Care Services: Abuse of Learning Disabled
Baroness Emerton Excerpts(11 years, 11 months ago)
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Baroness Emerton
My Lords, I, too, congratulate the noble Lord, Lord Rix, on initiating this debate, and I congratulate my noble friend Lady Kidron on her outstanding maiden speech. I want to concentrate on the management of change in the situation that we find ourselves in, and perhaps I may take noble Lords back to the beginning of Winterbourne. I was called in with Professor Jim Mansell to look at the footage before it was put out on television and asked why in the late 1970s we had been able satisfactorily to relocate 1,115 and 1,112 patients respectively from two large institutions, all suffering from learning disabilities, after 10 years; and why, in 2011, we find the same things happening now as happened in the late 1970s.
I want to raise the issues that we found. First, what were the principles and what were the things that needed to be looked at? We needed a multi-professional team, a strategy, a programme and research. We had no idea that the project would take so long, but we set about it. I was most fortunate in recruiting the then young Professor Mansell as a psychologist and researcher. It was his first post, other than working at the Kushlick centre, since leaving university, having changed his degree after the Ely inquiry. He was outstanding in the field of care for those with learning disabilities and continued his research right up to his sad death last year. The principles were that patients should return to their district of origin; that they would be individually assessed and diagnosed with their treatment set out; that they would work to a programme; that the staff would be trained to meet that programme; and that accommodation would be suitable to the need. Membership of the project team was large—we had a psychiatrist, a psychologist, a researcher, members of social services and we set up a university department. The principles were clear—that no patient would be discharged without an assessment, training programme, support programme and suitable accommodation.
The barriers were enormous. The psychiatrists at the hospital were totally against it being closed and the patients themselves were not happy about going, because it had been their home for a long time. The relatives became very edgy because they thought that it was a safe haven and that going into the community would be unsafe and the recipients in the community had a little of the “not in my backyard” attitude. Finance was an issue but at the time it was government policy and we were able to get funding. On the question of accommodation, we had to look at all the different types of accommodation that might be available—houses, housing association flats, and very small units.
The patients with less challenging behaviours were the easiest to relocate. Those with more challenging behaviours were more restricted: specialist skills were required to care for them. Fortunately, because we had Professor Mansell, we were able to relocate all of these with the right treatments and staffing levels. The training programmes were for support workers, who were trained but obviously not registered, at that stage, since they had never been registered. We also had trained nurses and social workers and we went through the programme. Resistance was overcome by influence, persuasion and personal visits to local councils, social services and parents themselves, and by going to hear what the patients had to say. We made sure that the team, which worked extremely hard, remained committed to overcoming the barriers.
Near to the closure of the 1,500 bed hospital, most of the patients had been relocated back to the sites from where they had originally come, but some—mostly those with challenging behaviours—remained. We had to persuade those within the counties and the districts: we had seven local London districts as well as Kent and Sussex. It took time to persuade them that it was possible, but Professor Mansell was instrumental in persuading people that even those with the most severe challenging behaviour could be housed in the community. We eventually succeeded in getting them out—the decisions were taken and the assessments went on—and the communities began to accept them and were happy. We found, through visiting them, going round to tea with the residents, that they had settled and that the community had accepted them. The budgets were sorted and the patients were happy. I remember a flat in Camberwell where three elderly gentlemen who had been in hospital for 30 years said what a treat it was to be able to go to a fish and chip shop; they also invited us to tea.
The programme would not have succeeded without the leadership of Jim Mansell and the rest of the team. It would not have succeeded had we not used leadership, influence and persuasion, or if we had not trained the staff. Today, the noble Baroness, Lady Jolly, and other Members have mentioned the need to register support workers. We cannot go on without having that registration of support workers, who are trained to understand the special needs that go with learning disability.
The point of making this reminiscent therapy that I have gone through is that today we face the same barriers and issues, and we have to overcome them. I am grateful that we have been able to see the report from the Government but we need to address these barriers urgently. If we do not, it will be those who suffer from learning disabilities who will be disadvantaged.
Health and Social Care Bill
Baroness Emerton Excerpts(12 years, 11 months ago)
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Baroness Northover
I am not suggesting that they would. What I am suggesting is that the registered nurse might go and check the chart.
Baroness Emerton
My Lords, perhaps I could be helpful at this stage. I am grateful to noble Lords who have contributed to this debate. A large number of issues have been brought forward; I shall start with the title “nurse”. As noble Lords have mentioned, a person who is nursed—and feels that they have been nursed—experiences care, compassion, respect and dignity. There has been a lot of discussion among the public, and indeed in this House, about registered nurses becoming graduates and whether they will be too posh to wash, to put it colloquially. To me, a nurse who is a graduate would be only too grateful to be able to attend to the basic needs of patients, because that is part of holistic care. When you do various intimate things for patients, you learn a great deal about their condition.
The point that has been raised about the nurse is very important. We talk about support workers but we cannot talk about support nurses, because the term “nurse” is completely left for the statutory requirement of a regulated nurse. We are looking for a support worker who is able to do tasks which they understand, with the skills of the graduate nurse—because by 2013, we will be producing all-graduate nurses—within holistic care. That is the point I was trying to make this morning: it is the holistic care we are looking for in the delivery of care. However, it is not only holistic care in the acute sector; we are looking at the holistic care which is integrated with social care, because we are now looking at patients going into the community. Indeed, people working in the acute sector need to understand that the patients they are discharging are going into the community, which is a different scene and which may require not only a nurse but social care support. Therefore, somewhere in our education we need to bring together a basic core of understanding healthcare, nursing care and social care.
The point that the noble Lord, Lord Warner, made is very important. We need to conduct this review. On the other hand, the research evidence shows us that as regards highly qualified registered staff, the higher the proportion, the less likely it is that patients will have a longer stay in hospital. They will have a better clinical outcome. I hope that the Government are not going to ignore that research. If possible, we should carry out a truly safe cost-benefit analysis into increasing the number of trained staff, seeing where they are needed, rather than having a higher proportion of support workers.
The Royal College of Nursing has been resolute in putting forward the regulation of healthcare support workers because it feels that that is the way to ensure that they are answerable to a registered nurse. We talk about employers but I am not sure who the employers are going to be—social workers, managers or the nursing profession. This whole issue needs to be taken away and looked at, and perhaps we could return to it. I do not know whether these comments are helpful but I feel strongly about this issue, as noble Lords may have gathered. I pass it back to the Minister.
Baroness Northover
I hear what the noble Baroness says. She is extremely well informed, as ever, and I hope that she will continue to engage as we take this forward, as she has done up to now. However, at this point I hope that she will withdraw her amendment.
Baroness Emerton
My Lords, I am prepared to withdraw but we will probably come back to this on Report. I beg leave to withdraw the amendment.
Health and Social Care Bill
Baroness Emerton Excerpts(12 years, 11 months ago)
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Baroness Northover
My Lords, we are always sympathetic to all sorts of amendments, and the fact that we take away amendments and consider them further should, I hope, reassure noble Lords—
Baroness Emerton
I apologise to the Minister; I was waiting to speak to my Amendment 236ZA. The issue of voluntary sector involvement is important because the changes proposed in the Bill have significant relevance to it and in particular to the voluntary aid societies. The British Red Cross and St John Ambulance provide emergency response and are recognised respondents under the regulations of the Civil Contingencies Act. I declare an interest as a member of St John Ambulance for 66 years.
The history of the status of these two organisations goes back to the Geneva Convention. Because they have a specific responsibility for providing emergency services, there needs to be clarity about the lines of accountability within local authorities. Both organisations are recognised in the humanitarian field and for first aid and for looking after civil or military emergency situations. That is their responsibility. The auxiliary status is enshrined both in the royal charter for the Red Cross and in the Geneva Convention. The Women's Royal Voluntary Service used to be included, but it has withdrawn from voluntary aid society status. Nevertheless, all voluntary organisations are important in that they are present and they will need to know how to be organised under these new arrangements. They want to be assured that they will be commissioned, as they are now under the Civil Contingencies Act. Prior to this Bill, they were commissioned by the PCTs through local authorities and these changes have significance for them in how they will be managed and how the chains of communication will work.
The community-based presence of both organisations means that they are involved in vital emergency responses. They are first-responders and deal with civil emergencies. They hold, for example, a large number of ambulances with four-wheel drive. Indeed, the London Ambulance Service says that it cannot possibly cope in an emergency without the backup of the volunteer ambulances, particularly in bad weather. I speak to this amendment because voluntary organisations need to be involved and need clarification of their communication with local authorities.
Lord Ribeiro
My Lords, I seek clarification because the noble Baroness, Lady Emerton, has just referred to a whole series of different emergencies. The noble Baroness, Lady Williams, referred earlier to Clause 43 and the question of emergencies. I am confused about what we mean by emergencies and, under the emergency powers, the relevant types of emergency that we are dealing with.
Clause 43 states that,
“‘a relevant emergency’, in relation to the Board or a clinical commissioning group, means any emergency which might affect the Board or the group”.
We then talk about the emergencies that might occur when there is a national disaster. I take noble Lords’ minds back to the bombings on 7/7 in 2005. That was a major national emergency that was managed by COBRA—an organisation that involves the Prime Minister, the Secretary of State and the Chief Medical Officer. All of them would be involved in that situation. We also referred to the E. coli epidemic earlier on and I take noble Lords back to the Asian flu and swine flu epidemics. The person who fronted that was not the Secretary of State but the Chief Medical Officer. He was the face of that particular epidemic. I think we need some clarification of what we mean by emergencies, because I, for one, am somewhat confused.
Baroness Northover
My Lords, these amendments address the response to emergencies. We agree entirely that dealing quickly, decisively and in a co-ordinated way with sudden threats to public health must be a priority for the new system. We believe that the establishment of the position of director of public health within local authorities will strengthen considerably their capacity to respond to emergencies. However, the overall response will depend on the precise nature of the threat, as my noble friend Lord Ribeiro has indicated, and it is very likely to involve the NHS and other agencies, such as Public Health England, as well as local authorities. Therefore we want to allow for local flexibility in deciding who is best qualified to lead the response to a particular incident. Nevertheless, we must also ensure, when incidents occur, that all the responders are prepared and fully understand the parts that they play. We agree that the duty for local authorities, which we intend to prescribe in regulations, must be strong enough to ensure that the right arrangements are in place, not just a document that describes those arrangements.
We believe that the Bill already provides for the kind of coverage that is required. Clause 27 sets out a number of responsibilities for directors of public health and is already clear that these include the local authorities’ functions in planning for and dealing with public health emergencies. This, we think, fully matches the intention behind Amendment 227.
We agree with the spirit of the noble Lord’s Amendment 235. Clause 15 gives the Secretary of State the power to specify in regulations certain steps that local authorities must take under their new public health duties. The regulations will be subject to the affirmative procedure in Parliament, but I can assure the noble Lord that we expect that the steps the Secretary of State prescribes will include ensuring that robust and agreed local plans are in place for dealing with threats to public health, even if they are not full-blown emergencies.
Amendment 236ZA, tabled by the noble Baroness, Lady Emerton, and other noble Lords, recognises the invaluable role that the voluntary aid societies, such as St John Ambulance, can play in dealing with emergencies. We certainly have no difference with the noble Lords on that, and hope—and expect—that local authorities will involve St John Ambulance and other agencies, such as the British Red Cross, when they ensure that plans are in place for tackling threats to health. We will consider how to address this issue in the regulations that we intend to make. On that basis, I hope the noble Baroness will be willing to withdraw her amendment.
I come now to the amendments in the name of my noble friend Lady Williams of Crosby. My noble friend Earl Howe said that at this point I should simply concede because they were in the Bill anyway, but I will address the substance of her amendments. She seeks to enhance the readiness for emergencies by conferring additional duties on the Secretary of State. I assure noble Lords that the Secretary of State already has the clear duty to protect health not only by virtue of Clauses 8 and 44 but under the Civil Contingencies Act 2004. Both the NHS Commissioning Board and the Secretary of State will be category 1 responders. As such, they will have a duty to assess, plan and respond before and during an emergency. This is made clear in Schedule 7 of the Bill. There might have been a slight misunderstanding over this.
The words at the start of Clause 43 that will replace the current cross-heading preceding Section 253 of the 2006 NHS Act that reads simply “Emergency powers”, are:
“Emergencies: role of the Secretary of State, the Board and clinical commissioning groups”.
New Section 252A then deals with the role of the board and CCGs, and Section 253 deals with the Secretary of State. We are not removing the Secretary of State’s role. The Secretary of State retains his role, exercising his powers as indicated in Section 2 of the 2006 Act and under the Public Health (Control of Disease) Act 1984, as well as his duties under the Civil Contingencies Act 2004. I hope that my noble friend will be reassured in this regard.
Amendment 238, tabled by my noble friend Lord Marks, would require the NHS Commissioning Board to consult a Secretary of State before it takes steps to facilitate a response to an emergency that requires co-operation between different parts of the health system. These are operational decisions that are often taken at a local level where speed is very important. For example, hospital operations in one part of the country may need to be suspended because blood supplies are needed elsewhere. The amendment could inadvertently introduce additional delays into the decision-making process in a response to emergencies.
The clauses as currently written allow the health service to respond to emergencies directly and effectively and give the Secretary of State the power to intervene. We will consider what noble Lords have said but, in the mean time, I hope that they will not press their amendments.
The noble Lord, Lord Ribeiro, asked for a definition of emergency. I am assured that emergency has its ordinary meaning. I will write to him with the full definition rather than take noble Lords’ time. On the basis of what I have said, I hope that the noble Lord will be willing not to press his amendment.
Lord Patel
My Lords, I thank noble Lords who took part in this debate. As I said in my opening remarks, the amendment seeks to clarify the responsibilities of the local authority in situations that arise as an emergency, either locally or nationally, and within that the role of the public health director. I realise that the Bill says that the Secretary of State, through Public Health England, will be involved, but there is still a lack of clarity in the Bill. Apart from saying that local authorities will produce documents about their preparedness to deal with an emergency, it does not say who will take charge. Further clarification may be required, and the Minister might undertake to look at the amendments again to see whether there is some need to clarify this in the Bill.
Health: Cancer
Baroness Emerton Excerpts(14 years ago)
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Baroness Emerton
I, too, congratulate my noble friend Lady Finlay on raising this debate and on so eruditely setting out the complexity of the integrated care plans for patients suffering from cancer. It is important to ensure a seamless service to patients who, together with their families, as the noble Baroness, Lady Pitkeathley, said, are filled with trepidation by the word cancer.
I shall highlight the importance of specialist cancer nurses. A recent report from the Royal College of Nursing entitled Changing lives, saving money states that evidence to date demonstrates that specialist nurses play a vital part in a range of ways in assisting patients through a complex pathway by delivering high-quality specialist care. They frequently help avoid unnecessary admission or readmission to hospital. They reduce post-operative hospital stays, thereby freeing up consultant appointments for other patients. They provide treatment at the point of need, so reducing patient drop-out rates. They assist in the education of health and social care professionals, provide direct specialist advice to patients’ families and ensure rapid referral if necessary to other medical treatment, so reducing waiting times.
A survey conducted by health advocacy groups nationally demonstrated that patients consistently rate the specialist nurse higher than any other healthcare professional in understanding patients’ needs. Specialist nurses provide a lifeline to many patients and families, the patient having gone through incredible physical and mental upheaval. While the good news is that survival rates have increased, patients will continue to need to access expert care and support. It is also proven that specialist nurses’ expertise keeps patients safe and exposes them to less risk.
The noble Viscount, Lord Bridgeman, mentioned the recent announcement in the comprehensive spending review that the right to one-to-one nursing care for patients, having been promised, is to be rescinded. I have heard that further consideration is being given to this decision. Will the Minister confirm that? Evidence points to unequal access to cancer specialist nurses across the country, and it is also reported that one-third of them are supported by the Macmillan Cancer Support.
Commissioners need to address as a priority whether there are enough specialist nurses to meet patients’ needs. Local management needs to ensure that the skills and expertise of specialist nurses are not deployed to fill gaps in ward or department staffing, as this is a waste not only for patients but also in economic terms. Another study shows that if provision could be made for administrative support for specialist nurses it would save 6.6 hours per week per specialist nurse. Specialist nurses are highly qualified and educated mostly to masters level and are too precious to be deviated from their dedicated programmes which would result in a loss of care to patients.
It is a known fact that patients prefer to be cared for at home where at all possible. Obviously early diagnosis is vital in order that treatment starts immediately; the majority of patients starting with surgery. With the least invasive approach, the length of stay in hospital is reduced and then the requirement is for expertise in the home by specialist nurses and experienced nurses in post-operative care. The Marie Curie and Macmillan nurses provide a very good service.
The noble Viscount, Lord Bridgeman, also spoke about the Healthcare at Home service as a leading provider of home care to cancer patients. The service has developed over the past 15 years and continues to grow, and now includes the administration of highly cytotoxic chemotherapy regimes to patients at home by highly skilled experienced nurses. The service delivers 24/7, 365 days a year and has improved efficiency and safety by investing in bespoke industrial leading infrastructure and new technology. It continues to develop outcome measures.
The service works in partnership with the Department of Health. The important thing is that the patients who have received Healthcare at Home are still maintained by their clinical teams, who retain ultimate responsibility for patients and with whom Healthcare at Home maintains close contact. Evidence so far shows improved outcomes, as has already been mentioned by Dr Foster Intelligence, and that a considerable amount of money has been saved.
Innovations as described by Healthcare at Home certainly cannot be ignored in taking forward the ways to increase the quality and quantity of life for cancer sufferers. I mentioned the good news of improved survival rates and much work is being developed in Living with Cancer. Emphasis on this work needs to continue with education to patients and the public as mentioned by the noble Lord, Lord Clement-Jones. This is an important point for all patients, their families and their friends. Healthcare professionals are taken up with the actual delivery of care, but there needs to be healthcare provision by experts in setting out the information that is so necessary for the understanding of the general public as well as patients and their friends.