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.

Health and Social Care Bill

Baroness Barker Excerpts

Monday 28th November 2011 Lords Chamber

[Baroness Cumberlege]

My Lords, I was heartened by a lot of what my noble friend said about maternity services, but it seems that the variations will be reduced through NICE quality standards. I understand that NICE has a very long queue of services to be considered for quality standards and I wonder whether my noble friend and the Government have any influence over which services have priority to have their standards set early and which will have to wait. As maternity involves a tremendous number of women who are giving birth, it is really important to get it in the front of the queue, as far as possible.

[Baroness Barker]

My Lords, can my noble friend tell me where in the legislation it is made clear, if a CCG were to have a conflict—that is, a disagreement—with the commissioning support organisation, where and how that conflict would be resolved?

[Earl Howe]

My Lords, in the interests of time I suggest that I write to noble Lords on those questions, and I am happy to do so. However, I say to my noble friend Lady Cumberlege that I recognise the particular importance of the maternity quality standard. I will try to find out for her what stage NICE has reached or is likely to reach within a certain timescale, and if I can provide her with any further information I will be happy to do so.

Funding of Care and Support

Baroness Barker Excerpts

Thursday 24th November 2011 Lords Chamber

[Baroness Barker]

My Lords, I thank the noble Baroness, Lady Pitkeathley, not only for the characteristically thorough way in which she introduced the debate but for securing it in the first place. She is absolutely right that the timing is of the essence. Many noble Lords have buried themselves deep in the Health and Social Care Bill. I was going to observe that perhaps today was light relief for some of us—but it is not. Everything that we will discuss today has an impact on the National Health Service. We have known for so long—and it has been confirmed by every report that the noble Baroness talked about—that if we do not sort out the system of social care, which we know does not work, it will inevitably build up costs for the National Health Service. As ever, it is a great shame that while people are passionately vocal about changes in the NHS, there has been something of a silence on social care, which never gets the same level of reaction despite being so important.

I will not go into great details on the reports. I will focus for my seven minutes on things that have to happen now. It is clear that the public know that they are likely at some point to need social care. However, they do not know the likelihood of that happening to them. We know that for people aged 85 and over, of whom there are a growing number, the figure is three out of four. According to an ABI survey, 51 per cent of the public do not know who will pay for their care; 21 per cent think that their family might pay for it; and 19 per cent think that the Government might pay for it. They have no idea where to go for independent advice. Those are the key issues that we must work around.

We must recognise that this is a generational issue. One’s ability to afford social care depends entirely on whether one has property. That is the determining factor. There is also an age factor. People aged 85 and over at the moment will have to pay for social care from their savings or capital. Those who are 65-plus and already retired will have to try to secure an annuity. As we know, the private market so far has failed to develop appropriate products. People of working age who want to plan for their future social care needs will either have to come to some kind of annuity arrangement or hope that in future insurance products will be made available.

As the noble Baroness, Lady Pitkeathley, said, it is crucial that politicians come together now to agree which parts of the Dilnot report they will accept, and the criteria and level of funding, so that individuals can know with some degree of certainty what the likely state contribution to their care will be, and private companies can come up with forms of insurance that are sustainable. That will take considerable time and is an urgent matter.

The noble Baroness, Lady Pitkeathley, mentioned in passing the Law Commission. She is absolutely right. The Law Commission report is critical to this. It calls for two things: a new statute and regulations that set out community care criteria and eligibility, and the process of assessment for individuals. The importance of community care assessment is something that people in the world of community care understand, but nobody outside it does. It is fundamental to this issue. If individuals cannot tell at what point their care needs will be recognised, accessed and taken forward, we cannot begin to build insurance products that will help people to plug the funding gap.

I will make a further point that has not come out in either of the documents. It is crucial that there is a system of care assessment that runs alongside but is completely independent from any form of financial assessment. In future, people will have to undergo both processes, but one must not contaminate the other.

I mentioned property. It is inevitable, given the generational distribution of property ownership, that equity release and the ability of individuals to release resources that are tied up in capital will become increasingly important. At the moment we do not have equity release products that are deemed to be safe. Nobody who wishes to go down the route of funding their own care in that way knows where to go for reliable advice. I ask the Minister whether the work done on equity release by the Joseph Rowntree Foundation in 2006 is being revisited, and whether the Government are engaging with the FSA on how they might build an equity release market in future that people will be able to trust.

Members of your Lordships' House conducted a seminar in which Andrew Dilnot introduced his report. He spoke to a pretty tough crowd. One political point was raised by the noble Lord, Lord Campbell-Savours, who is not in his place. He challenged Andrew Dilnot on whether his report was not a subsidy to people who were well off. That is the outstanding political point. Andrew Dilnot made the fair rebuttal that healthcare in the NHS is a system of pooled risk and we do not draw the distinction. That is the only substantive political point that was raised against the Dilnot report. I hope that if the noble Lord, Lord Campbell-Savours, agrees that the system that has been devised is equitable across the piece, all parties should be able to agree.

We have been here before. We have been very close to reaching agreement. Some weeks ago Ed Miliband said that he would be willing to take part in cross-party discussions. It is very easy to make such a statement and then find some reason, process or proposal that you cannot agree with. This requires political consensus and courage from all parties. It will take a degree of sustaining. It requires all politicians to convince the media that this is the correct way forward. If we do not agree this now, we will be back in 20 years debating the same issues, and the situation will be worse for the individuals concerned.

--- Later in debate ---

[Baroness Thornton]

My Lords, I thank my noble friend Lady Pitkeathley for initiating this debate and pay tribute to Andrew Dilnot and his colleagues, including my noble friend Lord Warner, for the report which they produced in July this year. I am sorry that no Conservative Members on the Benches opposite are present to take part in this debate because the band of “usual suspects” to which reference has been made includes members of the Conservative Party. Their voices have been missed in this debate.

I am grateful to all noble Lords who have taken part in the debate for their insights. We felt that it was important that those on these Benches should initiate this debate as we seem to be at a standstill, or making slow progress, on many social care fronts, and in some areas are possibly moving backwards. That is a matter of grave concern. I echo the final words of my noble friend Lord Warner that we cannot afford not to do anything.

We can all agree that the need to secure a sustainable funding settlement for social care has never been more urgent, with local government and NHS finances under significant pressure and demand for services increasing as the population ages. We all agree that the NHS will never work properly without a sustainable approach to social care funding. The Dilnot report therefore offers a credible and costed way forward. We believe that the Government must move quickly to undertake detailed work on the report’s recommendations and honour their pledge to publish a White Paper, followed by legislation in 2012.

The adoption of the capped cost framework recommended by Dilnot offers a fairer and more transparent way of sharing the costs of care between the individual and the state. This will make it easier to tackle the deeper problem of underfunding that has led to the tighter rationing of services and escalating levels of unmet need, which have also been mentioned by several noble Lords, including my noble friends Lord Lipsey and Lord Warner, and the noble Lord, Lord Sutherland.

The much mentioned budget deficit is no reason for delay. The questions of affordability go beyond the current economic situation, and the additional public spending needed to fund the proposals, as we have noted, is less than 0.25 per cent of GDP. The social care system is widely regarded as inadequate, unfair and unsustainable. Under the current means-testing arrangements, anyone with assets of more than £23,250 must pay the full cost of their care. This leaves one in 10 people over 65 facing costs of more than £100,000. Eligibility criteria for council-funded services have been tightened whereby in most areas only those with very high needs now qualify for help.

The squeeze on local authority budgets over the next four years will widen the gap between needs and resources, despite the additional £2 billion announced in the spending review and the best intentions of all local authorities to protect social care. As my noble friend Lord Warner mentioned, the King’s Fund estimates that a funding gap of at least £1.2 billion could open up by 2014 unless all councils can achieve unlikely and unprecedented efficiency savings.

In addition, only this week, the report of the EHRC, led by the noble Baroness, Lady Greengross, shone a light on the too often invisible experiences of older people receiving care at home. It reveals a service stretched to the limit and older people denied the dignity and respect they deserve. It is shameful and unacceptable for elderly people to be left for hours without food and drink and not properly cleaned.

We know that the Dilnot report called for the improved integration of health and social care. Evidence suggests that this can improve outcomes for individuals and deliver cost savings. We know all this, and we have been talking about it not only for the past 40 years but in the past few days during the proceedings on the Health and Social Care Bill. However, despite notable successes, the progress has been limited, with less than 5 per cent of NHS and social care budgets being subject to joint arrangements and wide variations across different parts of the country in the quality and achievement of joint working. Indeed, part of our scrutiny and testing of the Health and Social Care Bill is whether it will make that situation better or worse.

Nor should we forget that Dilnot did not claim to have the whole answer to the challenges that we face. He claimed that his report was part of the process and addresses very importantly, among other things than those I have mentioned, the injustices of portability of care assessments. The Government’s response to the Law Commission report is most important and was mentioned by my noble friend Lady Wilkins and the noble Lord, Lord Pearson of Rannoch. The Minister should be able to respond that progress is being made on this and other matters.

The proposals for carers are also important in the Dilnot report, as is the establishment of a national source of advice. The commission recommends that better advice should be complemented with a national awareness campaign on the cost of care and a new funding system. I look for that to be part of the Government’s response to this report. Indeed, the assessment and provision of services will be available using the same system as for older people, but the funding cap will work differently for younger adults and the report sets out how this might be achieved.

We must not forget that the need for timely, effective social care not only involves the long-term disabled, those in old age and people with long-term conditions. I thank Macmillan for its briefing and for reminding us that integration across health and social care is also vital in helping to meet the practical, emotional and financial needs of people living with cancer and those reaching the end of their lives. Macmillan welcomes the findings of the Dilnot commission, as it believes that the report also represents the foundation for a fairer funding system for social care.

I have mentioned all the things on which we agree, and I have done so quite deliberately. We all agree that we urgently need a long-term solution for the funding of social care, and that is why Labour offered cross-party talks on this issue from the outset. I urge the Government to get round the table so that we can tackle the care crisis and find a fair and sustainable solution for the future.

I hope that what I have to say now may help the scepticism of the noble Baroness, Lady Barker. Indeed, when I explain how we would like to proceed, I hope that she will nudge her own Government into conceding on this and making faster progress than they have done so far.

As the Minister will recall, when the Dilnot report was launched in early July, my right honourable friend the leader of the Labour Party welcomed it and offered cross-party talks on the future of social care, using the report of the Commission on Funding of Care and Support as a stepping stone to secure a better, fairer system of care for older people and the disabled. I understand that there was an exchange of letters in September and October, and most recently a letter to the Secretary of State dated 8 November.

There are some outstanding questions that the Government need to address in their commitment to this process, and I should be grateful if the Minister would indicate to the House whether progress on them has been made. There are four points. First, securing agreement on funding and implementing the Dilnot proposals clearly goes beyond the remit of the Department of Health and the Secretary of State for Health—it should involve all the departments affected. Given the public spending implications of both the Dilnot proposals and the rising costs and needs, the engagement of the Treasury in this process is crucial. Does the Minister agree with that, and is there agreement that that is how we need to proceed?

Secondly, the Government should nominate an independent person to chair the talks. Again, does the Minister agree with that, and when might it happen? Thirdly, we would like to see established an independent secretariat with the specialist expertise to provide equal access to the negotiations as required. Fourthly, there should be a party leaders’ meeting to agree a clear timetable to demonstrate that we are all equally and seriously committed to talks at the highest level.

Those commitments do not stand in the way of the process: rather, they will facilitate it. I put them on the record now, as they have been put to the Secretary of State for Health, and say that I think it would help the House and the process if the Minister would take the opportunity to respond on this matter. Finally, I thank all noble Lords for taking part in the debate.

[Baroness Barker]

I thank the noble Baroness very much—I did not know about the correspondence. However, can she explain why an independent chair is necessary for the process? I understand the other three points but I do not understand that one. What is the reason?

[Baroness Thornton]

We think that having an independent chair is a sensible way to move forward. We have not suggested that we should appoint the chair; we have asked the Government to suggest the name of the person who might chair those talks. I do not think that any of those things is a barrier to progress in this matter.

Finally, we on these Benches think that this is one of the most important issues facing our society today. It is one that we cannot neglect or leave in the long grass, and it is one that we are determined to resolve.

Health and Social Care Bill

Baroness Barker Excerpts

Monday 14th November 2011 Lords Chamber

[Baroness Armstrong of Hill Top]

My Lords, I rise briefly to lend support to the amendment. I work with charities for the homeless and for children. If the Government’s ambition is to enable the NHS to work with the patient on the full pathway—rather than work being done in little bits by different organisations—then making the playing field level for the voluntary sector is absolutely critical to developing those pathways. In my experience, the voluntary organisation is frequently the glue in making sure that the pathway for the patient works for the patient.

I remind the Minister that when this works well there are often savings for the National Health Service. I have experienced that in homelessness, where we have been able to work with the PCT to get a community matron. That has reduced the number of expensive admissions to hospital and A&E for the most disadvantaged—the homeless. I have also seen that work well with, for example, children with disabilities and children who are very ill. They have been enabled to remain at home with the proper support instead of being frequently admitted to hospital.

It is to the advantage of the NHS that we get this right. What will the Government do to bring forward in the Bill comfort and encouragement for the voluntary sector? After the pause, that sector has been left with a rather large amount of confusion.

[Baroness Barker]

My Lords, for over 25 years I have worked either in or as a consultant to voluntary organisations. Consequently, my eyes lit up at the sight of an amendment that said VAT and charities. In my time, I have sat with wet towels around my head trying to figure out this, one of the most complicated subjects. I have attended seminar after seminar with the Inland Revenue at which people with bigger brains than me have come away with their heads reeling from trying to understand the issue of VAT and charities. It is infinitely more complicated for charities than it is for the private or public sectors. That is not new. As various people have said, this issue has been running for some considerable time.

I want to correct two impressions that might have been given inadvertently in the debate. First, there is the impression that there is a view in the charitable sector on this issue. There is not, because the issue effects different organisations disproportionately. While there may well be a consensus among hospices that it would be advantageous for them to make such a change, it may not be and indeed is not for other, smaller charities. That is the first thing.

Secondly, we have this new generation of social enterprises. These organisations are not charities but businesses. They are intended to be big players in the provision of services. The noble Lord, Lord Patel, has been clever here in not asking for the Government to take a particular step. He simply asks for a report on a subject that will fascinate some of us quite deeply. Were the Government to take on board the point that the noble Lord makes, apart from looking at a whole range of different charities—not just hospices—would they also consider the effect on social enterprises? I do not think that it is possible to come up with a set of legal proposals that relate simply to health and social care. By definition, they would have to go across the whole of public services. I hope that the noble Lord, Lord Patel, would accept that an exercise of this kind should do that.

Finally, be careful in the questions that you ask of HMRC. As someone who advised charities, I was always brought up never to ask a question of HMRC unless I was pretty confident that I would get back the answer that I wanted. This may be an answer that the hospices want but I would wish to be pretty clear that it worked for charities across the board. I simply finish by saying that if this subject were straightforward, it would have been sorted out a long time ago—but it is not and that is why it has not been.

[The Lord Bishop of Chester]

I am very grateful to the noble Baroness, Lady Barker, for what she just said about the complexity of the question. However, I would like to go back to what the noble Baroness, Lady Pitkeathley, said about what charities do well. Particularly important is their face-to-face concern with the whole needs of whole persons rather than the abstract application of principles. I would add two things that some charities offer that intersect with other bits of our social agenda at the moment. One is the passion of those volunteers who work particularly for local, small charities. A lot of energy is sapped by precisely the issue that we are discussing this afternoon. If we are concerned for what might be called in the most general way the big society, how you engage people in maximum participation at a local level in concerns and charities—particularly small ones, which are very close to the action—is extraordinarily important, it seems to me. Passion and localism are two aspects of this that must not be forgotten.