Health: Dementia

Baroness Gardner of Parkes Excerpts

Wednesday 22nd January 2014 Lords Chamber

Asked by

[Baroness Gardner of Parkes]

To ask Her Majesty’s Government what action they are taking to inform the public of the particular problems associated with dementia and the support available for individuals suffering from that condition.

[Baroness Gardner of Parkes (Con)]

My Lords, dementia is such an important issue that I am pleased to have the opportunity to focus attention on it tonight, at a time when it has been very much in the news. My belief is that people need to be informed. Without doubt, a degree of stigma attaches to the diagnosis of dementia. For this reason, many people prefer to use the word “Alzheimer’s” rather than the wider term “dementia”. I have found this to be the case for years and we need to ensure that that attitude changes. No stigma should attach to any medical diagnosis of a condition that the person did not bring upon themselves, be it dementia, epilepsy or cancer.

I am old enough to remember clearly when, in the 1950s and earlier, people would say when they heard of someone they knew being diagnosed with cancer, “I wonder what they did to get that”. The attitude was that cancer was a punishment for the wicked only. Over the years, people have had a much greater understanding of diseases and the internet has made it easy for them to learn about cancer and its causes. Because cancer is so widespread there has been marvellous research in the subject. Information has created an awareness of the great importance of early diagnosis as the best hope of a cure. Now people know that hereditary genes may cause additional vulnerability in some people.

Just last week, I read an interesting article on a change of diet being the way to avoid dementia. It recommended a high-fat diet, which has always been deplored in the past. It stated that all white bread, pasta and sugar—in fact almost all carbohydrates—should be eliminated from one’s diet, that gluten-free products should be used and that, in following the “five a day” health advice about fruit and vegetables, only certain fruits of the low-sugar type should be consumed. This new diet seems as extreme as the low-fat diet was, but in reverse. At present, these are the views of Dr David Perlmutter, a neurologist. The article in the Times on 18 January sets out much more detail about them.

Reading constantly conflicting dietary reports is not good for anyone; what we need is solid evidence-based research. At present, it is not possible to know who will develop dementia. It is no respecter of persons and can strike the most brilliant people. Research is essential to determine what measures can be taken to prevent dementia from developing and to control the progress of the condition.

In the early stages of dementia, often a person is aware of their mental deterioration but, as the condition progresses, they can lose all awareness. Usually, short-term memory goes first. There are therapies that can be applied to bring back happy memories from long ago that give pleasure to patients.

In the Daily Telegraph of 28 December last, there was a report to the effect that dementia patients were bedblocking to the extent that urgent cases could not be admitted to major hospitals. There were other very distressing press reports, for those who have relatives or loved ones needing special care, of horrible and degrading attacks on such patients, who could not defend themselves.

Solutions are needed. I think that it is time for us to rethink some of the treatments and facilities that we have thrown out of the NHS. More daycare provision would allow patients to enjoy those hours in a safe and caring environment while providing necessary relief for carers. Respite, on a daily or longer-term break basis, is essential for relatives and carers to enable them to fulfil that very important role.

Cottage hospitals were ideal for dementia patients needing in-hospital care but who did not have urgent or immediate need for acute services. Both day centres and cottage hospitals require full-time nursing and genuinely caring staff. Those staff filled a need and were a valuable part of the NHS. Dementia cases need genuinely caring support.

I support the view—and the changed stroke care in London has proven this—that we need highly specialised centres where essential, urgent care can be provided for some life-threatening conditions. Such centres, which are being developed, should be used for cases in need of immediate and urgent high-intensity care, and the patient should remain in until ready to return home or to go to an appropriate intermediate-care facility.

Nursing is an essential part of any patient’s treatment at all levels. I think it is splendid that nurses now can obtain the highest qualifications, and I am a strong supporter of nurse practitioners. Specialist nurses in whatever field are invaluable to patients, consultants and the NHS. However, I remain convinced that it was a mistake to insist that all nurses must have A-levels and obtain full academic qualifications. The loss of the SEN qualification has done great damage. Some of the best nurses I have known—and I have been involved in most levels of the National Health Service—could never have gained sufficient A-levels for university entrance.

When I have taken part in health discussions at the Commonwealth Parliamentary Association international conferences, I have asked what other countries have done in nurse training. There is fairly wide agreement that nurses should be able to train at various levels to meet patients’ needs. Nurses with high clinical skills and qualifications are needed, but so, too, are less qualified but capable, compassionate, caring nurses who are willing to carry out the most mundane tasks where there is a need and to treat people as valuable human beings, not just cases.

In most Commonwealth countries, they have nurses train to the top level, but when they brought in academic degrees for nurses, they retained that intermediate level of nursing which we call the state enrolled nurse. I am convinced that the Government should be liaising with the nursing profession to look into the issue of our need at that intermediate level. It is no good saying that people can become “care assistants”. Even the talk of registering care assistants has not moved people in a way that would make them proud to bear that title. People consider it an honour to be called “nurse”, and so it is, but there can be nurses and nurses, and titles could be appropriately chosen to make clear those who had a degree and others.

Dementia can cause isolation as the patient becomes cut off from reality. It is only at the early stages of the condition that the patient is able to realise that they are losing contact with reality. Some treatments can delay progress, but, at present, nothing can turn back the clock. It is very hard for loved ones to see progressive dementia in a friend or relative, and it can be a great test of their patience, as often the sufferer becomes increasingly repetitious or even difficult.

The number of people likely to suffer from dementia is projected to double over the next 30 years, so there will be further pressure on services. The Local Government Association states that there will be a funding gap by 2020. It cites the Greenwich advanced dementia service as a new model of care for people with advanced dementia which, to date, has supported more than 100 people to stay in their own homes and is saving up to £265,000 a year on reduced care home costs and hospital admissions.

Dementia patients are more likely to die or suffer an injury than other patients. A study of more than 17 million hospital visits found that patients with the condition had far higher mortality rates, longer lengths of hospital stay and a higher likelihood of readmission than other patients. They are also three times more likely to suffer a fall while on a ward than other patients. There were 380,000 such incidents in a year.

As with so many health conditions, accurate, up-to-date and well presented information for patients, their families and friends is vital. Specialist charities can help with providing just such information and reassurance to support the information received from the health professionals. Today in my GP’s waiting room, I checked the large number of information leaflets for patients. These covered almost everything but there was nothing on dementia.

However, my doctor told me that the practice has put people in touch with the Contented Dementia Trust, which has proven to be of great help to carers. Often, dementia can be associated with changes in temperament, with some sufferers having spells of violence and others lengthy times of apathy. Carers find it valuable to know that these situations can arise and how to deal with or prevent them. It is an important point that these specialist charities, of which the Contented Dementia Trust is one and the Alzheimer’s Society is another, can help with providing such information and reassurance.

Marvellous progress has been made in healthcare and people are living so much longer that dementia, usually associated with ageing, is becoming a major issue. Florence Nightingale stressed the importance of the need for a patient’s cleanliness and comfort; to those, I would add caring. These essentials remain the same today. We must do more to see that genuinely caring help is provided while working towards having greater understanding, better information on the condition and a promising future due to continuing and developing research.

I thank all the speakers tonight, who can make a real contribution to the debate on this important issue. Research is the only real answer. Until we can fully establish the cause of dementia, we cannot develop methods of prevention or means of curing the condition. The Government can encourage research and increase awareness and understanding of the crucial need for genuine caring for dementia cases, and they should do so.

Health: Flour Fortification

Baroness Gardner of Parkes Excerpts

Tuesday 21st January 2014 Lords Chamber

[Earl Howe]

My Lords, I am not aware of that study but I shall of course make myself familiar with it. I do not doubt that it will feature in the consideration that we give to this issue, which I can assure the noble Lord we will do as speedily as we can. It is important to say that adding to the list of fortificants would be a major step and we need to be absolutely sure that it is the right one.

[Baroness Gardner of Parkes (Con)]

My Lords, is it not a fact that in the United States bread is already fortified not only with folic acid, which of course prevents spina bifida in newly born children, but also vitamin D? At present there is a great deal of concern here that none of us is getting enough vitamin D due to the lack of sunlight in winter. Would it not be a good thing for us to have that benefit? Can the Minister also assure me that if this applies to wheat it will cover wholemeal as well as ordinary loaves, as we recommend people to eat those?

[Earl Howe]

On my noble friend’s last question, we are slightly jumping ahead of ourselves because we need to decide on the principle before we decide on which types of wheat might be fortified. However, I recognise my noble friend’s main point. Indeed, the Scientific Advisory Committee on Nutrition, in recommending mandatory fortification of flour with folic acid, sought to highlight the benefits of fortification as well as the risks. It was a balanced recommendation. We value it and we will look at the advice very closely indeed.

World Innovation Summit for Health

Baroness Gardner of Parkes Excerpts

Monday 16th December 2013 Lords Chamber

[Earl Howe]

My Lords, the principles espoused at WISH do indeed apply with equal force to mental health services in this country. Those principles are several, but I would draw the noble Lord’s attention to the need to draw on evidence-based practice; to strive for universal mental health coverage; to respect human rights and to take a life-course approach. We try to embody all those things in our mental health services. Regarding DfID, I can tell the noble Lord that there are a number of multilateral and bilateral programmes which are in train and supported by the Government. We are supporting work in the Caribbean and Bermuda and promoting work in a number of countries in sub-Saharan Africa. I would be happy to write to the noble Lord with a complete list of these.

[Baroness Gardner of Parkes (Con)]

Is dementia included in this?

[Earl Howe]

My Lords, in broad terms, dementia falls outside the scope of mental health but it is, of course, closely allied. Many of the principles that apply to good mental health care apply equally to dementia. We are, again, doing our best, in responding to the Prime Minister’s challenge on dementia, to ensure that those who contract this dreadful condition are looked after with dignity and respect in the appropriate setting.

Tobacco: Packaging

Baroness Gardner of Parkes Excerpts

Thursday 28th November 2013 Lords Chamber

[Earl Howe]

My Lords, I am grateful to the noble Lord, who has indeed been a consistent champion for plain packaging over the years. I also appreciate his endorsement of the choice of Sir Cyril Chantler to lead this review. Noble Lords will know that Sir Cyril has a very distinguished record as an academic and paediatrician. As regards the timeline, I cannot be definite at this stage. All I can say is that, should the Government decide to lay regulations in the light of Sir Cyril’s recommendations, we believe that, taking into account a period of consultation and the statutory provisions surrounding European law, we would be able to introduce the regulations within a reasonable time.

[Baroness Gardner of Parkes (Con)]

My Lords, is the noble Earl aware that in Australia plain packaging has been very effective? They say that that is, above all, because it is no longer “cool” for young people to smoke. The noble Earl mentioned age as being effective, and that is very relevant.

[Earl Howe]

It most certainly is relevant, which is why we are taking the legislative opportunity in the Children and Families Bill to drive home that very point. My noble friend is right.

Health: Tuberculosis

Baroness Gardner of Parkes Excerpts

Thursday 21st November 2013 Lords Chamber

[Earl Howe]

The noble Lord is absolutely right. That is one reason why we are placing a particular focus on research into multidrug-resistant TB and diagnostics in that area. We fund UNITAID, which aims to triple access to rapid testing for MDRTB and to reduce drug prices for treating the condition. We have made a 20-year commitment to UNITAID of €60 million a year, subject to performance.

[Baroness Gardner of Parkes (Con)]

Following the comments of the noble Lord, Lord Walton, is the Minister aware that point of entry is very important? When I was involved in a health issue as a local councillor, we had a case of someone detected at Heathrow. It took two weeks to track him down, by which time he had infected 40 other people because he had moved into very limited accommodation where many people were all living in one room. This situation is developing again. What facilities are available at the airport now to pick up these cases?

[Earl Howe]

My Lords, there are regulations covering ports and airports which provide a contingency for when a passenger on a ship or a plane enters the UK, is suspected of having a notifiable disease and perhaps refuses to seek medical attention. The regulations include provisions for notification of such a case to the destination port health authority and for the detention of that person for the purposes of a medical examination. There are also quite flexible powers for local authorities to deal with incidents or emergencies where infection or contamination presents or could present a significant risk to public health.

Health: Local Healthwatch Organisations

Baroness Gardner of Parkes Excerpts

Tuesday 5th November 2013 Lords Chamber

[Earl Howe]

No, my Lords. As the report from Robert Francis identified, the patient voice has to be at the heart of the health and care system, and Healthwatch plays a crucial role in supporting that as the new consumer champion for health and social care. It is very easy to get fixated on the amount of money that is going into Healthwatch. One additional consideration could be the investment that a local authority may be making in other areas to ensure that the voice of service users and the public is heard—for example, through the voluntary and community sector. Surely what matters are the outcomes that are achieved for service users and the quality of those services.

[Baroness Gardner of Parkes (Con)]

My Lords, are good activity and good results really coming out of these Healthwatch groups? In particular, have they done anything to help stroke victims or underprivileged or autistic children? Can the Minister give us an update on what good they are doing and whether they should be continued?

[Earl Howe]

I am grateful to my noble friend. The first annual report from Healthwatch England was laid before Parliament on 9 October and it outlined some encouraging progress at both a national and a local level. There are already examples of the impact that local Healthwatch is having—for example, the work of Healthwatch in Peterborough, which is looking at how to improve health outcomes for offenders. My noble friend mentioned autism. I am aware that Healthwatch Cornwall uncovered a gap in the services meant to deliver a diagnosis of autism in children. That work resulted in a really practical solution so that families could access a diagnostic service without losses to other services in the area.

Care Bill [HL]

Baroness Gardner of Parkes Excerpts

Monday 21st October 2013 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, we come to an important amendment that relates essentially to staff ratios and guidance. I refer back to the Francis report, which focused very much, among many other serious matters, on staffing ratios and appropriate staffing numbers employed by NHS trusts.

We know very well that given the financial strain currently on the health service there is a large concern about whether there are enough staff on the wards to give appropriate care. Much of the concern around the quality of nursing care and the quality of care by healthcare assistants has related to essential aspects of care, including feeding, caring and all those things associated with what we would regard as appropriate caring. Underlining those things has been a concern as to whether enough staff are employed on the wards.

The noble Earl will know that the Francis report recommended that NICE should benchmark issues around appropriate staffing levels. He will also know that since the Francis report came out we have had the Keogh report into 14 trusts with outline mortality rates. It is interesting that one of the important conclusions of the Keogh review was the need to look seriously at staffing numbers. There seems to be a direct relationship between outline mortality rates and staffing levels on the wards and in clinical areas. We have also had the Berwick review, which the Government established, looking more generally at staffing levels within the health service. The review identified staffing levels as being one of the most important areas on which to focus when it comes to reviewing quality of care.

My amendment relates to ensuring that in its responsibilities the CQC has sufficient focus on staffing levels. This is a very important matter at a time when the health service is being presented with an increase in the number of patients and an increase in technology and complexity at the same time as having to operate on a budget that is just above a level budget. Things are very difficult indeed in the health service. Roughly 70% of the budget of NHS organisations is spent on staffing and expenditure on nursing and healthcare assistants forms perhaps the most important element of the staffing budget. Therefore, in some way we need to protect staffing levels in such circumstances. My amendment suggests that this is a very important role for the CQC to play and I hope that the Minister will be sympathetic to it. I beg to move.

[Baroness Gardner of Parkes]

My Lords, I do not want to speak before whoever supports the noble Lord, Lord Hunt, in his amendment, so I will sit down and speak after the noble Baroness.

[Baroness Wall of New Barnet]

My Lords, I did not intend for that to happen. Noble Lords may find this quite tedious, but I want to follow both the theme and the specifics of the amendment moved by the noble Lord, Lord Hunt. As to the theme, his statement that things are difficult out there today is quite an understatement. Things are hugely difficult. I spent the morning with the TDA in my trust and heard very difficult messages around performance and, more importantly, around finance.

On the specific point about the suggested skill mix and the way of dealing with it in the Care Quality Commission, when we had our Care Quality Commission representative for Barnet and Chase Farm with us a couple of months ago—on a routine visit rather than an impromptu one—she set aside a session to talk to people about healthcare assistants. She got the same message that I have tried to impart to noble Lords on several occasions that the regulation of these people is hugely important. She was trying to understand what difference it would make. Patients who came in to listen at the event could not understand why healthcare assistants were not regulated in that way—although some thought that they were. There is also confusion about who they are and what role they play.

Healthcare assistants and nursing assistants are hugely important to the skill mix, but what they do and what they are able to do is paramount to being able to understand how their contribution to the skill mix really fits. I support the amendment. It can ensure that we once and for all deal with what it really means to be a healthcare assistant, what they can do and how they are regulated.

--- Later in debate ---

[Lord Willis of Knaresborough (LD)]

My Lords, I am delighted to follow the noble Baroness, Lady Emerton. May I say—not as an aside but as genuine comment—that we are all in awe of her commitment to nursing and the care profession? It is not just eight weeks, but a lifetime of commitment. I think the whole House is enormously grateful for the contribution she makes.

I rise to support Amendment 144 in the name of the noble Lord, Lord Hunt, having first thought that it was not required. It seems fairly obvious that the Care Quality Commission shall, in carrying out its functions,

“have regard to any official guidance on staffing numbers and skills mix”.

The idea that any inspector or regulator would look at the guidance and then apply that as criteria would seem an absolutely normal process. Yet on reflection, having read the Francis report and the Winterbourne View report, one suddenly realises that, certainly from 2009 but far back in time as well, the department under successive Governments has offered guidance about safe staffing levels. It has done that in everything, but particularly in acute settings, I appreciate that. The fact that that was not taken into consideration makes the noble Lord’s amendment absolutely appropriate. I cannot see for the life of me why my noble friend would not accept it as a very sensible addition for making sure that the CQC, when it carries out inspections, takes that into consideration.

I would like to spend a little more time on Amendment 159, which has been so superbly introduced by the noble Baroness, Lady Emerton. Amendment 159 covers a lot of the same ground but goes further in spelling out the direct link between staffing and patient safety. It is important for my noble friend to understand what it does not do; nobody on either side of the House has sought to impose statutory staffing limits in legislation. That would be counterproductive in getting the sorts of outcomes that we want.

I prefer, as I am sure colleagues on all sides of the House do, to have strong statutory guidance with good inspection, which is what we have had in the past. The amendment of the noble Lord, Lord Hunt, does this—it completes the circle. I am very concerned that this House and the department spend too little time addressing the question of safe staffing. What does that actually mean? I declare an interest as an honorary fellow of the Royal College of Nursing. The RCN associates safe staffing with nursing because nurses, together with healthcare assistants under their supervision, do most of the care. But safe staffing is about the total product, not simply about nursing. It is also about the ward managers and everything else that goes into ensuring that when patients go into any setting, whether it is domiciliary, a care home or an acute hospital, there is an appropriate level of staffing.

When I was writing the Willis Commission report last year, one of the things that came up over and over again was a demand for mandatory staffing levels. I spent some time looking at the literature on safe staffing levels to see whether there was a correlation between having the right number of staff—registered nurses, care assistants, doctors or consultants—and outcomes. Frankly, it is very difficult to find empirical evidence to support it one way or another, simply because nobody in the healthcare system works in isolation from their colleagues. You are only as good as the team that works around you and their skills and training mix. I looked up what was happening in California where for more than 10 years they have had mandatory staffing levels for registered nurses. No other state has followed that. In April Senator Barbara Boxer introduced a Bill in the Senate to try to establish a federal system of ensuring that all hospitals had particular staff levels but nobody has followed that through.

There is some research being done in the UK, such as Anne Marie Rafferty’s 2007 study, with which Members are familiar. It was a really good piece of work which showed a 26% higher mortality rate in the cases of very high patient to nursing ratios. Kane’s meta-analysis in 2007 of all the literature indicated an emerging consensus that there are particular staffing levels beyond which the situation becomes dangerous. It is an issue for the department to constantly keep that under review. The amendment does not go over that ground but makes it clear in terms of safe staffing that there would be a duty on the provider, such as the hospital or the care home or those providing domiciliary care, to ensure that staff levels were appropriate and that staff competence is such to carry out safe care. After all, there is nobody in this House who does not want to see safe staffing within all NHS and other providers of health and care. That seems to be a basic starting point for a high-quality health and care system. We need to be able to ensure that that is the case. You will only find out what safe staffing levels are in a particular scenario and setting if you monitor them. That is why there is a requirement in the amendment to report on it. We are not talking about a report every three or five years, but there should be a continuous report so that when the CQC goes into a setting, it can look at the correlation between safe staffing levels, acuity and mortality rates and other factors, to see whether outcomes are dependent on particular mixes of staff.

Nor is the amendment saying that there should be annual reports. The Secretary of State would decide how often the department should be able to look at those reports. In essence, however, we are trying to establish that ensuring that the staffing mix is appropriate to the setting and to the patients who are being cared for is fundamental to healthcare. I hope that the Minister can give us some serious comfort on that. If we can get that right, we will have a good healthcare system.

[Baroness Gardner of Parkes (Con)]

My Lords, I am of course impressed by what has been said by the noble Baroness, Lady Emerton, who always knows so much about this subject. We have benefited from her great expertise over time. I am also interested in what the noble Lord, Lord Willis, has just said on the same amendment; he cited Amendment 159 but I thought it was Amendment 158.

[Lord Willis of Knaresborough]

It was Amendment 159.

[Baroness Gardner of Parkes]

I leave it to the department to work out whether it was Amendment 158 or 159, but that is not too important.

In many ways Amendment 144 does not go far enough. I am sure that the point of the noble Lord, Lord Willis—that the Care Quality Commission should be capable of thinking of these things for itself in any case—is right. However, the phrase “the skills mix” concerns me. There can be huge differences in the skills mix. I was concerned that the Chelsea and Westminster Hospital, having waited for perhaps as long as 10 years, at last got a specialist nurse for neurological conditions. The hospital was delighted because it had had huge demand for such a service. I am a great supporter of specialist nurse services.

The Royal Free then came along and poached that nurse from the Chelsea and Westminster, which then looked at what it could do. I was informed by word of mouth that there was no question or even thought of a replacement because there was a long list, and it was a case of “the first cab on the rank” as to who was deemed to be most needed. It could have been an ordinary nurse, it could have been a surgical nurse or anyone. You moved on and did not replace the person with the skills that you needed and wanted. You had to replace your missing person with whatever the next thing on the waiting list was. That seemed to be a serious cause for concern.

It is essential to know what skills mix is needed. The amendment mentions “official guidance”. It would have to go much wider than official guidance. It has to be attributable to the particular hospital or service that is involved. Although the amendment covers many of the important points, it does not cover the need for every facility to have cover within that department and not to then find that they have lost it because someone left—they could have gone off on maternity leave, they could have left for any reason, but in this instance they were poached by another NHS hospital.

Whatever the answer, it is important. The relationship between the staffing levels is hard to assess and has to be individually done. The Care Quality Commission should be capable of having an indication of what it should be looking at, and needs to be aware of all these problems. Of course, not one of us could oppose having enough staff on the wards, which the noble Lord, Lord Hunt, said was necessary. However, we are now faced with positions where budgets are limited and they have to look at and work out what they need most. I do not agree at all that it should be just a progression from whoever has been waiting the longest; it should be whatever the hospital, or a particular department, needs the most. Although I support the principle, perhaps it needs more than this. I am hoping that the Minister will be able to assure us that he can incorporate some words within those he already has to make it clear that there must be this obligation. I strongly support Amendment 144 and I am open to conviction about Amendment 158 or 159.

Care Bill [HL]

Baroness Gardner of Parkes Excerpts

Wednesday 16th October 2013 Lords Chamber

Placing them for care can be very complex. A young person with all the needs of a young person and all the emotional needs and sexual-development needs does not want to be placed in an institution which is full of people over 85, some of whom have got dementia, where the staff are not comfortable even discussing with them some of their more intimate needs and desires. These young people want to discuss contraception; they want to discuss sexual experience; they may want to drink alcohol. In an older person’s environment, that is not always the atmosphere. As the parents get older, they know that the physical strain of providing care is becoming too great, and they will not be able to do it anymore. That is why we feel strongly that the government amendments are fantastic, as far as they go, but having an extension with clear timelines to make sure that this is a gentle process is particularly important. I hope that the Minister might have some words of comfort for us, if it is not to accept the amendment but certainly within regulational guidance later, that this period of transition will be looked at because it is so difficult for both the young people and for their parents or carers.

[Baroness Gardner of Parkes (Con)]

My Lords, I particularly wish to speak on Amendments 83A and 84, but I could just as easily have spoken on any one of these amendments—there is such a big group of them—because the issue that I wish to raise is my concern over this care issue falling down between this Bill and the Children and Families Bill. The timing of these two Bills makes it very difficult unless the Minister, having heard all these debates that everyone will give now, and the comments on these issues, gives us an undertaking that he will liaise with the noble Lord, Lord Nash, and that between them they might try and sort out where it is going to go. This is what worries me: that it will end up going nowhere or come up from the noble Lord, Lord Nash, in a form that will make it too late to bring back here, unless the Minister says that he will look at everything said today and bring back an amendment—or at least accept an amendment if we could all agree on one.

So much of what has been said made sense. The comments of the noble Baroness, Lady Finlay, were fascinating, and the noble Lord, Lord Patel, put it all very clearly. The noble Baroness spoke more on issues about which I am particularly concerned. My eldest grandson is a Down’s child. His Down’s is fairly severe. He has been fortunate in having wonderful care at a Mencap home. He is 22 and this is his last year of receiving full support. He was very happy at the home for some years, until a glitch appeared in the past year. In his unit, a number of residents are put together to live a normal life and to learn how to go out and live in society. Unfortunately, a very aggressive boy was put into the group. No one knew that he was aggressive. He attacked the staff quite violently. As a result, others—I do not know whether it was just my grandson, or whether it was others as well—copied him. This is a terrible risk. If we do not supervise people and have continuing care and assessment of them, how do we know that they will not meet a violent person who behaves in this way, either deliberately or for some other reason—for example, because they are violent and cannot help trying to impose violence on everyone else? It is a real worry not only for the person but for society and the community.

The noble Baroness, Lady Finlay, spoke about the parents who care so much. The parents of this boy are both very clever doctors. One of his siblings is just starting medicine and the other hopes to in the next year or so. So he has siblings who would be able to care if his parents die before him. However, people with Down’s syndrome can live to a considerable age. I have met people of 50 and 60 who have the syndrome. In many cases, their parents will not be alive. It is a huge responsibility to pass on to siblings. Therefore, it is important that, as far as possible, these people should be brought into society to live as normally as they can. As they grow older, they usually grow bigger and stronger. Therefore, they are more of a worry to themselves and to other people. It is terribly important that the assessment of cases for continuing care should be made, and should continue to be made—and not just at 25. If people are going to live to 50, they may need support until then.

A number of the amendments put down by the noble Earl, Lord Howe, cover that issue, but without defining it clearly. This is why I am speaking in general on the amendments in this group. It is important that this should be clear. I have added my name to an amendment of the noble Lord, Lord Rix, in the Children and Families Bill. It is in response to the implication that the Government are thinking of taking out care completely: that once education finishes, nothing more will follow. That is why it is so important to be assured in this Bill that something else will follow.

My daughter tells me—and she has sent me a letter from another parent—that there is great concern that parents are not listened to nearly as much as other people are. The noble Earl’s Amendment 84 does not really cover anyone except a remote person in a local authority who will be responsible for needs. There is nothing to say that they will consult, or even consider the views of, parents or the person who is doing most of the caring for the person concerned. None of the amendments in this group quite reaches what is necessary to cover the issue. I hope that when the Minister sums up, he will give an assurance that will leave the way open for this to be considered at Third Reading. The rules on what can be brought back at Third Reading are very specific. If today we all ended up either winning or losing on some particular thing, it would not necessarily mean that we could modify it in a way that we all thought was better and brought a better answer. I support Amendment 83A and probably quite a number of others, but I will not go into the details because my argument applies both for and against so many of these amendments and I do not want to waste the House’s time by speaking more than once.

[Earl Howe]

My Lords, I am pleased that I have been able to table amendments that significantly strengthen these important provisions, and I am grateful to noble Lords for acknowledging that. Currently, assessment under the transition provisions has to be requested and I sympathise with the concern that in some instances, people who are unaware that they can request an assessment may lose out.

Amendments 84, 87, 89, 92, 94, 96, 98, 102, 103, 106, 108 and 113 remove the need to request the assessment. I have also tabled Amendments 85, 95, 99 and 104. They will replace provision that local authorities may assess a child, a child’s carer or a young carer when it appears to them that it will be of significant benefit to the individual to assess and where they are likely to have needs once they turn 18, with a duty that a local authority must assess in these circumstances.

Amendments 110 and 111 reflect an amendment to the young carer’s amendment to the Children and Families Bill. This is an example of the detailed work undertaken to ensure that the two Bills work together. I want to reassure my noble friend Lady Gardner in that context that we have done a great deal of work over the summer to make sure that that is indeed the case. Amendments 83A, 84A, 89A, 93A, 94A and 94B, tabled by the noble Lord, Lord Patel, and the noble Baroness, Lady Finlay, reflect concern that a local authority may leave it too late to carry out an assessment. I need to be very clear about this. The amendments I have tabled place a duty on local authorities that they must assess at the time where it appears to them that there is likely to be a need when the young person turns 18, and it is of significant benefit to that individual to assess at that time. My noble friend Lady Gardner was worried that the government amendments might not be sufficiently precise or prescriptive. The clauses are formulated in this way precisely so that assessments happen at the right time, whether that is before or after the age of 14, depending on the individual. The Bill approaches transition planning with a firm focus on assessing at the right time for the individual by the new duty to assess where it would be of significant benefit to the individual. I am not persuaded that the interests of young people are best served by prescribing when assessment should take place.

Tobacco Products Directive

Baroness Gardner of Parkes Excerpts

Tuesday 15th October 2013 Lords Chamber

[Earl Howe]

My Lords, the tobacco products directive, as the noble Lord will know, does not seek to introduce standardised packaging. As he will also know, the Government have decided to wait before making a final decision on that issue but we want member states to have the flexibility to make further progress on domestic tobacco control measures in certain key areas that go beyond the new directive. We have been helping to shape the final text of article 24 to achieve that objective.

[Baroness Gardner of Parkes (Con)]

Is my noble friend aware that in this country people who have suffered even major amputations are still so addicted to tobacco that they will ask the doctor to hold up the cigarette to their mouth? I have had this report from doctors. Does he not think that what we really have to aim at is stopping smoking among the young? Is he aware that in Australia it is no longer cool to smoke if you are young? Apparently, that is more effective than any of the health warnings.

[Earl Howe]

My noble friend, as ever, makes some very wise comments. The good news is that the most recent figures on smoking prevalence are going in the right direction. It is undoubtedly true that we can never do enough to raise our game on smoking cessation measures, one of them being nicotine-containing products. That is of course a major focus for Public Health England.

Care Bill [HL]

Baroness Gardner of Parkes Excerpts

Wednesday 9th October 2013 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, on reading carefully the amendments in the name of the Minister, I hope that he will be able to provide reassurance that his amendments will go further than Amendments 22 and 25 to which I have added my name and that they will be much more about the whole person and the whole person’s needs. I recognise that there are dangers in putting a timeframe around anything; there is the danger that it will be used as a so-called minimum standard, down to which people will drop. I initially wanted to support these amendments and I suppose, if I had a choice, I would have added my name to those of the Minister now, because there is a real problem if care is not adequate in quality and promoting well-being in that it creates dependency rather than reablement towards increasing independence. There is a sense of personal worth that goes along with being able to do things, however slowly, rather than having to accept somebody doing them for you because they are in a terrible rush. I hope that the Minister will provide us with a much wider reassurance than the words suggest at first glance.

[Baroness Gardner of Parkes (Con)]

My Lords, I was most interested to hear the comments of the noble Baroness, Lady Meacher, and I agreed with every word, but I do think the time limit specified would not be right and I strongly support Amendment 27. However, there are other aspects of this care issue that we have not really thought about.

One that is covered in Amendment 27 is about the well-being of carers. I find it very disturbing that a woman I know who lives in with a person needing pretty comprehensive care every Saturday and Sunday and stays overnight on both nights, is appallingly paid for this because she is self-employed. I said to her that I could not believe she was earning so little when it is such a very important job and so very time consuming. I told her I would look on the internet to see what she is entitled to as a minimum wage. It turns out that there is no minimum wage for a self-employed person. That quite stunned me; there is a great reservoir of people who would be willing to take on self-employed caring positions and do them for quite long periods, not rushing people, but not at her rate of pay, which worked out at a little over £2 an hour for all the hours she was there. I suggested that, since she had done training in care, she should work instead for the people who provide a service for the local authority. She followed that up and it turned out that she would not earn much more, because they are not paid for travelling time. Unless the organisation improved so that her two, three, four or 10 jobs—whatever it is—were almost next door to one another, the unpaid travelling time would constitute much more of her day than the time actually caring for people.

The other point raised by the noble Baroness, Lady Finlay, is that it is more than just physical care. We have heard much in recent days about people’s extreme loneliness, how they can go almost for days with hardly a word with anyone. That is a most essential thing in life, to feel that you have not been abandoned. The woman in the television report talked about taking your coat off, making your booking and going through it all, and how you are left with 10 minutes in the middle and then you book in a final 10 minutes to reverse everything. That is exactly what I remember from when I was chairman of local social services 30 years ago; that was exactly the same problem then.

These are not new problems; because there are so many more older people who need more care, and there is more awareness, with people wanting to stay in their own homes, this problem has grown, and we do not have the solutions to match the need. I strongly support the emphasis on the well-being of carers, which is mentioned in Amendment 27—that is important. People should feel that they are doing a worthwhile job and that what they are doing is helping other people. They should also be reasonably remunerated for it. There is so much that we would all support; I feel that all noble Lords in this Chamber want to see more help and more efficiently used help. Amendment 27 in particular covers a lot, but whatever offers can be made, so much the better.

[Baroness Emerton (CB)]

My Lords, I apologise for not having heard the first part of the speech made by my noble friend Lady Meacher; I can only say how much I agree with her. In the past nine weeks, while the carer was away, I had the personal experience of doing two weeks’ full-time caring. I timed waking up, giving the medication, getting breakfast, rushing up to do my post while she was having her breakfast, and then attending to her personal care and getting her dressed. It took an hour and a half, every day, and that was just the morning.

On the point made by the noble Baroness, Lady Finlay, the minimum quality standards in the noble Earl’s amendment set a good standard. However, that needs to be supported by an assessment and care programme. There needs to be a proper assessment of what is required in terms of the total care, not just the minimum. We have a system for some of our residents in the retirement development where I live, where prevention to admission to hospital is done by an assessment of how much time care is required. Two people come from the unit—a nurse and a physiotherapist—and fully assess the patient. If there is a proper care programme, that gives the time element. Amendment 25 says “excluding travel time” and that a visit should not take less than 30 minutes. It is difficult to be so prescriptive, but if that was according to the care plan, it might go a long way.