Health: Clinical Commissioning Groups

Baroness Barker Excerpts

Thursday 26th April 2012 Lords Chamber

[Earl Howe]

My Lords, the watchword in this context is transparency in that the governing body of a clinical commissioning group will usually meet in public. There will be provision for the health and well-being board of a local authority to challenge decisions made by the clinical commissioning group in its annual commissioning plans. In general, if anyone has a concern about a conflict of interest, or indeed a perceived one, it is open to them to refer the matter, first to the CCG and, secondly, to the NHS Commissioning Board itself.

[Baroness Barker]

My Lords, have the BMA and the royal colleges been involved in drawing up the guidance? And if a member of a CCG believes that there is no conflict of interest but a member of the public believes that there is, what mechanisms are available to resolve such a dispute?

[Earl Howe]

My Lords, we are involving all relevant stakeholders in drawing up the precise rules that we expect the NHS Commissioning Board to follow. As I mentioned in my initial Answer, part of that has resulted in guidance that has already been issued and the rest will follow shortly. As regards the second part of my noble friend’s question, the key is for CCGs to make arrangements to make sure that actual and potential conflicts of interest do not affect the integrity of the group’s decision-making process and do not appear to do so. Therefore, the CCG must not only be fair and open and honest, it must also be seen to be all those things, because a perceived conflict of interest which is not managed appropriately would be as damaging to the reputation of a CCG as an actual conflict.

Health and Social Care Bill

Baroness Barker Excerpts

Thursday 8th March 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, my noble friend has made a powerful case for having a champion for older people to look not just at the impact of decisions made in the NHS but going much wider. She is right to refer to pejorative remarks such as bed-blocking being very insensitive to old people. We face a considerable challenge within the health service to ensure that we are sensitive and reflect that there is huge demand from frail older people which is not being met as effectively as we would wish.

My noble friend said that the amendment may not be perfectly formed but that we have to start somewhere. I wonder whether the noble Earl, late on this Thursday afternoon, might give some comfort. After all, it would not be impossible within HealthWatch England to have a designated person with responsibility for overseeing—or, if you like, monitoring—services for older people. It could be well worth exploring whether the thought behind my noble friend's amendment is worth pursuing.

[Baroness Barker]

I just make two or three simple points. I have enormous sympathy with the amendment of the noble Baroness, Lady Bakewell. My party's policy is in favour of the establishment of an older people's commissioner in England, building on the interesting work that has been done in Wales. I have a great deal of sympathy with what she is trying to do. She made the argument that one has to start somewhere. I disagree with her that this is the right place to start. If one had to start somewhere, it should be in social care. The deficiencies in social care matter more to more older people than those in health.

Having said that, the noble Lord, Lord Hunt of Kings Heath, is right. Given that older people are by far the biggest users of NHS services, it would be remarkable if healthwatch were not to include people with the expertise to follow up older people's issues.

My deep resistance stems from two things. First, I think that the biggest challenge set out in the Bill, which has been overlooked, which is why I take the opportunity to mention it again, is the challenge for the NHS to get to grips with social care and enabling older people—all people, but, by definition, older people—to live healthier lives for longer and not to wait until they turn up in the NHS.

However, my fundamental point is that I have talked to lots of older people over the years and I believe that old age has to be about more than the health service. If the only government recognition that older people have is the right to have someone to complain about the health service, I think we will be in danger of medicalising old age and inadvertently removing the full experience, wealth creativity and knowledge that older people bring to many aspects of life. I know that, given her former role, the noble Baroness, Lady Bakewell, would not intend that. Therefore, I hope that she will accept my support for what she is trying to do and my reservations about the way that she is trying to do it with this amendment.

Health and Social Care Bill

Baroness Barker Excerpts

Tuesday 6th March 2012 Lords Chamber

[Baroness Murphy]

My Lords, I think that the noble Lord, Lord Warner, is having us on. There is an urgent need to press the Government on bringing forward their White Paper on social care reform, which is the pressing economic and social care issue of our day—more important than this Bill. But we have to get it right. We are expecting a White Paper, and there are many arguments to be had about the recommendations from the Dilnot commission, although there is quite a consensus of opinion, and about the right and wrong and who will pay and when. I hope that we can have those debates in this House. But this issue requires a full Bill. This amendment gives a new Bill inside the Health and Social Care Bill on Report, and I do not really think that it will fly. I can imagine what the noble Lord, Lord Warner, would have done if it had been proposed when he was Health Minister. He would have given it very short shrift—and I urge the Government to do so again. We need a proper recommendation and discussion in the White Paper.

I also remind the House that last year the Law Commission came out with a report on adult care social services that said that we had had endless piecemeal bits of legislation over and over—and this amendment does it all over again. Let us not make the mistake of supporting this amendment. I am very sympathetic to what the noble Lord wants to do, and we all feel very impatient about it, but let us have a proper Bill and proper debates and get it right for the next generation. Frankly, it is our generation and the next one that will benefit from a proper social care reform Bill. Let us get it right and not do it this way.

[Baroness Barker]

The noble Lord, Lord Warner, asked what was to disagree with—what was not to like—and the answer is nothing at all. However, that is not to say that this amendment is not deficient and there are not an awful lot of questions that it begs.

The noble Lord is right that my party, along with others, has agreed with the Law Commission review and supported the efforts to see the Dilnot commission brought into law. However, he will know as well as I do that the history of social care law reform is littered with failed attempts to deal with one of the biggest issues that our society faces—the Royal Commission on long-term care. The Wanless report was largely about the NHS, but a significant chunk of it was about the need to reform social care to drive down future demands on the health service. Noble Lords have been critical of this Bill, and many of their criticisms are justified, but they overstate the extent to which the latter parts of the Bill, with the placing of public health into local government and the creation of health and well-being boards, attempt to deal with that agenda, decrease health inequalities and raise levels of preventive health promotion. I, too, think that this is an inadequate response, particularly to the Law Commission report, which was a good and detailed piece of work. It deserves extensive scrutiny and to be brought forward in law in a way that is far more comprehensive than this.

I will not have a go at the noble Lord, Lord Warner, for keeping the issue on the agenda, but I say to him that the Care Services Minister, Paul Burstow, has made it clear throughout his tenure that he is doing all in his power to keep social care to the fore. I come back to the £2 billion that was invested in social care at the beginning of the Government’s term. The Government are mindful of the need to deal with this, not least because the noble Baroness, Lady Murphy, is right to say that, as she often reminds this House, no one has a social care need unless they have a healthcare need—the two things are indivisible—and if the Bill is about anything, it is about tackling the health needs of the population as a whole over time.

I do not disagree with the noble Lord, Lord Warner, but I do not think that this is quite the way to go forward. I hope that all Members of this House will continue to uphold the consensus that there has been over the past two years behind the work of the Law Commission and the Dilnot report to bring this issue forward in a way that means that it can be determined successfully once and for all.

[Lord Campbell of Alloway]

My Lords, I would like to raise the matter of the process of putting in statute what in the ordinary course of events should be put in subordinate legislation by regulations or whatever. If you read the amendment carefully, it is a very wide command involving four assessments of individuals’ needs. I am not at all criticising what is sought, but I ask for it to be considered that the amendment would open a large gateway of legal challenge to the Secretary of State that would not exist if this were not put into statute. This question is concerned with finance at a time when finance need not be referred to again.

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[Lord Walton of Detchant]

My Lords, I will briefly speak to Amendment 167 in this group, which has been tabled in the name of the noble Lord, Lord Hunt of Kings Heath. I understand entirely why he has tabled this amendment but, with respect, I do not believe that it is necessary.

All medical bodies, including the BMA and the General Medical Council and others, now agree that the days of doctor’s orders are long past. The practice of medicine is a partnership in which it is up to the doctor to recommend to the patient what course of action is most appropriate in the patient’s best interests; what it is appropriate to do in order to reach a diagnosis; what tests are appropriate in order to achieve that diagnosis; and what course of treatment would then be necessary. However, it is up to the patient to decide whether or not to accept that advice and it is not possible for a doctor to carry out a test without the informed consent of the patient.

It is also well agreed by these medical bodies that if a doctor has given full and detailed information to a patient about the course of action that is appropriate, and if the doctor recommends a particular course of treatment that he regards as being necessary in the patient’s best interests, the patient may nevertheless have the right to refuse that advice even if refusal of that advice ends in the patient’s death. For that reason, as all of these issues have been dealt with repeatedly in the advice given by the GMC, the BMA and other bodies, I do not believe that this amendment is necessary.

[Baroness Barker]

My Lords, the noble Lord, Lord Walton, will be aware of many occasions in this house—when the noble Lord, Lord Hunt, was Minister and some of us were in opposition—when we listened to Lord Weatherill speaking on behalf of Christian Scientists, who often wish to refuse treatment. I understand that this amendment originated from the Christian Scientists, who merely wish to draw again to the attention of the medical authorities the fact that they have a belief system that deserves the same amount of dignity and respect as any other. Perhaps he might view the amendment in that light.

[Lord Hunt of Kings Heath]

My Lords, I do indeed recall the debates that we had during one of the many health and social care Bills that have gone through your Lordships’ House in the past few years. It was indeed Lord Weatherill who raised the issue with me. Essentially, it was about standards in nursing homes where there was some concern that an insensitive regulator would take action against a home that was actually respecting the wishes of a member of the Christian Science religion. We were able to reach a satisfactory solution. An appropriate amendment was put forward and I think the noble Earl, Lord Howe, was also part of what I like to think of as the “second Weatherill agreement”. We may need another one in a couple of years’ time—who knows? I ask the Government for an assurance that the position that we then agreed will continue under the new Bill.

Health and Social Care Bill

Baroness Barker Excerpts

Wednesday 29th February 2012 Lords Chamber

Moved by

[Baroness Barker]

79A: Clause 24, page 36, line 1, at end insert—
“14NA Registers of interests and management of conflicts of interest
(1) Each clinical commissioning group must maintain one or more registers of the interests of—
(a) the members of the group,(b) the members of its governing body,(c) the members of its committees or sub-committees or of committees or sub-committees of its governing body, and(d) its employees.(2) Each clinical commissioning group must publish the registers maintained under subsection (1) or make arrangements to ensure that members of the public have access to the registers on request.
(3) Each clinical commissioning group must make arrangements to ensure—
(a) that a person mentioned in subsection (1) declares any conflict or potential conflict of interest that the person has in relation to a decision to be made in the exercise of the commissioning functions of the group,(b) that any such declaration is made as soon as practicable after the person becomes aware of the conflict or potential conflict and, in any event, within 28 days, and(c) that any such declaration is included in the registers maintained under subsection (1).(4) Each clinical commissioning group must make arrangements for managing conflicts and potential conflicts of interest in such a way as to ensure that they do not, and do not appear to, affect the integrity of the group’s decision-making processes.
(5) The Board must publish guidance for clinical commissioning groups on the discharge of their functions under this section.
(6) Each clinical commissioning group must have regard to guidance published under subsection (5).
(7) For the purposes of this section, the commissioning functions of a clinical commissioning group are the functions of the group in arranging for the provision of services as part of the health service.”

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Moved by

[Baroness Barker]

82A: Schedule 2, page 281, leave out lines 32 to 34

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Moved by

[Baroness Barker]

86A: Schedule 2, page 281, line 38, at end insert—
“( ) The constitution must specify the arrangements made by the clinical commissioning group for discharging its duties under section 14NA(1) to (4).”

Organ Transplantation

Baroness Barker Excerpts

Monday 27th February 2012 Lords Chamber

[Earl Howe]

The noble Lord makes a good point. It is generally the practice that the relatives are consulted even where someone has expressed a wish to donate an organ after death. Doctors will normally respect the wishes of the relatives; however, it is equally true that that person’s wishes will be emphasised to the relatives. There is a delicate balance to be struck here. The moment that action by medical teams is seen to be high-handed, it risks damaging the credibility of the transplant service.

[Baroness Barker]

My Lords, what is the Government’s response to the recent BMA report on increasing donation, particularly regarding the obligation introduced last year on individuals who apply or reapply for documents such as driving licences and passports to answer a question about donation of organs?

[Earl Howe]

My Lords, the report from the BMA was very useful and we are looking at it extremely carefully. It made some useful suggestions about how we might expand the number of donor organs. A number of initiatives have already been taken: for example, there is a prompt when you apply for a driving licence online as to whether you wish to donate an organ. In general, public awareness is being raised in a number of useful ways, which has led to the increase in the number of people donating organs.

Health and Social Care Bill

Baroness Barker Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, we return to one of the most important matters in the Bill: clinical commissioning groups and their effective corporate governance, or lack of it—specifically, the question of how conflicts of interest are to be dealt with. In his letter of 16 February to putative clinical commissioning groups, the Secretary of State spoke enthusiastically of the freedoms that they were to receive. There can be little doubt that they are one of the most important features of this Bill. They are to be given a huge amount of money. They are to be given freedom to commission services. They are to be given freedom to decide when and how competition should be used. Because clinical commissioning groups will exercise such important roles, I would have thought that public interest demands that the principles of good corporate governance should apply as much to them as to any other public body.

In Committee, the noble Lord, Lord Kakkar, drew attention to the seven principles of public life and asked whether they applied to clinical commissioning groups. I asked the noble Earl, Lord Howe, whether independently appointed non-executives would be on the board of clinical commissioning groups. I also asked how conflicts of interest were to be dealt with. He said that the Bill places a duty on the Secretary of State,

“to publish a code of conduct for CCGs, incorporating the Nolan principles on public life”.—[Official Report, 14/11/11; col. 564.]

To my suggestion that each clinical commissioning group board should have on it a majority of non-executives and be independently appointed, he said—disappointingly—that each group must only have at least two lay members and that one must be either the chair or deputy chair of the governing body.

On the conflicts of interest, the noble Earl said that the Bill had three safeguards: statutory requirements on clinical commissioning groups to make arrangements to manage conflicts of interest, governance arrangements, and specific regulations on good practice in the procurement and commissioning of healthcare services. Is that sufficient? I do not think that it is. These groups are unique. In essence they represent groupings of small businesses which have had handed over to them billions of pounds, a proportion of which they can spend on primary care services. Sometimes these are to be provided in the surgeries of GPs who are members of the clinical commissioning group, or perhaps are to be provided by companies in which GPs within a clinical commissioning group may have a financial interest. The potential conflict of interest is so obvious that it surely begs the question as to why the Government are not putting safeguards on this matter in the Bill.

My amendment is a lengthy one, but I hope comprehensive. It sets up a register of pecuniary and non-pecuniary interests. It places an obligation on clinical commissioning groups to register. It prevents any arrangements being entered into between a clinical commissioning group and a party with whom a member has an interest. It provides for an exemption procedure whereby the board could approve the arrangement if it was open and transparent. It prohibits a member of a clinical commissioning group taking part in discussions with any business in which he or she has an interest. It also provides a process under which an adjudicator appointed by the Secretary of State can adjudicate on complaints about members of clinical commissioning groups breaching the code of conduct, which is provided for in my proposed new subsection (8C). The sanctions include removing the individual as a member of the clinical commissioning group and the termination of any contract which has been put in place between the group and anyone with whom the member has a registerable interest.

A clinical commissioning group board will have a majority of GPs sitting on it. They are involved in running businesses which are largely dependent on the NHS for their income. The role of a clinical commissioning group will be to commission services, some of which will be commissioned from those GPs who are members of that group or, as I said earlier, from companies in which some of those GPs may well have an interest. Independent lay members will be in a minority and we have yet to receive assurance that they will be independently appointed. We have not even been assured that the chairman of the clinical commissioning group will be an independent lay member. It will have the weakest corporate governance of any public body in this country.

We know that over the past 20 or 30 years any number of inquiries have shown the problems of poor corporate governance. After all, the Nolan commission was started because of such problems. This will explode in the Government’s face unless they strengthen the corporate governance of clinical commissioning groups. If you combine these weak corporate governance arrangements with the ability of a clinical commissioning group to make decisions that could be to the financial advantage of GPs who are members of that group, you are heading for trouble. We need robust safeguards and they ought to be in the Bill. I beg to move.

[Baroness Barker]

My Lords, noble Lords will recall that in Committee I too highlighted the issue of conflicts of interest. I did so because, like many other noble Lords, I had listened to and read the briefings sent by the professional bodies, many of which raised fears and concerns about conflicts of interest. Like many other noble Lords, I believe it is important not only that members of the public have faith in the integrity of the decisions being made by CCGs but that members of the professions believe in those decision-making processes and feel able to participate in them. They should also have the protection of good governance and good conflict-of-interest policies to enable them to carry out what will be a difficult role.

Before we look at the detail of this, it is important to remind ourselves a little of the context. There are conflicts of interest in the National Health Service now. There always have been, as anyone who has ever sat around the table at a joint finance meeting at which every single person has an interest in the discussion will know. It may not be a direct financial interest; it could be about a post, a project or money. Managing conflicts of interest is something that the NHS and PCTs do now. That is not to say that we should not take the opportunity of the Bill to make the principles according to which the NHS should act more overt. They should be the highest of principles.

It is for that reason that my colleagues and I raised the matter in Committee. We then drafted a set of amendments that are in this group—Amendments 84, 89, 91, 92, 93 and 116. I am very grateful to several noble Lords, including the noble Lord, Lord Newton of Braintree, who looked at those amendments with the seasoned eye of an ex-Health Minister. His response was, “Very good but an awful lot of this needs to be in regulation, not in the Bill”. I took his comments to heart, which is why my colleagues and I withdrew those amendments on Friday and noble Lords now have Amendments 79A, 82A, 86A and 86B before them on the Marshalled List.

It is also important that noble Lords understand one particular point about the interpretation of the Bill. A great deal of anxiety has been expressed by some of the professional bodies about the role of commissioning support organisations. Noble Lords may recall that I raised that in Committee. I have been in discussion with several members of the professions to try to understand the source of that concern. As far as I can understand, there is a view within some of the professional bodies that commissioning support and the commissioning of services are one and the same thing, whereas the Minister was at great pains in Committee to stress that they are two different processes that go side by side.

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[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Baroness. Could she clarify what happens in the situation that she has laid out in these amendments if a member of a CCG does not do the right thing? Are there any sanctions in her amendment?

[Baroness Barker]

The noble Lord is quite right and I will come on to that.

These amendments also refer to the board publishing guidance and what that guidance would include. As I understand it, members of CCGs who are in material or consistent breach of a conflict-of-interest policy might be referred to their professional body. Amendment 86A is a regulation-making power. It is under that power that many of the important details could be included. They would, I imagine, include issues such as the ones which the noble Lord has just raised about the sorts of sanctions which CCGs should include in their guidance and policy.

[Lord Hunt of Kings Heath]

My Lords, with respect to the noble Baroness, she has withdrawn some amendments and put in some substitutes, so I think it is fair to ask her these questions. Without sanctions, this is not going to have any teeth. There is a major concern about corporate governance in CCGs. Surely it would be better to put it on the face of the Bill rather than, as it seems to me she is doing, leaving it up to CCGs to do the necessary.

[Baroness Barker]

Not entirely, my Lords. As I was coming on to say, an important piece of work is that the GMC is updating its guidance on how its members should work in the new setup. It is important that members of bodies such as the GMC, the BMA and other professional bodies are involved, should they wish to be, in setting out the detail of what those sanctions should be. We should end up with something that is effective and workable, as well as principled. The noble Lord’s argument does not therefore stand up. Nothing in these amendments would preclude that sort of sanction being put into regulations or guidance.

Our amendments are, admittedly, not as detailed as the amendment of the noble Lord, Lord Hunt, nor do they—as his amendment does—incorporate language from the world of commercial legislation. The terminology of conflicted arrangements and exemption procedures comes from commercial law, and I am not sure that that is appropriate for what we are seeking to do. At the end of this debate we should achieve the objective that all noble Lords are seeking—transparency and accountability around the decision-making processes of CCGs, and the legislation and regulations around them should be sufficiently robust so that not only can members of the public have faith in those procedures but the procedures should be workable. I accept that our previous amendments included provisions that were so draconian that they would not work in practice. We could have ended up in a position whereby the very people who should be making decisions on CCGs would not have been eligible to do so, particularly at the precise moment at which their expertise would be necessary.

Our amendments are not by any means the end of the matter; they are the beginning of a process that should move on further in the discussion on regulations and guidance. That is where much of the detail of this should come to the fore, but the principles that we have set out in these amendments are robust and workable, and I hope that in his reply the Minister will accept them.

[Lord Patel]

My Lords, I support the amendments relating to conflict of interest and I agree that there needs to be something in the Bill. I will give an example to indicate why I believe that more strongly following a seminar that we attended before the Recess. For those noble Lords who were not there, we had a presentation from a GP who told us, first, that he was salaried, and I therefore presume he did not have a standard general medical services contract, and that his salary came from somewhere else—it may well have come from another general practitioner. He said, secondly, that he was involved in commissioning and, thirdly, that the commissioners had found that the provision of some services in his area was not satisfactory or of the quality that they had asked for—particularly, in relation to hand surgery. They therefore set up an independent provider of surgical services, of which the GP was a non-executive director. The conflicts of interest are quite obvious: here is a commissioner who is a salaried doctor, and that raises a question. If the commissioning board is to hold the contracts of primary care providers, will they not include those who have a general medical services contract, or will they include those who are salaried? More and more primary care providers are salaried GPs employed by other practitioners. We therefore also need to clarify who will be asked to be a member of the commissioning group: will it be only those who hold the general medical services contract, or will it be all those who provide primary care services? The conflict of interest here is many-fold, and therefore we need to address how it is to be resolved.

While I was, and still am, very attracted to the amendments of the noble Baroness, Lady Barker, because I had not seen those of the noble Lord, Lord Hunt, the question of sanctions needs to be addressed more clearly. I agree with the noble Lord, Lord Hunt, on the need for this question of sanctions to be clarified so that those who may be involved in conflict know from the very beginning how those sanctions will apply to them.

Health: Stroke Care

Baroness Barker Excerpts

Monday 13th February 2012 Lords Chamber

[Earl Howe]

My Lords, I can give the assurance that the noble Lord seeks. The NHS Commissioning Board authority has made it very clear that stroke networks have been immeasurably helpful to patients and there is every intention of continuing with them.

[Baroness Barker]

My Lords, have the Government monitored the impact of individual health budgets which were introduced by the previous Labour Government? What effect have individual health budgets had on the commissioning and delivery of stroke services?

[Earl Howe]

My noble friend is right: individual health budgets have enormous potential in the case of stroke patients. I do not have any specific data on that in my brief, as it is still relatively early days for the personal health budgets. However, if I have further information to give her, I will gladly write.

Health and Social Care Bill

Baroness Barker Excerpts

Monday 19th December 2011 Lords Chamber

[Baroness Barker]

My Lords, my name is not on these amendments, but I want to make a couple of points, partly because I have a longstanding interest in this and partly because in recent weeks it has been a very personal feature in my life.

The noble Lord, Lord Warner, is absolutely right to keep pressing the Government to come up with a definition of integration. Like him, I struggle to know what it is. I know the factors that should be focused on, which create or prevent integration. One is the overall sense of purpose in your work. For many of the health and well-being boards, the key role will be in the prevention of illness. The biggest challenge for hospitals and the acute sector, which perhaps they have not yet woken up to, in the way in which they are going to have to work with health and well-being boards is about discharge from hospital and ensuring that people who have been ill, particularly older people, have access to nursing care in the community that enables them to live with long-term conditions.

One of the most important factors is money. The noble Baroness, Lady Murphy, made me flash back to many a meeting that I have been involved with, but one in particular in a borough in south London where the local Age Concern had an excellent handyperson scheme. They worked with the OTs to dramatically speed up the process of older people being assessed and given aids and adaptations that enabled them to live with long-term conditions. I well remember sitting in the meeting when somebody from the health service announced that the health service were going to start their own rival service. Why? Because a pot of money had come along and they were going to use it. Patterns and flows of money have been the bedevilment of integration, very often.

Integration can work well, particularly when both parties take a strategic view of what they are supposed to be doing. I cite again the case in Islington, when my colleagues were running the council. The local authority took the decision that it would do everything related to children and the PCT decided that it would take responsibility for adults and long-term care. That is a very imaginative way to start addressing problems at a strategic level. If you address them properly at strategic level, the greater the chance that when it comes to individual cases, you will indeed get integration of services around a person.

I am therefore pleased to see Amendment 336, tabled by the noble Lord, Lord Warner. I would just query one point with him on drafting. As drafted, there is a slight problem, because it seems to imply that any move towards integration has to be approved by the commissioning board. I know that is not what he intends. Small-scale schemes should just go ahead without reference up the line, so I think he needs to look at the wording, but that is very helpful.

The noble Lord, Lord Patel, is absolutely right. Three different outcomes frameworks setting the agenda for the three different parts of what will make up a health and well-being board is wrong. It is only when people in the NHS understand that they have to help social care outcomes to happen that we are really going to move forward towards integration as a mindset for professionals and a reality for patients.

[Lord Warner]

Could I just clarify for the noble Baroness that I do not claim that my wording is perfect? I brought the National Commissioning Board in—slightly against my better judgment, I have to admit—because it has the responsibility for, in a sense, approving the commissioning arrangements and spending the money. My instincts were that it would not support this unless it had been consulted and was satisfied with the commissioning arrangements.

Health and Social Care Bill

Baroness Barker Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Walton of Detchant]

My Lords, I shall be brief but, as always, my noble friend Lady Masham was very persuasive. I have always felt, as indeed she does, that there is a powerful case to be made for the statutory regulation of healthcare assistants not only in hospitals but in homes, particularly old people’s homes. As we heard during the debate on the amendment tabled by my noble friend Lady Emerton, the Government are entirely persuaded that at present the regulation of such individuals could not be done by statute. I must say that I feel uncomfortable about that.

Is there any means by which the Government can suggest a mechanism whereby, perhaps in consultation with the Care Quality Commission, the terms of voluntary registration of healthcare assistants could be based on a set of agreed principles which were accepted generally by all the professions concerned? As it exists at the moment, voluntary registration is not adequate or strong enough and needs to be strengthened. Therefore, while I support in principle the ideas put forward by my noble friend Lady Masham, I think that for the present we will have to be satisfied with voluntary registration, which should be strengthened by whatever mechanism can be introduced.

[Baroness Barker]

My Lords, I have a great deal of sympathy with what the noble Lord, Lord Walton, has said. If noble Lords look at A Vision for Adult Social Care, a document published by the Government last year, they will see that the principles underpinning health and social care have been set out perhaps more clearly than they have been for some considerable time. I do not think the problem is that the principles are not there or are not known; it is that the training that brings those principles to life for a practitioner is not there.

I am torn on this issue. I listened to the noble Baroness, Lady Pitkeathley, and I was persuaded by what she said. I know of organisations which use staff who are not registered but who are exceptionally well trained and have very high standards. If the Government are reluctant—I am sure that my noble friend will again say that they are—to go down the path of full registration, I would understand that position if my noble friend would give a commitment to the development of training. That would go a long way to meeting the point to which I think all noble Lords are trying to get; namely, that the training of people involved in the direct care of those who, usually, have long-term conditions is of a high-enough quality. That is the most helpful thing that my noble friend might be able to say.

[Baroness Pitkeathley]

My Lords, in response to the two noble Lords from the Cross Benches who have spoken, the thinking of CHRE, which is to become the Professional Standards Authority, on the accreditation of voluntary registers is quite well developed. We would be very happy to participate in any meeting of the kind suggested.

Health and Social Care Bill

Baroness Barker Excerpts

Wednesday 7th December 2011 Lords Chamber

[Baroness Emerton]

My Lords, I support the amendments, first, because I totally agree with them. The second reason takes me back in history—I think it was 1976 or 1978—to when the Government had a Bill proposing that learning disability clients should be taken out of mental handicap hospitals and placed in the community. I had the privilege and lovely responsibility —this is when old age comes into experience—of managing that project. I worked with the noble Lord, Lord Warner, who was then director of social services. I also worked with Lambeth, Lewisham, Southwark and all the London boroughs, which were absolutely against having patients transferred to the community.

If there is something in the Bill and it is government policy, everybody will work towards it and understand that there must be integration. We have mentioned the word “culture”. I found this issue absolutely fundamental. It runs through the whole issue. The noble Baroness, Lady Cumberlege, was also part of this exercise. She was in Brighton at the time and some clients went to Brighton. It was extremely difficult to get local authorities to understand the needs of some of these clients. Some had special needs and difficult behavioural problems. However, we got there because we had target dates by which we had to do it and also because we had trained staff. We have not yet spoken about the workforce, except in terms of carers and social care. We need to have a workforce that will be able to supply the level and standards of care that will be required.

My noble friend Lady Greengross has just mentioned the fact that dementia care in hospitals is not good. That is probably very true, although it is good in some places. We must look at training needs for social care as well as for transferring patients to secondary care. The culture issues are important and once they are included in the Bill, one can get to work on them.

[Baroness Barker]

My Lords, I will speak briefly in support of the amendment and answer the point made by the noble Lord, Lord Warner. Since 1948, we have had a system whereby there has been an agreed national settlement on a person's entitlement to healthcare. It is delivered to national criteria and demand is managed largely by waiting times. Running in parallel is social care, where there is no national entitlement and demand is managed by eligibility criteria. The two systems are administered in parallel by completely different people, side by side. Successive reports have set out for us all the different ways in which the two systems do not work together. People have analysed the reasons why the systems do not work together.

The most telling thing for me is that we have known for a very long time, because we have evidence to prove it, that if older people are discharged from hospital and are supported through the period of discharge, the likelihood of them being readmitted to hospital is very low. We also know, because of that, that the cost to the NHS decreases. I am afraid to say that those of us who work in the charitable sector also know how impossible it is to get the NHS to run a hospital discharge system. The noble Baroness, Lady Emerton, is absolutely right. I do not want to throw blame about, but it leads to my point about why I think the amendment is important. The biggest single thing that will make an impact on the NHS is cultural change. There are a lot of barriers in the NHS to that change. We have heard the point echoed in our debates over the past few weeks. Some of our most eminent clinicians have made the point very glibly that there is very little evidence about what works in social care. That is true; social care has some way to go in developing an evidence base. However, we have some evidence and it still gets ignored because social care is not up there with healthcare.

Noble Lords have talked throughout our debates about specialist nurses and how important they are. I have come to the conclusion that the greatest asset of a specialist nurse is that they know their way around social care and can explain it to people in the NHS. I do not wish to denigrate specialist nurses in any way; they do a fantastic job. However, part of me thinks that if they are the only ones who understand the system, are they letting the rest of the NHS off the hook? The biggest single thing that will make the Bill work or not work is whether everyone in the NHS sees it as their responsibility to understand and work with social care.

The amendment of the noble Lord, Lord Warner, is cleverly worded. I congratulate him on that. It is based on Dilnot and the Law Commission, although he has crafted it using general terms so that it is not specific to those two reports. I commend him for that. On balance, the most important part of the amendment is proposed new subsection (2)(b), which reflects the Law Commission report. Until we get nationally agreed standards of eligibility, assessment and charging policies, it will be impossible for anyone who works in the NHS to know what it is they are supposed to be integrating with. That is the key point. I understand that Dilnot is important in terms of funding, but the Law Commission report is the important one.

I listened very carefully to what the noble Lord, Lord Turnberg, said. I always do. It is a very good report; I agree with that. However, he said that all these local developments in integrated care depend on funding. He is right, but there is a huge amount of wastage of resources throughout the health service. I pick up on this at local level. It comes down to two things: data are not shared and there is no understanding of common assessment of needs. Those two things cost the NHS and social care a fortune. Proposed new subsection (2)(b) of the amendment is so important because it covers the key area on which we have to work.

Perhaps noble Lords have been slightly pessimistic about the Bill. The existence of health and well-being boards is important. It will be possible, locally if not nationally, to begin to work on these issues. It will be possible for some areas to do highly innovative stuff. Noble Lords have talked about the work done in Torbay. When my colleagues were in charge of the borough of Islington, they had a very interesting approach. Social services took responsibility for everything that was to do with children and the NHS took responsibility for everything that was to do with older people, which included social care. I would like to see more of that and I hope that health and well-being boards will bring it about.

Presumably the noble Lord, Lord Warner, was told to have a go at the Liberal Democrats today. I was surprised that he asked about our attitude to the Dilnot report and the Law Commission report. At our conference in September we passed a resolution to the effect that we welcomed the reports and wished to see the Government implement them quickly. We have not come up with a series of bureaucratic provisions to hold up implementation. I pay tribute to Paul Burstow. He came into government when the previous Labour Government had not resolved the issue in 13 years. He found extra funding for social care and went out of his way to make sure that the Dilnot review was set up. He laid down a challenge to us that I pass on to noble Lords. He challenged us to campaign on social care with all the passion and vigour that we do on the NHS. I challenge noble Lords to do that. Actually, I would like to challenge 38 Degrees and everybody else to do that, because there are an awful lot of people who are willing to be as vociferous as you like on the NHS but are suddenly silent when it comes to social care. Some of us have had enough of that. I commend the noble Lord’s amendment.

[Lord Warner]

I was not doubting the enthusiasm on the Liberal Democrat Benches regarding this area. I just wanted to provoke the noble Baroness into giving the kind of excellent speech that she has given. I was hoping that we would hear from her. I also join her in paying tribute to Paul Burstow, and indeed Norman Lamb, for the very supportive way in which they have approached this issue.