Mental Capacity (Amendment) Bill [HL]

Baroness Meacher Excerpts

Committee: 2nd sitting (Hansard): House of Lords
Monday 15th October 2018 Lords Chamber

[Baroness Murphy (CB)]

My Lords, I find myself in something of a dilemma because I have already said that I am very anxious about the role foreseen for care home managers in this Bill. I am also getting the heebie-jeebies about how we are criticising the Bill because of how we have got here in the first place. The noble Baroness, Lady Finlay, and the noble Lord, Lord Hunt, have already mentioned that we are here because at the moment we have a bad piece of legislation; it is not being implemented appropriately because we cannot afford it. The Law Commission, the Department of Health and the Ministry of Justice have tried to bring forward a piece of legislation that makes it a lot simpler.

We are used to having conflicts of interest in public sector services. Every time a GP refers somebody for a hospital appointment or surgery or prescribes expensive medication they have a financial conflict of interest, but we live with that because of the way that the system works. We are used to it—we take account of it day by day.

I am not going to oppose these amendments but we have to say to ourselves that the care home manager is there and we know that the local authority has not got the resources. Would it work better if we could give care home managers proper training? I do not know, but I know that we must at every stage think very carefully about the alternatives that we propose instead of the departmental proposals. We have to make the process simpler. We have to reduce the numbers of people who are subject to it. Perhaps if we reduced the number of people subject to it, we could put in place these better arrangements. Maybe then we can take out the care home manager. Until we do so I still have this great anxiety that we have not come up with an alternative that will really work.

Although I share the anxieties about how care home managers will discharge this responsibility, I have some anxieties about the alternatives. We have to make the process simpler and more affordable. I neither support nor oppose these amendments. We need to give some very careful thought to making sure that we do not end up with a more complex and difficult process than is implementable and affordable.

[Baroness Meacher (CB)]

My Lords, I was not planning on speaking to this amendment at all. I am certainly not an expert on the Mental Capacity Act, but it was suggested to me by BASW that the Bill will cover people in domestic situations. It questions whether those people could be taken out of the Bill. I very much follow the point made by the noble Baroness, Lady Murphy, that it might be a good thing to do something really well for people in institutions while maybe avoiding duplication for people in domestic situations. There is the safeguarding procedure, which, as has been suggested by my medic daughters, is already incredibly bureaucratic, but I will leave that to one side for the moment. If at least the people in domestic settings were left to be assessed by the safeguarding system, that would achieve something and reduce the number of people covered by the Bill. This is particularly true because, as we go along, more and more people will be looked after in domestic settings rather than in care homes.

[Baroness Thornton (Lab)]

My Lords, it is our job to look at how things will and will not work and what the alternatives are. The noble Baroness takes a perfectly legitimate position that says, “If this won’t work, what will?” In a way, that underlines a lot of the discussions we have been having in this House: we need some time to discuss this Bill and we have not been able to have that.

My name is to the amendments tabled by my noble friend Lord Hunt. We are questioning the ability of the care home manager to be able to do this at all. The words that have been used to us by the stakeholders—we have now talked to dozens of stakeholders in the last month or so—are “capability” and “capacity” of care home managers. Professionals question the capability and local government and other institutions question the capacity. Those words are being used constantly while we discuss this issue.

It is also worth mentioning the voice of the care home managers themselves, which is starting to emerge. We recently had a briefing from a large group of care home managers who feel that they are not qualified to take on this role or to carry out assessments and that the administrative burden they could carry could mean that they will not have the capacity to take on the extra work to carry out liberty protection safeguard assessments.

There is some confusion here with what the Minister said during the first day in Committee and in the letter he wrote to us all following Second Reading. I admit that I am confused as to whether we are talking about initiating and carrying out assessments and what the powers of the care home managers are. It seems that the Bill team and the Minister have given us several different descriptions of what those roles might be. That has not helped our consideration of our concerns.

Mencap has stated that it believes that the views of the cared-for person have to be at the heart of this part of the Bill and that it should be refocused accordingly. The comments made by my noble friend and the noble Baroness, Lady Finlay, suggest that that has not yet been achieved, and that the role of the care home manager makes it less rather than more likely. That has been said to us not just by Mencap but by many stakeholders. They are concerned that the cared-for person is not at the heart of the Bill. It is therefore legitimate to ask whether the Government have got this aspect of the Bill right and whether they need to find a different way of delivering it.

--- Later in debate ---

[Baroness Jolly (LD)]

My Lords, I again refer noble Lords to my interests in the register. I am revisiting an area that we covered at Second Reading. Many of the issues we have been discussing, as we have just discovered, weave in and out of my comments, but this is about the appropriateness of the care home manager to carry out pre-authorisation reviews.

I should make it clear, given previous comments, that I recognise that DoLS needs replacing and that, in finding that replacement model, professionalism and expertise are important. This is not a personal, solo crusade—I do not fail to understand what a manger of a care home does and I recognise their professionalism in doing it. However, the noble Baroness, Lady Thornton, had it spot on when—it seems like hours ago—she used the description that they had used to her around the concerns about their capability and capacity.

Many of us have been supportive of this Bill, with briefings from and meetings with household-name charities, providers, royal colleges, academics, lawyers and interest groups. The two amendments in my name were drafted by a charity whose reputation for policy on older people is respected and admired—Age UK. It has several concerns about areas of the Bill and would welcome a meeting with the Minister to discuss them.

The cared for person’s interests are central to the Care Act, and I am delighted that the Government will bring forward amendments which will allow the voice of the cared-for person to be heard in this process, including 16 and 17 year-olds, and will do away with the term “unsound mind”. I join with all noble Lords in that.

At Second Reading, conflicts of interest were debated and we agreed that the cared for person’s interests must come first. However, this could be at odds with the care manager’s duty to keep their care home viable. Vulnerable people are at the heart of the Bill and how they are reviewed at a critical point in their care—the pre-authorisation review—sets the tone of the professionalism within their care. These reviews should be carried out by a trained professional—an AMCP—but, as currently drafted, only those objecting to the proposed arrangements will be provided with an AMCP. Generally, care home managers have not received professional training other than in running a care home—as the Minister mentioned, they may well have had that kind of training—and if they have, I would have no objection whatever to them carrying out the review.

However, many AMCPs have a first degree—possibly a masters—and professional training, with regular supervision and refreshers, and, whether they are social workers, mental health nurses, OTs or clinical psychologists, all will have the professional ethos and expertise instilled into them in their daily working. It is what they do. The proposed half-day familiarisation course does not really measure up.

This amendment will also protect the care home manager from accusations of conflict of interests or vested interests. It was a manager who made that point to me. I had not thought of it because I was looking at the issue from the point of view of managers considering their care home to be a business that needs to operate at 99% capacity for it to be effective. Managers have said that they would welcome an amendment similar to this one because it would give them some sort of cover. Perhaps I may remind the Minister that, in mental health legislation, an assessment made in a private setting must be carried out by an independent assessor. This amendment does not break new ground or indeed set a precedent.

While we are on the issue of finance, the noble Baroness, Lady Finlay, repeated a concern expressed in the sector about the costs of assessments and reviews being added to the bills of self-funders, which might be seen as a licence to print money. We know already that some care homes are charging £250 for a referral, but an assessment is a much more complicated piece of work and might well cost £1,000. People in the sector are concerned about this. Fee levels are not regulated, so I wonder whether the Minister could take the issue away and look at it. I welcome his willingness to listen and I look forward to his response. I beg to move.

[Baroness Meacher]

My Lords, I applaud the noble Baroness, Lady Jolly, for tabling this amendment and I will add a few comments to those she has made. In my view, all pre-authorisation reviews should be undertaken by a professional who really understands the assessment of capacity. I accept that the amendment goes further than the Law Commission recommended, but it is not clear that the commission envisaged care home managers undertaking or being responsible for assessments and pre-authorisation reviews.

The whole point is that too often it is just assumed by everyone that somebody with limited capacity does not have a view or that they are content. Also, the person may not even have adequate information on which to base a view or make a comment. They may therefore not feel able to make an objection. It is not reasonable to expect care home managers to know about all the alternative and possibly less restrictive options available; why would they? As the noble Baroness, Lady Thornton, argued, the care home manager has a job to do in keeping costs down and filling beds.

It is not a criticism of care home managers to suggest that independent scrutiny is essential in all cases to ensure that those imperatives do not lead to an understandable failure to focus on the needs of the individual. Again, we should not expect care home managers to put the interests of the individual ahead of their business imperatives. I understand that many care homes close because they cannot cover their costs. They are desperate to fill their beds, and that is going to take priority. We just have to respect that that is simply how life is.

In the letter from the department to noble Lords dated 24 July following Second Reading, the Minister said that the local authority would undertake the authorisation itself, thus providing independent scrutiny and oversight. I think that the Minister will recognise, however, that if no concerns are raised during the pre-authorisation review, the local authority will be in a very poor position to question the conclusion of the care home manager. The noble Baroness, Lady Barker, suggested that there might be a form of to and fro between the local authority and the care home manager, but I am not sure how meaningful that can be when all the work and the pre-authorisation review has been done. Given that, I would have thought that the local authority would just not be able to get at it.

Another concern is that it is in the gift of the care home manager to identify whether a person would benefit from advocacy. It seems that most of these people will, but the current proposals are unclear about who will pay for the advocate. I would be grateful if the Minister could clarify that issue.