Care Bill [HL]

Baroness Hollins Excerpts

Tuesday 16th July 2013 Lords Chamber

[Lord Touhig]

My Lords, I support Amendment 88Q, which was so powerfully moved by the noble Baroness, Lady Grey-Thompson. I certainly welcome the Government’s intention to establish national eligibility criteria, so that local councils across the country will be required to provide care for all those with a minimum level of need. However, I share the concerns which were so well articulated by the noble Baroness and the noble Lord, Lord Low of Dalston, that setting the fair access to care services criteria at “substantial” is simply plain wrong. It is wrong because it will exclude many people who I know with autism, and who have a low-level need of support. They will no longer be able to live independently if the level is set at substantial.

Setting the threshold at this level also seems to be running counter to the Government’s stated intention in the Bill, which is to focus on prevention. The requirement for people to have a physical or mental impairment to qualify for support could mean that those without a diagnosis will be excluded and miss out altogether. A great many people with autism do not get a diagnosis. I have been dealing with a case recently where people have been waiting four years to get their daughter diagnosed. I join the National Autistic Society—again, I declare an interest as a vice-president—in urging the Government to reconsider this and set the threshold at something equivalent to “moderate”. That is by far the fairest and best way to do it.

I make no apology for saying something which I think I have said about three times in this Committee: there is substantial evidence from the National Audit Office and NICE to indicate that investing in services for those with a moderate need is cost-effective. New economic modelling by Deloitte, published recently, shows that every £1 invested in support for people with autism and other disabilities who have moderate needs, generates a return across the piece of £1.30. That is not to be ignored and should be part of our consideration. There is much merit in this and I rather feel that the Minister, who is a decent and honourable man, will see that there is. I am sure he is going to give us some good news; at least, I hope he will.

[Baroness Hollins]

My Lords, I would have added my name to this amendment because it is excellent and necessary. I, too, hope that the noble Earl will see the sense of it. Certainly, people’s fears that the Government would propose to set the national eligibility threshold too high have been confirmed. Rather than celebrating the achievements of councils that have been able to provide highly valued, innovative and low-cost services to people with low and moderate needs, we are instead to fall in line with the majority of local authorities, with the false hope of avoiding financial strain. Failing to provide services to people with moderate care needs is, at best, a missed opportunity to encourage preventive care and significantly improve the quality of life for a highly disadvantaged group of people. At worst, we are leaving a considerable proportion of people with a lifelong disability to fend for themselves.

Case reports of those recently excluded from receiving support are extremely troubling. We have heard some examples already today with some people losing all daycare provision and facing an isolated life at home. Other case reports demonstrate the importance of lower levels of support. I want briefly to give the example of Frances, a middle-aged woman with a mild to moderate learning disability who has always struggled to understand and manage bills. Since receiving a few hours support a week she has finally had relief from receiving constant threats and eviction notices. How long will her support survive before she is declared ineligible? Clearly the resources of the state are limited but they need to be used wisely, and I believe that our care system must encourage and incentivise local authorities to provide lower intensity interventions that can make a difference to the quality of life for many people.

On the face of it, opting for a moderate national eligibility threshold may sound as if it would require considerable additional funding, but providing these services to a group who by definition are often highly vulnerable and disadvantaged could result in great savings by avoiding more costly acute care later. I hope that the Government will rethink this amendment.

[Baroness Greengross]

There are vast numbers of older people—for whom this Bill is designed, in terms of quantity—who we know want to stay in their own homes in their community. Early intervention can make that possible. If we delay, the alternative is crisis-driven. It leads to many older people going into expensive care homes where they do not want to be and from which they do not emerge again or into hospitals, adding to the problems we know about with frail elderly people. I very much hope the noble Earl will reconsider and enable people with moderate needs to have access to services.

Care Bill [HL]

Baroness Hollins Excerpts

Tuesday 9th July 2013 Lords Chamber

[Baroness Hollins]

My Lords, I want to speak briefly in support of Amendment 82B, tabled my noble friend Lady Meacher, which emphasises the need to facilitate access to information and advice services relating to care and support. This is particularly the case for vulnerable adults such as people with learning disabilities. They may benefit from specialist facilitation to access such information. I should say that I chair a social enterprise which makes information on health and social care issues easier to understand for people who find written information too difficult. I am also the carer for an adult who currently receives care funded by the local authority, and who himself needs easy information.

I hope that the Minister will agree that my noble friend’s emphasis on facilitation will add necessary strength to Clause 4(4), which states that information,

“must be accessible to, and proportionate to the needs of, those for whom it is being provided”.

Without appropriate facilitation, the information may not achieve its objectives for those for whom it is provided unless it is done in the right way and in a timely fashion. Certainly, my own experience as a carer is that at the moment far too much information of the wrong kind is often provided, which is confusing. Facilitation is also about helping to choose the right information at the right time so that people can make good use of it.

[Lord Rix]

My Lords, as we are approaching Statement time, I will be brief. I want to support the noble Baroness, Lady Browning, in her Amendment 88G, which advocates the need for advocacy. In the world of learning disability, advocacy is often totally essential. Information and advice which is not proportionate, frankly, can be quite useless. Advocacy may well come from parents and carers, but sometimes it can be the wrong advocacy. An independent advocate is essential to many people with a learning disability, so I wholly support this amendment.

Care Bill [HL]

Baroness Hollins Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Turnberg]

My Lords, after that tour de force by my noble friend Lord Campbell-Savours, there can be hardly anyone who does not believe that the training of healthcare assistants should be mandatory. Indeed, most of the public would be surprised to know that they are not trained or may at least get through without any training whatever.

I strongly support the amendments. They are a slightly less strict version of Amendment 16 from the noble Baroness, Lady Greengross, in that it focuses heavily on the mandatory nature of the training, and that is of course the basic requirement. It omits the need for statutory registration, but the case for mandatory training is incontrovertible; I cannot see anyone believing that it is not.

I hope that the Government are open to this proposal. It is a valuable step in the right direction, even if we cannot have registration at the moment. I sincerely hope that the Minister will be open at least to this proposal, which has such merit and such strong support from almost everyone; I do not know of anyone who argues against it. I do hope that he might see this sympathetically.

[Baroness Hollins]

My Lords, my interest is as the parent of two adult disabled children who receive publicly funded care. I did not speak to the earlier amendment on the need for the regulation of health and social care assistants, but I strongly believe that some such staff are currently poorly served by the lack of an adequate professional framework. Many have poor pay and variable conditions of work, and perhaps poor protection for themselves. They also have varying access to training, supervision and education.

To give one example, a care assistant was employed to work with an autistic person without receiving any autism-specific training, even though it was specified in a support plan. One would hope for some basic mandatory training that also specified what future training might be needed to support specific people with specific needs. That seems to be common sense.

My noble friend asked clearly for mandatory training in basic standards of care, and that these candidates should then be registered as suitably trained. It is a neat solution to the problems that we are facing and it makes very good sense. I have one more example: in the interests of more integrated health and social care, care assistants are often required to support disabled or elderly people to access healthcare, but they are not very good at doing that. The confidential inquiry into the premature deaths of people with learning disabilities found that it was often the lack of persistence of people who were supposed to be supporting learning-disabled people that led to a failure in follow-through of their healthcare investigations and treatment.

I have a question about how personal assistants employed directly by people who are in receipt of direct payments would fare under such a system. Disabled people would need assurance that the personal assistant applying to work with them also had basic skills. One would hope that disabled people employing personal assistants would be reassured by the knowledge that someone had been registered as having a certificate of basic standards of care. I add my support to these very good amendments, particularly Amendment 23A.

[Baroness Cumberlege]

My Lords, I support these amendments on mandatory training. I know that the noble Baroness, Lady Emerton, has fought and fought for this. I served with her on the United Kingdom central council for nursing, midwifery and whatever it was. She pioneered the whole idea of improving nurse training, and it was very successful.

To follow on from the noble Baroness, Lady Hollins, it is interesting that we now have two different parts to the arguments. One concerns the benefit to patients and the public, while the other concerns the benefit to the workers themselves, which I thought was a very interesting angle. It was Terry Leahy who said that he built his empire just by ensuring that all who worked for him felt good about themselves, and I thought that that was very interesting.

I am concerned about how the amendments are fashioned because I am not quite sure what we are talking about. Perhaps the noble Baroness or the noble Lord, Lord Patel, will clarify that for me. We talked about healthcare support workers, and I understand that such workers predominantly work in the NHS. However, subsection (2) of the proposed new clause refers to,

“a health or care support worker”.

I am not sure what a care support worker is, as opposed to a healthcare support worker. Does the support worker work, as the noble Baroness, Lady Hollins, said, in people’s homes? Do they work in residential care? Are they covered by this or not?

The noble Baroness made another point, which I was also going to raise and on which I would like some clarification: what about the people who work for others who need care, through direct payments or personal budgets? Will this rule out those volunteers who often come in and sit with someone, who may do some minor tasks and may even do some relatively nursing-style tasks, such as putting in eye drops, which a member of the family would do? I should like to clarify who we are talking about.

National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013

Baroness Hollins Excerpts

Wednesday 24th April 2013 Lords Chamber

[Lord Davies of Stamford]

I am in favour of scrapping all these regulations completely and simply voting them down tonight. That is my simple answer. I put the onus on to the noble Lord—if he can come up with a suggestion which reassures me, so much the better.

My second concern is over the future of networks. I was lobbied over the weekend by one or two doctors in Lincolnshire and I undertook to speak about this matter. One of them served as a junior doctor in Newcastle under the noble Lord, Lord Walton, and was full of affectionate and very admiring memories of the way in which he ran his department. Nevertheless, those doctors are deeply concerned—as are so many across the country—about the impact on networks. We have all read the handouts and papers from the BMA on this subject. I notice from the way in which the regulations are drafted that the protections regarding networks and integration in Regulations 2 and 3(4) in no way override the requirement in Regulation 5 to go for tendering. That is not a sufficient protection. They simply say that there is one criterion, and that is not good enough. If the Government want us to take these regulations seriously, I expect them to provide some specific reassurances on that.

My third concern is this. We all know that the ratio of fixed to variable costs in healthcare is extremely high. To use a technical term, the operational gearing of healthcare, particularly in the secondary sector, is very high. That means that if you take out any particular activity from a general hospital, the existing overheads will then fall on a reduced range of activities and therefore a reduced range of revenues. So you will make unviable—or are likely to make both financially and possibly technically unviable—other services which are being delivered in that particular hospital.

Under these new regulations, will it be possible for a CCG to take the view that it does not want to tender either service, which, if it took it away from the existing provider, would make that provider unviable not merely for that service but for the whole range of services currently being provided? In other words, will it be possible for a CCG to take the view that it is not in the interests of the patient in that particular area to run down or destroy a local hospital or a local unit? Will the regulations provide any protection for a CCG which, in the public interest, decides not to tender out for that particular purpose?

My final concern is one on which, again, I should like a specific reassurance from the Government—it can be in a yes or no form. We live in an international digital age. We know that medical services, even remote surgery, can be provided not merely here but anywhere around the world. If electromagnetic waves travel at speed c, that merely means that you have something like a 20th of a second delay if you are operating from India. A 20th of a second may not be crucial to that operation in terms of security.

Therefore, we may well face the possibility of tendering out services all around the world. It may be that a CCG will quite legitimately decide that the Massachusetts General Hospital is the best place to go for a particular type of surgery. That is fine but, again, if a CCG decides—or, more likely, if the national Commissioning Board decides—that it is in the interests of this country to keep a capability here, will it be protected in taking that decision against Monitor or against the competition laws which will then operate?

An even better example, perhaps, than remote surgery is imaging. Whether it is computerised thermography, ultrasound or magnetic resonance, these things can be read anywhere around the world in real time 24 hours a day, seven days a week. It may well be that very good offers will come in from India to provide this particular service. In those circumstances, if we went for those offers in a particular region—perhaps in the whole country—we would not have any radiologists left at all. They would all have gone somewhere else in the world. Will the national Commissioning Board and the CCGs be protected if, in the interests of keeping what they regard as an essential capability in this country, they decide that it is not appropriate to tender out a service or to accept a tender, however financially and technically attractive that tender might be?

[Baroness Hollins]

My Lords, I begin my comments by reminding the House that I am the current president of the BMA and a psychiatrist. The matter we are discussing this evening has been one of the most controversial aspects of implementation of the Health and Social Care Act. We are in a rather unusual situation, debating regulations that have already been subject to revision, following widespread concern about their intent and the strength or otherwise of ministerial assurances. This is remarkable. However, the opportunity has been afforded to us tonight to rehearse the issues once again and to ascertain why there is continued unease about these regulations. It is worrying that these concerns have not abated, despite repeated assurances from the Government during the passage of a Bill that we spent so many hours debating and further assurances received since the regulations were laid earlier this year.

The regulations are intended to ensure good procurement practice, as required by the 2006 EU directive and subsequent case law. They are substantially the same as those that were in place prior to the 2012 Act, which had the status of declaratory guidance and should have been enforceable in the courts. Will the Minister tell us how many legal challenges have been made since 2006 and how many organisations have deferred court action pending Monitor’s new powers? Will he also confirm that in future Monitor will provide regular reports on the scale of legal challenges and on their outcomes? The new regulations have the effect of binding the new clinical commissioning groups into the existing legal framework. This reminds us that the NHS of 2006 was a rather different organisation from today’s NHS, which is evolving rapidly after the radical changes of the Health and Social Care Act 2012.

NHS: Healthcare UK

Baroness Hollins Excerpts

Thursday 14th February 2013 Lords Chamber

[Earl Howe]

The noble Lord makes an extremely important point. This is not only a one-way street in terms of exporting British expertise. I know one very good example in which some of our trauma clinicians have been seconded to hospitals in South Africa where there is tremendous expertise on gunshot wounds, for example. That has been of direct benefit to clinicians in this country.

[Baroness Hollins]

There are some very rare conditions, such as Hunter syndrome, in which the United Kingdom is a world leader in developing treatments. These treatments are very expensive to deliver for the very small number of people who have the condition. Would they be more affordable for UK citizens if the treatments were offered to a wider population base, such as across Europe? Will Healthcare UK have this kind of initiative in mind?

[Earl Howe]

My Lords, potentially that is an area at which Healthcare UK could look. Certainly, some of our conversations with our partners in the Middle East have indicated that they are very interested in taking advantage of our world-class facilities in highly specialised areas.

Diabetes

Baroness Hollins Excerpts

Thursday 10th January 2013 Lords Chamber

[Earl Howe]

I agree with my noble friend about the importance of targeting obesity as a serious public health risk and one which leads to diabetes in many cases. I believe that, if my noble friend were to talk to NICE about its recommendations to prevent obesity, he would find that its line is slightly modified from the one that he has criticised. We should pay tribute to NICE for the good work it has done in the specific area of diabetes. The recommendations and guidelines it has issued have been very positive. There is, of course, a quality standard for diabetes, which is also excellent.

[Baroness Hollins]

My Lords, people with learning disabilities and those with serious mental illness have a higher incidence of diabetes. They have a later diagnosis and are therefore more at risk of complications. Does the Minister agree that one way to reduce the number of amputations associated with diabetes would be to improve access to diabetic care for people with learning disabilities or mental illness?

[Earl Howe]

My Lords, yes, I certainly do. There are a number of positive ways in which we can do that. One is the NHS health check, which should, if it is performed correctly, pick up those with undiagnosed diabetes. Early identification of diabetics is key in this area, particularly for those who are at risk of ulceration. Other ways are targeting preventive services at those most at risk, including those with learning disabilities; early management of foot infection and rapid access to multidisciplinary teams; and having good diabetic foot prevention and ulcer management services in local areas.

Care Services: Winterbourne View

Baroness Hollins Excerpts

Monday 10th December 2012 Lords Chamber

[Baroness Hollins]

My Lords, I welcome the report and the detailed actions that are listed in it. Indeed, it fills me with some hope after so many years of commissioning failure. The proposed change support programme is to be led by the NHS Commissioning Board and the Local Government Association. There is something ironic in responsibility for leading this change being vested in those who primarily have been responsible for the current failure. The evidence is that local authority and NHS leadership do not have the skills or knowledge to effect change. Indeed, my former colleague Jim Mansell’s first report on challenging behaviour was published 20 years ago and made similar recommendations to those in today’s report. Can the Minister confirm that the programme board will indeed be expected to engage with those from the learning disability sector, who understand the issues involved in the design and delivery of the support programme? Finally, why does the report make little or no mention of the need to provide access to the same range of mental health treatments that other citizens have access to, including psychological therapies?

[Earl Howe]

The noble Baroness brings us to a set of key points. She said that in her view the NHS and local government simply do not have the capacity to address these issues properly. In many respects we would agree with that, although it would be wrong to make a blanket statement about the whole country because we know that very good pockets of commissioning and provision exist. One of the tasks of the joint improvement team will be to identify those areas of best practice, and to enable those operating in those areas to go out and mentor other areas. Part of the sum of money that we set aside will be devoted to enabling those high-performing areas to backfill the places while they are engaged in that mentoring exercise. Her basic point is well taken. We think there is a job to do here but it is one of those things that the Board and the Local Government Association need to oversee on a national basis.

That is only a short extension from the function of the Commissioning Board in general, which will be to support commissions. We are grateful to the Local Government Association for its overseeing role for local authorities. I fully expect that they will engage with the learning disability sector. I commend to her the concordat, which is accessible on the department’s website, and she will see from that that the 50 organisations that have signed up to it include a number of voluntary organisations in this sector. Jointly, these bodies have committed to a programme of action. It is not just about defining what needs to be done but about how it will be done. It is an impressive set of commitments that those bodies have signed up to.

NHS: Women Doctors

Baroness Hollins Excerpts

Tuesday 6th November 2012 Lords Chamber

[Baroness Deech]

To ask Her Majesty’s Government how they propose to facilitate the retention of women doctors in the National Health Service.

[Baroness Hollins]

My Lords, on behalf of my noble friend Lady Deech, and at her request, I beg leave to ask the Question standing in her name on the Order Paper.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, over the past 10 years, from 2001 to 2011, the number of female doctors in the National Health Service has increased by 75%. Female consultants have increased by 105%, female registrars by 288% and female GPs by 58%. The Government, in partnership with other organisations, including NHS employers, the NHS Leadership Academy and royal colleges, support good working practices, such as flexible working, job sharing and part-time working, which support the retention of female doctors.

[Baroness Hollins]

Is the Minister aware that part-time training in the NHS is becoming much less available because of workforce pressures and difficulties in filling hospital rotas? Now that the majority of medical students are women, does he agree that the challenge is how to support those doctors who wish to work part time, perhaps while their families are young or while they have other caring responsibilities, and then to support them to move between full-time and part-time work that makes proper use of their talents and training? I declare an interest as president of the BMA and also as someone who worked part time for seven years as a trainee doctor.

[Earl Howe]

My Lords, I agree with the noble Baroness. I think this is less of a problem with retention of female doctors than a problem with the career progression of female doctors, which is a serious and significant issue. The noble Baroness, Lady Deech, published a very well argued report about three years ago, and a number of worthwhile initiatives have been started as a result of that. I do think that these need greater focus with more support at a higher level. Women are in a significant minority in more senior leadership roles in the NHS, and that is a loss all round.

NHS: Specialised Services

Baroness Hollins Excerpts

Wednesday 18th July 2012 Lords Chamber

[Baroness Hollins]

My Lords, until 2008, I was deputy chair of the National Specialist Commissioning Advisory Group, which was a predecessor organisation to AGNSS.

There are some very rare conditions affecting mental health. Services meeting the criteria defined by the noble Baroness have been commissioned, such as: the children’s gender identity development service, for children struggling with the development of their gender identity; services for those with very severe obsessive compulsive and body dysmorphic disorders; secure mental health in-patient services for young people, including those with learning disabilities and those who pose a forensic risk; and services for young deaf people with acute mental health problems. Each of these disorders is low in overall national numbers, which makes it difficult to assess the suitability of proposed services and treatments. The proposal made in the draft mandate to the NHS Commissioning Board is that the board will commission those services that fall into the national specialised services definition set. I understand that 85 services are being considered, of which about 10 are mental health services. These include some services that were previously commissioned following recommendation by AGNSS, such as the services I have already briefly described.

My worry, and I seek ministerial reassurance on this, is that learning disability and mental health services will fall though the specialist commissioning gap. Some of these services are quite messy. They do not conform to the medical model of rare medical diseases that can be researched in the lab, even if they have a serious impact and are rare. Even moving these services to NICE would create a problem since the research investment needed to provide evidence-based treatment has been neglected until now.

If there is to be parity of esteem between mental and physical illness, people with severe mental illness and with learning disabilities need equal attention to their complex clinical conditions. For example, there is no new, well funded research into drugs to treat serious mental illness and no repurposing of drugs, and I am unaware of any investment into exploring, for example, the role of immunology in drug treatment for severe mental illness.

I would like the Minister to comment on the continuing need for such highly specialist commissioning skills that have been developed within AGNSS and its predecessor NSCAG. There is some concern, which I share, that the successful work of AGNSS will be lost, with the risk of forgetting important lessons learnt about national, highly specialised commissioning in the past few decades. The NHS constitution states that the NHS’s resources are to be used,

“for the benefit of the whole community”,

to,

“make sure that nobody is excluded or left behind”.

There are concerns about whether any group which replaces AGNSS would comprise sufficient expertise to assess the unique requirements of highly specialised services, as well as about how the strong relationships built by AGNSS with royal colleges, patients and others will remain within the national Commissioning Board.

For me, the most important message is that some highly specialist services are needed for a small number of people with severe mental illness and learning disabilities which may meet, or nearly meet, existing criteria. New criteria for highly specialist services must ensure parity for these groups. Can the Minister assure the House that the new commissioning arrangements for highly specialised services will indeed mind the gap for complex psychiatric conditions, including those affecting people with learning disabilities and deaf people, and that the skills that AGNSS has demonstrated, which are still needed to commission highly specialist services in the future, will be retained and further developed as suggested by the noble Baroness, Lady Jolly?

NHS: Mental Illness

Baroness Hollins Excerpts

Tuesday 17th July 2012 Lords Chamber

[Earl Howe]

I am very happy to take the advice of my noble friend, who is of course an expert in this area. Historically, it is true to say that access to talking therapies in the broadest sense has been very poor. That is why we have invested £400 million in rolling out the IAPT programme, which makes available a range of NICE-recommended therapies to a much larger cohort of people. However, I will take my noble friend’s point away and, if I can throw any light on the issue that he has raised, I will gladly write to him.

[Baroness Hollins]

My Lords, I, too, commend the report. What action would the Minister expect in response to two of the recommendations that relate to training? First, there is the recommendation that an automatic component of general practice training in future should include mental health. Only a minority of GPs currently receive any training in mental health. Secondly, with respect to the current recruitment crisis in psychiatry, it is recommended that we recognise that psychiatrists have an essential leadership role to play in mental health care.

[Earl Howe]

My Lords, as regards GPs, the Royal College of General Practitioners has identified improved care for people with mental health problems as a priority within its enhanced GP training programme, which forms part of the college’s proposals for a new evidence-based four-year programme of training.

As regards the workforce issues, I am aware that there is concern about recruitment into psychiatry. My department and the Royal College of Psychiatrists are looking into this matter. The royal college has established a task force to make recommendations to improve recruitment, and it is investigating the factors before medical school, during medical school, during foundation training and in core and higher psychiatric training so as to get to the bottom of the issue as best it can.