Care Bill [HL]
Baroness Meacher Excerpts(11 years, 9 months ago)
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Baroness Meacher (CB)
“( ) the need to adhere to specific minimum quality standards and requirements in the commissioning and provision of services to adults, as regulations may prescribe;”
Baroness Meacher (CB)
My Lords, I will also speak to Amendments 25 and 26 in this group and acknowledge the Government’s Amendments 24 and 27, which I will mention later. I start with Amendments 22 and 25. As many noble Lords have said, the Care Bill has the potential very significantly to improve the care of elderly and disabled people. However, there is also the possibility that only a part of that potential will be realised, particularly in the face of significant cuts to local authority budgets. Amendment 22 therefore places in the Bill a requirement for there to be regulations about how services are commissioned to ensure that they offer at least a sufficient level of quality to the individual. Amendment 25 ensures that home visits are not normally commissioned for less than 30 minutes. The amendments provide for a service of at least minimum quality, as I said, which will ensure the dignity of each elderly or disabled person. They also allow flexibility—which is important—for short visits, for example for the delivery of a meal or for giving an injection, and also for longer visits.
This became very clear to me when I met the director of the Bikur Cholim social care organisation, which has been in operation for many years looking after people in the Jewish community. The director told me that for a disabled, doubly-incontinent client, a morning visit cannot be completed in less than one hour. Dealing with the incontinence—and one does not want to go into too much detail about that—can be time consuming. A bath or shower is essential for a doubly-incontinent person; they need a change of clothes, possibly a change of sheets, to have food provided and help to get dressed.
When you think about all that, it is fairly obvious that you could not possibly do it in half an hour. However, in our financial context there is an increasing tendency to commission ever-shorter home visits, many lasting only 15 minutes, as has been well publicised on the “Today” programme twice this week. Indeed, a survey by the UK Homecare Association found that one in 10 visits already last only 15 minutes and the proportion of 15-minute visits has increased by 17% over the past five years.
Leonard Cheshire Disability has seen tenders for visits of only 10 minutes and, according to the person on the “Today” programme, these carers tend to take 10 minutes to take off what they describe as “their hat and coat”. I am quite curious about carers arriving in a hat and coat, but there we go. It means they would then have to shoot out of the door without their hat and coat. The mind boggles. This is a very serious issue and a tragic quote from a disabled client makes the point better than I can: “By the time they have got me to the commode and helped me to change, the time is up. I end up choosing between getting my meal prepared or having my commode emptied. Do I get a drink or do I go to the toilet?”.
Imagine having to make those kinds of choices. The public do not support depriving elderly and disabled people of a dignified service. Some 96% are critical of these very short visits for personal care; people understand about an injection, I think. Will the Minister clarify on the Floor of the House that a visit to deliver personal care, including, as it will inevitably, dressing, taking the client to the toilet or bathing, within a timeframe of 15 minutes is simply impossible and always will be. Therefore, one can say something pretty firm about it.
From the point of view of the carers too, workers complain that they have had to stay longer than 15 minutes in almost every visit, even though they are paid only for 15 minutes and they are not paid for their travel time either. As one said, “You just cannot possibly do this job in that length of time”. The question is whether we are giving sufficient priority to elderly and disabled people living at home. I think we have to answer, “Surely not”. The Minister, Norman Lamb, has very publicly criticised 15-minute personal care visits, but there is nothing in the Bill to prevent this practice from continuing and, indeed, from spreading further. The government amendments do not really tackle the problem, although I know that the Minister always tries very hard to do what he can. He will be aware of the 2,000 plus e-mails that have landed—not necessarily on his desk but in the office—within the past few days expressing concerns about this issue. It has concerned people very deeply.
I hope that the Minister can assure the House today that the Government will guarantee that our most vulnerable people can rest assured that their needs will be met and their dignity will be protected. This means, I fear, carers having enough time. I know, of course, that this means resources, so we are here coming down to priorities and where they really lie.
Amendment 26 is supported by the Care & Support Alliance of 70 organisations representing old and disabled persons, those with long-term conditions and their families. Clause 5 acknowledges the benefits of quality services but only requires local authorities to,
“have regard to … the need to ensure”,
that sufficient services are available. I am not quite sure how one has regard to those matters and then disregards them, so I am genuinely not sure what that means. The amendment would “require” local authorities to ensure that sufficient services are available to meet the needs for care and support of adults and their carers in their area. We are talking here about good planning of services over time, and also the planning of a comprehensive range of services for people with very different disabilities and needs being undertaken.
We take the view that the social care system is in crisis, too often leaving older and disabled people and their families without essential care and support; certainly, I take that view. Indeed, I emphasise that I fear that abuse of elderly and disabled people is very likely to be the next national scandal. We have had physical abuse of children; we have had sexual abuse of children. One has only to think about the love of parents for children to wonder, if parents are doing that to their children, how many elderly and disabled people may face abuse? I say this with the greatest possible sympathy and understanding for carers. How many of us can honestly say that we could live with, say, a dementing parent—I have had a dementing parent, so I have an understanding of this—year after year, without sufficient support, and always find the emotional, physical and every other kind of energy to provide that care, and often to give up your life to do so, without being reduced to behaviours of which one would be profoundly ashamed? If abuse occurs, we cannot blame the overburdened carers. It is up to us.
Meeting short-term needs is essential. This is not straightforward for people with fluctuating disorders. Somebody with multiple sclerosis, for example, can from time to time need full-time, 24-hour care. If that is not available, that person will have no option but to be moved into a residential home. Very often, the only space is in a residential home for the elderly. For, say, a 25 or 30 year-old, that is a deeply distressing experience, apart from being very expensive.
On the range of quality services, a tragic story about a deafblind man says it all. Some unqualified person delivered his breakfast but never told him where it was, so he went without breakfast for days. It was sitting on the fridge, but you have to have the training to tell you that you need to be very good on your communication. You could say that it is all very basic stuff, but this poor chap went hungry.
I very much welcome the Government’s amendments in response to these concerns but, unless I have missed something important—I confess that I may have—they do not seem to ensure that sufficient appropriate services are made available for vulnerable people. I am confident, nevertheless, that the Minister well understands the importance of this issue and very much hope that he can assure the House this evening. I beg to move.
Baroness Masham of Ilton (CB)
My Lords, I support Amendment 22 but am concerned about Amendment 25. Is it wise to mention 30 minutes? I declare an interest as president of a spinal injuries association. Some of our members have broken their necks and are paralysed from their neck down. To get a paralysed person up, to do an evacuation of their bowels and to wash and dress them, using a hoist, might take at least three hours. Surely it is better to stress the individual’s needs rather than to set in stone half an hour. Providers of care may use that as a marker.
A visit taking 15 minutes, as has recently been in the headlines, is totally ridiculous. Having the choice of whether a carer takes someone to the lavatory or gives them a drink is unacceptable. If stress is put on the carer who cannot do the job in that time, they will leave and not do the job at all. The person needing care is left in a dangerous position if adequate care is not given. The amendments need to be flexible and aimed at an individual’s personal needs. I hope very much that the Minister will look at this and will do something to make it acceptable.
Earl Howe
My Lords, we certainly know that the reduction in resources has had some effect. However, it is interesting that the feedback from local authority chief executives and directors of adult social services suggests clearly that the detrimental effect on the provision of adult social care is not as dramatic as one might suppose from the drop in local authority budgets. This is partly because of the funding provided by my department to local authorities to make up some of the gap. I would not wish to say that there has been zero effect. We think, from the feedback, that the volume of services has diminished by about 5%. This is 5% too much, in most people’s eyes, but may not be as significant as some have feared.
My second point is that central prescription risks prohibiting practices that may, in some circumstances, be consistent with high-quality care. For example, 15-minute homecare visits could well be appropriate in some situations, for instance for helping people to take medication, which is not a process that takes very long at all. Further, using legislation to ban specific processes may result in perverse incentives arising, without addressing the actual problem. A number of noble Lords made that point.
Thirdly, legislating for a specific period of time for which homecare visits must last risks reinforcing one of the key problems here: inappropriate use of time and task commissioning. Instead, we need to move away from overly prescriptive commissioning practices which focus on—
Baroness Meacher
My Lords, I apologise for intervening, but I want to make clear that there is absolutely no prescription: there is flexibility. It is simply saying that you cannot do a personal care visit of less than 30 minutes.
Earl Howe
My Lords, I was distinguishing between providers and commissioners. The CQC can do thematic reviews under, I believe, Section 48 of the Act, but we are talking there about providers. As regards commissioners, we are proposing in a later amendment to give the CQC powers to conduct special reviews where concerns have been raised about a particular local authority or NHS commissioner; there would not be periodic, regular reviews. However, the CQC will be looking at every provider over a period of time. The amendment from the noble Lord, Lord Hunt, specifically addresses the ability of the CQC to examine providers. I was saying earlier that it already has the necessary powers to do detailed work in whatever area it chooses.
I return to the issue of local authority commissioning practices. As I argued, the underlying causes of poor commissioning are cultural, and we need to work with local authorities to tackle these issues. We are therefore undertaking a number of non-legislative activities, including the development in co-operation with ADASS of a set of commissioning standards. These standards will enable individual authorities to gauge their own effectiveness, and will support the LGA and ADASS to drive sector-led improvement.
In addition, we are working with the Towards Excellence in Adult Social Care initiative to support local authorities to seek continuous improvement in their adult social care functions, and in the outcomes achieved. This programme brings together local, regional and national stakeholders, and is focused on providing peer support and interventions by local government to share learning, find new ways of engaging local people, and use knowledge of what works, data and innovation to drive improvement in the quality of services.
I hope that these arguments, and the amendments we have tabled, are sufficient to demonstrate to the House that we understand and agree with the strength of feeling around these issues. For the reasons I have set out, I cannot support the amendments tabled by noble Lords, but I hope that the arguments I have made today will be sufficient for those noble Lords to feel able not to press their amendments. I do not yet know what the noble Baroness, Lady Meacher, intends to do with her amendment, but it may be helpful for noble Lords to know that the Government do not consider that a decision on Amendment 25 is consequential on Amendment 22.
Baroness Meacher
My Lords, I thank the noble Earl for his thoughtful response and also all noble Lords who contributed to this debate. It has been very considered, and the points raised have been very important. These visits can require three hours of work, or one and a half hours—all sorts of different lengths of time. Whatever is decided ultimately must enable those visits needing that length of time to be undertaken in that way. I welcome the amendment of the noble Lord, Lord Hunt, and I am sure that the CQC has an enormously important role to play in this. I wonder whether the Minister would think it appropriate to require a thematic review of this issue to be undertaken by the CQC, bearing in mind the level of concern across the country about what is happening at the moment, which clearly is not acceptable in terms of these very short visits for personal care.
The noble Earl mentioned the 5% reduction in the budget for adult social care. It sounds small, but we all know that the adult social care budget has always been incredibly low—way below what it should be. Priority has never been given to this area of work, so a 5% reduction is pretty serious. There is a lot to be done. The noble Earl referred to guidance, regulations, and so on. I personally would welcome an opportunity to have a discussion with him about how, in the guidance and regulations, it might be possible to ensure that adequate priority is given to this area of work. This is really what we are talking about here.
My amendments are aimed at stimulating the debate. They are also an effort to draw out some commitments from the noble Earl, and to some degree I think we have achieved that objective. I do not know whether the Minister would be willing to have a conversation about what might be included in the guidance and regulations.
Care Bill [HL]
Baroness Meacher Excerpts(12 years ago)
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Baroness Meacher
Baroness Meacher
My Lords, Amendment 82B has the effect of requiring local authorities not only to provide information about the system of care and support, how to access it and so forth, but also to take action to facilitate access to that information; that is, to try to make sure that people know it is available. My remarks also apply to Amendment 86C, to which I have added my name, which requires that the local authority must produce or arrange for the production of packs of information relevant to the needs of individuals with specific medical conditions and ensure that these packs are provided to individuals following the diagnosis of a specific condition—not waiting until much later on, when they probably need social care or other intervention.
First, I apologise to the Minister and to your Lordships that I was unable to be here for earlier sittings of the Committee. I have been out of the country a lot on other Lords’ business and just have not been able to participate. I also must thank the Alzheimer’s Society for its help with these amendments.
I join other noble Lords who have welcomed the Bill, which has an emphasis on the provision of care and support for people who need it. I was impressed by the quote at the top of the Department of Health Factsheet No. 1, which states:
“Information, information, information; without it, how can people be truly at the heart of decisions? Information should be available to all regardless of how their care is paid for. There are some things that should be universal; information is one”.
That is from a Department of Health document; perhaps other noble Lords have quoted it before me, in which case I apologise. The point is that if people are unaware that information and advice are available, they are unlikely to look for them. We can assume that if these amendments are not accepted by the Government, there will be considerable underuse of information services and, of course, that the people who will lose out will, as always, be the most vulnerable—those who most need that information.
The Alzheimer’s Society tells me that it frequently hears of the difficulties people face when struggling through the complexities of the health and social care system for the very first time. Too often, people with dementia and their carers report that they did not have access to the information and advice they needed because they simply did not know it was available. We all know that feeling: if only we had known that it was available, we would have looked for it, whatever it was. Sadly, people often come across services by chance and far too late.
If a person in the early stages of Alzheimer’s is aware of a memory clinic, for example, which can either provide help itself or refer the client on to organisations such as the Alzheimer’s Society well before they need social care, the client can make adjustments to help them continue living as normally as possible and for as long as possible in their own homes. These are simple things like putting a note on the front door that says, “Are your keys in your pocket?”, and suchlike. With guidance, carers can gradually increase the home adjustments as they notice the need for them and thus defer the need for the involvement of social services and ultimately residential care.
Noble Lords will know the point that I am coming to. We all know that resources are incredibly tight. The point is that timely information and making people aware that it exists is very cost-effective. If you manage to keep people in their homes much longer, and if you manage to help them avoid social services intervention, all this will save taxpayers’ money. We can expect that a small spend on a proactive approach to information provision will save the taxpayers a great deal of money over time. I beg to move.
Baroness Greengross
My Lords, I support Amendment 82B in the name of the noble Baroness, Lady Meacher, to which my name is also listed. At the same time I speak to Amendments 83, 83A, 84, and 85. I think that Amendment 86C is in the next grouping; I hope that I am right.
On Amendment 82B, we know that many people, as well as their carers, say that they did not have access to the necessary information and advice—and that they did not even know that it was available. They have had to seek out the information themselves. We are talking about people who are vulnerable and often at crisis point. It is the worst time for either frail people or their carers to have to find out where to go and how to find the advice they need. I would add that, in my long time working in this field with older people, I once had a telephone call from a Minister in the department whose mother needed care and who was asking me to help because this Minister had no idea where to go to get the information and advice. It is not just people who do not know their way round the right office—it is all of us at certain times. We just do not have the knowledge of where to go.
If we require local authorities to adopt a proactive approach to information provision, perhaps it will ensure not only that people have the right information at the right time but that the information is in a format that is accessible. This will help people to get the right care and support in place and give them the confidence they need in very difficult situations.
On Amendments 83, 83A, 84 and 85, I was very pleased to see that, in Clause 4, the Government have incorporated a key element of the Joint Committee’s report into the Bill, namely that it is part of a local authority’s duty to establish and maintain the service for providing people in its area with information and advice. We must make sure that advice relating to care and support includes information about access to regulated independent financial advice.
The Bill will also oblige local authorities to offer deferred payment agreements which will involve local authorities in taking an interest-bearing charge on the property of an individual against the cost of care fees which, as we know, will be repaid after the individual’s death. As has been said, however, individuals offered these products may be highly vulnerable. They expect the same authority to assess fairly both their eligibility for care and their ability to fund it, as well as providing appropriate advice and information about a financial product which the local authority itself is offering to pay for that care.
In a way this is in competition to FCA-regulated financial products, so, obviously, there is a potential conflict of interest here. This conflict is exacerbated if the care for which the loan is made is directly provided by the local authority and if the level of charges and interest are also determined by the local authority. It is therefore very important that people are directed towards regulated financial advice as part of the decision-making process. This amendment seeks to do that through regulated, accredited financial advisers such as the people who are members of SOLLA, the Society of Later Life Advisers. Only in that way can the development of safe and secure financial products be facilitated.
Baroness Meacher
I welcome the Minister’s assurance that Alzheimer’s patients will be a priority when it comes to the provision of information and advice— I shall have to clarify what that means in due course. I thank the Minister for his usual courteous and sensitive response to the many amendments that have been debated this evening. I am sure that many noble Lords will want to come back to those issues on Report—in particular, I hope that the noble Baroness, Lady Browning, will come back to her point about social workers being a suitable vehicle for providing information in their care planning work. It could save a lot of resource and waste of time. I beg leave to withdraw the amendment.
Care Bill [HL]
Baroness Meacher Excerpts(12 years ago)
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Baroness Wilkins
My Lords, I will speak to Amendment 88A. This amendment relates to Clause 9, which requires a local authority to carry out an assessment where an adult may have needs for care and support. The clause sets out things that the local authority must consider, for example the outcomes the person wants to achieve in their day-to-day life. There are similar provisions in Clause 10 in relation to a carer’s need for support. There is, however, an anomaly between Clauses 9 and 10. Under Clause 10(6), the local authority also has to take account of whether the carer works or wants to work, and whether the carer is taking part—or wants to take part—in education, training or recreation. That provision is missing from Clause 9, while in other respects the two clauses closely mirror one another. Surely the same provision as Clause 10 proposes in relation to carers should apply to people in need of care and support? While many of those with a need for care and support may be elderly, or may not be able to—or want to—work, others will want to. Many will be interested in education, training or recreation. This is an important gap that sends an unfortunate message about the ability or desire to work of those with needs for care and support.
Of course, it may be that the Government will argue that this is covered by Clause 1(2)(d), which includes in the concept of well-being,
“participation in work, education, training or recreation”.
If that were so, however, presumably the separate provision for carers in Clause 10(6) would not be needed.
I understand that overwhelming evidence exists that carers are often forced to withdraw from education or employment. That may well be why the Government felt they should include the emphasis on these things in relation to the assessment of carers’ needs. Possibly there is not as much evidence in relation to disabled people, and, as I have said, many social care users are older people. That does not mean that they will not be interested in education, training, recreation or even work. One in three people who use social care services are disabled people of working age.
In the recent report The Other Care Crisis by five disability organisations, the researchers found that time and again disabled people told them that the right care and support was critical in finding and sustaining work, studying and keeping fit or enjoying the arts. How can you hold down a job if the hours and type of support you are provided with take no account of a course you may be studying or of a job? What if the job starts at 9.30 am but your carers do not come to get you up until 9 am, or they turn up at different times each morning because of short-staffing?
Carers UK and others have rightly worked very hard to show the impact of caring on employment chances. As I say, this may well be the reason why the Government has included Clause 10(6). The Government may simply not have realised, however, how this would come across to users of social care services who wish to work. I hope the Government will want to rectify this anomaly.
Baroness Meacher
My Lords, I shall speak to Amendments 88SA, 88SB and 92ZZCZA, all of which are designed to ensure that parents who have care and support needs receive sufficient services to ensure that the caring burden on their child is not such as to impede their education and well-being.
Young carers are, of course, children and young people under 18 who provide regular and ongoing care and emotional support to a family member who is physically or mentally ill, disabled or misuses substances. The 2011 census identified 178,000 young carers in England and Wales; an 83% increase in the number of young carers aged five to seven years old; and a 55% increase in the number of eight and nine year-old children caring. I find these numbers staggering. We are talking about a lot of children of a very young age caring for a very considerable number of hours each week.
Why are the amendments important? Apart from a concern for the well-being of children, the issue is important for taxpayers. Young carers whose parents do not receive the support they need have poor educational and employment outcomes and suffer from negative health, with obvious cost implications for the Treasury. These amendments and the resulting early intervention could alleviate those problems and avoid crises, family breakdown and child protection issues, which, again, are a tragedy not only for the family but for the taxpayer and society.
National Health Service (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013
Baroness Meacher Excerpts(12 years, 2 months ago)
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Baroness Meacher
I would simply like to ask the noble Lord, Lord Warner, whether he has any interests in private sector provision and, if he does, whether he would like to declare them to this House.
Lord Warner
If the noble Baroness was listening, I think I declared my registered interests at the beginning of my utterances. She is very welcome to look at the register, which will show those particular interests, but they do not shape my view. I would like to finish the argument. If noble Lords want to go on interrupting me that is fine, but I would like to finish the arguments which substantially substantiate the case for accepting these regulations.
As I was saying before I was interrupted, these rules are very similar to the rules produced under the previous Labour Government but with the addition of some sensible provisions on integration. Let me remind colleagues that these regulations are totally compatible with the policy of using the independent sector in the NHS set out in the 2005 election manifesto of the Labour Party. Some may recall that Labour won a third election on the trot with that manifesto. I also remember, as a Minister, implementing the NHS parts of that manifesto with a policy of “any willing provider”. Many of the interests opposing these regulations look remarkably familiar to me from those days.
Even in the swashbuckling new Labour days of modest NHS competition, most PCTs’ contracts were rolled forward each year under that regime without any tendering process, competitive or otherwise. My guess would be that there were probably somewhere of the order of 50,000 of those contracts each year. It would have been totally impracticable and unnecessary to put many of those out to competitive tender each year, or even every three years. It will be the same with the 211 clinical commissioning groups. They will not be able to put out to tender on any great scale a large number of contracts, and they will be operating with a smaller number of staff than the PCTs.
The clinical commissioning groups will have to concentrate their change efforts on those services where there is continuing failure or underperformance, or where it is clear that there is a bigger prize of patient benefits from a major overhaul and out-tendering of services. I suggest that it is almost a paranoid fantasy to suggest that David Bennett and Co. at Monitor, with about 40 staff working on competition issues, will be able to act as a kind of Stasi outfit, rounding up clinical commissioning groups which have not recorded enough competitive tendering processes.
I am afraid that I have to disagree fundamentally with many of my colleagues. My sympathies are with the Minister over these regulations. He has done his best, in his customary patient way, to clarify them. In my view, they are perfectly acceptable in their present form and can always be amended in the light of experience. To my colleagues on these Benches, I would say that we ought to remember what was satisfying to the British public when we were winning elections. This approach of injecting, on an agreed basis, some measure of competition and change where NHS public providers are consistently failing is in the best interests of patients.
NHS: Private Companies
Baroness Meacher Excerpts(12 years, 5 months ago)
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Earl Howe
My Lords, there are tariffs that are nationally set and others that may be locally set, but there is scope to vary even the national tariffs if there is a good reason to do so on the grounds of local variation in costs. There is some flexibility in the system, but the main basis of the policy, as I stressed earlier, is that, where competition occurs, it should be on the basis of quality and not price.
Baroness Meacher
The CQC has an incredibly important job to do, but we know that it is very overstretched. What systems do the Government have in place to ensure that the CQC’s scope is adequate to monitor all private and NHS facilities and ensure that they are providing a sufficiently good service?
Earl Howe
I am aware that the board of the CQC is looking at that very question at the moment in the light of the Mid Staffordshire review. The noble Baroness is absolutely right. I think the essence of the answer to her question is that a risk-based approach must be adopted so that areas that are deserving of more attention from the CQC receive it and areas that are of lesser concern are allowed to act accordingly without interference.
Health: Mental Health
Baroness Meacher Excerpts(12 years, 7 months ago)
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Earl Howe
My Lords, the way in which mental health services are commissioned locally is of paramount importance. One of the features of the reforms is to bring together local authorities and the health service to plan services in a much more integrated way. Clinical commissioning groups will ignore the imperative of mental health at their peril, because they will be charged—under the commissioning outcomes framework, which the board will set—to deliver meaningful progress on all the indicators, including mental health indicators. It is an absolute necessity that good commissioning takes place at a local level.
Baroness Meacher
My Lords, the Minister is well aware that only a third of people whose lives are being ravaged by depression and anxiety are receiving treatment. He rightly pointed out that the commissioning board has a responsibility here, but I understand that it does not regard this as one of its priorities. Will the Minister give a very clear signal to the commissioning board that Ministers regard the equal treatment of mental and physical illnesses as important, and that parity must be achieved?
NHS: Evidence-based Medicine
Baroness Meacher Excerpts(12 years, 9 months ago)
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Earl Howe
My Lords, I do not think I can add to what I said previously as regards my right honourable friend. No doubt he will take the noble Lord’s comments into consideration. As regards NICE guidance, as the noble Lord will know, there are concerns that in certain parts of the health service NICE guidance is not followed as we would expect it to be. There are various initiatives in train to correct that, both as regards the NICE technical appraisals and also clinical guidelines.
Baroness Meacher
My Lords, the noble Earl knows very well that NICE has issued excellent guidance in relation to the increased access to psychological therapies, and these therapies are the best way, according to the evidence, to deal with depression and anxiety. Can the Minister explain to the House what actions he will take to make sure that these evidence-based therapies are available across the country? As the Minister knows, at present they are not.
Earl Howe
The noble Baroness will remember that one of the features of the Health and Social Care Act is a duty placed on the NHS Commissioning Board to promote the quality of care. In doing that, it will promulgate commissioning guidance based on advice received from NICE. In the mandate there is another means for the Secretary of State to ensure that instruments such as NICE clinical guidelines get traction within the health service.
NHS: Mental Health Services
Baroness Meacher Excerpts(12 years, 9 months ago)
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Baroness Meacher
My Lords, I congratulate the noble Lord, Lord Alderdice, for tabling this important debate; a debate, in my view, of national importance and of particular importance to the Government in their quest to take a million people off employment support allowance, or, in the future, universal credit figures within about 10 years. That is a major objective of this Government. We know that more than 40% of ESA claimants have mental health problems, the vast majority having depression or anxiety. That is nothing new. We also know that NICE recommends improving access to psychological therapies, and CBT most particularly. Not everyone likes the conclusions of NICE, or IAPT, but we have to take seriously the enormous amount of work that NICE does in looking at all the research available on a subject such as this and drawing its conclusions.
I do not share the views of the noble Lord, Lord Alderdice, that the style of therapy does not matter too much and that you can have bits here and there. This is a much more serious matter and people who practice these therapies tell me that these treatments, like other medical or pseudo-medical treatments, are potentially dangerous if they are not done really well. The quality of the therapist is absolutely vital and the methods and the types of therapy that they use. If we want to help people, rather than make them worse, it is no good using the wrong type of therapies, or short-term therapies, with the wrong kinds of people. We have to be very careful. It is essential that these IAPT services are of the best possible quality, which means, of course, using the best possible people. These services need to be available right across the country, so that GPs, wherever they are, can refer people for such help so that they do not lose their jobs—that, surely, has to be the first priority—or, if they have already lost their jobs, so that they can be prepared, as soon as possible, to get back into work and stop claiming benefits.
I shall leave my noble kinsman Lord Layard to talk about the national perspective. I shall talk about what is going on on the ground, as I am familiar with that. One problem is that the tendering process can result in services being provided by two or three different organisations. Far from just giving these services to the NHS, our experience is that they tend to be divided between different organisations. That may be all right but, over the years, health and social services have struggled to ensure that services provided across several organisations hang together and provide a good pathway of care for patients. It is very difficult on the ground; it sounds nice, but it does not work. The second best solution is to ensure that these different organisations work effectively together so that patients have a good pathway.
Competition rules may be being misinterpreted, but commissioners on the ground understand that these different organisations must use different IT systems, even though they are very happy to use the same one. The result is that these organisations do not communicate effectively with each other. That may be due to the limited understanding of commissioners. I do not think that the problem lies with competition, per se; I think it lies within the capacity of commissioners to operate competition in the best interests of patients and, to be perfectly frank, that simply is not happening.
Another issue is the tariff for IAPT services. The “any qualified provider” guidance for commissioners makes it clear that local commissioners should set their own tariffs. We know what happens if they do that. We know that the money supposedly put into IAPT psychological services is not ring-fenced and that local authorities are tempted to siphon it off into other things, and who can blame them? I do not blame them, but it means that we have to be very careful if we want a really good psychological service to deal with the unemployment problems of people with anxiety and depression. We cannot cut corners and a lot of tariffs are being set too low because of a lack of understanding.
The most serious problem, as I understand it, applies to steps 3 and 3 plus services. To treat effectively those with severe anxiety, severe obsessive-compulsive disorders and those with tricky, difficult and often multiple problems we need skilled therapists. That cannot be done by a low-cost therapist. Under AQP rules, a session of high-intensity therapy costs £40 to £50. High-intensity therapists themselves will cost more than that. There are also other costs such as administration, office costs and so on. However, when properly funded, we know from research that these services are highly cost effective; they get people back into work. The big question is why this is happening.
Even if trusts downgraded their intensive therapists from band 7 to band 6, which will inevitably mean losing their very best people—the noble Lord, Lord Alderdice, said, that they should not do that—and even if they made huge and probably unrealistic assumptions about productivity, organisations could not afford these services at steps 3 and 3 plus. My understanding is that steps 1 and 2, although challenging, will be deliverable. The whole benefit of the IAPT programme is that it is a stepped care programme. If someone is identified as needing step 2, and after a bit the therapist realises that that person has much deeper and more extensive problems than they originally presented with, they will need step 3 and if step 3 is not there, the value of step 2 will be lost. Such people will not get better and they will lose their jobs or not get back into work. That is the sort of concern felt at the bottom, where people are trying to deliver these services. I am not saying that they should all be delivered by the NHS. The NHS is having to renegotiate contracts and is having to cut the amount of money to deliver the same service, or something nearly as good. However, with IAPT it is not like that; it will all be tendered out, and change will be much more radical.
The view that I have had from others is that this consequence is more of a cock-up than a conspiracy. People are not trying to destroy this, but these AQP services will go live in November 2012 through to March 2013. The consequences of all these inadequate tariffs and problems on the ground, separating the different bits of the service across organisations, will become apparent during that six-month period and will get worse over time.
Before I finish I want to refer to a rather nice little piece of information, which supports my concerns. I happened to be at the Verulam School in St Albans talking about the House of Lords last Friday. The sixth formers were an impressive group of people. They were so concerned about mental health among young people—that is, themselves—that they undertook a survey of 1,800 young people in the St Albans area, which is not known for its deprivation. They really got at some of the problems and concluded:
“The value of mental health provision and the overwhelming need for it has become clear to us, as has the need for appropriate access and early support”.
They were very concerned about cuts to counselling support services for young people in St Albans. If you go along to east London you will find that things are even tougher, but it was interesting to find that result in a relatively well heeled part of the country.
I appeal to the Minister to do all that he can to rescue this inexpensive and highly cost-effective contribution to the Government’s goal to reduce unemployment. Will he try to ensure that IAPT is removed from the AQP system, if at all possible, even at this late stage? Will he try to secure the continuity of the central policy unit for IAPT? Those two things would transform everything. I have great trust in the Minister and look forward to hearing his comments.
Drugs: Prescribed Drug Addiction
Baroness Meacher Excerpts(13 years ago)
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Earl Howe
There are no plans to revert to the former situation as regards heroin, but my noble friend makes the point that alcohol addiction is an extremely important issue. The commissioning of services to treat addiction will in the future architecture of the system be devolved to local areas. The all-party group on benzodiazepines on which the noble Earl sits has done some important work in exposing those areas where services are not as good as they should be.
Baroness Meacher
I applaud the Minister’s comment that treatment must be based on need rather than on whether a substance is legal or illegal. Is he aware of the excellent work being done to treat heroin addicts in Switzerland, where a third of people are in employment and two-thirds of people are living legally within 18 months? Will he consider introducing to this country these highly cost-effective approaches?
Health and Social Care Bill
Baroness Meacher Excerpts(13 years, 4 months ago)
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Lord Hunt of Kings Heath
My Lords, we now move on to another group on the regulation of healthcare workers, and social care workers as well. In debate in Committee, I made it clear that I was concerned about the decision of the Government to abolish the General Social Care Council and to transfer responsibility for regulation of social care workers to the Health Professions Council. I am concerned for two reasons. First, I know that the General Social Care Council had rather a bumpy ride to start with and was the subject of a review, which was critical of the way in which it performed. However, it is right to pay tribute to the tremendous work undertaken in the last two years under its current leadership and the chairmanship of Mrs Rosie Varley to improve and enhance the quality of the regulation by the council. It is very disappointing that the Government have decided that, just at the time when the GSCC is starting to prove itself, the whole thing is to be dismantled and the function transferred to the Health Professions Council.
I also do not understand why the Health Professions Council is considered to be the right regulator for social workers. There is a difference between social work and health work. We touched on that in the last debate. I agree with what the noble Earl, Lord Howe, said in response to the noble Baroness when he reflected on the value of social care workers but also on the difference in role. The Health Professions Council regulates a number of bodies, but they all have a health basis in the main. Therefore, it stretches the imagination to see how this body will effectively regulate social care workers in the future. The profession of social work is pretty fragile and having its own regulator is one of the building blocks for boosting the status, confidence and quality of the social work profession.
I oppose the abolition of the GSCC and the transfer of social worker regulation to the HPC in principle. If I am unsuccessful in persuading the Government, even at this stage, to change their mind, I suggest that a number of issues would help to reassure me and many social workers about the way in which the HPC will perform. This is why I have a number of amendments, which seek to ensure that there is an appropriate definition of “social worker”. I think that it would be appropriate, inside the HPC, to establish an office of chief social worker. I also think that the name of the HPC should recognise that it is regulating the social work profession. I have not yet had any rational answer as to why “Social Work”, or something of the sort, should not appear in the title of the HPC. We know that the reason is that the HPC has refused to have it. I think that the department is finding it difficult to tell the HPC that it is subject to parliamentary provision and that it is not enough, simply because it does not want “Social Work” in its title, not to agree to it. I refer the noble Earl, Lord Howe, to the Bill before us. It refers, in these clauses, to a number of orders, including health and social work orders. Therefore, there clearly cannot be an objection in principle to the use of “Social Work” in the title. It is totemic, but it is at least a way of showing the 100,000 individuals in the social work profession to be covered that in fact the HPC is not going to continue with a medical model of regulation.
My final point is this. I invite the noble Earl to state clearly that it is not his department’s intention that the HPC should eventually take over the regulation of nurses and doctors. He will know that a review is being undertaken of the Nursing and Midwifery Council and I gather that there are also proposals to change the governance of the General Medical Council. A number of people in the health service have told me that they think the eventual aim is for the HPC to regulate all the healthcare professions. The noble Earl would provide a great deal of reassurance if he would say that it is not his department’s long-term ambition to turn the HPC into the sole regulator of all the health and social care professions. I for one would be very concerned about that. I beg to move.
Baroness Meacher
My Lords, I shall speak to Amendment 241C, which is tabled in my name. I also support the amendments tabled by the noble Lord, Lord Hunt. I was tempted to add my name to them, but I was a bit late yesterday. These amendments concern the implications of abolishing the General Social Care Council and the dilution or indeed the elimination of some of the functions carried out by that body. I thank the Minister for the briefing meeting that he held yesterday. At the tail end of this most unpopular of Bills, and after what I gather have been more than 100 meetings with Peers and others, I want to acknowledge the extraordinary work that the noble Earl has done throughout.
The social work profession is perhaps the most battered profession in this country and, if I may say so, the previous Government did not help in that. A certain Secretary of State for Education in the other place took what I thought was completely unreasonable action following the Baby P incident, which left the social work profession pretty much on its knees. The idea of having a chief social worker in this country who would act as a spokesperson for social work—someone who would promote and defend it—is enormously justified at a time when the profession, as I say, is on its knees. It is very difficult to appoint good people because of the reputation of the profession and because of the actions of that Secretary of State. He happens to be a friend of mine, but I think that he made a terrible error on that occasion.
Amendment 241C seeks to ensure that best interest assessors under the Mental Capacity Act continue to have their training regulated. I realise that the Government’s agenda is to reduce regulation wherever possible and I broadly support that objective, because we have had too much regulation in this country. But there are limits to that process and I believe that this is one issue over which the Government have in fact gone beyond a reasonable limit. Post-qualification training is currently regulated by the General Social Care Council, but under the Bill only the training of approved Mental Health Act practitioners will be regulated by the Health and Care Professions Council. Although the GSCC accepts that it could have done a better job with that regulatory power, to do away with it altogether seems to be the absolute opposite of the right answer.
Why is this important? It is because the issue here is often about the deprivation of liberty of elderly patients with dementia and those with severe learning difficulties. Civilised countries always take extra care in protecting individuals where their liberty is being taken from them. It is somewhat arbitrary that these groups happen to fall into the ambit of the Mental Capacity Act on the one hand and that of the Mental Health Act on the other. I am sure that in time those two pieces of legislation will be brought together, but in the mean time we have to manage the fact that people are being detained either under the Mental Health Act or the Mental Capacity Act and that very similar processes are under way in the two sets of circumstances. Mental Capacity Act clients in residential homes or nursing homes, for example, who do not have the capacity to make their own decisions about their lives, are in essentially the same position as psychiatric patients who are not able to make a rational decision about whether they need to be detained in hospital.
Psychiatric patients are assessed by approved Mental Health Act practitioners to determine whether they warrant that detention. In Mental Capacity Act cases, the professional is assessing whether a particular decision is in the best interests of the patient or resident, assuming that the patient does not have the capacity to make the decision for themselves. In both cases this is likely to involve assessing whether the individual can live safely at home. That is the whole point. People are assessing pretty much the same thing under the two different pieces of legislation. It is true that in some cases approved mental health practitioners have to assess the risk to others, but the issues are honestly very similar. Is there any logic, therefore, in regulating one and not the other? We know that abuse of these adults is commonplace. Relatives may of course be absolute angels in terms of protecting their family members, but they may not be, and the best interest assessor is there to protect vulnerable people when relatives let them down.
The words of Mr Justice Peter Jackson in his ruling in the London Borough of Hillingdon v Steven Neary and Mark Neary and the Equality and Human Rights Commission highlight the importance of the deprivation of liberty safeguards. The deprivation of liberty safeguards were designed to protect the human rights of some of our most vulnerable people. Employers and supervisory bodies have to be sure that the professionals they charge with undertaking this vital role are competent, compassionate and able to approach the situation from both a practice and legislative basis. With the closure of the GSCC, I urge the Minister to put in place a system at least as robust as the current one, and ideally more robust, to ensure that the providers of training for best interest assessors can clearly demonstrate their ability to produce and, importantly, assess potential best interest assessors. That would go a long way towards protecting some of these very vulnerable citizens.
I want to turn briefly to a number of the amendments tabled by the noble Lord, Lord Hunt. The first concerns student registration, which we discussed in detail at the briefing meeting yesterday. I shall not go into all the detail again. However, it has to be said that if it is justified to register social workers, it has to be justified to register social work students. That is because these people are unknown and untried. They go into vulnerable people’s homes on their own and they are probably more of a potential risk to their clients than qualified social workers. There is once again an issue of logic here, which I hope the noble Earl will take seriously.
A further concern is that, as I understand it, the Health and Care Professions Council will not introduce the satisfactorily assessed and supported year in employment as a requirement before someone can be accredited as a fully qualified social worker. This is another important safeguard, as people have to prove themselves over the course of a year’s work. There is no great administrative problem about this. It is simply a requirement so that employers meet certain standards. I would argue that it is not a bureaucratic nonsense; it is an important requirement.
Finally, there is to be no regulation of social care workers. The arguments that were rehearsed in the previous debate probably apply just as much to this one. The case for statutory regulation where vulnerable people and low-paid workers are concerned seems absolutely overwhelming. Again, I hope that the noble Earl might agree also to have a review of this area. At the minimum, is the process of voluntary regulation really working?
I fear that the Government have gone too far in dismantling the protections for vulnerable clients. Of course employers and universities have important responsibilities for their workers and clients, but I hope that even at this late stage the noble Earl might want to maintain some state responsibility for the protection of these most vulnerable clients when their liberty may be taken from them.