Care Bill [HL]

Baroness Jolly Excerpts

Monday 29th July 2013 Lords Chamber

[Lord Warner]

I move this formally, on behalf of the noble Lord, Lord Patel, as I have already spoken to it.

[Baroness Jolly]

I support the two amendments in the names of the noble Lords, Lord Warner and Lord Patel, and the noble Baroness, Lady Greengross. The House is probably getting quite tired of hearing about the Joint Scrutiny Committee, but this is another area where we completely agreed, and our unanimous report recommended pretty much the contents of these amendments to the Government. Sadly, the Government indicated their willingness to fund end-of-life care, but have not put the amendments in the Bill. So it was a sort of “but not now and not yet” response. The response that came back from the Government to the report was:

“We note the Joint Committee’s endorsement of our position that free social care at end of life has ‘merit’ and note that they strongly endorse the case for its introduction at the earliest opportunity”.

That is the Government responding to the report, but nothing is reflected in the Bill before us.

Both the present system and the new system that we are debating for access to care are really longwinded, and a lot of people in this position, at end of life, do not need a longwinded system of access. The DS 1500 certificate, which indicates that you have a terminal illness, can take weeks to complete. We all know that NHS care is easier to access. However, it does not link up with social care in most cases. A terminally ill patient can get NHS care but it is really difficult to get social care. Bring on integration, really. This is not fair for somebody who needs and wants a dignified death—wherever it should be. As the noble Lord, Lord Warner, has said, most people want to die at home. Often, the inability to cope at home without any support and social care drives people to hospital. Therefore, they find themselves ending up in expensive hospital care in a setting that is just not their choice. The noble Lord, Lord Warner, has quoted some figures so I will quote a few more that support his case. The Nuffield Trust has researched this and a 10% reduction of hospital admissions for people at the end of life could result in savings of £52 million. According to Marie Curie figures, this would easily cover the costs of free care at home for all the people who would die within a year—with some to spare. This also leads into the debate of the noble Lord, Lord Warner, about moving funding from health to care. We are talking about £52 million that would be spent by people dying in hospital. We would save that £52 million if we were able to keep them where they wanted to be. The £32 million assessment by Marie Curie is more than easily covered.

We all die. Most of us will have care needs. Most of us would want to die at home. Funding adult social care at the end of life would go an awful long way to achieve this. I am therefore more than happy to support these two amendments.

Cigarette Packaging

Baroness Jolly Excerpts

Thursday 25th July 2013 Lords Chamber

[Earl Howe]

The noble Baroness gives me the opportunity to make clear that plain packaging of tobacco is very much still in our sights; we have not decided to reject that option. I am sure that the psychology of marketing is one very important area that we will continue to focus on.

[Baroness Jolly]

My Lords, what better adviser is there for the Department of Health or indeed the Prime Minister than Cancer Research UK, whose only interest is preventing children starting to smoke? When did my noble friend’s department last speak to that organisation about tobacco packaging?

[Earl Howe]

My Lords, I cannot tell my noble friend about the dates on which the department spoke to Cancer Research UK; I can tell her that we have very regular dealings with Cancer Research UK. CRUK made a submission to the consultation on the plain packaging of tobacco. I can feed back to my noble friend with specific details.

NHS: Accident and Emergency Services

Baroness Jolly Excerpts

Thursday 25th July 2013 Lords Chamber

[Earl Howe]

As the noble Lord will be aware, the latter issue is currently being scrutinised by the Independent Reconfiguration Panel, so it would be wrong of me to comment on that. On the question of reconfigurations generally, we are clear that this is a matter for local decisions by doctors, nurses and all those with a stake in the system. It is not for Ministers to issue edicts from the top. We are clear that any reconfiguration of A&E services has to take into account the capacity of the system to absorb any closures of A&E and the capacity of community services to step in where that is appropriate.

[Baroness Jolly]

My Lords, there is emerging evidence that younger people are using A&E as their first point of contact with the health service rather than their GP or out-of-hours services. Are there any plans to run local campaigns to remind people that accident and emergency units are just that? They are for accidents and emergencies and not coughs and colds.

[Earl Howe]

My noble friend is exactly right. In the work that we are doing on NHS 111, we are seeking to promote to members of the public the advice to phone before they do anything else. If they phone NHS 111, they will be signposted to the correct area of the health service.

People with Learning Disabilities: Health Inequalities

Baroness Jolly Excerpts

Thursday 18th July 2013 Lords Chamber

[Baroness Jolly]

My Lords, I, too, thank the noble Baroness, Lady Hollins, for bringing to the attention of the House the report that gives us the opportunity to discuss this issue. The report makes for sobering reading. Many noble Lords speaking in this debate have far more expertise in these matters than I have—in fact, looking around the Benches, I think that they all have—but the first NHS trust board that I sat on more than 15 years ago was a community trust with learning disability, mental health and community health responsibility for all of Cornwall, so I come at this with at least some understanding. I commend the work in this area by both the noble Baroness who, during her tenure as president of the BMA, sought to raise the profile of learning disability, and the noble Lord, Lord Rix, a long-time advocate of those with learning disability, and president of Mencap, which I thank for producing an excellent briefing.

In the past, there have been plenty of situations and reports, and we have heard about some of them today, that should have given successive Governments a wake-up call regarding poor provision for people with a learning disability—Budock Hospital and Winterbourne View, to name two, both of which point to the inevitable health inequalities. For many years now we have known that the health commissioning of learning disability services has been poor. Many PCTs wrote a cheque to providers and effectively asked them to get on with it. Indeed, there is a historic similarity with mental health service commissioning. Mental health now has parity of esteem status with physical health, but it does not feel as if the same can be said for learning disabled people.

The history of a lack of communication between health and social care in this area is well known, too. It was as if, after the move to take people out of large establishments and put them into domestic settings, commissioners and providers decided that the job was done, the spotlight went off, attention moved elsewhere and quality was forgotten. I must acknowledge that there are some splendid services, but that standard is not yet universal.

So what are good services? Here I have to thank Professor Jim Mansell of the University of Kent for the list from his 2010 report, Raising Our Sights. Good services should be individualised and person-centred, treat the family and carers as expert, focus on staff relations with the individual, sustain the package of care and be cost-effective. In addition, they should be supportive, use appropriate advocacy and be predictive and well implemented. I do not wish to belittle the work of the professor but none of this list should come as a surprise to the House. The surprise and shame is that this list is not part of universal practice.

That brings us to the Confidential Inquiry into Premature Deaths of People with Learning Disabilities. The report was commissioned by my right honourable friend Paul Burstow following the events at Winterbourne View. It is thorough and contains a detailed and practical set of recommendations. In the time that we have, I am unable to cover all aspects of the report so shall focus on information, staffing and the Mental Capacity Act. The report puts the spotlight back on mortality. As we have already heard, it is particularly appropriate that we are discussing the mortality of people with a learning disability in the week when the Keogh report did just that for the total population served by 14 hospitals. Sir Bruce was able to do that because he had the data. This report is based on a dataset that is not normally collected for people with a learning disability.

The report’s first recommendation is that people with learning disability should be clearly identified on the central NHS registration system and in all healthcare systems. Although outside the scope of the report, this information should be recorded on social care records too. A learning disability flag should be part of a standardised dataset and I would hope that a combined, patient-held record would be a reality in the not too distant future. Not only does this make identification easier, it would aid audit and research, make joint strategic needs assessments far more accurate and easier to produce and make reasonable adjustments easier to flag, thus improving commissioning and contracting. This is not an unreasonable request, it is an issue of equality, and without it people with learning disability cannot be treated equally. I would like the Government to commit to a clear timeline for this work, so would the Minister tell us what that is, or when we might know what it is?

Moving to staffing, the report calls for a named health worker to be allocated to those with complex or multiple health needs, and I welcome the Government’s response and further suggestion of a named worker in acute settings. There is also a need for specialist learning disability liaison staff in community settings. Can the Minister give an indication of when it is intended to roll this out?

These changes bring a need for training. Will the Minister reassure the House that Health Education England can put training programmes for health workers in place, and when they might become available in local training settings? Would he also confirm that training will be mandatory and included in continuous professional development for all health workers?

Finally, I turn to the Mental Capacity Act, which the noble Baroness, Lady Browning, has covered well. As she has said, it is currently under scrutiny in your Lordships’ House and is pivotal to people with a learning disability, as it is to any vulnerable group. Advice under this Act should be available at all times and easily accessible. That will pose challenges in delivery, and I ask the Government not to forget or ignore patient involvement and engagement in this. Members of the sector are very good advocates, but there is a real need for people with learning disability to be consulted and involved in improving access to the Act.

In conclusion, I have outlined the issues around records, data and information, the Mental Capacity Act and staffing. Would the Minister ask his colleague, my honourable friend Norman Lamb, the Minister for Care and Support, to come to the House in the autumn with NHS England’s new lead for learning disability to share with members of the House its thinking on these issues and the action plan that has arisen from this report?

I think that it was Gandhi who said that society could be judged by how it treated its most vulnerable. Reducing health inequalities should be central to that. It is not an issue which will attract the attention of voters; it is something that we do solely because it is the right thing to do. I would hate it if, 10 years on, we were seen to be wanting.

NHS: Foundation Trusts

Baroness Jolly Excerpts

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

My Lords, I am sure the noble Lord is aware that the provision for reviewing NHS mergers on competition grounds is not at all new. Responsibility for reviewing NHS mergers has moved from one independent body—the Co-operation and Competition Panel—to another, the OFT. This is a continuation of the approach that has been in place since 2009. In all these decisions what matters is what is in the interests of patients. The competition authorities will continue to review whether the potential benefits of a merger outweigh the potential costs to patients.

[Baroness Jolly]

My Lords, would my noble friend confirm whether any of those trusts yet to achieve foundation trust status were planning to merge with any on today’s Bruce Keogh list?

[Earl Howe]

I am not aware of any on Sir Bruce Keogh’s list which were planning to merge but, if I may, I will write to my noble friend with further details if that needs clarifying.

NHS: Keogh Review

Baroness Jolly Excerpts

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

We will see the Chief Inspector of Hospitals picking up the baton, as it were, from Sir Bruce Keogh, whose way of working in this exercise has been very instructive. His judgments were based on talking, not just to a few people in the trust, but to patients, a wide range of staff and, in some instances, people outside the trust. I am sure that Sir Mike Richards, the new chief inspector, will want to learn from that. It will be up to the CQC to decide whether this will be institutionalised. Its methodology is evolving. The hospital aggregate rating system will have a role to play in systematising the evaluation of performance and in any future instances of very poor care we will no doubt see a level of transparency from the CQC which we have, perhaps, not had before. However, I would not want to commit the CQC to reporting annually to Parliament in a particular way. It will report annually to Parliament but it is largely up to it how it does it.

[Baroness Jolly]

My Lords, we welcome the drive to improve quality in these trusts and across the NHS, based on the eight ambitions for improvement held in the report. In the Statement read by the Minister, the Secretary of State said:

“In some cases, trust boards were shockingly unaware of problems discovered by the review teams”.

Surely the boards were in receipt of data on quality. If not, why not? If so, why was action not taken? What attention is being paid to issues of trust board governance and its support and development?

[Earl Howe]

We will now see follow-up action by the CQC, not least in the area of trust governance where the quality of that governance has been called into question by Sir Bruce. That will be done rapidly. It is by no means the case that governance is defective in every trust, but question marks have been placed on some and it is important that assessments are made, not just by the CQC, but by the Trust Development Authority and Monitor as the two bodies responsible for overseeing the provider section. It may be that the CQC will be asked to carry out further work, but we are looking, for the time being, to the TDA and Monitor to do that.

Care Bill [HL]

Baroness Jolly Excerpts

Tuesday 16th July 2013 Lords Chamber

[Baroness Wilkins]

My Lords, I strongly support this amendment. If the Government do not agree with the intention behind the amendment, it is clear that they accept, no doubt at the Treasury’s insistence, that the social care crisis should continue for years to come. As we have already heard, the social care system is currently failing to support four out of every 10 disabled people of working age to do the basic things in life such as washing, dressing, eating and getting out of the house. The proposed national eligibility threshold will do nothing to change this. The cap on care costs for these people will be a fiction; unless their needs are assessed to be at the equivalent of “substantial” under the current FACS criteria, they could well spend a small fortune paying for care, none of which would count towards the overall cap.

The public would be shocked to learn that the level of needs spelled out in the amendment in the name of the noble Baroness, Lady Grey-Thompson, is not covered by the cap on care costs. The Government envisage that people whose needs are below the proposed national eligibility threshold will be helped by the universal preventive services covered in Clause 2. However, as the Care and Support Alliance points out, many of these services have already been axed in the cuts or are at risk of closure. The £2 billion funding is very welcome, but we need the Government to be clear with the public that they are endorsing the continuation of the social care crisis unless a major shift of resources takes place.

[Baroness Jolly]

My Lords, I, too, am delighted that these amendments have given us the opportunity to debate the eligibility criteria and I echo the comments of noble Lords who know better than I do how this will affect them. Eligibility is a critical issue, which affects both disabled people and older people with care needs—disabled people account for one-third of the people affected by the Bill and elderly people the other two-thirds.

The Joint Committee warmly recommended the introduction of a national minimum eligibility threshold as a key way of resolving the current postcode lottery in social care. The new eligibility framework and national threshold proposed in the Bill will go a huge way to alleviate the lottery of care and will be vital in ensuring that there is more clarity and consistency in the provision of care for disabled people and the elderly in England.

The focus on well-being in the Bill was hugely welcomed by the committee. This principle is the thread that runs through the Bill and will ensure that the care system not only delivers basic support but promotes older and disabled people’s independence, allowing them to realise their potential through participating more fully in their communities. This is a bold vision for the future and one that could truly revolutionise the care system. It is therefore key that these two elements of the Bill work seamlessly together so that the well-being principle is at the forefront of the Government’s mind when considering who will be eligible for care, something that the committee explicitly recommended in its report on the Bill.

However, as the Government have rightly recognised, social care is not merely about allowing people to “survive” but about enabling them to live full and independent lives. The Bill explicitly places a duty on local authorities to provide care that promotes the well-being of individuals. In a conversation yesterday with the Minister for Care and the noble Baroness, Lady Grey-Thompson, it was acknowledged that the draft regulations, which have already been referred to in this debate, were just that—draft. Much more can and needs to be done to make them asset or strength-based. Can my noble friend ensure that the work on the draft regulations proceeds at pace so that they are fit for purpose and meet the needs and requirements of all within the scope of the Bill? Can he also ensure that any work involves those from the sector and expert Members of this House?

[Lord Rix]

My Lords, the Minister knows perfectly well where I stand because I already talked about eligibility at Second Reading and in the debate last week on the future funding of health and social care, led by my noble friend Lord Patel. I was backed in that part of the debate on the question of someone having to reach a level of substantial disability before becoming eligible for care. It should be the right of all people with a disability at least to be assessed properly, from the lowest level of disability to the highest. A level may be set where tens of thousands of people are excluded, such as people with a learning disability. Many are already being excluded by local authorities and being denied the use of day centres, or whatever. I can only plead with the Minister to say something which would give a glow of optimism to all of us who are totally and utterly opposed to the level which the Government are likely to set.

Health: Prescription Drugs

Baroness Jolly Excerpts

Thursday 11th July 2013 Lords Chamber

[Earl Howe]

My Lords, of course I will revisit that Answer, and I will come back to the noble Baroness if I find cause to correct what I have said. However, I agree with her that the risks associated with long-term use of tranquillisers have been well recognised for many years. There are several authoritative sources for guidance for prescribers on this issue. I believe that that guidance is having an effect because, as I said, the prescribing rate has considerably diminished of late. There is no shortage of guidance out there. There is the national formulary, which already describes the importance of gradual withdrawal from benzodiazepines, and there is a wide variety of other impartial and trustworthy information resources to support prescribing.

[Baroness Jolly]

My Lords, GP training is important but for a user the crucial thing is the availability of the services. Will my noble friend tell the House whether services for those addicted to prescription drugs are readily available within each CCG area and where one might find details of such services?

[Earl Howe]

My noble friend will be encouraged to know that Public Health England has published a commissioning guide for the NHS and local authorities which sets out its expectation that support should be available in every area for people with a dependency on prescription or over-the-counter medicines. Local authorities are now, as she is aware, responsible for commissioning services to support people to recover from dependence in line with local need. Most of the support available for people who are addicted to prescription drugs is with their GP and not in services treating those addicted to illegal drugs, but there is a range of services available.

Care Bill [HL]

Baroness Jolly Excerpts

Tuesday 9th July 2013 Lords Chamber

[Lord Rix]

My Lords, having heard the words about Mencap spoken by the noble Baroness, Lady Wilkins, I, as president, must of course support this amendment. I say “must”, but I am surprised that these amendments have to be tabled at all. I would have thought that any Bill dealing with care must deal absolutely explicitly with housing. After all, noble Lords will remember when the long-stay, sub-normality hospitals were closed in the late 1970s, the 1980s and the early 1990s, the very thing that was required was housing. Mencap did provide the housing in those days, as best it could, with the Mencap Homes Foundation. It has progressed now to Golden Lane Housing, which allows people with a learning disability actually to own their own housing with the appropriate support. These provisions are necessary, and I am amazed that these amendments were necessary in the first place.

[Baroness Jolly]

My Lords, I support this suite of amendments—this flight of amendments—on housing. As noble Lords have eloquently said, housing is the third side of the care triangle. Those of us who sat on the scrutiny committee were absolutely clear on that. We thought that it had been extended to our report, but clearly it has not been reflected totally in the Bill. There was mention of it in Clause 1, the well- being clause, in Clause 6 on co-operation, and also in Clause 8 on how to meet needs. The noble Lord, Lord Best, has filled in the gaps, with Clause 2 on prevention, Clause 3 on integration, Clause 4 on the provision of information and advice, Clause 5 on market shaping and Clause 9 on the assessment of needs. In each of these elements of the Bill, housing is imperative. The anxiety that many of us share is that if housing is not in these clauses, it will not be dealt with when an individual is assessed, or when there are issues around integration.

In the Select Committee, the most compelling witnesses were from the housing sector. They understood the impact that appropriate housing, and any adaptations to houses, would have on the lives of the people living there—on the health and well-being of the individual. The amendments in this group put housing where it should be. It is core to assessment and core to integration of care. It is a preventive measure, and it is also core to the provision of information. There is no point in having a conversation as a result of your assessment and as part of the information process if you are not aware of what your housing needs are, because without housing, the conversation makes no sense.

Local authorities need clear direction from the Government. The noble Lord, Lord Best, articulated this clearly when he introduced his amendments. Some health and well-being boards have got it and some have not. Those that have not should have it spelled out, so the amendments in this group are absolutely appropriate. I hope that my noble friend, when he sums up, will reassure the House in this regard.

Care Bill [HL]

Baroness Jolly Excerpts

Tuesday 9th July 2013 Lords Chamber

[Baroness Jolly]

My Lords, I will speak briefly to Amendment 86N, in the name of the noble Baroness, Lady Greengross. We have had an interesting debate, with quality at the heart of it. That is absolutely right because the whole principle of shaping markets has to be around providing quality and safe services for vulnerable people.

I was interested in the response to this that the noble Lord, Lord Hunt, had from ADASS. Certainly, I do not recollect from when it came to give evidence that that was its reaction, but I will look that up.

The other thing that I want to reflect on is this business of changing people for domiciliary care. That is not what people want. What people want is to be cared for by people they know; they do not want different people coming in day after day. My mother has a team of eight or nine people who call on her but she knows them all. That gives flexibility to the agency that sends them her way. It is not impossible. People need to know their care staff. My mother knows a week in advance who is coming, on what day and at what time, which is hugely reassuring.

I also have huge sympathy with those who have pointed to the scandal of zero-hours contracts. Whatever can be done to try to stop that practice must be looked at with some urgency. This is all about quality.

The amendment would ensure that services commissioned from providers are of high quality and provide a high level of safety for patients or those being cared for. The scrutiny committee recommended linking quality and safety with the NICE quality standards. That is really very straightforward: the NICE care quality standards exist, so why should services not be commissioned based on them?

Will my noble friend explain how quality will be assured and what the rationale is behind abandoning, or not taking up, the NICE link? Is he able to offer assurance by putting into regulations the link with those NICE standards?