRC there needs to be real reform and genuine improvements in governance, including decentralisation. We need a balanced, negotiated political approach that ensures that everybody has a stake in the future. We need a regional context that will help to bring peer pressure and, I hope, economic progress to the area. Women must be much more involved than they have ever been before in these discussions and efforts across the whole region.
I want to ask the Minister some questions quickly within the time allocated. First, as this is a unique opportunity, perhaps a once-in-a-generation one, to see some progress, how strong is the Government’s support for this regional peace process and what actions have we taken to secure its success? Secondly, what actions have we taken to support the new UN special envoy, Mrs Robinson, and what discussions have taken place with her? Thirdly, do the Government have an update on the peace talks in Kampala, which appeared until recently to have stalled and whose stalling may have triggered some of the violence at the weekend? Fourthly, do the Government have an update on the events of the past few days and a response and reaction to them?
Critically, do the Government agree that there is a need for a regional approach not just by the 11 states of the Great Lakes region and the African Union as a whole, but also by the British Government, other major European and North American donors and the European Union? Can we do more to integrate our diplomatic and development efforts across the region, taking a regional approach to our development decisions and our diplomacy? Can we use the European Union more? Can we integrate our various initiatives, including the Foreign Secretary’s admirable Preventing Sexual Violence in Conflict initiative, and can we review the decisions on aid to Rwanda and Burundi to secure their greater enthusiasm for this approach? The killing, rapes, fear and incredible violence against women and children in particular have gone on in this area for far too long. Along with others, we have been too inconsistent in our attention to this matter in the past. I hope that we can use this opportunity to say that we will be consistent and determined to see this through to an end that might actually bring some hope to the people of a land that has suffered for too long.
Baroness Chalker of Wallasey
I thank the noble Lord, Lord McConnell of Glenscorrodale, for asking for this debate. It could not be more timely. Anything that we can do to halt the conflict in the eastern region of the DRC and its wider ramifications—as I will mention—needs to be done. I thank him, too, for the visit that he has made, because not many people have gone across this territory—with some fear, I have to be honest—in many years. The eastern Congo area is not a specific concern of my company, Africa Matters Ltd, at this time but I declare an ongoing interest in the whole of sub-Saharan Africa, as stated in the register of interests, and I am an unpaid or volunteer chairman of that company.
My first journey to the Congo was in 1986—a very long while ago. I made other trips in the late 1980s. My first time in eastern Congo was in 1994 after the flood of refugees out of Rwanda following the genocide. One thing undeclared at the beginning of that was the number of ordinary people suffering from death and disease, not just in the camps but over a far wider region. Kinshasa, Kigali and until recently Kampala have not really focused on what this is doing to ordinary people who could otherwise be productive in agriculture or small business and making a change in those areas of Africa.
I want to say a word or two about the developing refugee problem. I hope that the Minister will be able to give us some of the detail of what I know Britain is already doing through DfID and non-governmental organisations in the area. There are literally hundreds fleeing every hour into neighbouring countries, mainly women, children and the elderly. Mary Robinson’s comment, to which the noble Lord referred, that it is time to do things differently caused me to wish to speak in this debate.
Two days ago, in addition to more than 210,000 registered refugees and asylum seekers in neighbouring counties, 63% of whom came from the DRC, a further 66,000 refugees had fled into the western part of Uganda. Today, Congolese government forces have attacked the M23 rebels near Goma and this is, as the noble Lord said, the third day of heavy fighting, causing hundreds more still to flee their homes. It is right that the UN should now be deploying the 3,000-strong intervention force of South African, Tanzanian and Malawian troops, patrolling and not yet in combat role. The new mandate may help, although it could hinder, because it will allow UN forces to attack if rebels continue to attack local populations. We hope that we will see some progress under the new mandate.
However, progress in stopping fighting is not going to be sufficient to sort out the immense problems in the region. I am quite certain that the UN would now block any attack on Goma, but that comes long after a period of waiting to see what would happen. If there is one thing that I ask my noble friend on the Front Bench, it is that we stop waiting to see what happens and, with others in the Security Council, ensure that Mary Robinson and others in the field have all the support that they need to make a difference.
Reuters recently reported that three Congolese government helicopters were in the area and were attacking the rebels in the town of Kibati, about four kilometres north of Goma. Congolese government forces are pushing rebels back to wherever those rebels come from, but there have been further attacks and so the churn of new refugees increases hour by hour. I know that, on Monday, rebels and the Congolese government troops traded mortar fire again in the north. This is happening not in a mining area, as some would have us believe, but in inhabited areas.
That is what I wish to underline in this debate. Over the past 20 years, millions have died from violence, disease, wounds and hunger. Whoever is arming the rebels is prolonging the unrest. What do the British Government know about the sources of the weaponry and the other means by which the rebel forces are prolonging the campaigns against ordinary people? One of the past failures in the area has been to communicate with people on the ground the reality of what they are doing. There is a need for a tougher line to explain to the rebels and to others who may be drawn into the conflict exactly where this is leading. I for one have deep fears about what is happening.
The other line that I hope my noble friend will pursue is the question of how people are recruited into the M23 or any other rebel groups. There must be some knowledge in the UN of exactly how people are recruited. It is not happening by accident. They may be recruited from border areas of neighbouring countries without the permission or blessing of those Governments. I am well aware that the Government of Rwanda have declared that they do not assist the M23, but if Rwandan people—and I do not just mean Tutsis who may happen to be in eastern Congo but are citizens of Rwanda—are turning up among the rebel forces, it must be for the Governments on both sides of the border to take action about those who are crossing simply to perpetuate the violence and warfare.
This is causing a real refugee crisis for the neighbours. The only way in which we can be of maximum help is by taking the sort of action that we took years ago, with clear direction, in Sierra Leone under General Sir David Richards. We need to give a lead to the UN troops about how they deal with this continuing insurrection because, unless we and others who have the ability to make the change do so, Mary Robinson’s task will be impossible.
Lord Chidgey
My Lords, I, too, congratulate the noble Lord, Lord McConnell of Glenscorrodale, on securing this very timely debate, and I thank the noble Baroness, Lady Chalker of Wallasey, for her very informative contribution.
The distance from the Atlantic coast of the DRC west of Kinshasa to Goma on the eastern border with Rwanda is not far short of 2,000 kilometres as the crow flies. If it were possible to make the journey by road, the distance would be at least half as much again. As in many African countries, the road network is at best patchy, mainly graded and rolled laterite. At worst, it is just muddy tracks. In fact, the maps show that the river network in the Congo is far denser than that of the roads.
Much of the economic activity in the DRC, apart from mining, is confined to the urban area around Kinshasa. Communications with the rest of this vast country are at the mercy of an unreliable internal air service. The difficulties of administering a country with such sparse infrastructure are bad enough. Factor in a non-existent local government and a central government described as weak and corrupt and the task becomes immensely challenging.
Local elections have never occurred in the DRC. They have been regularly postponed since 2006. Civil society, NGOs and international donors all agree that the organisation of these elections would form a critical education and empowerment process. Beyond elections themselves, the reform of the National Electoral Commission—CENI—has been under scrutiny since before the 2011 general elections. Prior to the election, I and a small team of parliamentarians met CENI in Kinshasa. Its main objective seemed to be to present an election-funding and facilitating wish list beyond reason. We were not impressed. It may be that the mission that visited in May, which the noble Lord, Lord McConnell, described, has better news, and I look forward to seeing its report in due course.
Civil society sees revision of CENI as just one step in a wider process of reform of electoral institutions. A review of the electoral roll, the redefinition of constituencies and improving and supporting civic education are all on the urgent agenda. According to the constitution, the president should not be able to run for a third term but, having amended the constitution in 2011 to reduce the presidential election to just one round, many anticipate Kabila being tempted into further amendments to give himself a third term.
International commentators are slowly coming to the conclusion that there is little to show for all the peacekeeping missions, special envoys, inter-agency processes and diplomatic initiatives in the failed state that is the DRC. Since Mobutu’s removal from power in 1997, probably more than 5 million people have died in the DRC through civil war, massacre and criminal activities. The DRC is second only to Somalia in the failed states index. It is last in the UN Human Development Index, last in GDP per capita, behind even Somalia and South Sudan, and very close to bottom of the Transparency International’s corruption perceptions index.
Since 2000, the DRC has received $27 billion in development assistance and is probably the world’s largest recipient of international assistance after Afghanistan, yet there is still no effective governmental structure serving the needs of the two-thirds of the population—60 million people—who live outside Kinshasa’s area of influence. To DfID’s credit, it has launched a humanitarian development aid programme from 2011-15 which, if the security situation allows, will begin to make a difference to the people of the DRC.
In November 2012, the M23 rebel group, which is thought to be backed by Rwanda, seemingly walked past MONUSCO troops and occupied Goma, North Kivu’s provincial capital. A few days later, their point made, the rebels melted back into the forest. This March, fighters of the Mai-Mai Bakata Katanga entered the DRC’s second largest city, Lubumbashi, clashed with government forces and then surrendered, harking back to events in the 1960s when Katanga province broke away from the Congolese state. The latest report from a UN group of experts given the role of gathering and analysing relevant information on flows of arms and networks operating in violation of the embargo on the DRC has to date found no evidence of support for the M23 rebels from Uganda. However, it has evidence of limited and continuous support to the M23 from within Rwanda. When my noble friend the Minister responds, will she say what impact the continuous outbreaks of violence are having on DfID’s programme for 2011-15?
The UN Panel of Experts report goes into great detail about the changes in leadership of the M23 and the rivalry between indicted war criminal General Bosco Ntaganda and his deputy Sultani Makenga. Their struggles led to a split in the M23 and, ultimately, to military confrontations and the surrender of Bosco Ntaganda. Supplied with arms in exchange for gold and ivory gained from poaching activities in many parts of the DRC, the M23 are now thought to have some 1,500 soldiers spread over an area of 700 square kilometres. Yet the authorities have been slow to recognise the dangers in the current situation, given Katanga’s pivotal prominence in the region’s economy. Meanwhile, Joseph Kony now has a window in which to regroup his repugnant LRA in the Central Africa Republic that could soon spread again to the DRC. This could well reverse the gains made in quelling the rebellion in the region which, with the help of US advisers based in Uganda, cut attacks by half. There is a real concern that, with this mission currently on hold, attacks will build again. Can my noble friend the Minister shed some light on when this US-supported mission is likely to recommence?
As part of the strategic review of MONUSCO included in the peace, security and co-operation framework for the region, the UN Security Council’s resolution 2098 provides, as noble Lords have mentioned, for a brigade of over 3,000 troops drawn from Tanzania, South Africa and Malawi. At last, MONUSCO has been given a more offensive mandate, providing for targeted and robust offensives with a view to neutralising and disarming armed groups, while taking into account the necessity to protect civilians and reduce risks.
The MONUSCO senior staff I met in Goma would have been mightily pleased at the strengthening of their mandate. However, the emphasis on civilian protection will be hard to achieve. I met a group of five women in a church hall in Goma who had come to tell us how they had suffered multiple rapes at the hands of soldiers: whether they were rebels or army was not clear. They carefully and earnestly explained the details of their suffering. One had had a toddler snatched from her arms and butchered in front of her before they raped her. Another had been caught on her way to school and repeatedly raped. At that time, she was just nine years old.
Ban Ki-Moon has made it clear that the UN brigade is only one element of a much larger process. The peace deal has to deliver a peace dividend: health, education, jobs and opportunity. Can my noble friend tell the House where the allocation of additional resources needed to support the implementation of the peace, security and co-operation framework is to be made? What is the Government’s assessment of the military and logistics capability and capacity of the 3,000-strong UN brigade to take on and eliminate the 20 to 40 guerrilla groups consistently wreaking havoc across North Kivu and South Kivu alone? What does my noble friend believe has been learnt from the UN operations in 2009 that were intended to enable the government to regain control of the region? Finally, what plans are in place to prevent a repeat of armed groups being chased away to be immediately replaced by new ones, resulting in more displacement of civilians, armed groups fragmenting and spreading across Kivu and more retaliatory attacks on the civilian population?
Lord Collins of Highbury
My Lords, I, too, thank my noble friend, Lord McConnell for tabling this debate. His recent first-hand experience in the DRC brings a terrific insight to the debate and highlights some of the issues to which all noble Lords have referred.
After a three-year period of relative stability and closer security co-operation between the DRC and Rwanda, the political and security situation in eastern DRC has once again worsened during the past year. As my noble friend described, it commenced with an armed rebellion by a breakaway militia from the DRC army—the M23 group—which, as we have heard, has close links with Rwanda and which seized the regional capital of Goma.
As my noble friend and the noble Lord, Lord Chidgey, have highlighted, this happened despite the presence of the largest UN peacekeeping force anywhere in the world, consisting of 17,000 troops. When tested, on this occasion and others, the force has unfortunately failed to maintain security and to protect the civilian population. As the noble Lord, Lord Chidgey, has just said, the humanitarian impact of conflict is huge and women, in particular, have suffered atrocious sexual violence which continues to occur with impunity. As the noble Baroness, Lady Chalker, has said, the Guardian reported today that some 66,000 Congolese refugees were pouring across the border to Uganda after a surprise attack by the Islamist ADF.
As my noble friend Lord McConnell highlighted, fresh fighting erupted near Goma on Monday when, according to the residents, more than 100 armed men, disguised in women’s clothing, entered the country from Rwanda. Like my noble friend, I ask the Minister what the Government’s immediate response is to these recent events.
As we have heard, eastern DRC requires radical security-sector reform, a political settlement and a focus, as my noble friend highlighted, on long-term development assistance. As the noble Baroness, Lady Chalker, said, there is no doubt that Rwanda should immediately cease its interference in the east of the DRC. However, the DRC cannot continue to blame Rwanda for all its problems. It needs to tackle its serious governance issues. I, too, recognise the terrific role that DfID has played in the DRC in the most challenging of circumstances. The UK is one of the largest donors to the DRC and should be taking a leading role in the east, including setting up a DfID office in Goma; that was discussed in 2009 but never delivered.
We need to start to address the key structural causes of poverty and underdevelopment across the world. I welcome many of the initiatives that the Prime Minister has announced. However, those issues are nowhere more pertinent than in the DRC. As my noble friend Lord McConnell said, it is crucial that the international community supports the implementation of the peace, security and co-operation framework initiative, which attempts to bring stability and prosperity to the eastern DRC. Only a coherent strategy that combines security, a regional political process and a development focused on the long term has the possibility of achieving sustainable change.
First, radical, not superficial, reform of the security sector is necessary. The police and army need to be professionalised and properly paid. As we have heard, the UN’s MONUSCO force is unable to act sufficiently effectively at the most critical of times. Secondly, there needs to be a genuine political process between the DRC, Rwanda and their neighbours to negotiate a political settlement for the long term and to ensure that it is implemented by all parties; and, as the noble Baroness, Lady Chalker, said, to ensure that all parties are held accountable. The new framework and the role of Mary Robinson are undoubtedly crucial to this.
Thirdly, a shared strategy from the Government and donors is necessary for the country to move from humanitarian and emergency assistance, vital though that is, to sustainable economic and social development. This will have to include new governance arrangements and transparency to ensure that the benefits of the rich natural resources of that country are no longer lost to corruption. For this to happen, first and foremost, as the noble Lord, Lord Chidgey, so ably highlighted, there needs to be a functioning DRC Government and state. Many of the political party representatives desire to rebuild the country, promote peace and rebuild their national economy. However, over many years the Government have failed to deliver any significant progress on these objectives.
The DRC is suffering a crisis of legitimacy and leadership. The most urgent task is to organise local and provincial elections, which the noble Lord referred to, which have been delayed since 2006. With the next presidential election due in 2016, the international community must make it very clear that any attempt by President Kabila to change the constitution to extend his mandate will be unacceptable and will lead to a strong response.
I also have questions for the Minister, but perhaps rather than simply repeating those which have already been asked, I will ask: given the concerns over the last presidential election, what are the Government doing in conjunction with the European Union, the African Union and the US to help ensure that the Kinshasa Government are more representative? What are the Government doing to secure a more legitimate mandate for the Government of the DRC from the people of that country? I hope that the Minister will be able to respond to the immediate concerns that noble Lords have raised, but also to focus on what my noble friend Lord McConnell described at the beginning of this debate—the longer-term sustainable development of a country that is rich in resources and in wonderful people.
The Senior Minister of State, Department for Communities and Local Government & Foreign and Commonwealth Office (Baroness Warsi)
My Lords, I thank the noble Lord, Lord McConnell, for introducing this timely debate. As noble Lords who took part in this debate this evening will be well aware, the eastern Democratic Republic of the Congo has been subject to cycles of conflict for many years, and more than 5 million people have lost their lives as a result. Its people have suffered too much and for too long. Many have fled their homes, villages have been attacked, there have been summary executions, and there are high levels of sexual violence, including mass rape.
The noble Lord, Lord McConnell, and my noble friend Lady Chalker referred to the ongoing tension, but also to the recent increase in fighting. The actions of the ADF-NALU militia have driven tens of thousands of refugees into Uganda, and the ongoing fighting between the M23 and the DRC army are, of course, concerning. This is an appalling record—more concerning in recent times—and it cannot be allowed to continue. We have urged all sides to show restraint and all militia groups to lay down their arms. We have heard reports of connections with extremist Islamic groups, but at this stage those claims cannot be evidenced and substantiated.
The UK has, of course, been a long-term partner of the DRC. The Department for International Development provides much-needed funding—£790 million between 2011 and 2016—to those in greatest need. UK taxpayer-funded assistance in the DRC over this five-year period alone will include: providing almost 2 million people with clean water; protecting 13.5 million people from malaria—the leading cause of death for children under five in the country—through the simple provision of insecticide-treated bed nets; providing assistance to almost 400,000 women in childbirth; and creating nearly 45,000 new jobs. Through its contribution to the UN, the UK helps to support the work of UN peacekeepers on the front line of the conflict, trying to prevent armed groups wreaking havoc among long-suffering local populations.
In response to my noble friend Lord Chidgey, I can say that I am not aware whether the recent fighting has had any impact on DfID’s programmes, but I can ask DfID to write to him with further information.
A different approach is needed if the cycle of violence in the DRC is to be broken for good. We have now reached a critical moment when there is a window of opportunity to help bring lasting stability and prosperity to this conflict-torn region. Noble Lords, including the noble Lord, Lord Collins, have spoken of immediate responses, but we need to focus on long-term sustainability.
Four events now give us a window of opportunity. First, the signing of the UN-brokered peace, security and co-operation framework—the PSCF—in February marked a moment where 11 regional countries, including the DRC and Rwanda, came together to sign up to commitments which, if implemented, will lead to peaceful co-operation and economic integration across the whole region. This agreement was also signed by four organisations: the UN, the African Union, the Southern African Development Community and the International Conference on the Great Lakes Region.
For the DRC the framework means commitment to deepening security sector reform, consolidating state authority, working towards decentralisation, building economic development, and further structural reform of public institutions—the long-term developments needed for stability. The DRC’s neighbours have committed to respect their neighbours’ sovereignty and territorial integrity. They have also committed to neither tolerate nor assist armed groups, to strengthen regional co-operation, and to refrain from harbouring or protecting anyone accused of war crimes or crimes against humanity. The PSCF is a great example of the region coming together, with the support of the international community, to agree to the principle of peace and a way forward to make it happen.
Secondly, there was the appointment in March of Mary Robinson as the UN special envoy to the region. The Government strongly welcome this appointment, and we have offered our support to her and her office as she implements her mandate to oversee the implementation of the PSCF, which she has referred to as “the framework of hope”. We support her approach of working with regional Governments to bring stability to the region, but also with communities to encourage peace-building at all levels. The noble Lord, Lord McConnell, referred to that as both top-down and bottom-up.
I welcome, in particular, the noble Lord’s recent visit to Burundi, where he supported Mary Robinson at a women leaders consultative meeting, which looked at the role women across the region could play in implementing the PSCF. The noble Lord also asked about contacts. Foreign Office Ministers have been in contact with Mary Robinson, both in person and by phone, and I understand that the Minister for Africa saw her in London about three weeks ago. He underlined to her the UK’s support for her role, and offered to consider any requests for practical assistance that she may need.
Thirdly, there is the new mandate for MONUSCO peacekeepers. While protection of civilians remains the core principle of the peacekeeping operation, this mandate also, for the first time in the UN’s history, includes an intervention brigade—the FIB—with a specific task of preventing the expansion of, and neutralising, armed groups in eastern DRC. We have welcomed the deployment of the FIB, which we feel will act in support of the PSCF. We hope that it will help to bring a period of stability to eastern DRC to allow reform and peace-building to take root. The mandate also allows for the use of unmanned aerial systems—another first for a UN peacekeeping mandate. Given the size of eastern DRC and its hostile terrain, we think that this will provide a useful tool to help peacekeepers monitor the situation on the ground more effectively.
Lastly, talks in Kampala between the DRC Government and M23 continue. While this process has been somewhat irregular, and the talks alone cannot achieve a sustainable peace in eastern DRC, they have a part to play in the wider peace process. The confluence of these events, with the military track in support of political and development efforts, provides an opportunity to achieve lasting stability in eastern DRC, for the cycle of violence to finally be broken, and for the terrible human rights abuses that have afflicted the people of that region to end.
Of course, we recognise that the causes and drivers of conflict in eastern DRC are many and various, and often deeply entrenched, so we do not claim that resolving conflict there will be easy or quick. It will require the sustained effort of the signatories to the PSCF, which contains some hefty commitments. It is important that all signatories fulfil these commitments—for the DRC to carry out significant reform of its security sector, for example, and for the other signatories, including Rwanda, to respect the sovereignty of their neighbours and refrain from supporting armed groups. It is equally important that all signatories work together for the potential peace dividend, for greater regional economic integration and development.
We welcome the progress that has been made so far—for example, the steps taken in DRC towards its PSCF commitments, including starting to establish a national dialogue mechanism and providing an initial plan for security sector reform. But much more remains to be done. Ensuring the success of the PSCF will also require the sustained attention and collaborative efforts of the international community.
The UK will take a joint diplomatic and development approach to supporting the framework, in support of Special Envoy Robinson as she works to encourage the full implementation of the PSCF. This means that we will use our diplomatic assets to urge signatories to meet their commitments, ensuring that the Department for International Development’s work to support conflict resolution and peace-building in the region is effective and sustainable. A number of noble Lords asked about the EU. We are already working through the UN, the EU, the African Union and other organisations, with Governments in the region and other major donors to DRC and Rwanda.
My noble friend Lord Chidgey spoke of the appalling sexual violence. He will be aware of the Preventing Sexual Violence initiative launched by my right honourable friend the Foreign Secretary last year. This was the focus of his visit to DRC and Rwanda in March this year. The UK now has a specialist team of experts to deploy to conflict areas to support UN and civil society efforts to help build national capacity to investigate allegations of sexual violence, helping to replace the culture of impunity with one of deterrence. In the DRC, the UK is supporting the NGO Physicians for Human Rights with the deployment of an expert in eastern DRC. The expert is working with local health, legal, and law enforcement professionals in north and south Kivu provinces to ensure they are better equipped to conduct crime scene investigations. He will assist local professionals in the documentation, collection and preservation of forensic evidence to ensure that perpetrators of sexual violence crimes are brought to justice.
The noble Lord, Lord McConnell, asked about donor co-ordination. This is something that Mary Robinson has emphasised the need for in DRC, and we strongly agree with her. We are working closely with partners in Kinshasa to ensure that we remain co-ordinated with other donors. While effective donor co-ordination remains challenging in DRC, it is improving, and we are committed to investing the time and resources to accelerate progress in the coming months.
The noble Lord spoke about the visit by the All-Party Parliamentary Group on the Great Lakes Region of Africa to eastern DRC. I pay tribute to the work of the APPG and am aware of the very successful visit that it paid to Rwanda and the DRC. The knowledge that it brings back to this and the other place helps inform much FCO thinking, as well as our officials on the ground.
We have no details on dates for the Kampala talks at this stage, but we are concerned about their irregular nature. We think that they should continue in good faith and that neither side should try to force an agreement through force of arms.
My noble friend Lady Chalker asked about the source of rebel arms and funding. Of course, I share her concerns about the source of the arms in eastern DRC, and we are working with the UN and the Government of DRC to challenge the activities of rebel groups of different allegiances, which are using conflict minerals to secure the irregular supply of arms. I absolutely agree that the one thing that the eastern DRC does not need is more weapons.
My noble friend also asked whether we have any knowledge of recruitment into M23. We are aware of reports of recruitment into M23 from Rwanda and of forced recruitment from areas that it controls. We have urged the DRC’s neighbours to ensure that such activity ceases.
In conclusion, there is no doubt that the Democratic Republic of Congo faces enormous challenges. The Government of the DRC, regional Governments and the international community must work relentlessly to respond to these challenges if we are to bring lasting stability to the region. The DRC is of course a huge country—the often-quoted comparison in terms of size is that of the whole of western Europe—and in the east there are areas of seemingly impenetrable forest with very limited roads, communications and infrastructure. We know that there are deeply entrenched problems to overcome, but the framework for peace is in place and, with the commitment of the Governments of the region and the support of the international community, real progress can be made; progress that will be felt by communities and people across the DRC, so that the many who have waited far too long for the opportunity to live their lives in peace will finally see that happen.
Care Bill [HL]
(10 years, 9 months ago)
Lords ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Lord Lipsey
“( ) The regulations must provide that where the financial resources of a carer who has needs for support or of the adult needing care (whether in terms of income, capital or a combination of both) as calculated in accordance with the regulations exceed the financial limit, payments by the local authority shall be tapered in such a way that each complete increase of £500 in resources held by the carer or adult over and above the financial limit shall result in a reduction of annual payments of £1.”
Lord Lipsey
My Lords, this has been a great test of my filing system, which fortunately has stood up to it on this occasion. Each of these three amendments in my name is entire of itself and could be passed on its own, but they are designed as a package. Taking them individually to start with, they would do three things: first, to make the tariff for the means test proposed by the Government less draconian; secondly, to increase the allowance given to people helped through the means test to pay for their personal expenses; and thirdly, by abolishing overtime of current nursing care allowance to pay for both the above and leave some money over for better care services.
Let me explain this thinking. I am a supporter of Dilnot—at the margin, I disagree with my noble friend Lord Campbell-Savours on this. I do not regard Dilnot as perfect, but I regard the distribution of ill effect, which I quite agree with him exists, as a small price to pay for the advantages of Dilnot, namely the danger that people quite at random are chosen to be wiped out financially. So I support Dilnot’s scheme. However, I am, as my noble friend is, aware of its defects. The plain fact—Dilnot is perfectly clear about this—is that it helps only one lot of people and not another lot of people. The Minister quoted figures about who benefits from the system as a whole before the dinner break, but the reality is that, under Dilnot, the poorest gain nothing from a cap; they are paid for by means-tested benefits anyway. Nearly all the benefits go to better-off people. That is a serious defect and it is very expensive—not as expensive with the cap at £72,000 as it would have been under Dilnot’s original proposals, but very expensive. This means that it will compete in practice with another set of problems, namely the sheer lack of resources going into long-term care, a short-fall that is getting worse as the number of older people rises and which will go on getting worse as the demographics described in the House’s report on the ageing population continue. So we have a serious problem.
The package is not designed to take apart the fundamental architecture of Dilnot. It does not take from anyone a single penny that they would gain under Dilnot. It is designed to spread the benefits more widely, all without increasing public spending by a single penny. Is that magic? Your Lordships will be the judge of that.
That is the easy bit, I am afraid, and I apologise to the House for any lapses in techno-speak in the words that follow. The first amendment refers to the tariff. I will explain briefly what the tariff is, because it is not altogether familiar. Suppose that you are above the minimum threshold for the tariff, which is around £14,000 at the moment, and you have some assets. For every £250 in assets, you lose £1 a week in benefit, about £50 a year—the equivalent of an assumed 20% return on your capital. That continues under the present system until you reach the £23,250 cap for the means test, but will continue under the Government’s proposals in 2016 until £118,000 is reached, the top level of the cap. You are fined £1 a week for every £250 that you have in assets. If you start applying that to the government system you discover something that has been virtually unremarked upon in the Dilnot proposals. Although the Government are, in theory, raising the upper limit to £118,000, the fact is that someone with £118,000 in assets will gain virtually nothing under the changed means test. That is for two reasons.
First, once you start to claim local authority help with your care, you stop receiving attendance allowance four weeks later. Indeed, according to Philip Spiers of the old persons’ charity, FirstStop, many people with £100,000 or more in assets, if they were properly advised, would be worse off, not better off, if they claimed local authority support, because they would lose £79.15 a week in the higher rate of attendance allowance, or around £87 when inflated to 2016-17 prices. In other words, the apparent cap for means testing under the Dilnot proposals is actually much lower because you do not need much in assets.
The second thing is that the tariff is ripping into your entitlement. Suppose that you are in a home where the fees are £400 a week—if you live up north, and that is what the local authority allows. Say, for example, you have £100,000 in assets above the lower threshold. It is not nothing, but it is not a large amount. On £100,000, the tariff will amount to virtually all the benefits you get under the means test. There you are, getting quite excited because the Government have improved the means test to help you, but you suddenly find that they have not. You will notice that this feature of the Dilnot proposals was not emphasised by either Andrew Dilnot or government proposals. That is a cruel system to confiscate the wealth of people who have only a little bit of it. If the Bill goes through with this feature intact, I predict that we are laying the basis for disappointment and even anger among a generation of older people and their families—people of modest means—who deserve something better.
My amendment makes the tariff less harsh. Instead of losing £1 for every £250 in assets, you lose £1 for every £500. According to estimates by Ruth Hancock of the University of East Anglia and her colleagues at the PSSRU, the substitution of a £500 tariff for the current £250 would cost around £150 million in public expenditure. That is element one of the package.
I am sorry, but this will take a while because I have three amendments wrapped together. The second component of the amendments is the increase in the personal requirements allowance. It deals with a nasty feature of a very nasty means test. I think that Dilnot himself said that it was the nastiest means test in Britain. If you are on the means test for your care home fees, you are left with just £23.90 a week for all your personal needs. Perhaps you want to give your child or grandchild a birthday present, buy cosmetics or some little comforts, a few sweeties, or even pay for taxis to the doctor when you cannot get about. All that comes out of £23.90 a week. That is not a rich reward for the poorest people in our society to be left with at the end, many of whom have worked long and hard. My amendment raises that to £32.75. That figure, I hasten to add, is completely arbitrary. It is because it costs the same—£150 million—as the change in the tariff. It helps the poorest among us. Thus I have one proposal that helps people of modest means, and one proposal that helps the poorest people. All it means is that they get a smallish share of the goodies handed out by Dilnot to the better off.
Lord Warner
My Lords, I support the creative thinking of my noble friend. The truth of the matter is that we certainly did not have enough time to go into the kind of detail that he has done, which he has explained very clearly. I have to confess that we were not aware of the nursing allowance. Perhaps we should have been. If we had been, I think that we would have justified the scrapping of it by saying that that would be used to help to finance our mainstream proposals.
Also, we said in our report that we thought that the Government should look again at the personal expenses allowance. We thought that it was extremely mean. In a way, it has not kept pace with inflation over the years and it now seems a rather derisory amount. Therefore, anything that could be done to improve that without increasing the cost of public expenditure would seem to us a good idea.
I commend my noble friend for his creativity. I hope that the Government will take his amendment away and look at it seriously to see whether something can be done with it, because I think that it is an improvement on our recommendations.
Lord Hunt of Kings Heath
My Lords, I, too, have a great deal of sympathy for the core of my noble friend’s proposal to change the means test to increase personal allowances to support people so that they have enough money for what he described as “small treats”. Like my noble friend Lord Warner, I should be interested in the noble Earl’s response to that point.
I also sympathise with my noble friend’s second proposal to help those with modest assets by making the means test less severe. It is clear to most of us that the benefits of Dilnot will go to the better off. I think that one must be sympathetic to my noble friend’s aim of trying to spread the benefits more widely. Of course, that comes with a cost, and my noble friend’s answer to that is the proposal to abolish the nursing care allowance or to phase it out. Perhaps the term is grandparenting; I am not sure of the phrase but the Lords reform proposals come to mind—the transition.
Whether that is the right approach must of course be subject to some debate, and I would certainly need some convincing about the phasing out of the nursing care allowance. However, I think that my noble friend has done us a service and I hope that we will have further discussions on it between now and Report.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, on one level I sympathise with the intention of the noble Lord, Lord Lipsey, to redistribute funding between health and care and support so as to increase the personal expenses allowance and local authority support for those in residential care. However, we need to face the reality of the current economic climate. One important aspect of our reforms is that the greatest support will go to those with the greatest need, and that is surely the policy aim that we need to keep most closely in mind in this context.
Currently, the NHS funds nursing homes to support the provision of registered nursing care. This reduces the burden on the NHS of having to provide NHS nurses in residential care homes. Removing this funding would risk increasing costs elsewhere in the NHS, but it would also breach a serious point of principle. If we were to stop people in residential care homes from being eligible for NHS-funded nursing care, it would undermine one of the founding principles of the NHS, which is that it should be a service free at the point of delivery. I am sure that noble Lords would agree that we would not like to see that.
I understand why the noble Lord seeks to increase the personal expenses allowance. If someone is contributing to the costs of their residential care from their net income, for example from their pension, the personal expenses allowance is the amount people can retain to spend as they wish. This is currently set, as he rightly said, at £23.90. The amendment would increase it to £32.75. When living at home, people pay for their food and heating from their income. It is right that people should continue to contribute towards these costs in residential care. The personal expenses allowance reflects the fact that for most people these costs represent a large proportion of their income, but it allows people to retain some of their income for other uses. The reality is that spending additional resources on the personal expenses allowance would reduce the resources available to provide support to those with the greatest needs.
I heard what the noble Lord, Lord Lipsey, said about the loss of the attendance allowance meaning that people would be worse off. Local authorities should support people to maximise their income. If a given individual would be better off receiving the attendance allowance, the local authority should support them to achieve this. We will bear this in mind as we draw up the regulations.
I turn now to Amendment 91, which relates to financial assessments. One of the problems the Dilnot recommendations attempt to tackle is the cliff edge between being a self-funder and being supported by the local authority. By extending the means test for people in residential care, we aim to avoid a situation where a small change in a person’s capital results in a large change in what they pay for care.
From 2016, the maximum tariff income for someone with £118,000 in assets will be £404 per week. If we reduced the rate at which people contribute toward their care costs from their assets to £1 per week for every £500 of assets, the contribution for someone with £118,000 in assets would become £202 per week. This means that an individual facing a typical care home fee would be over £200 per week better off if they had assets of £117,000 than if they had assets of £119,000. This would reintroduce the cliff edge that surely none of us wants to see.
I believe that our plans represent a fair balance between the individual and the state. People with care needs will receive additional support with care and support costs through the extended means test, safe in the knowledge that health services will remain free at the point of use and that they are protected by the cap from unlimited care costs. I hope the noble Lord will see that there is method in the Government’s proposals. While I totally understand much of his rationale, I think our proposals have a better balance. I hope that he will feel able to withdraw his amendment.
Lord Lipsey
My Lords, I am usually extremely complimentary about the noble Earl’s replies to debates, but I do not think that he lived up to his normal standards in that one. He seems to be under a number of illusions. He seems to think that this Bill increases the amount of public spending that goes to the worse off, rather than the better off. It does not. The Bill incorporates what is a most extraordinary priority in terms of distribution, for reasons that I believe to be compelling. Concentrating money on those most in need may indeed be the Government’s general philosophy, I do not know, but this certainly is not implicit in this Bill.
The noble Earl seems to say that if you do as I suggested on the nursing care allowance, you would increase spending by the NHS. The exact reverse is the case. The nursing cost allowance is paid for by the NHS. I am subject to correction, but I believe it to be paid for by the NHS, so you would have an immediate reduction in NHS spending of some £500 million-plus a year.
Lord Lipsey
“( ) After section 54(2) of the Health and Social Care Act 2001 (funding by resident etc of more expensive accommodation), insert—
“(2A) The regulations shall only restrict the right of residents to top up their fees to the extent that is reasonable, and in particular they shall not limit top-ups to residents using the 12 week property disregard or the deferred payment scheme.””
Lord Lipsey
This is another piece of arcanery, I am afraid, for the House. It is a genuinely probing amendment.
Not everyone may know what top-ups are, any more than everyone knows what nursing care allowances are. They arise for people who are not paying in full for their own care but want a better standard of care than the local authority is prepared to pay for. There are a quite a lot of these people. There are about 350,000 people in care homes and about 50,000-plus of them get care allowance. If a local authority claims a person’s needs can be met in a home costing £400 a week and the old person or their family prefers one costing £500 a week, they get the means-tested support as if they were in a £400-a-week home and the family finds £100 from their own pockets.
However, there is a strange twist. As long as a third party—usually the old person’s family—is prepared to dip into their pockets for the extra £100, there is no legal problem. They can do so under LAC circular (2004) 20, which derives from the National Assistance Act 1948. But if the old person wants better care, they can top up out of their own pocket only in very limited circumstances. They can do so only if they are subject to the 12-week disregard—which is the period you can be in a care home to see whether you get better and come out—or if they have a deferred payment agreement with the council, when the council may make top-up payments on their behalf. In theory, people cannot top up their own home fees but these can be topped up by other people.
As a historian of the Treasury, I can sort of see how this might come about. The Treasury would not want those whose means-tested contribution is offset by the tariff, as has been discussed, running down their assets to pay for better care, thus throwing more of the burden on the state. However, those in the know say that the restriction is widely ignored, often with the connivance of councils that do not want to get into an argument about whether the accommodation they will provide within their own limits is adequate for the old person. As a result, they allow the old person to chip in for their own care—perhaps he or she puts the money into a son’s bank account, the bank account pays the home and we do not know what goes on.
In parentheses, it is perfectly clear that local authorities know very little about what is going on with top-ups. I refer to the report due to be published by the charity Independent Age tomorrow, which analysed this after doing a freedom of information request on all councils. Out of the councils they asked, only 30 or so can be reckoned to have best practice or a good system for keeping account of top-ups. The rest are either bad or worse.
These mysterious top-ups go on, otherwise the old people would have to move out of the home they are in and into a local authority home. As noble Lords know, if you move old people from the home they are in to another home, what frequently happens, I am afraid, is that they die. This strange top-up mess is more difficult in the post-Dilnot world. Because of the extension of the asset limit for means tests, many more people will be receiving means-tested support, and anyone who is receiving means-tested support cannot do a top-up; that is the law. Many more people will therefore find themselves limited in what they can do if they stick by the law—which, as I say, they often do not.
Secondly, because the deferred payments scheme will be made available to everybody, more people will escape through the loophole in the current regulations that allows those on deferred payments to top up—you can do it if you have a deferred loan from the local authority but you cannot if you do not. The injustice between those who can and do defer and those who do not is made worse—the former can top up but the latter cannot. That will be a growing problem and a huge incentive for people to take out deferred payments, because they can legally top themselves up that way.
Thirdly, and potentially more importantly, let us suppose a person is self-funding and in a home where the fee exceeds what the local authority will pay. They reach the cap, having spent their £72,000. What will happen then? The state will meet that part of the cost of the home that they are in which is equivalent to what they would pay if they were in the home selected and provided by the local authority—their limit. If the home costs more than that—£600 a week not £400—where will the rest of the fees come from? Perhaps their family does not have any money for a top-up or is unwilling to provide it. Who is going to top it up? I am afraid that the crude reality is that some people will persuade the council to pay the higher fee while others will be moved—and, as I have already said, people who are moved will as a result, on average, die considerably younger. That is not a side-effect that Dilnot planned for but it is a side-effect of the way it is going to work out. Nothing much has been said by the Government about what happens if you reach the £72,000 cap and are in a home costing more than the local authority is prepared to pay. Until we get reassurances on that, the reality must be that they will be moved out to another, poorer, home and that this is going to be a tragedy.
The irony is that these are not poor people falling back on the state. They may well have assets and might be very willing to put in a bit extra to ensure that their last years are comfortable, but they are prevented by law—if they obey it—from doing so. Either they decide to opt out of Dilnot and fund their care in full, in which case they will not benefit from the cap and Dilnot, for them, amounts to nothing, or they go through the business of moving to the inferior home and we will have inflicted that disaster on them.
This area has not been much explored but there is a simple way of dealing with it, which is incorporated in this amendment. It is simply to end the ban on residents topping up their own fees. I do not think the cost would be very much but if the Minister has some other way of dealing with it, he should tell the Committee now before we endorse a policy which could lead to the mass eviction of old people from the residential homes in which they have long lived, in sharp contravention of all we are aiming to do in this Bill. I beg to move.
Lord Warner
My Lords, I intervene on this to talk very briefly about what the Dilnot commission said on this issue. I will quote just two sentences from page 22 of our final report, which are worth putting on the record. We said very clearly:
“The state-funded care element will be based on a local authority care package, but people will be free to top up from their own resources, should they wish. If someone moved to a different local authority, they would take with them a record of their contributions to date”.
That is a very clear statement of what our policy was. When we were taking evidence, there was not a lot given to us about the extent of top-ups.
If I fast forward to my time on the Joint Select Committee with other Members of this House, the issue of top-ups seemed to have changed quite significantly between the time when the commission reported, having considered all this, and the time that the Joint Select Committee was working on it. There were not good data, other than that many of us have been increasingly learning that the top-up levels have been quite considerable in some homes. There is clearly a problem with the cross-subsidising of people who are state funded from self-funders. The issue is now complex and I do not know how good the Government’s data are on the use of top-ups. We were clear that you could count towards the cap only what the state-funded element of that payment was, which would be determined by what the local authority would pay in its area for the care being provided. If we depart from that principle, we will end up in chaos—and probably end up with a much higher public expenditure bill.
There is an issue here that the Government need to think about, but in principle we should do nothing to stop people topping up if they and their family are prepared to provide for a higher level of care. The present rules were drawn up for a different time and on top-ups, the world has moved on. We need to get this straight before we finish this Bill.
Lord Hunt of Kings Heath
My Lords, I, too, would welcome a debate about top-ups and the Government’s present position and response to the Dilnot proposals, as enunciated by my noble friend Lord Warner. It would also be helpful if the noble Earl could give us a little thinking about how the Government expect this to work out in practice.
We start with the fact that a local authority has to have an assessment to add to the baseline to set the clock running, so as to get to the £72,000 cap. We have already discussed transparency and the problems arising where self-funders find that they have in fact been subsidising those people funded by the local authority. I would be particularly interested to know from the noble Earl what calculations have been undertaken by his department about the impact on self-funders when responsibility is taken over by the local authority once the cap has been reached. Has any work been done on the extent to which those self-funders will be forced to move home because the local authority will not fund them at the rate that they have been self-funding, while the home itself is requiring those people to move?
My noble friend Lord Lipsey referred to the general experience—we have seen it in the health service—that when very frail elderly people are forced to move from one care setting to another their life outcomes are very poor indeed. Clearly, it would be wholly unsatisfactory if, as a result of bringing in the £72,000 cap, we had the perverse incentive of forcing a lot of movements by frail, vulnerable people that would have a deleterious effect on their health and life outcomes.
That brings us to whether removing the top-up restriction would be an appropriate response. My noble friends have put forward a persuasive case. It is important that the Government should enable the House to come to a view on these matters, having made an assessment of how the introduction of state support for self-funders who have reached the cap is going to work in practice.
Earl Howe
My Lords, having disappointed the noble Lord, Lord Lipsey, on the previous group of amendments, for which I shall try to make amends over the summer holidays, I hope to do a little better with this one but I predict that he will not be completely satisfied with my answer.
People should be supported to receive the care they want and should be able to use their own assets to achieve this when they can afford to do so, but this should never be an excuse for local authorities to underfund the cost of meeting people’s needs. I agree with the noble Lord that people should be able to spend their money on purchasing more expensive care and support for themselves if they wish to do so, provided this is affordable. We are seeking better to understand the impact of such a relaxation and the protections that are appropriate for vulnerable people. It would clearly be undesirable for a person to spend their life savings on residential care and late in life be faced with the prospect of having to move to alternative accommodation purely on affordability grounds. I take that point absolutely. In addition, we want to consider the implications for the ability of local authorities to arrange services for other people. If individuals were to use their resources to purchase more expensive care, this could ultimately reduce local authorities’ income from charges. This in turn would reduce the amount of care the local authorities could arrange for other vulnerable people. There are a number of factors at play here, which we need to think through a bit more.
In principle, people should be able to use their savings to purchase more expensive care if they want to. We are determined to clarify and modernise the care and support arrangements in a way that is fair and reasonable to people who need care, their families and the taxpayer. The revised arrangements for people to use their savings to pay for their own care will be set out in regulations made under Clause 30(2) of the Bill. Through the public consultation on funding reform, we are seeking better to understand how relaxing the existing restrictions on making additional payments, which the noble Lord, Lord Lipsey, outlined, might impact on the wider care and support system. The evidence we hope to gather from the consultation will inform the regulations that will set out the revised arrangements. Those regulations will also be subject to further public consultation. In view of that, which is really a long-winded way of saying that this is work in progress but we are on the noble Lord’s side, I hope he will feel able to withdraw his amendment.
I can clarify one point in relation to when local authorities take over responsibility for funding care. It may be appropriate for the local authority to meet any additional cost, for example, where moving the person receiving care and support would adversely affect their health. However, where paying the higher cost might limit the local authority’s ability to support other individuals with care and support needs, the person may have to move to less expensive accommodation. In making any decisions, the local authority has to consider the exercise of its duty to promote that individual’s well-being.
I hope that those are helpful remarks. I would be happy to discuss this issue with noble Lords between now and Report.
Lord Lipsey
My Lords, I thank the Minister for that reply. Having berated him for his previous speech, I can more than fulfil his expectations on this. He has done all that I could have hoped for and more. It will be extremely well received in the world outside that the Government are finally getting to grips with this long-outstanding anomaly. I do not blame this Government. Various Governments have been exactly the same. We are going to get a solution that is essential if the Dilnot scheme is to work as we meant it to work. It is very good news to hear the Minister state so strongly in principle that if people want to use their own money to top up their fees, they should be able to do so, although I understand his reservations about the impact that might have on the local authority market. I look forward to his further work on the subject and to discussing it with him and his officials, as will, no doubt, other noble Lords who have an interest in this. I beg leave to withdraw the amendment.
Baroness Greengross
where there is a person authorised to do so under the Mental Capacity Act 2005 or otherwise in a position to do so on the adult’s behalf, but that person nonetheless asks the authority to meet the adult’s needs.”
Baroness Greengross
My Lords, I have a number of amendments in this group: Amendment 92ZZCA in Clause 18, Amendment 92ZZLA in Clause 26, Amendment 92ZZQA in Clause 28, Amendments 92ZZR and 92ZZRA in Clause 30 and Amendment 92ZZRB in Clause 31. I will try to be brief.
These amendments follow on from the discussion relating to the amendments tabled by the noble Lord, Lord Lipsey. The first amendment is about the duty to meet needs. We know that carers are often old people themselves. They have often cared for a long time for somebody with dementia or something similar before that adult meets the eligibility threshold for care. In my view and that of the Alzheimer’s Society, those carers should have the right to ask the local authority to arrange that person’s care because it is important that an individual who is in a position to arrange care and support has the right to ask the local authority to do so even when the adult is self-funding. Enabling a carer who would otherwise be required to arrange care to request that the local authority meet that need would help to reduce the strain that that carer is under. Being able to ask the local authority to arrange care would also enable the adult to take advantage of the better rates for care that the local authority can command through block booking and other means. It would be unacceptable if adults who do not have capacity but who have deputies or other representatives were forced to pay higher costs than other people.
Amendments 99ZZLA and 99ZZQA are about the usual rate of independent personal budgets. Clause 26 refers to the calculation of a personal budget that will enable eligible needs identified by the assessment to be met. The budget needs to be sufficient to enable this to happen. Clause 26 treats this as being the cost to the local authority of meeting that person’s needs, whereas a person receiving their direct payment as a cash payment would not necessarily be able to purchase care at the same amount since care homes, as we know, routinely charge self-payers more than they charge local authorities. Legislation has to be clear that local authorities have a duty to meet eligible needs, and personal budgets must therefore be, after application of the local authority’s normal means-testing system, sufficient to purchase that level of care at its local actual cost and not at a tariff rate based on the bulk purchasing power of the local authority.
Clause 28 refers to calculating the independent personal budget, which is, confusingly, different from the personal budget referred to in Clause 26. The independent personal budget is used to calculate the amount that an individual can spend on his or her care that will count towards the expenditure cap. Clause 28, therefore, refers always to expenditure by the individual, so it should be the true cost available to the individual of meeting their assessed needs, rather than the cost to the local authority. Once again, there is a difference.
The amendment to Clause 26 also has an impact on Clause 30. This clause replaces the current choice of accommodation directions which enable a person to choose a different residential care home from that provided by the local authority and to top up the payments if their preferred accommodation is more expensive than the local authority’s usual cost. The Minister has confirmed that this is possible. However, the current system is widely abused with local authorities often requiring top-ups even when there are no places available at the so-called usual cost and the person has chosen the only available accommodation that meets their needs.
Clause 30 does not refer to the usual cost but, instead, defines “more expensive” as being more than the value of the person’s individual budget. If the personal budget is defined in Clause 26 by how much the local authority says it will pay to meet the person’s needs, the system is open to the same abuses as the choice of accommodation directions. However, if Clause 26 requires that the personal budget should be sufficient for the person to purchase services which will meet their needs, this ensures that the rate that the local authority will pay for care is directly related to actual market conditions.
Amendment 92ZZR is about the review of independent personal budgets in Clause 28. People should be able to refuse an assessment as long as they understand the implications of that refusal. However, this clause does not offer adequate protection to people who lack capacity. As it stands, the clause puts people with a deteriorating condition, such as dementia, at risk of falling through the gaps. The proposed new clause stipulates that Clause 28 does not apply when an adult lacks capacity to refuse the assessment. It would stop vulnerable individuals from falling through those gaps as local authorities would be required to carry out a needs assessment and continue to maintain their care account.
Amendments 92ZZRA and 92ZZRB are about the choice of a care home. I declare an interest as chair of the All-Party Group on Dementia and the Alzheimer’s Society shares my concern about this. There is potential that the Bill will not provide the same right to choose a care home as currently exists. Individuals currently have a right to exercise genuine choice over where they live. If an individual has a preference for a particular care home, the local authority should arrange accommodation in that home subject to the following conditions being met: that the home that is chosen is suitable to meet the individual’s needs and as assessed; that it does not cost more than the local authority would usually expect to pay to arrange accommodation for someone with those assessed needs; and that it is available and the provider is willing to enter into a contract on the local authority’s terms.
An individual may wish to move to a home that is more than the local authority’s usual cost, even though there is a home that meets their needs and it is within the local authority’s usual cost. In these circumstances the individual or another person can make arrangements to make a top-up payment, as the Minister has said. The Bill states that regulations “may” provide that the local authority must arrange for the provision of the preferred accommodation. This should be amended to “must” rather than “may” to ensure that the right to choice continues. In addition, the Bill currently says that regulations may provide that where an adult expresses a preference for a particular home, the local authority should act on it. The risk is that this excludes an adult’s representative from choosing a home. Holders of lasting powers of attorney relating to welfare are examples of representatives who should be able to express a preference, and that preference should be acted on by the local authority. I beg to move.
Baroness Browning
My Lords, I will speak to two amendments in this group: first, Amendment 92ZZK in my name and those of the noble Lord, Lord Touhig, and the noble Baroness, Lady Tyler of Enfield. This is very similar to an amendment that I tabled to an earlier part of the Bill, and it focuses in particular on transition:
“In preparing a care and support plan, the local authority must have regard to the young person’s education, health and care plan, where such a plan exists, and integrate the care and support plan with the existing education, health and care plan”.
I will not repeat what I said earlier, but this certainly applies to this clause because the integration is very important. This amendment is supported by the Care and Support Alliance, and particularly affects young people who are coming from adolescence into adulthood, where the seamlessness of their care package is very important. As I mentioned in moving the earlier amendment, this has, of course, a read-across into other legislation. I know that my noble friend gave me a reassurance last time, but it is important that the Bill requires that double-banking, if you like, to make sure that there is joined-up government here between not just two government departments but two plans that affect an individual’s future.
I also briefly raise the question of a probing amendment—Amendment 92ZZGA, in the name of the noble Baroness, Lady Emerton. In Clause 25(1)(e) the amendment seeks to change the words,
“includes the personal budget for the adult concerned”,
to “can include”. What has concerned the noble Baroness, Lady Emerton, here is that, although there may well be sanction for a personal budget for the adult concerned, the impression given by this particular wording is that it could possibly constrain the choice as to how that personal budget was spent. I appreciate that the care plan or the support plan would identify that sanction had been given for a personal budget. However, it is very important that it in no way presumes the choices in a prescriptive way that would take away from the individual concerned what is at the very heart of personal budgets—the right to choose services and items, which might well be something that they have a preference for and on which the local authority should not get too much into the detail, having sanctioned the personal budget in the first place. It would be helpful, when my noble friend responds, if he could give some reassurance on that matter.
Lord Dubs
My Lords, I shall speak to two amendments in this group, both of them amendments to Clause 25 —Amendments 92ZZH and 92ZZJ. I must say that I do struggle with all these initials; they make it hard to spot which amendment is which—but it may be that there is no better way of doing it.
Amendment 92ZZH is about people who have fluctuating needs for support because their condition is not constant. A fluctuating condition is a chronic condition, physical or mental, of which a characteristic feature is a significant variation in the overall pattern of ill health and/or disability. There are many millions of people in the UK with fluctuating conditions. Those could include MS—I am an officer of the All-Party Group for Multiple Sclerosis—rheumatoid arthritis, HIV, Crohn’s disease and colitis, epilepsy and Parkinson’s disease; there may also be others. Those conditions cover a large number of people.
The problem is that when people have fluctuating conditions it will be much harder to plan ahead on the basis of the present drafting of Clause 25. There is not the flexibility to enable account to be taken of the ups and downs associated with fluctuating conditions. If the plan could take account of fluctuating conditions, individuals could be assured that they would get the level of care they needed, consistent with the fluctuations in their condition. By allowing for that, we can also prevent costly hospital admissions. That in itself is an important aim both for the well-being of the person concerned and, in terms of cost, for the health service.
For example, a snapshot survey of individuals showed that 30% of respondents with rheumatoid arthritis had been admitted to emergency care as a result of a flare-up of the disease in the past year—of which, of course, no account is taken by the Bill. The benefit of my suggestion is that it would make it possible to plan ahead for variations in care and support, in advance of those variations being required.
Amendment 92ZZJ is about the period over which care will be made available before the need is reviewed. The current wording of Clause 27 gives local authorities the power to,
“keep under review generally care and support plans”.
“Generally” is an all-purpose word which can mean anything. Local authorities are not required to specify when they expect such reviews to take place. Anyone who is subject to something “generally” lives in uncertainty, and what I would like to achieve with my amendment is some element of certainty.
The key benefit of the care and support planning process would be to allow a discussion between the local authority and the person concerned about the best way their care needs could be met. Then there could be an agreement between the local authority and the adult or carer. It is important for such an adult to be confident that their care will remain consistent until their circumstances change. Under my amendment they would not be subject to an early review if there was no need for it, but when things happened, that could be reflected in their care plan. The amendment would give that adult the confidence that their care would continue as agreed until the specified date, or until the adult himself or herself chose to request a review in line with Clause 27(1)(b). That may seem a small change but it would be important to the individuals affected.
Lord Sharkey
My Lords, I shall speak briefly to my Amendment 92ZZS. Its purpose is to ensure that the direct payment system works well. In particular, it would ensure that all parties to the decision to use direct payments fully understood the implications of that decision.
I raised this matter at Second Reading because I was concerned that some successful applicants for direct payments may underestimate the difficulties involved in administering those payments. I was concerned that there was no clarity about exactly how local authorities would make the decision about who was and was not a suitable recipient for direct payments. For example, it is likely that many in receipt of direct payments will want to employ people directly. Will they understand how very complicated it is to employ even one person? How will they find out? Exactly how will local authorities assess their ability to do this, and will people properly understand any contractual arrangements they may enter into? Who will help them understand? Exactly how will local authorities assess their likely abilities in this area?
I suggested at Second Reading that a way of dealing with this was to give local authorities an obligation for friendly oversight of the administration of direct payments for an initial period of six months or so. In his very thorough and helpful letter of 5 June to those who spoke at Second Reading, the Minister pointed out that Clauses 31 and 32 set out that, before a direct payment is made, the local authority must be satisfied that the adult or someone nominated on their behalf is capable of managing the direct payment. He felt that these and other provisions in Clause 4 should ensure that direct payments are used appropriately.
I am sure that these provisions will be very helpful, but they would be more helpful if the local authority had to explain to applicants on what basis their capability was being assessed and the exact criteria for assessment. It would be more helpful still if the explanation was in written form and followed by discussion with the applicant. That is what my Amendment 92ZZS would put in place. It simply requires the local authority to make known in writing and discuss with the applicant the criteria that it uses to satisfy itself that the adult is capable of managing a direct payment. This would have the effect of bringing about a proper discussion of the implications for the applicant of managing direct payments and provide a proper and informed basis for the local authority to make a judgment. I hope that it would also ensure that the criteria for judgment were clear, understandable, user-friendly and completely transparent. Making this simple change would greatly improve the chances of correctly matching direct payments with those who understand the implications and can effectively manage the system. I very much look forward to hearing the Minister’s thoughts on the matter.
Baroness Wilkins
My Lords, I speak to Amendment 92ZZSA, which stands in the name of the noble Baroness, Lady Campbell of Surbiton. The amendment seeks explicit clarification from the Government that nothing in the Bill lessens the strong duty on local authorities to offer direct payments to those requiring care and support services. A right to request direct payments is a welcome encouragement to those who would like to arrange their care and support with the autonomy that direct payments bring. However, it should not undermine the duty of local authorities to offer direct payments as enshrined in the Health and Social Care Act 2001 and regulations. It would be unhelpful to shift the onus on to individuals to know about and request direct payments and away from local authorities’ duty to offer them.
In general, case studies in this area show that where people already have a care package and then want to convert to direct payments, a battle is often involved. Care services recipients need a clear indication that direct payment is one of the support options available. The Bill requires local authorities to tell an adult which, if any, of the needs can be met by making direct payments. It is vital that local authorities understand that they must always provide information about direct payments. This information must include how to request one, the conditions, and advice and brokerage services.
Local authorities need to provide support to help the adult to manage direct payments. As the Bill stands, they can refuse a request if the adult has no help available to manage the payments. Could the Minister make the Bill’s intentions clear in this regard? It is important that the rights and duties enshrined in the original Act, which have proved so beneficial to many disabled people, are not, as it were, lost in translation, and some reassurance on this matter would be very welcome.
Baroness Wheeler
My Lords, this has been a valuable debate and important issues designed to probe and improve aspects of these crunch stages in the care and support journey have been raised. The amendments relate to the duty of the local authority in respect of the care and support plan for the adult, the support plan for the carer, the personal or independent budget resulting from the assessment of the adult’s and carer’s needs, and care accounts and direct payments. This is a large grouping and we have nine amendments. I will speak to them as they relate to other amendments in the group as briefly as I can.
Amendment 92ZZG seeks to specify in the Bill that the adult or carer needs in the care and support plan or support plan include both social care, to be met by the local authority, and health needs, to be met by NHS bodies in the area. This requirement would reinforce the need for local authorities and primary, secondary and community health services to work closely together for the benefit of the adult and the carer. It would also provide a clear, joined-up picture of the adult and/or carer’s interlinking care and support and health needs and how they are to be met. Amendments 92ZZP and 92ZZQ also provide for this important joining-up mechanism to apply to the care and support plan and support plan reviews by underlining that in the review process, local authorities must have regard to any changes in the health needs of the adult or carer, including any health provision that they are entitled to receive.
Amendment 92ZZK, in the name of the noble Baroness, Lady Browning, extends the intent of our amendment by specifying that in a young person’s care and support plan, both health and education, in addition to care and support, should be included, integrating with any existing plan in these areas. The importance of this amendment to young people with autism—or indeed to their carers, as the amendment is not specific—has been underlined by the noble Baroness.
The noble Baroness, Lady Greengross, has tabled a number of amendments. In the time available I will refer to four of them. Amendments 92ZZCA and 92ZZR address the need for the Bill to be explicit and thorough in relation to the assessment and eligibility entitlements where the adult lacks mental capacity to arrange for the provision of care and support. The amendments are designed to ensure that the local authority provides free care and support in the circumstances where the person authorised to represent the adult under the Mental Capacity Act 2005 asks for the care and support on the adult’s behalf.
Amendment 92ZZR addresses concerns raised by the Alzheimer’s Society and other groups that Clause 28(7) does not offer adequate protection to people who lack capacity and puts people with deteriorating conditions such as dementia at risk of falling through the gaps. Government Amendment 92ZZQC is designed to address this and the Minister’s recognition that the clause is open to misinterpretation is welcome. These are complex issues but we all recognise the importance of ensuring that the Bill is watertight in respect of adults lacking capacity to arrange care and support, and of having clarity in respect of the local authority’s duty to carry out a needs assessment and to continue to maintain their care account. Can the Minister reassure the House that the Government’s amendment addresses the concerns raised by noble Lords in this debate?
The noble Baroness also raises a key issue in her Amendments 92ZZRA and 92ZZRB, which go to the heart of the choice agenda to ensure that the current right for individuals to choose a preferred care home, and the ability of their representatives to choose a home on their behalf when, for example, the individual has dementia, is upheld in the Bill. Currently the Bill does not make this mandatory on local authorities and it is important that it does. I ask the Minister how the Government’s policy on patient choice can be met when the Bill does not reinforce the current right for people to choose their preferred care home.
Our Amendments 92ZZRAA and 92ZZRAB probe this issue further and are intended to explore the Government’s appetite for including the right to express a preference for the nature and location of accommodation. We support the intention of the Government, the Law Commission and the Labour Party that the Care Bill should increase the choice and control of adults using social care and their carers. I am, however, intrigued to determine whether the Minister thinks that this right in Clause 30 might be made more meaningful if it were extended to include the nature and location of this accommodation. It is important to seek to give adults needing care and support both choice and voice, including them in decisions about them. I look forward to the Minister’s response.
I support the intention of my noble friend Lord Dubs in his Amendment 92ZZH to ensure that care and support plans or support plans specify contingency planning for an emergency, ensuring that plans reflect the flexibility needed for fluctuating conditions, such as MS and other conditions referred to by my noble friend, where there can be severe changes and rises and falls in care needs. Having discussions and planning in advance for this, so that the care is there when it is needed, would be a significant step forward.
It is also important to look at contingency plans in case the carer suddenly becomes ill or is unable to provide care. The self-direct assessment model includes discussion on contingency and risk, but the extent to which clear provision is covered in the care and support plan is patchy. Indeed, it is not always easy to be specific about what would happen because often the reality is that instant emergency care cover is hard to organise when relatives live a considerable distance away or the cared-for person is not able to summon emergency help themselves.
My noble friend also underlines the importance of including a review date in the plan. It would be valuable to require social services departments and providers to be clearer about not just the review date for the plan but what the monitoring and review process is, and what kind of client feedback, or complaints process, there will be, as well as client/carer involvement in assessing quality of care and standards of service. I suspect that very few care plans currently address these issues. Our Amendments 92ZZMA and 92ZZQB probe how a reasonable request for a review of a care and support plan is to be interpreted and, most importantly, to be interpreted fairly across the country. We support a national care service and a national entitlement to care.
We also in our Amendment 92ZZEC draw attention to the important issue of the need for the completion of the care and support plan and support plan to be conducted within a reasonable timeframe. The assessment is a worrying and often traumatic time for the cared for and carer, so knowing what the timeframe is from interview to completion, and then for the personal budget decision, is pretty important. Getting an early assessment and getting the clock ticking towards the cap will also be crucial, so there must be targets and timeframes for the local authority to adhere to and meet. Assessments under the self-directed support process in my local experience as a carer involved four meetings with social services, including with the domiciliary care agency provider and with the daycare provider, and a lot of supported work to be undertaken by the adult or the carer on the client’s behalf. Is the Minister confident that local authorities will really have the capacity and resources to cope with the demands of the new system, including the estimated quarter of a million additional assessments for self-funders that will need to be carried out?
Finally, our Amendment 92ZZSB seeks to implement the recommendation of the Joint Committee on lifting the Department of Health’s current ban on direct payments being used to pay for local authority services if the individual chooses to achieve the agreed outcomes. Our amendment would bring this into effect by underlining in the Bill that there should be no restriction in terms of type of provider placed on the services which can be purchased by direct payments. I hope that the Minister agrees, and I look forward to his response.
Earl Howe
My Lords, I thank all those who have contributed to the debate on an issue which is crucial to the Government’s vision for a personalised care and support system—the care planning process.
In relation to Amendment 92ZZCA, I hope I can reassure the noble Baroness, Lady Greengross, that it is already the case in the Bill—the Explanatory Notes make this clear—that where the adult lacks capacity to make a request, it may be made by someone else on their behalf. This is the effect of the Mental Capacity Act 2005. It is not necessary to set this out in legislation each time. We will also make this clear in guidance. Condition 3 in Clause 18(4) imposes a duty on the local authority to meet needs in cases where the adult lacks capacity and has no one to arrange care on their behalf. This is an additional safety net, enacting a provision previously set out in guidance.
On Amendment 92ZZEC from the noble Baroness, Lady Wheeler, it is vital that local authorities retain the ability to be proportionate to the needs to be met. For some people the care planning process may be relatively simple and therefore can occur relatively quickly, but that may not be the case for people with multiple complex needs. As we discussed earlier, there may be a need for experts to be engaged in some cases, and this should not be overlooked in order to meet a centralised target. Introducing a defined timescale may also have the unintended consequence of some plans being rushed in order to meet the deadline, or even introduce gaming into the completion of care plans. I hope that the Committee will agree that this does not fit very well with our vision of a personalised care and support system.
We will work with stakeholders to set out best practice for conducting care and support plans in guidance. This will include indicative but not definitive timescales for care plans. Amendments 92ZZG, 92ZZP and 92ZZQ in the name of the noble Baroness, Lady Wheeler, raise the issue of specifying health needs in the care plan. The Bill creates a clear legal framework to enable such integration to happen in practice. However, it is not for the local authority to specify in the care plan which needs the NHS should meet. Clause 25 requires local authorities to involve the adult and carer, and take all reasonable steps to agree the plan with them, which would include whether to refer to any health needs.
In relation to Amendment 92ZZGA in the name of the noble Baroness, Lady Emerton, we believe that everyone should receive a personal budget as part of their care plan to ensure individuals are made aware of the cost of their care and the contributions both they and the local authority need to make. Giving local authorities discretion on whether to provide a personal budget would undermine our aim of giving people more choice and control over their care and support. Removing this duty will also affect the ability of the local authority and adult to track progress towards the care cap. I realise—at least I hope I realise—that the amendment was a probing one.
Baroness Browning
I think the concern of the noble Baroness, Lady Emerton, was not about the discretion over whether or not to give the budget, but about discretion over how that budget should be spent. I think that she was concerned that the personal budget, if it were put into the plan in a certain format, might start to prescribe how the budget was spent. That, I think, is what she was concerned about and why she suggested the change of wording.
Earl Howe
I am very grateful to my noble friend and I think I had better reflect further in the light of those comments.
I completely agree with the noble Lord, Lord Dubs, in relation to Amendments 92ZZH and 92ZZJ, that a modern, comprehensive care and support system should be able swiftly and effectively to respond to changing patterns of need. But the issue of fluctuating or emergency needs and anticipated review dates should be left to the local authority and the adult to discuss and agree when going through the care and support planning process. Again, we will consider these matters when producing statutory guidance with partners.
I turn to Amendment 92ZZK in the name of my noble friend Lady Browning. As I have indicated previously, the transition of children to adult care and links between this Bill and the Children and Families Bill merit further consideration and will be discussed at a later date. But I share my noble friend’s expectation. Where an adult has an education health and care plan, their care and support needs assessment and plan should be integrated with it. Both the guidance supporting the Care Bill and the SEN code of practice will set out how we expect this to work.
I turn to Amendments 92ZZLA and 92ZZQA in the name of the noble Baroness, Lady Greengross. The Bill is intentionally very clear that the personal budget and independent personal budget must be the cost to the local authority of meeting the adult’s needs, not an arbitrary or hypothetical figure. I can reassure the noble Baroness that the local authority may not set the personal budget to an amount which is less than it would cost the authority to meet the adult’s needs. The personal budget or independent personal budget must reflect the cost to the local authority of meeting the adult’s needs, not the cost to the individual of doing so himself or herself. Otherwise, this would create an unfair advantage for those with more means who are able to pay more for their care and would therefore reach the cap quicker.
I turn now to Amendments 92ZZMA and 92ZZQB, spoken to by the noble Baroness, Lady Wheeler. Enabling adults to request a review of either the care and support plan or the independent personal budget without a determination of reasonableness may leave the process open to abuse and create frivolous reviews costing the local authority time and money. For example, it would not be reasonable to request a review when a review has recently been conducted and needs have not changed. If an adult request is considered unreasonable, then the adult should be informed of the grounds for the local authority’s decision. We will cover this further in guidance.
On Amendment 92ZZR, we wholeheartedly agree with the noble Baroness, Lady Greengross, that if an adult lacks capacity the local authority must carry out the assessment if it believes that this would be in the adult’s best interests. We have addressed this in government Amendment 92ZZQC. This puts beyond doubt that the provisions of Clause 11 should apply to any refusal of a needs assessment by an adult with an independent personal budget. As a result, where an adult lacks capacity or is at risk of abuse or neglect, the local authority must carry out the assessment if it believes it to be in the adult’s best interests.
On Amendment 92ZZRA, I can reassure the noble Baroness that it is the Government’s intention to make regulations on choice of accommodation in residential care.
I turn to Amendments 92ZZRAA and 92ZZRAB, spoken to by the noble Baroness, Lady Wheeler. It is important that people should, as far as reasonably possible, be able to choose the accommodation they live in. People may wish to move into a care home in a new area—for example, to be close to relatives—and they should be able to do this even if this is in another local authority area. I can reassure the Committee that we intend to make regulations that enable people to exercise choice of accommodation both within and outside their current local authority. However, we do not believe that it would be appropriate to require local authorities to find and arrange care in another local authority area. While some might choose to do so, others might lack the local knowledge effectively to undertake this task. The requirement may also potentially have significant costs and could reduce the funds available to support those with the greatest needs.
I turn to Amendment 92ZZRB of the noble Baroness, Lady Greengross. Our approach in the Bill is simple. It allows any “person” nominated by the adult to receive a direct payment on their behalf, provided of course that the conditions specified in the Bill are met. In legal terms, a “person” means anyone with legal personality. Therefore, Clause 31 already allows the local authority to pay the direct payment to a person of a type specified by the adult. This includes user trusts set up as companies and organisations set up as companies.
On Amendment 92ZZS, I understand my noble friend Lord Sharkey’s concerns, and I hope I can reassure him that the local authority cannot fulfil its duties under the Bill unless it tells the adult what he or she needs to know in order to make a decision and reach agreement about whether or not to take a direct payment. Further, the Bill contains a regulation-making power at Clause 33(2)(f) to set out cases or circumstances in which the local authority must review the direct payment to ensure that it is being used and managed appropriately.
I turn now to Amendment 92ZZSA of the noble Baroness, Lady Campbell, to which the noble Baroness, Lady Wilkins, spoke. There may be only a limited set of circumstances in which a direct payment would not be appropriate, such as where needs can be met only through local authority-provided care and support. It is not our intention to for this to be used to limit access to direct payments. However, it is important that this provision remains in order to ensure that the adult’s needs are met via the most appropriate method.
Finally, I turn to Amendment 92ZZSB, spoken to by the noble Baroness, Lady Wheeler. It has always been our policy that, as long as used legally, there should be no restrictions on the type of services purchased with a direct payment, provided it accords with the care and support plan. Indeed, this reflects current guidance. Clause 25 requires the care plan to detail the needs to be met by the direct payment and, under Clause 31, a direct payment must be an appropriate way to meet those needs. There is no need to state in the Bill the type of providers from which people can purchase care and support.
The noble Baroness asked me what kind of client feedback there will be in the planning process. I am sure that she will agree that deciding the way that care needs are to be met is at the heart of a person-centred care and support planning process. These decisions should be agreed between the local authority and the person after considering the range of options and the person’s own wishes and goals.
We have made a number of changes to the draft Bill to address some of the concerns that we heard—that the balance of the care and support planning process was not adequately weighted towards the wishes of the adult. The process must also include involvement with the carer or any other nominated person, so that all people who can contribute have the opportunity to do so. It will in some circumstances not be possible to reach agreement between the local authority and the service user on the care and support plan, much as that is the aim. In those cases, the local authority will have to act to ensure that the person’s needs are met and that any risks to their safety are prevented. I hope that I have reassured the Committee that the care and support planning process is robust, and that the noble Baroness will feel able to withdraw her amendment.
Baroness Greengross
My Lords, I thank all noble Lords who have raised issues and amendments in this discussion, which has been extremely interesting. I also thank the Minister for his response, which was very positive in all but one or two areas, where I am still not absolutely certain that we are clear on the different levels of payments in care homes. However, I shall come back to the House on Report or speak to the noble Earl later. Again, I thank everybody, and particularly the Minister for his very positive responses. I beg leave to withdraw the amendment.