Care Bill [HL]
(11 years, 4 months ago)
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Lord Patel of Bradford
Lord Patel of Bradford
My Lords, I shall also speak to Amendment 92AZ. I welcome the aspects of the Bill that are aimed at securing the sustainability of the social care sector and social care provision. It is particularly important to put measures in place setting out the action to be taken to protect people from the negative impacts of business failure in adult social care. However, I have some concerns about the key clauses that relate to provider failure and market oversight. I refer specifically to Clauses 47 to 54, which specify the criteria for the application of market oversight, determine whether criteria apply to a care provider and cover the assessment of financial sustainability of care providers.
Amendment 92AY focuses on the financial regulation of providers. The Bill currently allocates to the Care Quality Commission responsibility for maintaining quality care services, mitigating risk to business sustainability and ensuring continuity of care for any person who receives care services. These steps will include obtaining regular financial and relevant performance information, working with the provider to develop a sustainability plan to manage any risk to the organisation’s ongoing sustainability, using powers to commission an independent business review to help the provider to return to financial stability and requiring information from the provider to enable the CQC to support local authorities to manage provider failure.
I concur with the view that all providers of care and support services should be subject to thorough financial checks which may indicate that a care organisation might be unable to fulfil its obligations as a provider of services in the future. However, plans to allocate responsibility for financial regulation to the CQC appear to be poorly thought through and Monitor, as the current financial regulator for health services, should assume this role. The pressures facing the CQC as part of its expanded remit for regulating quality across the health and social care sectors have already been eloquently highlighted in previous debates on this Bill by many noble Lords, including the noble Lord, Lord Sutherland, and my noble friends Lord Hunt and Lord Campbell-Savours.
We are all aware that the CQC is undergoing significant structural change and it does not have the capacity and organisational expertise to take on responsibility for assessing the financial stability of care providers. This is being proposed because of the belief that service users would benefit from having a single regulator, specifically the CQC, to oversee care and support services and provide an overall assessment of performance, combining quality and financial data. I am also aware that the Francis report highlighted the importance of simplifying the quality and financial regulation regime for health providers to eradicate overlap and minimise the gaps between the functions of the different organisations and regulators. This included changes to the current division of regulatory responsibilities between Monitor and the Care Quality Commission.
However, the noble Lord, Lord Sutherland, in a previous debate, specifically highlighted the key concerns—which I share—about giving the CQC additional responsibilities for financial assessment. He stated, and I agree, that the CQC is not prepared for these additional responsibilities. I would question whether it has the specialist staff, skills, experience and, most importantly, expertise required to decide whether care providers have financial sustainability.
Alongside all the other demands it faces, the CQC will also be pressured into developing a rushed financial accountability system, without proper consultation and checks and balances. These additional responsibilities for financial regulation place added pressure on an organisation that is already undergoing significant change and faces a greatly increased workload as part of its expanded duties for quality assurance. The development of a poor-quality financial accountability system will only affect its credibility further and I therefore question the rationale for designating the CQC as a financial regulator for the care and support sector.
In fact, under the Health and Social Care Act 2012, Monitor became the economic regulator to promote effective and efficient providers of health and care, promote competition, regulate prices and safeguard the continuity of services. Monitor can license providers, work with NHS England to set prices for NHS-funded services, prevent anti-competitive behaviour and work with commissioners to ensure continuity of services when providers get into financial difficulty. I would therefore argue that Monitor already has its own robust financial oversight regime for healthcare providers that can be adapted and applied to the social care sector; and the Government should use these existing powers as a means to effectively regulate the sector in the future. My amendment to Clause 52, on the assessment of financial sustainability of care providers, simply replaces the CQC with Monitor. I hope that the noble Earl will agree that this is a sensible and helpful amendment.
I now turn to Amendment 92AZ on the accountability of commissioners. As many noble Lords have commented throughout the Committee stage, the focus in the Bill on greater integration between health and social care services is to be welcomed. As services between health and social care become more integrated, it is essential that the plans of local authorities face the same levels of scrutiny as clinical commissioning groups and have clear lines of local and national accountability.
However, there is at present no effective regime in place to oversee and monitor the standard of local authorities’ commissioning of care and support services. The annual performance assessments previously undertaken by the Care Quality Commission to evaluate the quality of councils’ commissioning of adult social care services were scrapped in 2010. Of course, the Minister may argue that the scrutiny of commissioning plans is now covered under the provisions of the Health and Social Care Act 2012 and that additional oversight is not therefore required.
I know that that Act contains a number of duties that focus on aligning the plans of clinical commissioning groups and health and well-being boards to ensure that clinical commissioning groups take into account the joint strategic needs assessments when preparing their commissioning plans. Equally, I am also aware that health and well-being boards are expected to have a key role in bringing together local authorities, clinical commissioning groups and local Healthwatch to assess the health and care needs of local populations through joint strategic needs assessments and joint health and well-being strategies.
However, recent cases such as those at Winterbourne View and Southern Cross have demonstrated the devastating impact on vulnerable people when commissioners, commissioning systems and processes are found wanting. Winterbourne View was set up as an assessment, treatment and rehabilitation centre for people with learning disabilities and autism, but the review into Winterbourne View found that it had “strayed far” from this purpose and stated that the commissioners, as well as the owners, Castlebeck, were to blame for this. The primary care trust commissioners who placed people at Winterbourne View did not set performance targets for the company or effectively check the progress of patients, despite being charged an average of £3,500 a week for places. Their reviews were clearly flawed, completely ineffective and did not bring to light either concerns about the quality of assessment and treatment or the detail of abusive practices. Strategic health authorities also did not effectively performance-manage primary care trusts in their commissioning of placements for this client group. The review concluded that closed establishments such as Winterbourne View would benefit from a more prescriptive approach. This includes far more effective planning processes, and performance management and monitoring systems by commissioners.
That is why I am proposing a new clause that focuses on the accountability of commissioning organisations that would give NHS England a duty to scrutinise the commissioning plans of local authorities for adult social care services to ensure that they are upholding the safety and care of vulnerable people, and the efficient and effective operation of a market. Equally, notwithstanding my previous comments, I would be content if the noble Earl thought that the CQC rather than NHS England would be able to provide that scrutiny. I beg to move.
Lord Warner
My Lords, I intervene briefly to make a couple of observations and put a question to the Minister on this set of amendments. I must confess that I am not thrilled by the idea of NHS England being asked to supervise the commissioning of local authorities. I think that it may struggle to supervise the commissioning of 211 clinical commissioning groups, or however many we have this week, without our turning it loose on 152 local authorities as well. There must be some doubts about whether it is the right body to supervise local authority commissioning.
My noble friend Lord Patel of Bradford makes a very fair point in asking where we will get some sort of overview of the quality of local authority commissioning. It may not be NHS England, but we could perhaps have some idea of the Government’s thinking on how they will be satisfied that the commissioning is of a reasonable standard across 152 local authorities. If the Minister could tell us this evening which quality assurance mechanism the Government have in mind, that would be a useful insight.
The other point was about whether it should be Monitor rather than the CQC. This is an area where I have struggled quite a lot, because I think that there is a problem with what is going on with the financing of adult social care. Who actually bankrolls the providers in this sector? I question whether, without a lot more expertise, either Monitor or CQC are well placed to penetrate some of the private equity models of financing adult social care provision. These models are being brought in almost as we speak.
The financial complexities of this sector are very considerable. The providers of residential and nursing home care within the adult social care sector have moved on a long way since my days in local government as a director of social services. People are assembling packages of money to buy groups of homes, and they put groups of homes together in what is often basically a hedge fund or private equity-type process, essentially consolidating providers in this sector. The days of mom and pop homes seem to be passing quite quickly, as the sector tries to secure greater financial capability to respond to the buffets of a market system.
In this extraordinarily complicated market, it is not clear to me how the Government will equip any regulator—or help it equip itself—to secure the expertise to actually raise the money to buy and merge groups of residential and nursing home providers. It is not a very transparent system. Either CQC or Monitor will require a lot of expertise. It will have to go into territory into which few of us are equipped to go, and find out what is actually going on, if we are not to have another Southern Cross experience.
I suggest that the risks of that happening again are becoming greater as the funding systems for these organisations become less transparent. They are not publicly quoted companies, and in many cases they are hidden behind a rather mysterious cloak of financial allocations. Without making adverse comments, I suggest we look at what happened with Four Seasons, which was taken over by Terra Firma. Where are the loyalties? Are the loyalties of that organisation to the people receiving care, or are they to the people who are creating the funds for the purchase of that organisation? I would like some reassurance that CQC or Monitor—I do not feel strongly doctrinal, one way or the other—will have the expertise to penetrate some of these rather opaque organisations that are now involved in funding providers in this sector.
Lord Mackay of Clashfern
My Lords, when this issue was discussed previously I had the feeling that Monitor had at least some claim to having the kind of expertise which goes some distance in this area whereas, as far as I could understand it, CQC did not seem to. I entirely agree with the noble Lord, Lord Warner, that what either of them has at the moment is probably unequal to the task of seeking out exactly what is going on and seeing how great the risks are. It is pretty obvious that to understand the risks in these financial transactions is a very difficult task. We have seen examples, not particularly in this area but in others, where serious risks have emerged which were not suspected until very close to the time of their emergence.
I also agree with the view that one great factor in the care regime is the number of local authorities that are to be involved. Some degree of understanding at least the variation across these 152 authorities is essential. During the workings of the Joint Committee, I was impressed by the skill of some of the local authority representatives we had before us but they were in quite a particular position in relation to their work. I am not sure that their knowledge, expertise and feel for the situation necessarily goes right across the sector. I do not at all decry the valuable work that local authorities do but the variety of tasks assigned to them is very great and the care situation must be among the most difficult of their responsibilities.
Lord Hunt of Kings Heath
My Lords, this is an important debate and the collapse of Southern Cross has brought it home to us how the risk of financial failure is likely to be a continuing problem in this sector. That is why it is important to understand whether the regulatory regime that the Government are proposing will be robust enough and whether it will have access to the kind of information that will enable the regulator to take a view on the viability of those companies which seek to do business in this area.
We are going back partly to our earlier debates when we discussed the new failure regime. At that time, I referred to the Department of Health factsheet that we were given, which said that the new failure regime will give regulators clear roles in tackling failure. However, I do not think that is actually so in practice. According to the department, the Care Quality Commission will focus on exposing problems and requiring action while Monitor and the NHS Trust Development Authority, which deal with non-foundation trusts, will focus on intervening if a poorly performing provider is unable to resolve the situation by working with commissioners. As we have heard today, the CQC retains enforcement powers for social care, general practice and independent sector providers. This whole picture is very confusing and in his Mid Staffordshire inquiry Robert Francis made it clear that regulatory complexity can contribute to system failings.
I am still unclear about the interrelationship between Monitor, CQC and the NHS Trust Development Authority so as to know whether they are going to work together to ensure that problems are acted on. I am still unclear whether when Monitor and the NHS Trust Development Authority are asked to intervene as a result of the CQC’s concern about findings in relation to safety and quality, they simply carry out the instructions of the CQC or have to go through the same process to satisfy themselves as public bodies with specific statutory duties—certainly in the case of Monitor—whether they share the concern about quality or simply take the CQC’s word on trust. As the actions of these regulators are likely to be tested in the courts, one way or another, clarity at this stage would be very welcome indeed.
My noble friend makes the case that, because of its expertise and experience, Monitor would be a better bet for looking at financial issues to do with care providers. It is very difficult to understand why bits of the system have been dealt with differently and the CQC is considered acceptable in relation to private care providers for adult social care and so on but not for NHS foundation trusts. The Government have brought a rather curious mish-mash to your Lordships’ House.
On my noble friend’s second amendment, I share his view and am not sure that NHS England is the right body to have a duty to scrutinise the commissioning plans of local authorities. However, I very much agree with my noble friend that it is very important that there is a method of checking on the performance of local authorities in their commissioning of adult social care services. My noble friend mentioned Winterbourne View as an example of where a number of local authorities placed clients but having placed them paid no attention to their experience. That was a salutary warning about the problems of local authority commissioning.
I wonder whether the CQC ought to be the body which undertakes that responsibility. Clause 5 sets out that the local authority is responsible for promoting diversity and quality in provision of services. The local authority clearly has responsibility for ensuring that there are sustainable providers in the market. I also refer my noble friend to Clause 80 which sets out the CQC’s responsibilities in performance assessment and performance ratings. My noble friend will see that under Clause 80(2) the proposed new Clause 46(3) of the Health and Social Care Act 2008 sets out that:
“The Commission must, in respect of such English local authorities as may be prescribed … conduct reviews of the provision of such adult social service provided or commissioned by the authorities as may be prescribed”.
My reading is that the CQC is given powers to do what my noble friend wants. The question—we debated this when we debated Clause 5—is the extent to which the Government are so going to prescribe. I would like to hear from the noble Earl, if possible, that the Government have reflected on our earlier debate and have come to the view that it would be a very good thing to prescribe that all local authorities should have their commissioning performance reviewed by the CQC as a matter of priority.
My noble friend raised the question of Winterbourne View. We debated the problem of the contracts local authorities have set with private providers where they are contracting staff on very low rates of pay. These are the same providers which in some cases are giving 15-minute periods of service, with staff on zero-hour contracts and often having to pay the cost of their travel. I do not believe that those are the right circumstances in which a quality service could be given. That is why I believe that the CQC should prioritise the commissioning responsibilities of local authorities. If it did, it would answer the question posed by my noble friend.
Earl Howe
My Lords, I begin with an observation that I hope is incontrovertible: it is unacceptable for care users to be left without the services that they need, particularly where the interruption of those services, or the worry that this might happen, could badly affect their well-being and place unacceptable stress on them and their families, friends and carers. As the noble Lord, Lord Hunt, rightly observed, the collapse of Southern Cross in the autumn of 2012 highlighted the importance of this principle. Although no one was ultimately left without the services they needed, many people suffered from a considerable amount of stress and anxiety as a result of worries over whether the services that they, their friend or their relative relied on would stop being provided. At the time, there were no formal mechanisms for the Government to ensure that that was the case.
The Government are therefore introducing, through the Bill, a new system of financial oversight of the 50 to 60 providers of care and support that are the most difficult to replace. The system will provide local authorities with early warning that one of those providers is likely to fail or could fail, and will support authorities to ensure that, if a provider does fail, the continuity of care is maintained. The Care Quality Commission will assess the financial sustainability of all providers that are part of the regime, ensure that providers are taking adequate steps to tackle any risks to the sustainability of their business and support local authorities to tackle the risk of individuals suffering gaps in the services that they rely on when providers fail.
I sympathise with the arguments set out by the noble Lord, Lord Patel of Bradford, in favour of this function being undertaken by Monitor. He should be under no misapprehension: the decision about which regulator should undertake this role was a finely balanced one. This would have been a new role for either regulator. For the CQC, although its existing powers extended to some financial issues, it had not in practice used them significantly. For Monitor, this would have been an extension into a new market and type of provider with which it had had no previous experience. In the end, we came to the view that the CQC was the most appropriate body to perform this market oversight function, for three key reasons. First, this approach ensures that there will be a single regulator for care and support providers. The financial performance of a provider, whether exceptionally good or exceptionally poor, can be a leading indicator of serious quality failures. The CQC will be able to integrate quality and financial information and assess both together.
Secondly, the CQC is better placed to implement this regime because of the existing working relationships that it already has with providers through its current role. This should also contribute to minimising the regulatory burden on providers by ensuring that they have to work with and provide information to only one regulator rather than two. Thirdly, the CQC already has established working relationships with local authority commissioners. The main objective of this regime is to support local authorities in managing the failure of a difficult-to-replace provider. The CQC’s existing relationships will be invaluable in assisting it in performing this function effectively.
The noble Lord, Lord Hunt, questioned that rationale and pointed particularly to the advantages of Monitor undertaking the role, not least because of its current functions. I am the first to accept that Monitor has existing expertise in financial regulation, but it does not have experience in the care and support services market. The nature of Monitor’s licensing regime differs from this market oversight role in two key ways.
Lord Hunt of Kings Heath
Is the Minister satisfied that the CQC will be able to have access to sufficient information about the ownership of these companies? To pick up the point made by my noble friend, ultimately, when a home is at risk of going down, there is a danger that the interests of shareholders are put before the interests of the residents. Clearly, issues to do with ownership become very important there.
Earl Howe
The noble Lord makes an extremely important point, and one that has not been lost on us. We recognise that ownership structures can be extremely complex and that true ownership can be hidden from normal view. It is one of the factors that we will have to build into our discussions with the CQC. I do not pretend that there is an easy answer because some businesses quite consciously and deliberately set themselves up to ensure that it is very difficult to probe the true state of their financial affairs and their true ownership. As and when I can come back to the noble Lord on where we are with that, I will be very happy to do so.
Lord Mackay of Clashfern
My Lords, I crave my noble friend’s indulgence. I am concerned about the warnings in advance of a collapse. That seems to be an area of very considerable importance, and I wonder whether Monitor is supposed to be responsible for trying to forecast that. Secondly, if that is correct, obviously the discussions will need to ensure that it has the necessary expertise to do that and, as the noble Lord has said, that is a pretty difficult task.
Earl Howe
My noble and learned friend is, of course, right. That goes back to a question posed in an earlier group by the noble Baroness, Lady Wheeler, about what the definition is of business failure. We propose to define in regulations circumstances in which a provider can be deemed to have failed. Those circumstances may include a situation in which a provider is struggling to service its debts as they fall due or has breached its financial covenants under loan agreements, or an administrator, liquidator or receiver has been appointed—which is a clear-cut case of failure. As I said, this will be defined in regulations because we want to capture these various different scenarios where a business can be deemed to have failed. We will, of course, consult on the regulations before they are laid. No doubt what I have just said will be refined and augmented during that process.
Lord Warner
The Minister mentioned that the Government will look very closely at some of these ownership issues and their opacity. Will he be willing to look at some of the other sectors which have been regulated? I would cite water and the electricity and gas industries, where we are already seeing the emergence of a clear conflict between the rights and needs of shareholders and those of consumers. There are lessons to be learnt from these other sectors, which now have a lot of experience of regulators trying to hold the balance between those who invest and those who are receiving the services from the providers of those services. Consolidation has also taken place in those industries, particularly in the energy sectors.
In this sector, we are seeing the early stages of consolidation, which is moving apace. Given the vulnerabilities of the people who live in these homes, it is conceivable that some ownership patterns could simply not be acceptable in this particular sector because of the high risk that they pose for the users of the services. Will the Government look at those other sectors and at that issue as they start to consider this? I am the last person to want to stop new entrants coming into a market, but Southern Cross was a wake-up call for us. We have to see whether certain ownership patterns have too much of a conflict of interest between the investor and the user of the services for us to be able to be comfortable that they could ever deliver the bacon in a satisfactory way.
Earl Howe
The noble Lord is absolutely right. We are entirely open to looking at the lessons to be drawn from other sectors and the regulators of other sectors. I am sure that important messages will come from such sectors of the kind the noble Lord describes—no doubt not just the energy and water sectors but others, too.
I will move on to the question of whether there should be central oversight of local authority commissioning practices. I wholeheartedly agree with many of the arguments that have been expressed this evening. Commissioning practices which risk undermining personal dignity and lowering quality are simply not acceptable. That is why Clause 5 of the Bill introduces a duty on local authorities to shape high-quality, diverse and sustainable markets in care and support services. Clause 5(4) requires local authorities to have regard to this duty when commissioning services. As I said when the Committee discussed Clause 5, we are aware that there are examples of poor commissioning practice across the country. We need to move away from overly prescriptive commissioning that focuses only on price or time slots, to consider how it can do things differently and deliver better outcomes in quality care.
In relation to the option of central oversight of local authority commissioning that the noble Lord, Lord Patel of Bradford, suggested, the Bill leaves open the possibility of the CQC conducting reviews of local authority commissioning. However, by enabling the CQC to review local authority commissioning, if it is prescribed in regulations, the Bill gives us the opportunity to discuss this option further. In particular, we are considering whether the new chief inspector, who will work with local authorities that commission care and support, should have a formal role in assuring the performance of those authorities, building on the strength of the current programme of improvement activity and peer assurance led by councils.
I emphasise at this stage that if there is to be central oversight of commissioning, the CQC, as a consequence of its links with the chief inspector and its existing relationships with, and expertise in, the social care sector, will be the most appropriate body to undertake this function. Although we have not closed our minds to the option of central oversight of local authority commissioning, the fundamental problems underlying poor commissioning practices are cultural and structural. Central oversight on its own will not necessarily tackle these issues.
The noble Lord, Lord Warner, asked how we could be satisfied that local authorities’ commissioning will be of a suitable quality. It goes without saying that it is for local authorities to decide the most appropriate way for them to fulfil their duty of commissioning and of shaping local markets, responding to local needs and circumstances. They will be accountable locally for those decisions. However, we are working with local authorities to support them to develop their capacity to shape local markets. We launched a programme of support last year and intend to continue working with local authorities to improve commissioning practices. We are committed to working with the sector to support local authorities to shape diverse and high-quality markets, including through improving commissioning practices, through the recently announced homecare challenge and through a programme to support the authorities in their market-shaping capacity.
In conclusion, I fully understand and sympathise with the issues raised by the two amendments. However, I hope that I have been able to shed some light on why the Government have come to their view on the issues. In so doing, I hope that I have provided a measure of reassurance to the noble Lord, Lord Patel of Bradford.
Lord Patel of Bradford
My Lords, I thank the Minister for his detailed response. On the first amendment, which deals with financial regulations, he singled out three issues that were relevant to why the CQC was chosen: having a single regulator, better relationships with local authorities and better relationships with commissioners. That goes some way towards reassuring me, but I still feel, coming back to the comments of my noble friend Lord Warner, that this is not necessarily about relationships and capacity but about the expertise and skills required in a very complex financial arena. That is the key.
If I were naive, we lived in an ideal world and I was providing care homes, and either my accountant was not very good and I did not know that I was going bankrupt or I wanted to carry on and would do everything possible to keep the company running, regardless of my relationship with the CQC, that is where somebody with the real financial expertise required in this day and age could come in and spot what was happening. I am not 100% reassured that the CQC will have that capacity or expertise. I suppose that I recognise that Monitor does not understand the social care sector as well but it has the financial expertise that I think is invaluable. I may want to return to this issue again and to have a further discussion about it.
However, I am far more reassured by the response that the noble Earl has given me on central commissioning. I suppose that I stipulated NHS England in the amendment because I could not think of another body. Having said that the CQC does not have the capacity to do this, I could not say that the CQC should be doing it. However, I am reassured that the potential is there for central oversight through regulations and other areas. In the mean time, I beg leave to withdraw the amendment.
Lord Patel
“(1) When a child receiving services reaches the age of 14, or a local authority receives a request from the child, or a parent or carer of the child, to assess the child’s needs for care and support (whichever is sooner), the authority must, if the consent condition is met, assess—”
Lord Patel
My Lords, I shall speak also to my Amendments 92C and 92D, 94 to 100 and 101 to 104 concerning Clauses 55, 57 and 59. I also support Amendment 92BA, which is in a similar vein to my Amendment 94, and Amendment 104ZA in the names of the noble Baronesses, Lady Browning and Lady Tyler of Enfield, and the noble Lord, Lord Touhig, which is similar to my Amendment 92C. I also support government Amendment 93A. I thank all noble Lords who have added their names to my amendments, for which I am very appreciative.
My amendments deal mainly with the problems experienced by extremely vulnerable children as they transit from children to young adults, then adults and adulthood, by placing a duty on local authorities to assist this group of children. There are about 45,000—I repeat: 45,000—children or young people from newborns to the age of 19 who have long-term health conditions which will eventually end the lives of most of them and for which they may require palliative care. Medical advances mean that more young people with a range of different conditions are living into adulthood than ever before. The greatest increase is among those aged 16 to 19, who now account for 4,000, or one in 10, newborns to 19 year-olds needing palliative care.
The majority of young people who may require palliative care have a range of severe disabilities and complex health needs. Cancer represents just under 14% of diagnoses. Many young people have cognitive impairments, meaning that they lack capacity, and many are cared for over long periods by parent carers. Many young people with life-limiting or life-threatening conditions who are more cognitively able struggle to achieve independence or to enter education or employment because plans are not made for them. Those who are unlikely to be cured by treatment are offered palliative care. Transition for children after their 16th birthday is complex. Successful transition needs to address the transfer of responsibility for young people from children to existing adult social care, health and education services, and the development of new adult services tailored to young people’s additional needs.
It needs to be planned years in advance, but sadly the reality is that transition planning is too often disjointed and poor. As a result, many young people and their families find transition daunting. All this happens at a time when young people’s needs may be greatest, as many chronic, progressive conditions reach a crisis during late adolescence and young adulthood. Given the situation, these young people and their families cannot afford to wait and adult agencies need to ensure that their responses are timely and appropriate.
Together for Short Lives is a consortium of charities that looks after these children as a transition task force. It sought the opinions of young people who need palliative care. The view of young people is that the adult services they need are inadequate. They want services that enable them to lead ordinary lives, including a social life. They want a feeling of freedom, and not to be overwhelmed or bossed around by adults, while at the same time to be offered appropriate support. The young people’s frustrations with transition are shared by their parents.
I recognise that the Government have included Clauses 55 and 63 with the intention of ensuring better planning for young people who need to transition. I welcome the powers that local authorities will have to assess young people under the adult statute ahead of the young person’s 18th birthday. Despite the Government’s good intentions the clauses as they stand will not offer the certainty and reassurance that young people with very complex needs, and their families, desperately seek. On Second Reading, the Minister stated:
“The Bill will ensure that no child reaching the age of 18 should go without the care and support that they need around the point of transition”.—[Official Report, 21/5/13; col. 828.]
However, in only giving powers and not duties to local authorities to undertake a child’s needs assessment, the wide variation in the quality of transition planning will simply remain in those cases where children and their families do not request an assessment. Local authorities will face particular financial pressures.
My Amendment 92B would ensure that no young person misses out on a child’s needs assessment. It would replace the power for a local authority to undertake a child’s needs assessment request with a duty. Setting the age threshold for a child’s needs assessment at 14 is based on existing statutory requirements for every young person in year nine—that is age 14 to 15—with a statement of special educational needs to have a transition element. The amendment merely mirrors that.
Amendment 92C sets out the existing legislation underpinning the services that a young person who needs palliative care receives. The amendment would ensure that a local authority would be obliged to carry out a child’s needs assessment for a young person receiving the services specified over a long-term period up to the age of 14.
If 14 is the age at which transition planning should begin for a young person who needs palliative care by the age of 16, every young person who is likely to need adult health or social care when they reach 18 should have received a child’s needs assessment. That would ensure that the assessment happens in good time before the transition to adult services takes place. My Amendment 92D would mean that this is the case.
Amendment 94 would ensure, by putting a duty on local authorities, that if a child’s needs assessment finds that a young person is likely to need health or social care when they reach adulthood, a statutory five-year rolling transition plan should be prepared for the child or young person by the time they are 16. Amendment 94 has a number of other important features. It would mean that children, parents and carers are involved in the transition planning process. It would ensure that transition plans are maintained until the young person reaches the age of 25.
Like all young people, many of those who need palliative care want to strike out on their own and establish their independence. It should be remembered that these are children who are on longer-term palliative care. They hope to go into further or higher education, get a job, move into their own home and develop a social life. Amendment 94 would ensure that young people’s aspirations to move into their own homes would be included in the transition plan. Tragically, as a result of lack of planning, many are unable to do so. Too many of these young adults die while they are waiting on housing lists.
One of the provisions included in the Children and Families Bill is to introduce an integrated education, health and care plan—EHC plan—for young people who have special educational needs. This will include many, but crucially not all, young people who need palliative care. When a young person stays in education and training, they will be eligible for an EHC plan until the age of 25. I recognise that an EHC plan could fulfil the functions that I intend a transition plan in my amendment to do. Indeed, an optimal position would be where EHC plans are available to all young disabled people up to the age of 25. In lieu of that, this amendment is necessarily lengthy—I apologise for that—to ensure that a statutory plan is put in place to provide similarly joined-up transition provision for young people who need palliative care but do not have SEN.
Amendments 95, 96 and 97 aim to ensure that transition planning is maintained for young people who need palliative care and who move from one local authority area to another. They mirror Clauses 36 to 40 in the Bill, which place duties on local authorities to ensure continuity of social care when adults move from one area to another—so why not for these vulnerable children?
Amendment 97 would provide for the Secretary of State or an appointed person to step in to resolve any disputes about where that young person lives with regard to assessing the child’s needs and preparing a transition plan. The amendment would provide for the continuation of a young person’s transition plan where such a dispute arises. In considering young people who need transition from children to adult services, it is vital that we take into account the needs of those who care for them. Again, I recognise and support the Government's aspiration to do so in the Bill. However, as with the clauses relating to planning for young people’s needs on transition, I believe that we need to go further in order to ensure that planning for carers also happens in practice.
Amendment 98 would place a duty on local authorities to assess the likely care needs of those caring for a child who is likely to need services as an adult. Under the current wording in the Bill, local authorities would have the power to conduct a child’s carer assessment but would not be obliged to do so. That has the potential again to create unnecessary variations in transition planning for carers in local areas.
As I proposed in Amendments 92D and 98, 14 is the age at which transition planning should begin for a young person who needs palliative care and their carer. The young person’s and the carer’s needs should be assessed by the time the young person is 16. This would ensure that the assessments happened in good time before the transition to adult services took place. Amendment 100 would ensure that that is the case.
Amendments 101, 102, 103 and 104 are consequential to Amendment 100. Amendments 101 to 104 further strengthen the Bill by making sure that local authorities are duty bound to meet a child carer’s need for support.
I repeat that my amendments seek to put a duty on local authorities to assist 45,000 of the most vulnerable children whose lives will be short because of their conditions. The amendments will give them an opportunity to have a semblance of normal, enjoyable life with appropriate support and care. It is neither organisationally nor financially a great deal to ask.
I realise that my amendments are lengthy and I am sure that the Bill team could do a better job with much abbreviated amendments to meet the same needs. If the Minister feels that the amendments are too wide in scope, I will be pleased to be of assistance in narrowing them down to focus particularly on these vulnerable children. I beg to move.
Baroness Pitkeathley
I rise to speak to my amendments in this group and to support the amendments of the noble Lord, Lord Patel, to which my name has been added.
I have tabled Amendments 93B, 100A and 104ZZA because I am concerned about the wording in Clauses 56 and 61, which may risk preventing the provision of services, and that the references to families and friends or others suggest a reliance on carers that is inconsistent with other provisions in the Bill and with the intention that a decision on eligible needs should be carer blind. That the provision should be carer blind is an important and welcome commitment by the Government in this part of the Bill.
My amendments seek to remove the reference to assessment of the capabilities of a child, a child carer and a young carer and the support that family members could provide to meet a child’s need for care in Clause 56, a parent’s need for support in Clause 58, and a young carer’s need for support in Clause 61. Similar amendments tabled by the noble Lord, Lord Hunt, were debated when we discussed Clauses 9 and 10.
The references to the capabilities of a child, a child carer or a young carer and any support likely to be available to the child from friends, family and others should be removed. There could be an undue reliance on family and friends to provide care and support, and voluntary support from family and friends will not be properly planned for or sustainable and will not be subject to checks or review. Family and friends may not be willing and able to provide support but there is a risk that they will be relied on regardless of their own wishes. There is no check in the law and there are no provisions for this in the legislation. Carers could easily be pressurised to provide care and the vital contribution that they make may not be recognised. Those of us who deal with carers all know how often they are pressurised, sometimes quite subtly. The implication is, for example, that they will have to give up their job in order to provide care for the particular person needing care.
I am also concerned, as a member of the Joint Select Committee, about Clauses 56, 58 and 61. They were not part of the consultation on the draft Bill and this is quite a substantial departure from the process set out in it and recommended by the Law Commission. The new parts which have been added to Clauses 56, 58 and 61 blur the distinction between consideration of needs and ways of meeting needs, other than through services at the stage of assessment, before any decision about whether the child, child carer or young carer have eligible needs. The assessment process should show what the needs for care and support are before consideration is given to how those needs will be met.
Carers UK—I declare an interest as its vice president—has tested the wording of these clauses on a number of front-line workers and their belief is that practice will be adversely affected. The distinction is important because if consideration of needs does not precede consideration of ways to meet those needs, there is a danger that needs will be defined with regard to whatever support is available and could result in children, young carers and parent carers finding it more difficult to access statutory care and support as a result of assumptions being made about the informal support that is available. These amendments seek to remove any risk that family and friends will be unduly and inappropriately relied on to provide care and support to the child, child carer or young carer, and to ensure that care and support needs are properly met following an assessment of needs and before considering the potential input of others.
The amendments tabled by the noble Lord, Lord Patel, to which I have added my name, emphasise the importance of the transition period to parent carers and disabled young adults and the vulnerability of both groups. I have little to add to his very eloquent presentation. It is sometimes remarkably difficult to focus the attention of policy-makers on the needs of parent carers. I have often been puzzled as to why that is. I think it may be about the very decided views that we all have about parental responsibility.
However, we must understand that the responsibility we gladly take for our non-disabled children is very different from what we expect from the parents of a child with special needs. These parent carers can find themselves providing care for many years and often at the very heavy end of caring—for example, someone who has severe mental and physical disabilities may need lifting and continence care—and for 24 hours a day. Do I need to point out that keeping such people engaged in caring by giving them enough support to stop them breaking down makes very sound economic as well as moral sense? At no point is this support more important than the transition stage, as the noble Lord, Lord Patel, has so eloquently reminded us.
Baroness Tyler of Enfield
My Lords, I will speak to Amendments 92BA and 104ZA. My noble friend Lady Browning and the noble Lord, Lord Touhig, whose names are also attached, are not in their places.
I welcome the attempt in the Bill to tackle the issue of transition from children’s services to adult social services and to try to make it work for young people. Clauses 55 to 63 undoubtedly present an important step in the right direction. However, some improvements are needed to ensure that the Bill provides the appropriate legal basis for the smooth transition for young people from children’s services to adult services that I am sure we would all like to see, and to remove the cliff edge that has been referred to in this and previous debates.
First, Amendment 92BA relates to Clause 63, which is about the continuity of services and is designed to ensure that if adult care and support is not in place by the time the child reaches 18, the services they receive under other legislation will continue until adult care and support is put in place. The potential for this change to benefit young disabled people making the transition to adulthood is very much to be welcomed. However, the benefits outlined in Clause 63 apply only if a request has been made for a child’s needs assessment by the time that child turns 18. The concern remains that some young people will not be able to benefit from this protection because they or their parents or carers will not be aware that they need to request an assessment by the time they are 18. Therefore, the amendment would ensure that every child who is receiving support under the relevant legislation and is likely to continue to have a support need after the age of 18 receives that assessment and the benefits that flow from it.
With regard to Amendment 1042A, as I have said in some of our earlier debates on the Bill, there is an overlap in the jurisdiction between this Bill and the Children and Families Bill, which specifically relates to social care for young people entering adulthood. The proposed new education, health and care plans, which the Children and Families Bill sets out to introduce, are at the very centre of this debate. If the aim of the current legislation is to create a better, joined-up system—as I think it should be and I am sure that other noble Lords agree—it is vital that the Care Bill makes reference to these EHC plans.
I will briefly explain that important link between the two Bills. At the same time as the Care Bill aims to bring adult social care into the 21st century, the Children and Families Bill aims to create a new joined-up system of support for children and young people with special educational needs between the ages of nought and 25. Plainly, with the Care Bill applying to adults from the age of 18 and the Children and Families Bill setting out the framework for children and young people up to the age of 25, there is an overlap in the 18-to-25 age range. It is vital that these plans are able to talk to each other if we are really to have the sort of integrated system that we all want, and if we are to achieve that desired goal of a one-stop shop of services that young people can access when they need them.
I support many of the other amendments in this group, but shall not spend time going through them.
Lord Adebowale
My Lords, I support Amendments 92B, 92C and 92D, which are also in the names of the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Patel, who have spoken eloquently on this matter. I declare an interest as the chief executive of Turning Point, which provides health and social care to many young people in the process of transition. I know, as we all do, that transition can be a very delicate process if not done well. Young people slip through the net between children’s and adult services and begin their adult lives without adequate care and support, which risks deterioration of physical and mental health, and the escalation of need to the point of crisis. That is both immoral and expensive.
The Bill goes a long way to improve the current situation. I am pleased to hear that Ministers informed the House during an earlier session that discussions between the Department of Health and the Department for Education about the links referred to between this Bill and the Children and Families Bill are already taking place. These transition amendments offer an opportunity for us to go further—it is quite rare for a Bill to offer an opportunity to do something quite brilliant for young people—and to ensure that all young people receive support under other legislation. That support is likely to continue after young people reach 18 and they will receive an offer of a needs assessment from their local authority. Importantly, this process will begin in good time.
This includes those young people—or their families and carers, as has already been mentioned—who have not themselves requested an assessment. It is an important addition to recognise that there may be cases, as mentioned by the noble Baroness, Lady Tyler, where a family just does not realise that they need to request an assessment. Good transition is about helping to ensure that local authorities are better prepared to meet the needs of young people. If assessments can be conducted earlier, so long as this is what young people and their families want, care and support can be in place sooner, and there is less risk of people’s needs escalating to the point of crisis.
I hope that the Minister will agree that the assessment process needs to begin in good time, and that he can assure the House that those who do not themselves request an assessment will also be able to benefit from the improvements that this Bill offers.
Lord Warner
My Lords, I will make two quick points, the hour being late. The Government need to look again at the way this Bill works with the Children and Families Bill. These arrangements look clunky for those moving from childhood into adulthood. The real problem is that this Bill does not seem to work on the basis that many, if not most, of these children will be known to the same local authority. Why, then, is this Bill framed as though they are strangers coming into the system, in which the local authority is permitted to involve them? The local authority should have an obligation to make seamless the move from childhood to adult services. The Bill does not really deliver that. The Government need to look again at that transition point, and reconcile the Children and Families Bill and the Care Bill, because they do not work together as well as they might.
Lord Patel of Bradford
My Lords, I have put my name to Amendment 94 in the name of the noble Lord, Lord Patel. I do not think that I can add to the detailed and clear exposition that the noble Lord has provided. I know that the amendment is slightly lengthy, but it is also very logical and clear—I understood it very clearly, so that is a bonus. I welcome the intention behind Clauses 55 to 63, which enable parents and young people to request a child’s needs assessment. Clause 56, on requirement’s for a child’s need assessment, states:
“A child’s needs assessment must include an assessment of … (a) the outcomes that the child wishes to achieve in day-to-day life”.
What is the intention behind “outcomes”? What outcomes are we looking at?
Lord Hunt of Kings Heath
My Lords, it was remiss of me not to declare an interest during our debate today as president-elect of GS1, chair of a foundation trust and consultant trainer with Cumberlege Connections.
Perhaps I, too, may raise the connection of this Bill with the Children and Families Bill. As my noble friend Lord Warner said, with the Care Bill applying to adults from the age of 18 and the Children and Families Bill setting the framework for children and young people up to the age of 25, there is a clear overlap in their jurisdiction in the context of social care provision. Education, health and care plans under the Children and Families Bill also include an assessment of a child or young person’s social care needs, which means that young people between the ages of 18 and 25 may be eligible both for an EHC plan and an adult care and support plan. That seems to reinforce my noble friend Lord Warner’s comments.
My understanding—perhaps the Minister could confirm this—is that the Government are considering bringing forward amendments to the Children and Families Bill to make sure that the two link together. If that is so, the problem that we have is that the Children and Families Bill will not go into Grand Committee until we come back in October, whereas this Bill should have cleared the House by about the fourth week in October. It would be very disappointing if we, in debating this Bill, were not able to see the changes that the Government were going to make to the Children and Families Bill so that we could make sure from our perspective that the two hung together. Can the Minister assure us that, if the Government are contemplating some amendments, we could see them so that we could debate them within the context of this Bill?
Earl Howe
My Lords, I thank Members of the Committee, and especially the noble Lord, Lord Patel, for a debate which illustrates the significance of transition to young people and their families and the need to get the legal framework right for them.
As we have heard, these amendments cover a range of issues. In respect of Amendments 92D, 98 and 100, I have listened with interest to concerns about the absence of a requirement that transition assessment should take place at a particular age. We are in agreement that the timing of assessment is crucial, but this is essentially a question of approach.
The Care Bill proposes that two tests be used to ensure that assessment takes place at the right time for each young person or carer. We believe that this is preferable to rigid timescales which take no account of an individual’s needs or circumstances. First, a local authority may assess a young person, their carer or a young carer where it appears to the local authority that the child or carer is likely to have needs upon the child turning 18. This is to be used in conjunction with the second consideration, whether assessment would be of “significant benefit”. This recognises that a one-size-fits-all approach is not in the best interests of young people or their carers.
Amendments 92B and 92C would limit the group of young people who can benefit from transition planning to those who are already in receipt of services. We would not wish to impose any such restriction. Indeed, this restriction was removed following public consultation and pre-legislative scrutiny, because transition planning may equally benefit those who are not currently in receipt of services.
I have heard the concerns expressed that local authorities are not under a duty to assess in every case. This is indeed true, and for very good reason. Some young people will not have needs for care and support after the age of 18. It will not be appropriate, nor indeed will it be in a young person’s interests, to assess in every case.
I listened with interest to concerns about provision for carers of children. We need to be clear about this. Support should be available where it is needed. The question is the source and nature of that support. Clause 59 provides a power, rather than a duty, for local authorities to provide support because existing children’s legislation already includes provision for support to a child’s carer. Duplication of existing legislation may cause confusion and is unnecessary. This power is intended to enable support to be provided under adult legislation where a certain service is available only locally via that route.
I turn now to planning for transition and Amendments 92BA and 94. Provision for transition assessment is focused on the outcomes that the individual wants to achieve. I can reassure the noble Lord, Lord Patel, that such outcomes may include employment, education or housing. I also share the noble Lord’s expectation that, when a child has an education, health and care plan, any assessment under these clauses should take the EHC plan into account and the assessment should be integrated into that plan.
The Care Bill and the Children and Families Bill include provision that assessment can be joint, including joined-up assessments in relation to an EHC plan. These issues will be addressed by both the guidance supporting the Care Bill and the Department for Education’s SEN code of practice.
In respect of Amendment 94, I briefly add two further points. First, when a young person over the age of 18 has an EHC plan, and as such the care part of that plan is provided under this Bill, we would expect co-operation between adult and children’s services in relation to any review of the plan under Clause 6(5)(a) and (b). Such co-operation for those under 18 who are in transition is provided for by Clause 6(5)(c). This would include co-operation with the preparation, maintenance and review of the EHC plan as provided for by the Children and Families Bill, in respect of children. Guidance can ensure that this is clear.
Secondly, requiring a local authority to make arrangements to secure provision for children and young people with a transition plan would not be appropriate. Services to children cannot be provided under the Care Bill. Children’s legislation provides for this. Services to young people over the age of 18 would be provided, if necessary, under provisions earlier in Part 1.
In relation to Amendment 104ZA, I agree on the need to ensure continuity of care. However, we must avoid creating overlap or confusion with local authorities’ existing duties in relation to children, including rights to assessment and support under the Children Act 1989. For this reason, it would be preferable for the young person to request assessment as they see fit and for the local authority to initiate this conversation with the child. The request itself is not envisaged as a formal process. Indeed, for some young people the request will form part of a conversation the local authority initiates about transition to adulthood. Guidance can be used to make this point.
Young people and their families will need information in order that they can understand the adult care and support system and, crucially, that they are aware of their right to request assessment. Clause 4 requires local authorities to establish and maintain an accessible system for information and advice including information and advice about how to access the care and support that is available.
Through Amendments 95, 96 and 97, the noble Lord, Lord Patel, the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Patel of Bradford, have also expressed concern that there should be provision to support children with care needs to move between areas, without the fear of experiencing a gap in their care and support. I agree. Provision for people over the age of 18 already exists at Clauses 36 and 37 and provision for children with an Education Health and Care plan exists in the Children and Families Bill. If a young person under the age of 18 who has had an assessment under the provisions of Clauses 55 or 60 moves to a new area, the general duties of co-operation, in particular with other local authorities under Clause 6(6)(b), would also apply.
I should like to reassure the noble Baroness, Lady Pitkeathley, in relation to Amendments 93B, 100A and 104ZZA that consideration of “other matters”, a person’s own capabilities and the other support that may be available does not exclude the provision of more conventional care and support services where needed. Indeed, when the child becomes 18, if the individual’s needs are eligible, the local authority must meet them, in accordance with Clause 18, if the adult wants the authority to do so, and those requirements are not diminished by these three paragraphs. The intention is to recognise that, in order to make the right connections to the local community and the variety of support available, the local authority should consider how these matters, along with more formal care and support provision, could be of benefit in achieving the adult’s outcomes.
The noble Baroness suggested that carers might be pressurised by these provisions into providing care. It is certainly not our intention that pressure is put on carers. The clauses make it very clear that a carer must be willing and able to provide support and that the impact upon carers’ well-being must be considered.
She flagged up the concern that the new provisions in Clauses 56, 58 and 61 are departures from the draft Bill and asked why that was the case. The Bill as introduced includes greater clarification as to the nature of the assessment that should be carried out and what should be considered. It is largely for drafting reasons that we split the subsections relating to children, children’s carers and young carers into two subsections for each group.
The noble Lord, Lord Warner, pointed out that, in his view, the Bill is framed as though young people are strangers to the local authority. The Bill makes provision both for those who are receiving children’s services and are known to social services and for those who are not currently receiving care and support. Clause 6 provides a duty to co-operate, including within the local authority. In particular, in relation to children transitioning to adulthood, there is a duty for those internal discussions to take place. The request mechanism in the Bill is not intended to be a formal or bureaucratic process, as I mentioned earlier.
The noble Lord, Lord Hunt, asked me to confirm whether the Government are considering bringing forward amendments on carers, and expressed his concern that the timing of the Children and Families Bill relative to this Bill is unfortunate. I can tell him that my noble friend Lord Nash, at Second Reading of the Children and Families Bill in your Lordships’ House, said:
“As my honourable friend the Minister for Children has said, we are considering how the legislation for young carers might be changed so that rights and responsibilities are clearer to young carers and practitioners alike. We will also look at how we can ensure that children’s legislation works with adults’ legislation to support the linking of assessments, as set out in the Care Bill, to enable whole-family approaches”.—[Official Report, 2/7/13; col. 1201-02.]
The Minister for Children and Families and the Minister for Care and Support have met the National Young Carers Coalition to discuss the key principles for taking this work forward over the summer, as well as how we can most effectively involve the NYCC during this period.
Finally, the government amendment in this group will ensure that the provision added to Clauses 58 and 61, following consultation and pre-legislative scrutiny, specifying that a needs assessment must include an assessment of the impact of the adult’s needs for care and support on their well-being, is also added to Clause 56.
We have had much discussion recently about the need to ensure that services are organised around the needs of individuals. I hope that I have been able to explain how this legislative framework for transition is focused on meeting that aspiration. I hope, too, that I have provided some reassurance about the approach we are taking to smooth the transition to adult care and support. I hope that the noble Lord, Lord Patel, will feel able to withdraw his amendment.
Lord Patel
My Lords, I thank the Minister for his response, which was as detailed as my amendments. I am reassured by some of the things that he has said, and how the Bill addresses those issues. Although the Minister does not agree with me, there is an issue about specifying the age of 14 as the time of assessment for this small number of vulnerable children. There is a need to do so. However, at this point I do not wish to prolong it. I beg leave to withdraw the amendment, but I hope that we will have further discussion outside the Chamber.
“( ) the impact on the matters specified in section 1(2) of what the child’s needs for care and support are likely to be after the child becomes 18,”