Care Quality Commission
Baroness Barker Excerpts(11 years, 1 month ago)
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Baroness Barker
My Lords, last year the Government announced their intention to end the practice of domiciliary care visits being planned on the basis of a few minutes. In the current economic circumstances, can the Minister say how the Government plan to make that intention a reality?
Earl Howe
My Lords, my noble friend will know that in the care and support White Paper we set out our intentions to improve quality standards in social care, increase the capacity and enhance the capability of the social care workforce, ensure that people have better information about care providers, and improve the performance of the regulator. Within that spectrum of actions, we will be looking carefully at how precisely to deliver that ambition to which my noble friend rightly refers.
Carers
Baroness Barker Excerpts(11 years, 3 months ago)
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Earl Howe
I agree with the noble Lord. Carer’s breaks are extremely important, which is why we have pledged to invest £400 million between 2011 and 2015 to improve the NHS’s support carers to enable them to take a break from their caring responsibilities. The current operating framework for the NHS requires the service to work closer than ever before with local carers organisations and councils to agree plans to pool resources and ensure that carers get the support and the break that they deserve.
Baroness Barker
My Lords, is the Minister aware that in November 2011, in a report from the Cass Business School for Carers UK called The UK Care Economy: Improving Outcomes for Carers, the authors noted that the only reliable data about carers comes from the census, which is national? Given that CCGs and health and well-being boards are about to start commissioning services locally and that their information is at best incoherent and inconsistent, what help will the Government give them in order properly to assess the numbers of carers and the level of need they are supposed to be meeting?
Earl Howe
My Lords, my noble friend makes an extremely important point. Our report, Recognised, Valued and Supported: Next Steps for the Carers Strategy, had four key priorities, one of which was to identify carers earlier. Healthcare professionals undoubtedly have a role to play in supporting those with caring responsibilities to identify themselves as carers in the first instance. We therefore made around £850,000 available in the previous financial year to the Royal College of General Practitioners, Carers UK and the Carers Trust to develop a range of initiatives to increase awareness and understanding of carers’ needs in primary care. We are building on that further.
NHS: Hospital Beds
Baroness Barker Excerpts(11 years, 5 months ago)
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Earl Howe
Yes, my Lords. That is the precise reason why there are currently 5,000 midwives in training, which is a record number. The noble Earl is absolutely right to identify the midwifery service as key to enabling children to get a healthy start in life and parents to ensure that children get into good eating and exercise habits.
Baroness Barker
My Lords, the Dr Foster report identifies those hospitals which have a high level of inappropriate referrals of older people. Will the department do further research in those areas to see whether there is a correlation between out-of-hours GP services, and the work that they do, and a high level of inappropriate referrals of older people to acute hospitals?
Earl Howe
My Lords, it is questions of that kind that we expect the clinical commissioning groups to examine because they will become responsible for out-of-hours primary care. Therefore, it is incumbent on them to ensure that that service not only is a good one but does not lead to unwanted consequences in terms of unplanned admissions to hospital.
Social Care
Baroness Barker Excerpts(11 years, 5 months ago)
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Baroness Barker
My Lords, I, too, am one of the usual suspects. I thank the noble Baroness, Lady Pitkeathley, for bringing us back to this subject.
I will start by pointing out the contrast between today and a year ago. A year ago, we were inundated with messages about what people thought about the Health and Social Care Act and their fears for the NHS. Now, when we are talking about social care, which probably has a bigger impact on more people, we have received almost nothing. I know that over recent weeks a number of noble Lords have attended a lot of very good briefings and meetings with some of the more noted social care policy bodies—but apart from that, nothing. That is very telling. The future well-being of many of our citizens relies on the extent to which the NHS engages with, understands and promotes social care, so that fewer people end up going to hospital and those who do quickly return to the place where most healthcare will happen in future—their own homes. That is the debate that we should be having with people in the NHS, and we are not.
It is understandable that people talk in apocalyptic terms about social care. The Barnet graph of doom says it all. I have to say that the LGA laid it on by doing exactly what I would have done in those circumstances, which is to pick the very worst case.
The key issues in social care arise because of the successes of the NHS. The NHS was designed for and spectacularly successful at organising acute care for treatable conditions. As a result, the majority of people now live with long-term care conditions, but we still have a health service based on that old model. We need to work out ways in which the NHS and local authorities together can buy packages of health and social care that enable people to go along a health and care pathway. At the moment most people’s experience of health or social care is that a part of it may work fantastically well but it is not related to any other parts of the pathway of their lives. That experience and the economic models that underlie it are the key things that we have to turn our attention to.
I want to say a little bit about personalisation, a subject that I talk about quite a lot, as the noble Earl, Lord Howe, will know. It is the chosen method of the previous Government and this Government for addressing some of the many deficiencies in social care. I think that the noble Baroness, Lady Campbell of Surbiton, will be delighted when I say that the big problem with personalisation is that it has been taken by many people in its most basic and crude form to mean a direct payment and a list of providers. It is about much more than that. It is about more than disaggregating existing services and giving people money to purchase them. It is about finding new ways to enable people to have the power to shape the services they need. The Housing Learning and Improvement Network is currently engaged in working on some very interesting different forms of collectivisation of personal payments, enabling people, for example, to combine in buying a core housing service and then buying different personal services to turn what was previously residential care into assisted living. That is the sort of work which local authorities and, in future, the NHS need to support so that we can ensure that more older people remain in assisted living for longer, rather than ending up in hospital and acute care.
We have a plethora of examples of how community care can be improved and work very well in preventing people needing higher levels of care. All the usual suspects will recognise Dorset POPP, North East Lincolnshire Care Trust Plus and Southwark Circle—all of them packed with evidence about how older people can thrive in supported settings. However, to the best of my knowledge none of them has a model of economic sustainability. My key question for the Minister is whether, in this coming year—with the potential of health and well-being boards and the potential which arises from some of the changes in the NHS radically to alter the way in which services are commissioned, designed and provided—the Government will continue to work on developing economic models which can show us whether those small localised examples can be either scaled up or replicated in different parts of the country.
We are in danger of missing the point that the creation of health and well-being boards gives us the potential to do what is brought out in the subject of this debate—to create communities in places where older people want to be. They want to be at home; they do not want to be in hospital. It is for the Government to provide these new bodies with research, which so far has been lacking, into the efficacy of social care compared with acute treatment to enable the joint pathways of care that I talked about earlier not only to be real in terms of the services that they give older people but to be viable models in which the NHS feels it can safely invest, as opposed to investing, as it has done, in acute care.
In my remaining final minute, I want to say that so far we have achieved something quite remarkable—a consensus on Andrew Dilnot’s report. I hope that that consensus continues because, whatever one may think of its deficiencies, it is the only game in town. It is important that a form of Dilnot comes about soon and that it should be a compulsory and not a voluntary scheme. If that does not happen, we will never get the economic basis on which to build the new future of health and social care to which we aspire.
Contracting Out (Local Authorities Social Services Functions) (England) (Amendment) Order 2012
Baroness Barker Excerpts(11 years, 5 months ago)
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Lord Hunt of Kings Heath
My Lords, I thank the noble Earl, Lord Howe, for his full explanation of the order before us this afternoon. I find the contents to be unexceptional and it is right to avoid a hiatus in the pilots’ evaluation. The people affected should not have to go back to an old system before knowing whether the Government have decided that they should be extended, so the logic of the order is clear. I will ask the Minister about a couple of points. He mentioned evaluation. In relation to the trail-blazers pilots, he referred to the interim evaluation which, as he said, found the Right to Control had not been extended to a sufficient number of people to provide evidence to inform a decision about the future of the Right to Control approach. Will he say more about the emerging findings as to the impact on disabled people? He made a few comments about that and suggested that the signs so far are encouraging, with some positive outcomes. Could I tempt him into explaining a little more to the Committee?
I also ask the Minister about potential links between the Right to Control trail-blazers and initiatives taking place on public health. Following the debate when the order was first brought before your Lordships’ House in 2011, the noble Earl wrote to Members who had spoken to the order to say that the Right to Control trail-blazer pilot was intended to be run simultaneously with the public health budget pilots. In particular, he mentioned Manchester, where he said that there was one in-depth public health budget site—Manchester—alongside a Right to Control trail-blazer site. I wonder whether he could report anything on that. I also ask the noble Earl what feedback there has been from users of the service on Right to Control pilots.
On the adult social work practice pilots, I understand that the evaluation has been carried out by King’s College London. I have yet to track down any KCL publication on any emerging findings from those pilots. Perhaps the noble Earl could confirm whether anything has been published so far. I understand, however, that the Department for Education has published an evaluation report by King’s College London and the University of Central Lancashire on the original pilots for children and young people in care, in September 2012. That might be of interest in comparing those pilots with the pilots that are now being undertaken. That evaluation, I understand, found mixed views as to whether the pilots performed better than their local authority counterparts, or whether they represented good value for money. Would the noble Earl be prepared to comment on that? Overall, though, we of course support the extension of the pilots.
Baroness Barker
My Lords, I very much welcome the extension of these pilots. I am not quite sure why the order has to come back to the House; that seems rather strange.
I say that I welcome the extension as somebody who has been consistently critical of the premature way in which the previous Government seized upon the then interim findings of the IBSEN report into personal budgets for social care and proceeded to extend that away from the original client group on the flimsiest of evidence. I am therefore extremely pleased that the present Government are going to take a lot more time and care over these pilots. A lot is changing. A great deal has changed since 2009 when these pilots began, but there is massive, rapid and in-depth change going on in social care. I was talking the other week to a colleague who works for a major national charity and who has done some forward projections of the funding of services of some of the organisations with which she works. Believe me, if people are worried about the American economy and the cliff edge that it is coming to, they really ought to look at voluntary sector funding for the next two years. That is important and relevant, because many of the generic sources of advice to which people in need of social care go are currently under threat. In addition, health and well-being boards are in the process of being set up. That is a major change in the health and social care landscape in which these pilots are taking place. It would be advantageous if the Government were to extend, at least until 2014, its analysis of how these are working.
Mental Health Act
Baroness Barker Excerpts(11 years, 6 months ago)
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Earl Howe
The question that the noble Lord, Lord Laming, asks is not a naive one at all—it is a very important one. The draft legislation that has been prepared is very narrowly drawn and its effect will be to ratify retrospectively those decisions taken by the panels that assess doctors for approval and treat those decisions by the panel as if they had been lawfully made. So it does not apply directly to patients but to the approval of the clinicians involved.
Baroness Barker
Could the Minister say something about the role of regulators and professional bodies, and why none of them picked up this issue over time? Will that matter form part of Dr Harris’s review?
Carers: In Sickness and in Health
Baroness Barker Excerpts(11 years, 10 months ago)
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Earl Howe
As ever, the noble Baroness makes a really important point, and it is one that we fully recognise. In our plans to roll out psychological therapies, carers are very much within the scope of our thinking. As the noble Baroness will know, last year we published a four-year plan of action. We are investing around £400 million—the same sum of money that I referred to but additional to the other sum—in talking therapies: the Improving Access to Psychological Therapies programme. I am sure the noble Baroness will be glad to know that that investment is already making marked improvements, and there is a substantial increase in the number of people receiving the benefit of IAPT.
Baroness Barker
My Lords, in view of the Government’s stated intention to increase personalisation, can the Minister tell the House what happens when the expressed wishes and needs of somebody being cared for are in conflict with the expressed wishes and needs of a carer? Whose needs take precedence in that case, and how is the conflict resolved?
NHS: Annual Report and Care Objectives
Baroness Barker Excerpts(11 years, 10 months ago)
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Baroness Barker
My Lords, I thank the Minister for introducing a highly innovative document. This is the first time that the NHS has ever been treated in this way, with a document of this kind brought to Parliament and put out to consultation. I am delighted that in such a milestone document mental health has not been forgotten and is included alongside physical health.
I wish to ask the Minister three quick questions, because this document is important and the process of consultation about it is important for the future of the NHS. First, in the section on commissioning, will the Minister tell us whether he believes that the document fully reflects the decision taken in this House during the passage of the Health and Social Care Act that commissioners should not be under any obligation to put services out to tender when there is a justifiable case not to do so in the best interests of patient care? I want to make sure that he believes, as I do, that that point needs to be stressed during this period of consultation.
Secondly, with reference to the Public Administration Committee report in 2011 about the need for government to have robust accountability and audit trails as services are increasingly delivered by other providers, will the noble Lord reassure the House what the processes will be, given all the work that was done by my noble friend Lady Williams of Crosby about the capacity of Parliament and the Secretary of State to have sufficient information to judge whether or not the aims and aspirations of the document have been met in practice? How will it be evaluated and what data will be made available to Parliament to make that judgment?
Finally, I welcome the part of the mandate about the NHS in its broader context, but does the Minister agree that the omission of any mention of housing is a serious one—in particular aids and adaptations, which are so important to prevention of ill health and for the reablement of people who have been in acute care?
Earl Howe
My Lords, I am grateful to my noble friend. On her first question about commissioning and the matter that we discussed during the passage of the Health and Social Care Act, she will remember that the cardinal principle of “any qualified provider” is that it is for commissioners to judge whether putting a service out to tender is in the best interests of patients. If there is no need to bring in competition, there is no obligation on a commissioner to do so. Why should they wish to? On the other hand, a service may be failing. The classic example that I always give is that of children’s wheelchair services. In some parts of the country it is appalling. There is every reason in the world for a community service like that to be put out to tender. Nobody argues with that, if it delivers a better service at the same or roughly equivalent price. So I can reassure her on that point.
On accountability and audit trails, the way in which the board will hold the service to account will be based on the commissioning outcomes framework very largely, but of course there will be very tight financial controls through the accounting officer of every CCG. Broadly speaking, the service will be held to account through the results achieved for patients, the quality of care and the outcomes. There will be metrics attached to those—the indicators that I referred to, which fall below the NHS outcomes framework, as it were.
My noble friend will notice in the mandate that we have quite consciously not articulated umpteen sets of targets or indicators for particular disease areas, such as cancer or coronary heart disease. Once we started to do that, we would produce a volume 500 pages long; nobody wants that—the clear message that we had was that the mandate should be brief, succinct and to the point. That is what we have produced in draft, and we would be very interested to hear what noble Lords think about that. I encourage all noble Lords to feed in their views as to whether we have got the balance right.
On housing aids, I do not think there is anything specifically in the mandate on that. On the other hand, one of the features of the integration of services will be for the health service to work much more closely with social care. We believe that the health and well-being boards will provide the best forum to do that. I hope that through mechanisms such as pooled budgets—and indeed the support that my department is already giving local authorities to bolster their social care budget—such housing aids can be maintained as we move into the future.
Dementia
Baroness Barker Excerpts(11 years, 10 months ago)
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Baroness Barker
My Lords, I thank the noble Lord, Lord Touhig, for enabling us to hold this debate and for his eloquent and moving introduction. I confess that I am a veteran of pretty much every one of our debates in this House over the past 10 years. We have had dementia strategies and dementia plans, and I congratulate the previous Government on their work on those important documents, which have moved us forward. Dementia is something that affected my family until last December, when my mum died having, in her words, “kind of lost the place a little bit”. That was her euphemistic way of talking about dementia. It is a subject that for the past 20 years I have followed with a great deal of interest because, as noble Lords know, I work with older people.
I want to sound a somewhat more hopeful note than did the noble Lord, Lord Touhig, and I do so because two or three things have happened that give cause for optimism. Building on the work of people like the noble Baroness, Lady Greengross, and the all-party parliamentary group, as well as on important reports from Alzheimer’s bodies, the Prime Minister’s Challenge on Dementia and the updated dementia strategy are extremely good documents because they move us forward. Not only are they forward-looking, they are quite detailed. The strategy talks not just in broad terms about the need for more research and support, but it begins to draw down different areas in order to achieve a series of things which, over the next five years, will bring about real and actual change in both communities and the health service. They will be of benefit to people who have dementia and their carers.
The Prime Minister’s Challenge on Dementia is based on three things: raising awareness and understanding, early diagnosis and support, and enabling people to live well. There is a commitment to increase research funding to the unprecedented level of £66 million, some of which is to be spent in social care, which is extremely helpful. Some of the money will be spent on redesigning services in the health service, but some will also go to the Medical Research Council for further research into brain scanning. We are beginning to move away from broad strategies into more targeted and focused areas. I was pleased to see that resources are to be devoted to developing dementia-friendly communities. That is not jargon. People are starting to work towards a definition of what that is all about.
For more than 20 years I have followed the work of the Dementia Services Development Centre at Stirling University, both under its previous director and now under Professor June Andrews. It has contributed more than any other organisation to the understanding of dementia as an illness, to understanding the needs of carers, and to enabling academics and healthcare professionals to move forward. Recently, Professor Andrews gave a talk about design. She and her colleagues had been involved in a community pilot study in the Forth Valley. People from various disciplines worked for a year to see how, within their existing resources, they could manage things differently. I was pleased to see that not just the health service but organisations like the police, libraries, churches and the general public felt more confident in their ability to deal and interact with people who have dementia. We are getting close to the point where a diagnosis of dementia is not going to lead to older people and their carers automatically being cut off from the life they enjoyed previously and which, for many years to come, may still have some meaning for them.
Professor Andrews talked about the issue of design, and particularly design in people’s homes. I am very pleased that some of the people involved in the Prime Minister’s challenge are designers and private companies, looking at how they can respond in practical ways to the challenge of dementia. Professor Andrews also talked about the need to develop things like glass-fronted fridges so that people know that they have food. I look forward to the time when homes have glass-fronted freezers because I stopped counting the times that I had to throw away a freezer’s worth of food because my mum forgot about it and it went bad. Design, lighting and so on in people’s homes can make a tremendous difference to their ability to remember.
I want to focus on one particular area that has not been mentioned so far. Many older people with dementia also have other disabilities. If you are a carer supporting somebody and you try to find out about adaptations, they will be designed for a particular physical disability and not for someone who has a physical disability and also dementia. In this hopeful time, designers could look at the potential to design appliances for the home for people who have the multiple disabilities that most older people will develop.
One particular area we should focus on is telecommunications. It is great that there is enormous change going on in the world of telecommunications and that, for example, phones can now be used by people with hearing disabilities who could not use one before. Yet there is absolutely no point in having a phone that has wonderful functionality if you cannot learn to use it. Professor Andrews made an important point about the ability of people to design things in future that will have new functionality but will look like the objects that people with dementia remember—retro-designing things so that people can continue to use them.
I am also pleased that in the dementia challenge we are finally recognising that in future all health and social care professionals, whatever their discipline, will deal with people who have dementia. That will include dentists, pharmacists and others. We are now moving to a point where basic pre-qualification training for all health and social care professionals has to include dementia, whatever the area of specialism.
In the short time available, I will raise one more point. Last December, the Alzheimer’s Society produced a report, Short Changed, about the experiences of older people with dementia, and their carers, with banking and financial services. Older people with dementia are particularly vulnerable to financial abuse. We have known that for years. We knew it 15 years ago when the noble Baroness, Lady Greengross, set up Action on Elder Abuse. It is now more than five years since the passage of the Mental Capacity Act. At that time, the Office of Fair Trading and the British Bankers’ Association produced guidelines about tightening up procedures in relation to people who lack mental capacity, but we still have problems. Anybody who listens to “Money Box” will regularly hear reports of irresponsible lending to people with dementia.
I make one particular suggestion: will the Government, with the Office of Fair Trading and the British Bankers’ Association, now do some further work on banking services for people who lack capacity? Will that work draw a difference between people who have learning disabilities, people who have mental health problems which may be episodic and people who have dementia? All three have different issues but at the moment the banks treat them all the same. That is causing a problem, not least for carers of people who have dementia, who are worried and trying desperately to enable their relatives to keep control of their finances for as long as they can. They want a backstop for when the time comes when their loved ones can no longer manage.
Dementia is a terrible thing, and it is going to happen to more and more people as we live longer. It is going to become a part of life for more of us. I am not a Pollyanna, but having read the dementia strategy and the Prime Minister’s Challenge on Dementia, I think we now have reason to be much more hopeful than we have ever been that we will be able to see people living well with this terrible disease.
Care Homes
Baroness Barker Excerpts(11 years, 10 months ago)
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Earl Howe
The noble Baroness’s remarks will resonate with many noble Lords. We have been here before. One of the emerging issues from the review is around poor practice on the use of restraint, as she rightly mentioned. CQC inspectors found that only 73% of locations met requirements on physical intervention or restraint. There was ineffective monitoring of restraint data and learning from incidents. Staff were not always trained and restraint was not always delivered in line with the care plan. There are real lessons to be learnt by providers about the use of restraint. We have flagged this up as one of the actions that we will take in the department to work with the Department for Education, the Care Quality Commission and others to drive up standards and promote best practice in the use of positive behavioural support and ensure that physical restraint is only ever used as a last resort. The report published on Monday is an interim report and we will be publishing a final report later in the year.
Baroness Barker
My Lords, does the Minister agree that this report calls into question the role of local safeguarding adult bodies? What are they doing now while people are being mistreated in a way that the CQC has uncovered? Does the Minister think that it is time to revisit the legal bases of those organisations?
Earl Howe
My Lords, my noble friend is right to call that matter into question. My department will be working with the NHS Commissioning Board Authority to agree by January next year how best to embed quality of health principles in the system using NHS contracting and guidance. Those principles will set out the expectations of service users in relation to their experience. We are taking a range of other action—the 14 national actions to which I referred in my initial Answer—which I would suggest my noble friend looks at. We are clear that there is a need not just for providers but for everybody in the system to focus on their responsibilities and to work together to drive up standards in the way that we all wish to see.