Care Bill [HL]

Debate between Baroness Greengross and Lord Hunt of Kings Heath

Wednesday 9th October 2013 Lords Chamber

[Baroness Greengross]

My Lords, this amendment concerns discharge plans for people in hospital. I shall start by saying that, in response to my Amendment 87ZA tabled in Committee on this issue, the Minister was understandably reluctant to specify the particular circumstances in which the high-level aims of the general duty to co-operate, as set out in Clause 6(5), should apply. He felt that there should not be an exhaustive list of circumstances, such as discharge plan management, in which the power should be used, and said that he expected authorities and their relevant partners to co-operate when an individual was discharged from acute care under this clause. He asserted that Schedule 3 to the Bill sets out clear steps to ensure the safe discharge of a patient from an acute care setting, and that an assessment for care and support should be made before the patient is discharged, not afterwards. Clause 12(1)(b) already allows for regulations to specify other matters to which the local authority must have regard in carrying out an assessment. Given that this involves setting out procedural detail and related matters, he felt it more appropriate to set out such detail in regulations rather than in the Bill.

While I agree with much of that, my main point regarding the importance of discharge being included as part of admission planning into an acute care setting may have been misunderstood. The subject of discharge should be considered as part of the admission process, long before the actual discharge is instigated. That is the important point here, and I remain firm in my belief that it should be included in the Bill. The most important thing is the idea that discharge planning should be part of the admission process. We have all heard a large number of stories of people who have been discharged inappropriately because everything is decided too late in the day and no one is ready for the discharge. I personally could talk about two or three relatives aged 80 to 90 who have been dumped out of hospital in the middle of the night. Such instances are horrific, but I am afraid that they will continue unless we get this right.

Clause 12 is not relevant here because it refers to a need for a care assessment as being an essential part of the discharge process from an acute setting into either supported home care or longer-term residential care. I want to ensure that it will be facilitated by eventual discharge being part of the admission assessment, which is a very different process that is gone through at a different time by different clinical staff. Including such a duty in Clause 6 would ensure that this happens, so that the eventual discharge stands more of a chance of being successful. The Royal College of Nursing has expressed the view that:

“We are currently seeing far too many people trapped in a ‘revolving door’ between community and hospital services”.

Ensuring a suitable discharge founded on appropriate admission from acute care would, in my view, go a long way to reducing this terrible waste of resources and its associated human misery. I beg to move.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Baroness, Lady Greengross, for allowing this debate. This is an important question and I agree that ensuring that an assessment is made around the time of the admission of a patient to a hospital or other acute care setting would help the process of the appropriate discharge of that person when the time comes for them to leave. One has to say that the context in which we are debating this is one in which the health and social care system is under extreme strain. The Minister will know that the accident and emergency performance, and the issue of the four-hour target, is proving to be problematic for a number of trusts, including my own, in September and October. Clearly, if the health service is having difficulties in September or October, in pretty clement weather, it does leave one with some foreboding about what is going to happen later on in the winter.

The Government have injected a certain amount of resource into the system—I think it is £250 million—which is labelled on the tin “to A&E departments”. The Minister will know that the money has not gone to A&E departments; it has tended to go to the clinical commissioning groups. While limited amounts have gone to A&E departments, in the main, this has been dealt with through urgent care boards. My understanding is that in a lot of areas they still have not decided how to spend the resources. This is partly because CCGs seem to be slow to make hard decisions, and partly because some are not spending the money because they say that they have not received it yet. The problem is this: if by the middle of October you still have not spent or committed yourself to those additional resources, it could take another three months. If, for instance, it was a series of care packages or it was extra resource for employing more nurses, it could take an awfully long time from the decision to spend the money to it actually being in place, and then for the money to be spent.

I am really using this as an opportunity to say to the noble Earl, Lord Howe, that there is a real issue at the local level of actually getting all the partners together and to agree the actions that need to be taken to ensure that we do not get the kind of discharge problems that we are seeing.

What is the cause of the issue of A&E performance? There has been some debate about whether it is partly due to the lack of accessibility and primary care. No doubt, there are serious issues involved which would suggest that that is a problem. However, the noble Earl may have seen some work undertaken by Matthew Cooke, who used to be the adviser to the Government on urgent care and was a consultant in my own trust at Heart of England. His work would suggest that the problem is discharge; that there is simply not the capacity in the community or among personal social services departments to provide the support that is required. However much the Government want to beat up A&E departments, unless we can sort out the capacity in the community, these problems will continue.

The noble Baroness’s amendment is really trying to get to the heart of this. She is saying that it is a real problem—not just for older and more vulnerable patients, but it is probably more directed at those patients—if the first time you start to worry about discharge procedures is when they have spent quite a few days in hospital. First, it takes a long time for the system to intervene; and secondly, it may mean that the patient stays in hospital too long. We know all the problems of institutionalisation, when people have greater difficulty in going back to their own home or into low-level community provision as opposed to having to go into care homes.

The noble Earl, Lord Howe, will no doubt say that this is not the stuff of legislation. However, because of the seriousness of the current problems in our health and social care system, it would send a very powerful signal to people working at local level about the absolute importance of starting discharge planning almost as soon as a person comes into A&E, and of the need to have an integrated approach. It would also give a signal to local authorities. At the moment there is a real problem because local authorities often play around with discharges by saying that they are not convinced that a person is ready for discharge. That is simply trying to ration expenditures. A signal to local authorities that that is also unacceptable would be very helpful.

I am glad that the noble Baroness raised this problem. It is a very important issue. I hope that the noble Earl may be able to help us with it.

Care Bill [HL]

Debate between Baroness Greengross and Lord Hunt of Kings Heath

Tuesday 9th July 2013 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, as this is my first intervention, I refer noble Lords to my interests as president elect of GSI, chair of an NHS foundation trust and a consultant and trainer with Cumberlege Connections.

I have three amendments in this group. Amendment 86J seeks to delete “high quality services” and instead insert,

““services appropriate to their needs as identified in the needs assessment and carer’s assessment”.

The problem with the draft as it currently stands is that it is very vague and entirely subjective depending on who is defining “high quality services”. Perhaps the noble Earl can clarify how the Government think it ought to be defined. Otherwise, there is a risk of uncertainty and inconsistency which, certainly when it comes to eligibility criteria, the Bill is designed to eradicate.

My second Amendment 86K would ensure that those in receipt of care and those involved in providing care are involved in shaping the market, as required under Clause 5. I have received a number of submissions about the market-making role of local authorities, and I was concerned to receive a submission from the Association of Directors of Adult Social Services, which said that while the intention of Clause 5 in promoting quality and diversity within the market is laudable, ADASS was of the view that the proposed duty placed on local authorities is wholly unrealistic. It points to a large number of providers that have no relationship or contact with local authorities, and says that combined with increased personalisation and limited leverage through the regulation framework, the ability of local authorities alone to influence diversity and quality of service is restricted.

I was very disappointed with that response, and rather taken aback by it. I hope that the noble Earl will share my view that in fact local authorities ought to be able to influence not only the market but the quality of care provided by private providers to a very great extent. Would the Minister accept that, to be effective, local authorities need to have a strong engagement both with users of services and carers, and with those who are providing services, too? That is why I tabled the amendment.

I listened with great interest to the noble Baroness, Lady Emerton, and I very much agree with her about the need to ensure quality in provision of service. That brings me to my own substantive Amendment 86P, which is very much concerned with the conditions under which care workers are employed in the main by the private sector. This is a hugely important issue. Clearly, we have a growing number of disabled and older people who need care and support. The people working in the care sector are vital. We need quality people who are highly trained and who can give the right commitment to the vulnerable people they are asked to care for. Clause 5 is important because what we see is a very fragmented industry delivering care that in many cases is of questionable quality and employing insecure, low paid, unregulated staff. Amendment 86P is concerned with the importance of fostering a sustainable workforce to encourage the acquisition of skills and decent working conditions that support the continuity and quality of care.

I was shocked to see a parliamentary Answer from the Minister’s honourable friend Mr Lamb recently, showing that more than 300,000 people working in the care sector are employed on zero-hours contracts. The point that I wish to make is this: how can people who do not have the security of knowing what they will earn pass on a sense of security to the people whom they care for? The rise in zero-hours contracts is bad for service users, many of whom are, of course, extremely vulnerable. There is another issue. People who are being cared for want to see the same person to have a continuity of care relationship. We know that that is severely hindered by those wretched zero-hours contracts. I believe that secure employment would allow staff to concentrate on caring rather than worrying about whether they are earning enough money for themselves and their families to live on.

I ought to declare an interest as a member of UNISON, which produced an excellent report, Time to Care, which undertook a survey in 2012 of care home workers. It showed that 80% of those who responded had to rush work or leave a client early to go to another call on what is called call cramming— in other words, too many calls for a care worker to undertake—and 56% received between the national minimum wage and £8 an hour. The majority did not receive set wages. Not surprisingly, turnover is high, while wages and conditions are poor.

Here is a shocking statistic. Nearly 57.8% are not paid for travelling time between visits. This morning I met a carer in Southwark who works roughly 20 hours on a zero-hours contract. She reckons that, because of the travelling time, she actually works for 27 hours, but is paid for only 20. The problem is that there is a race to the bottom because local authorities are, in my view, neglecting their responsibilities for ensuring that, when they place contracts, they are with good quality organisations. The companies who are exploiting their workers in this way are winning contracts at the expense of companies who treat their employees wisely. No wonder, therefore, that 36.7% of respondents are often allocated different clients on a daily basis, so that there is no chance of any relationship being developed.

There are many other statistics. The scandal of the 15-minute visit is well known. Indeed, the UK Homecare Association survey shows that three-quarters of all trips to old people have to be completed in less than half an hour and one in 10 is limited to no more than 15 minutes.

In Committee last week, I discussed with the Minister whether the CQC could be persuaded—or indeed, I hope, instructed—by your Lordships, to prioritise the regulation and inspection of local authorities in their commissioning duties. We have heard a lot about the CQC’s past failures and future hopes. It is clear that the focus is going to be on the NHS. I do not disagree with that, but when you think of the thousands of vulnerable people dependent on care workers, I wonder if the priority is right. If I were in the CQC’s shoes, I would focus on the care sector and particularly on local authorities and their own responsibilities. That is probably the best way to get into this issue.

We could have a debate about the regulation of social care workers. We could debate mandatory training and the noble Baroness, Lady Emerton, has tabled an amendment which would very much focus on that. I hope the Minister will recognise that we have a problem here. If we are to see this legislation enacted in the way that we all hope it will be, I am convinced that we have to look at the way that workers in the care sector are employed and do everything we can to prevent the abuse that we are seeing with these zero-hours contracts.

[Baroness Greengross]

My Lords, I rise to speak to the amendments in my name—Amendments 86L, 86M, 86N and 86Q. These amendments are all about quality of care. We know what happens at the moment. There is the opposite of a monopoly in that there are lots of sellers, but largely one buyer of care. Many care homes know this. The local authority is in a very strong position and will tell the care home managers—in the private or voluntary sectors—that they will take 20 beds and negotiate a price which is very low. That means that the care home cannot provide a decent quality of care at that unrealistic price. This has been talked about and written about by Laing and Buisson and various other bodies. It is a known fact among those who follow very closely what goes on, but at the moment it is not really known to the public.