NHS: General Practitioners
Baroness Meacher Excerpts(10 years, 2 months ago)
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Earl Howe
My Lords, the resources that have been devoted to GP practice and primary care have gone up by a third in real terms since 2002. A lot of that was due to the revised GP contract. Unfortunately, that contract also allowed GP practices to opt out of out-of-hours care which, over time, has meant that patients have found it more difficult to access their GPs at evenings and weekends.
Baroness Meacher (CB)
My Lords, very much respecting the point about out-of-hours care, I am aware of a number of practices that are finding it extremely difficult now to recruit GPs. Will the Minister undertake a review of the impact of the now falling GP pay on recruitment and therefore on the capacity of patients to obtain appointments?
Earl Howe
The noble Baroness raises a very important issue. I can tell her that the department and Health Education England have commissioned an in-depth review of the GP workforce looking towards a more sustainable solution for the longer term. The final report will be published in the summer. The preliminary report suggests that increasing the supply of practice nurses and greater collaboration with specialists may help to improve effective workforce supply.
Children and Families Bill
Baroness Meacher Excerpts(10 years, 3 months ago)
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Baroness Jones of Whitchurch (Lab)
My Lords, the amendment is about the impact of the bedroom tax on children. I refer noble Lords to my housing association interests recorded in the register.
This simple amendment would allow local authorities to put the welfare of the child first when assessing the appropriate occupancy level in a home. Many aspects of the bedroom tax are unfair and unjust, and we have raised them repeatedly in this House. This amendment picks on one simple theme which has quite rightly dominated our consideration of the Bill so far: that the interests and the welfare of the child should always come first. This issue has united us around the Chamber, and I hope that noble Lords will support the continuation of this principle, reflected in this amendment.
We already know that the bedroom tax hits families hard. The chief executive of the National Housing Federation has described the policy as,
“an unfair, ill-planned disaster that is hurting our poorest families”.
It has resulted in an estimated 150,000 families with children being hit so far, forced out of their homes or pushed deeper into poverty and debt. We know from consistent research that children who are forced to move home, away from settled communities and their schooling, suffer health problems and have poorer educational outcomes. Meanwhile, families who stay put suffer an average loss of income of £14 a week, with much higher losses for many, impacting on their ability to feed and clothe their children.
The bedroom tax also has a disproportionate impact on disabled adults and children. Housing association studies have shown that a significant proportion of those affected are either disabled themselves or care for someone who is disabled. Many of them live in homes with adaptations, making it difficult and expensive to move. Others use their spare room for bulky medical equipment or facilities for visiting carers.
There are other adverse welfare implications of the bedroom tax. Recently, there was publicity for the very sad case of the Hollow family, whose 11 year-old son, Caleb, died in a car crash. After a year, the family were told that they had to move to a smaller property, causing added distress to Caleb’s siblings, who were still grieving for their lost brother and who now face the further disruption of a house move or a slide into poverty.
There is also the ongoing issue of the impact on foster carers. When we debated it in Committee, we welcomed the Government’s concession to allow one additional room in their home as long as they had registered as a foster carer or fostered a child within the previous 12 months. However, the reforms still apply to foster carers who have two or three bedrooms for fostered children. Foster carers could be deterred from providing foster care for more than one child at a time, so that more children would be more likely to be separated from their siblings. Given that there is already a shortage of foster carers in the UK, these reforms are likely to mean fewer new recruits coming forward and children’s well-being suffering as a result.
The application of these policies has seen local authorities and housing associations being put in an impossible position, trying to minimise the impact of badly designed policies on local people. As we know, there is often a mismatch in accommodation so that there are simply not enough smaller units even if tenants wish to move.
Meanwhile, under this Government, housing completions are at their lowest peacetime level since the 1920s. Local authorities find themselves trapped trying to implement an unworkable policy with little flexibility. Quite often, their only solution for tenants who are unable to downsize is to move them into the private rented sector, with all the additional housing benefit costs and the poorer standards that this entails.
The Government’s main response so far to the increasing number of tales of poverty and distress has been to set up the discretionary fund to support the most vulnerable families. However, alarmingly, the Local Government Association has reported a dramatic increase in the number of people requesting emergency financial help, with 81% of councils experiencing a sharp increase in the number of applications to the discretionary housing payments scheme, most of which are being made to stop people losing their homes. This demand is so great that councils report it is outstripping the money made available by the DWP, forcing them to make cuts to services in other areas. Anyway, these funds are, by their very nature, temporary, require regular reapplications and provide no ongoing stability for the families concerned. The Government have also issued guidance to local authorities on the application of the rules concerning children’s disability but again they have no obligation in law and the Minister will know that children’s charities remain concerned about the provisions and continue to challenge them.
We believe that our amendment gives local authorities the flexibility they need, based on their local knowledge and their local circumstances, to operate the bedroom tax rules to put the welfare and the interests of the child first. We believe that this would be welcomed by all those trying to implement this unwieldy and unjust policy. It would allow them to make an informed judgment of the options available to individual families in their local area to avoid some of the perverse outcomes that arise from the rules and to guarantee that the interests of the child are safeguarded. We believe that this is a simple but important amendment, in keeping with the spirit of the remainder of the Bill, and I urge noble Lords to support it.
Baroness Meacher (CB)
My Lords I support Amendment 57BC, tabled by the noble Baroness, Lady Jones of Whitchurch, to which I have added my name. She eloquently set out the case for the amendment and I will not repeat her comprehensive and cogent arguments. I have no doubt that the Government will regard the amendment as too wide-ranging. It provides for a determination setting aside the bedroom tax, potentially for a very large number of families. For a considerable number of families a move into new and smaller accommodation will be contrary to the interests and the welfare of the child. At the lower level of harms—if one can call them lower level—a house move may involve the children having to change school at the same time as they move home. Other children will move away from a grandparent or somebody else who looks after them when their parents are working. These sorts of changes could have very serious consequences for very sensitive children—not necessarily just disabled ones. At its most serious, a move may deprive a family of the basic space they need in order to continue managing a severely disabled child, or indeed an adult, in the family and therefore keeping the family intact. I want to focus on this to avoid duplication.
We know that families with a disabled child have been disproportionately disadvantaged by the bedroom tax, although the Government accept and have made changes to ensure that a disabled child should at least have a room of their own. That was certainly progress. The Minister always tells us that the discretionary housing payment is the answer to all possible problems. It will no doubt help many families with a short-term problem, if they are able to move into smaller accommodation—that is a big if—without serious consequences for a child or for the family as a whole, but where there is a short delay before the move can take place. I guess that would work pretty well. I accept that discretionary housing payments can be a helpful safety net for some people in the short term. That is how I think I see it working.
Children and Families Bill
Baroness Meacher Excerpts(10 years, 5 months ago)
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Baroness Tyler of Enfield
My Lords, I am sympathetic to the thinking behind the amendment. The idea of a “father quota”—an independent right for fathers to at least four weeks of leave—could be important if we are to achieve our aim, which the noble Baroness, Lady Lister, set out clearly and which is all about changing the culture.
There are two aspects of the culture that need to be changed. One is the expectation within the workplace, on the part of both employees and employers, about who is going to take parental leave. The burden is so much on the mother at the moment that the new legislation, which I strongly support, could make a reality of encouraging fathers to take parental leave and be much more involved in the early days and weeks of looking after newborn babies and children in their first year.
The second culture change that we are looking for is a different way for couples to decide how they are going to juggle bringing up their children and their work responsibilities—something that many people struggle with. We all know that it is not easy. What the Government are proposing is very helpful, but I want to see something that is going to provide that additional incentive to fathers to take this up. I really like the phrase “use it or lose it” because it says clearly what we are trying to do here.
The noble Baroness, Lady Lister, went through the evidence comprehensively, so I certainly do not intend to repeat that. When I reviewed the evidence, I was particularly struck by the impact that this had had in the nordic countries. It really seemed to be the thing that made the difference and started to tip the balance to get that culture change. If we really are trying to encourage fathers to take up leave—I think all of us here want to do that, judging by what has been said so far today—we need to take some heed of the international evidence of what works.
Baroness Meacher (CB)
My Lords, I will speak very briefly, having not participated in this Bill because of other commitments, in support of the noble Baroness, Lady Lister. As others have said, we are pressing here for a change of culture. We are looking for fathers to play a much more active role in the upbringing of their children. Clearly, as my noble friend Lady Lister has rightly said, if fathers are involved right at the beginning, they bond with the baby and will then be much more involved throughout the child’s early life. This has to be good. In my view, we are seeing that change of culture: more and more fathers are bonding with children in the early stages and being much more involved throughout the child’s life.
I want to put on record the link between this and what I regard as the Government’s very helpful inclusion in this Bill of a recognition of the equal importance of both parents to a child if the tragedy of divorce strikes. If you involve fathers very closely at the beginning of a child’s life, they bond, they become involved and they care for that child, but they are cut out after a divorce—which happens, as we know, all too often in this country year after year. This is actually very cruel. Maybe it was okay in the old days for men to remain outside the family, unattached, but if we are all working towards greater equality of mothers and fathers in terms of their involvement in the family—and therefore greater equality for women in the workplace—we have to follow through, as I believe the Government are trying to do, to the post-divorce situation, should that tragedy arrive. Having been through it myself, I know exactly how that feels for everybody. I strongly support the noble Baroness, Lady Lister, but it is very important to see these two parts of the Bill joined up.
Lord Stevenson of Balmacara
My Lords, this is a very interesting area, and I am grateful to my noble friend Lady Lister for bringing her expertise to bear on it and for analysing the case so well. It is curious that we are stuck on the horns of a dilemma here. We all agree that we are trying to bring in a new system which rightly promotes joint responsibility for children, in terms of the various histories that we have heard about already, and the future we wish to carve out in our country in which parents jointly take greater responsibility.
The underlying strain in that point, which has been brought up by the two recent conclusions from the noble Baronesses, Lady Tyler and Lady Meacher, is that we are coming from a position where fathers have not actively played a part, although there are notable exceptions and some of those might be present today. However, the generality which is revealed by the research is that fathers, despite what has been available to them up to now, have not taken advantage of it and, to misquote an earlier comment, they have “lost it”, in the sense that they have not taken what is available.
We have a reasonable expectation that the new arrangements will be a step in the right direction. However, will they be enough? That is the question. In particular, I was struck by the points made by the noble Baroness, Lady Meacher, about divorce situations, which we regret but which are a natural part of all this. Without the bonding early on or even quite late on in the growth of the child, the loss of the relationship between fathers, mothers and children in a divorce is tragic and will have a lifelong impact.
There is a big picture here; there is a lot of activity and change. This is a new system and the Government are rightly defensive of it, but the Achilles heel in their approach is the statement in the impact assessment that the take-up of the proposed new shared parental leave by fathers is expected to be very low—this has been mentioned already—at between 2% and 8% of those eligible, or between 5,700 and 22,800 fathers, representing less than 3% of all maternities a year. Is that really all that our expectations are for that? If it is, it is up to the Government to defend why that represents a satisfactory situation compared to the rhetoric that we have been listening to from the Minister, which tells of a glorious engagement of a much higher percentage where people would expect joint caring. It is not joint if only 2% or even 8% of those eligible are taking up what is available, and indeed are “losing it” if they do not.
It is indeed disappointing, as my noble friend Lady Lister has said, that the scheme of the parental leave model, which is good and which we support, seems to be suboptimal if it does not include anything new for fathers in their own right. It provides an enabling power for the Government to extend paternity pay by regulation, and there is already a power to extend paternity leave by regulation so it may be that the Minister can give us more hope that this will happen. However, the commitment does not seem to deliver the same outcome as the proposal in the amendment that we have just heard about. A father quota would mean that a father could take leave, as has been pointed out, on a much more flexible basis later on in the first year rather than in the early stages and perhaps even later, particularly when the mother is making the difficult transition back to work. The time would be at his choosing and the leave would not reduce the mother’s entitlement; those seem to be very important elements in this debate. I admit that I myself am not sure whether or not more is needed here but the case is certainly there to be answered, and I look forward to hearing what the Minister says.
The second amendment in this group, Amendment 266CA, suggests that we bear down with laser-like intensity on the facts and watch what happens: we would see how many fathers are taking this up, whether it is 2%, 8% or better. We would look at the relatively poor pay that has been provided for this, and try to work out what is going on here. That is also an important element of the new proposals, and it would be wrong to let it pass without signalling that we are concerned about it.
As the Official Opposition, we cannot yet support what has been proposed because it is a big spending commitment; I accept that, so we are not doing so. However, we suggest that more information, research, reporting, discussion, debate and academic work would give us a better handle on this for future times. If the powers are there in the Bill to do something about it, we would be satisfied with that.
Care Bill [HL]
Baroness Meacher Excerpts(10 years, 6 months ago)
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Lord Warner (Lab)
My Lords, although I am Lord Warner of Brockley in the London Borough of Lewisham, I do not intend to speak about the Lewisham case.
I am conscious that this is a topic which can rapidly cause eyes to glaze over as we go into some of the processes involved here. At the heart of this there is a fundamental problem which is much deeper and more serious than when the 2006 Act was passed. That was seven years ago. This procedure of trust special administrators was set up to deal with a relatively small number of cases that might come along. It was not a system set up to deal with major overhauls of acute hospitals up and down the country.
We are now in a very different financial situation from when this earlier legislation was going through Parliament. You pays your money and you takes your choice as to who you believe about the black hole that there will be in the NHS finances at the end of this decade. If you want to believe Sir David Nicholson, the outgoing chief executive of NHS England, it will be £30 billion. A number of noble Lords may be shaking their heads because they do not wish to believe him, but he says £30 billion. If you want to believe the Nuffield Trust, it will be somewhere north of £40 billion. If you want to consider the more measured estimate last week from the chief executive of Monitor, it will be £12 billion, but that assumes a level of efficiency savings which seem somewhat like fantasy football in terms of their deliverability. It is likely to be a lot more than £12 billion.
These are numbers which no one was even thinking about when the trust special administrator system was set up. I have some sympathy with the Government’s position because there is no doubt that we have a large and growing number of clinically and financially unsustainable acute trusts. The Government have a real problem that they are trying to tackle. However, I suggest that this particular way of tackling it is not the best way, because it is trying to adapt a system which was produced for a relatively small number of cases into a whole system set of arrangements. It has some curious quirks. It seems to treat clinical commissioning groups which are commissioning from foundation trusts differently from those commissioning from non-foundation trusts. I am not going to risk eyes glazing over by talking about this, but this set of proposals does not seem to treat different clinical commissioning groups in exactly the same way.
We must also start to engage the public in the scale of changes that will have to be made to the NHS in order to make it sustainable. It is not just that black hole issue; it is the clinical sustainability of some of its services. We are already finding difficulty in staffing A&E departments. There is a set of issues around whether the manpower would be sufficient to enable us to keep 24/7 acute specialist services on the same number of sites. I would suggest to the Minister as humbly as I can that you are not going to deal with the scale of the problem with this set of arrangements. For the sorts of reasons that the noble Baroness, Lady Warnock, set out, even if you have this set of arrangements on the statute book, you are going to end up with many cases of Lewisham hospital writ large, dotted around the country. There is nothing in these provisions which really ensures that the wider public debate about the reshaping of these services takes place. They are a recipe for a very large number of one-off local rows on a major scale. The lawyers in this House must be rubbing their hands at the prospect of judicial review because a very likely outcome of all this is a large number of contested claims about the way the exercise has been done. There simply will not be the political cover for TSAs to be bold in their thinking.
The noble Earl said we want them to be able to give very effective consideration to the solutions that are needed. I suggest that if you are a trust special administrator and you think you will be kicked from Land’s End to the north-east because of the controversy around the proposals, that is not likely to produce whole-system changes. We now have to think about reviewing whether the TSA system is fit for purpose and meets the needs of the circumstances we now face. That is why, although I am not normally in favour of wrecking amendments, I agree with my noble friend Lord Hunt’s idea that we should have a pause and think again about the best way to reconfigure hospital services so that politicians and the public can engage with this issue and have the kinds of public debates that we badly need to have if we are to maintain the NHS in anything like the form it is today.
Baroness Meacher (CB)
My Lords, in part, I support the Minister because, as the noble Lord, Lord Warner, said, the Government have a problem. We know that for many years there have been attempts to close hospitals that need to be closed and it can take 15 years for that to happen. If the Government can come forward with a sensible, reasonable way of making those decisions, I will back it all the way. However, I find myself agreeing with the idea that a rather quick fix designed to achieve some solution to the Lewisham problem is not the way to do it. This is a national problem of considerable significance. I ask the Minister to take this away, think hard about it and come back with a good set of proposals to help this country close hospitals when they need to be closed. I would certainly be there behind him.
Lord Kennedy of Southwark (Lab)
My Lords, although I sit in this House as Lord Kennedy of Southwark, I actually live in Lewisham, very close to the hospital. I agree with the comments made by my noble friend Lord Hunt of Kings Heath. This is a major change of policy being sneaked through the door by the Government. I am amazed that the Minister has brought his amendment today when we are just a few days away from the case being heard in the Court of Appeal—it will be heard next week, I believe.
I live close to the hospital and I refer noble Lords to my declaration of interest that on a voluntary basis I chair a small committee in the hospital. Whatever the problems of the South London Healthcare NHS Trust, I cannot adequately describe to noble Lords the sense of injustice, unfairness and hurt about what is being imposed by the administrator. We have a good local hospital, which is supported by the local community, delivers on its targets and objectives and is financially solvent, but the administrator came along and ripped the heart out of the hospital.
I contend that the purpose of this amendment is to try to stop the campaign that we have seen in Lewisham over the past few months. The campaign has united the community like never before. We had more than 25,000 people on our march. Streets are plastered with posters to save the hospital. Any political party would be envious of the posters up in people’s windows about this campaign. Our local campaign is chaired by a local GP and has brought together health professionals and the local community.
Will the Minister tell the House whether he has visited Lewisham hospital? I asked him that question earlier this year; I know that he had not been then and hope that he has been there since to see the amount of local support and what a good local hospital it is. More important, there is no support at all for what the Government propose today. I hope that the House will support the amendment of my noble friend Lord Hunt of Kings Heath and reject the amendment of the noble Earl.
Care Bill [HL]
Baroness Meacher Excerpts(10 years, 7 months ago)
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Baroness Meacher (CB)
My Lords, Amendment 41 is a probing amendment, so I will speak briefly. Before I say anything else, I applaud the Minister for the raft of amendments in this group. I was particularly pleased to see the amendments in relation to young carers, although this is not relevant to Amendment 41. However, government Amendments 32, 33, 36 to 38 and—perhaps in particular—39 and 40 are, of course, relevant to this amendment. My Amendment 41 requires that regulations that make further provision for carrying out a needs or carers’ assessment will specify the circumstances in which a person’s social care needs are to be regarded as complex—the amendments do not refer to that term, so I would like a further clarification of that—and that having defined “complex needs”, social workers should always be involved in the assessment of cases meeting that criterion. That is the proposal of the College of Social Work. I should say that the involvement of a professional social worker does not mean the exclusion of all others. Clearly, if a professional social worker is dealing with a deafblind person, he would need to involve a specialist in that particular group of disabilities.
The college makes the first point that a good assessor sets out to create a complete picture of a person’s situation, strengths, capabilities and aspirations. Social workers are trained and recruited on the basis that they have the necessary cognitive and emotional depth to undertake those assessments. The second point is that people with complex needs generally have an awful lot of different services to which they need to relate if all their complex needs are to be met. The role of the care co-ordinator therefore becomes vital in those situations; care co-ordinators tend to be professional social workers.
As the noble Earl knows, the Law Commission argued that where a person has complex or multiple needs, a proportionate assessment would require an in-depth and comprehensive exploration of those needs. It is difficult to imagine that somebody other than a professional social worker would be equipped to do that. The types of situation which would be treated as complex cases include: where a person is subject to legislation or national guidance; where a person is or may be subject to abuse; where there is conflict between a person and a member of their family or their carer; and where there is a need to support the applications of individuals or their families for continuing healthcare funding.
Government Amendments 32, 33, 39 and 40 could pave the way for regulations which would meet the concerns addressed in Amendment 41. The noble Earl will know that our particular concern is for clients with learning difficulties, mental health problems and, in particular, dementia—people whose needs will be quite complex and difficult to assess. You need people who have been trained in that sort of work. Can the Minister say, with respect to these vulnerable groups, whether regulations will clarify their need for a professional social work assessment, albeit involving others as well? If regulations will not deal directly with the assessment of people with complex needs, and in particular with those who have all those mental health problems, can the Minister explain what provision he plans to make in order to ensure that the needs of these particularly vulnerable people will be properly assessed and addressed?
Lord Dubs (Lab)
My Lords, I welcome how far the Minister has moved from Committee to today. I hope that noble Lords will not think it churlish of me to say that perhaps he might be persuaded to move a little further. I will speak first to Amendment 60, which seeks to oblige a local authority to provide advice and information about what can be done in the event of an emergency, or if needs change. I am specifically talking about what I think we have referred to before as people with fluctuating conditions and needs. We know that there are many millions of people in the country who have fluctuating conditions such as multiple sclerosis, rheumatoid arthritis, HIV, Crohn’s, colitis, epilepsy and Parkinson’s disease, and there may be many others. Therefore, we are talking about a significant number of people who will be affected by the provisions of this Bill.
Not long ago I was talking to a woman in a wheelchair who had MS. She was very lively, bubbly and sparky, and she said to me: “You know, I’m not always like this. Some days I go down and I can’t even get out of bed, so don’t judge my condition by the way you see me today”. I took that very much to heart, and it is clearly the sort of situation that this amendment is about. As the Bill is currently drafted under Clause 25, it would not really make provision for such situations.
This amendment is actually operationally simple. It would help to ease the pressure placed on formal and informal carers, and would give them more certainty. Not only will it ensure that individuals get the timely care that they need when they need it but, equally importantly, it has the potential to prevent costly and unnecessary hospital admissions. If this amendment is not in place, there is always the possibility that with a downward fluctuation in condition, the person without the support will then have to be hospitalised. That in itself is costly and is utterly undesirable from the point of view of the person who could be helped in the home if this amendment were to be passed.
Local authorities are surely in a position to provide better tailored care, to promote confidence and control and allow people to prepare for such rises and falls in their care needs. The current drafting does not allow for it. A snapshot was taken by the NRAS—the National Rheumatoid Arthritis Society—which indicated that currently more than 30% of respondents with rheumatoid arthritis have been admitted to emergency care as a result of a flare-up in the disease in the past year. This is something which I trust could be prevented if we changed the way in which this clause was to operate. A survey of 1,000 people with MS revealed that 95% of respondents felt that better services during a relapse or a sudden deterioration of their condition would help them to maintain their independence. More than 80% said that they want to be able to plan their care and support in advance of that care being required. This amendment would help people whose conditions might suddenly worsen and, as I said earlier, would potentially prevent unnecessary and costly hospital admissions.
I turn to Amendment 61. As the wording of the Bill in Clause 27 states, local authorities have the power to generally review care plans. However, they are not required to specify when they anticipate that these reviews will take place. This amendment seeks to put some certainty into the process. There should be an agreed date between the adult and the local authority upon which a review of the care and support plan would be offered. I envisage a discussion between the local authority and the person concerned about the best way in which their care needs can be met.
An anticipated review date, agreed between the local authority and the adults, would provide stability and certainty to those being cared for. It is not a large change but it would be beneficial for the people concerned. I do not want to spell out with examples where people have said what a difference it would make if they had this element of certainty. I would like this amendment to be passed, which will give the adult the confidence that their care would continue as agreed until the specified date or until the adult themselves chooses to request a review in line with Clause 27(1)(b).
Baroness Meacher (CB)
My Lords, I rise to speak to Amendment 123. In doing so, I add my support to Amendments 76 and 124, which were tabled by my noble friend Lady Greengross. Indeed, a few of my comments slightly overlap hers.
As the Bill stands, local authorities will be given many complex duties and will be required to make many decisions which will have a substantial—you could say devastating—impact on the lives of elderly and disabled people, but there is no statutory provision for any appeal or independent review process, even if decisions are made on the basis of factual or legal errors. That is the point of the comments I want to make.
I understand that the Government have committed themselves to consider a process of redress or appeal and that they recognised in their response to the Joint Committee that it is,
“vital that people have an effective way to complain and seek redress”,
but there is no assurance in the Bill that such a system will be put in place and, if one is, what its characteristics will be. As my noble friend Lady Greengross said, regulations under other legislation do not appear to do the job. I hope the Minister will comment on that situation.
For example, local authorities decide whether an elderly or disabled person should continue to receive care support. Many will lose that support as a result of cuts to local authority budgets. The impact of losing care support—an entire care package in some cases—can be catastrophic, according to Leonard Cheshire Disability and others directly in touch with disabled or elderly people. Many years ago, I worked with these people, and I find the very idea that a care package could simply be removed very frightening, even as an onlooker, let alone as somebody experiencing such a thing. People become trapped in their homes, unable to work and unable to get out. They become depressed and, in some cases, suicidal—and not surprisingly in my view. There can also be risks to people’s health. As they try to undertake tasks for which they are not well suited or which they are unable to perform on their own, they fall. Has anyone estimated the likely cost to the health service of increased falls, accidents and problems of this kind? What is the Government’s view of the economic costs to the country if family carers have to give up work in order to step into the breach when the state withdraws? The problem is that the local authority may save money but the DWP and the Treasury are likely to pick up the tab. I am not quite sure what the Minister in the other place would think about that.
It is easy for the state machinery to underestimate the incredible vulnerability of many elderly and disabled people. Applicants for care support will inevitably feel nervous and fearful of the consequences of upsetting the very people on whom they depend so heavily. It is terribly important that an appeal or review process is not only user-friendly and accessible but really is independent of the people making decisions about the person’s care. Can the Minister honestly say that care decisions will in future not vary across the country? Can he say that decisions will be made without error and always be based on the law? I do not think so. In preparing this amendment we have been mindful of the cost constraints and the need to allow Ministers flexibility to create a system that will be proportionate and sustainable. I hope the Minister will recognise this in his closing comments.
Having said that, I draw your Lordships’ attention to the fact that Leonard Cheshire Disability has specifically asked me to ensure that a full tribunal service be considered, although we did have a discussion about the financial implications of that. It argues that if such a system exists to deal with conflicts about school places, a decision to deny social care is equally as devastating. The Law Commission recognised the importance of a fair, independent and accessible system of redress.
I know that the noble Earl has discussed this issue with key stakeholders and perfectly well understands the points I am making. I hope he can give the House an assurance today that, if he is unable to accept the precise wording of the amendment, the Government will table an amendment at Third Reading that will guarantee that a suitable appeal or review process will be in place when the Care Bill comes into effect.
Lord Warner
My Lords, I support these amendments—not necessarily the specific wording but the principles behind them. I remind the House of a real difference between many of the appeals under the new framework for adult care and support and what has gone before. We are now talking about a set of arrangements with considerable financial implications for people and their families. In the social security system we set up a tribunal system to arbitrate, which has worked pretty well for a long time. Many of these issues are more akin to the social security system than to complaints about process. There will be complaints about process but many of the things covered in these amendments are about a failure to get a resource from the public purse to which people think they are entitled and have evidence that they are. This is much more akin to the arrangements in the social security system for people who have their claims rejected. It is much nearer to that than complaints about poor processes of work by a public body. The Government should think long and hard about this issue because they are in grave danger of ending up with the whole system being overwhelmed by the number of complaints. Without a convincing system for resolving appeals in the framework of the Care Bill we are heading down a path where judicial review will start to feature quite strongly.
I remind the noble Earl of some of the other issues where there could be appeals. The Joint Committee looked at some of the friction points where there was scope for dispute. There is a raft of areas for dispute over assessment of carers and service users and a whole range of areas for dispute about ability and whether you are going to be charged or not. After the previous debate on deferred payment I can think of another fruitful area for complaints—an inability to get on to some kind of deferred payment scheme. Another area, important to patients and service users, is setting the price for contracts to providers. Clearly, the price-setting mechanism may be disputed between the providers of services who may claim that the price offered by the commissioning agent will be bad for service users and patients. I am not suggesting that these could all come together under one process, but we want more convincing architecture in this Bill to give confidence that there is a sensible way of resolving and arbitrating areas for dispute and for the service user and their carers to secure redress without going through an excessively complicated process.
Lord Rix (CB)
My Lords, I lend my support to Amendment 77, tabled by my noble friend Lady Greengross. I would also like to express astonishment that we seem to have reached the target for tonight before the dinner hour.
My interest, of course, is with people with a learning disability and what is increasingly referred to as mate crime. This is where someone has befriended a person with a learning disability and is exploiting or abusing them in some way. In some cases this person may be living with them and, for example, concerns may have been raised by neighbours that the person may be being abused. Currently, the local authority would be unable to speak to the adult with a learning disability to establish if they are all right as the other person, the third party, always answers the door and will not let them in. This power would change that. I understand that the power on the statute book in Scotland is being used sparingly, and I believe that it is used appropriately.
I now turn to Amendments 79A and 81A, which are tabled in my name, on strengthening the safeguarding clause. Currently only financial abuse is defined in the Bill. However, there are of course many other types of abuse, such as physical, psychological and sexual abuse, as well as neglect. The amendment seeks to rebalance the definition. I understand that there has to be a definition of financial abuse in the Bill as there is not a legal definition elsewhere. However, limiting the definition to financial abuse, suggests that there are no other forms of abuse or that professionals and agencies should focus on financial abuse alone.
Although I do not doubt that people with a learning disability suffer financial abuse, other forms of abuse are far more common. Indeed, statistics on the number of safeguarding referrals detailed in the Abuse of Vulnerable Adults in England report for 2012-13 show that physical abuse and neglect were the most common. We would not wish inadvertently to elevate financial abuse above and beyond other forms of abuse. Of course, I understand that there is a reluctance to list types of abuse in case the list appears to be exhaustive and never-ending. The amendment adds the option to specify other forms as detailed in guidance, which I hope will allay such fears.
Amendment 81A, the second amendment tabled in my name, places a duty on safeguarding adults boards to send a copy of their annual report to the Secretary of State. These reports are important in that they detail the findings from safeguarding adult reviews that have been carried out. In addition, a welcome government amendment has added that these reports must now show the actions that boards have taken to implement the findings.
At the moment Schedule 2 says that a copy of the annual report must be sent to the CEO and leader of the local authority, the local policing body, the local Healthwatch and the chair of the health and well-being board. It is important that lessons are learnt nationally and sending these annual reports to the Secretary of State will allow us to understand the national picture and issue guidance as appropriate. People with a learning disability are some of the most vulnerable people in our country and not to monitor and respond to abuse at a national level is quite unacceptable.
Baroness Meacher
My Lords, I support Amendments 77, 80 and 82, to which I have added my name. I will also comment on Amendment 79.
I strongly support the need for adult safeguarding access orders and applaud the noble Baroness, Lady Greengross, for tabling the relevant amendments. As we discussed last week, as local authority resources shrink further—the Minister referred to a 5% reduction so far—the reality is that care will be left more and more in the hands of relatives, many of whom may themselves be elderly and frail; or indeed they may be younger, with childcare responsibilities and have great difficulty in providing support in all directions. Inevitably, many family carers will find it extremely hard to cope, and there will undoubtedly be situations when elderly or disabled people are neglected or in some way abused. I fear that the only way in which family carers will get the help they need will be if adult safeguarding access orders are available, so that following an alert the local authority can become involved, assess the situation and, where appropriate, prioritise further support.
As public services shrink, the neglect of elderly and disabled people—even gross negligence in some cases—will become a growing problem that could very easily become a national scandal. Having said all that, I part company with my noble friend Lady Greengross when it comes to Amendment 79. We have the criminal law. It may not cover absolutely everything but I would not want to see any increase in the likelihood that an overburdened family carer could face criminal charges if they reach the point where they cannot continue to care appropriately for a relative. For me, the purpose of adult safeguarding access orders is to ensure that problems are identified—they certainly need to be—and support is made available in order to enable a carer to cope in the style they would wish to provide.
Baroness Hollins
My Lords, I support the amendment in the name of my noble friend Lady Greengross on the duty to report adults at risk, which replicates a duty within the Welsh Bill. I spoke to a similar amendment in Committee.
Providers, together with other partners, will often be best placed to identify abuse and neglect, and it makes sense for them to report to the local authority. At Winterbourne View there were 40 safeguarding alerts, 29 incidents where the police were involved and 78 attendances at A&E but agencies did not take any action. They believed it was someone else’s duty to report and take action. Putting this duty in the Bill would emphasise its importance and would be a vital step in ensuring that the local authority is notified so that it can then take the appropriate action. Leaving this to guidance and local protocols is not a satisfactory solution.
I also support my noble friend Lord Rix’s Amendments 79A and 81A on safeguarding. My noble friend has highlighted how abuse comes in many different forms. The breakdown of the nature of referrals is set out clearly in the Abuse of Vulnerable Adults in England 2012-13 report. The most common was physical abuse at 38,500. There were 24,500 referrals for financial abuse, the third highest. It seems an eminently sensible amendment to add some balance to this clause.
My noble friend’s amendment on safeguarding adults boards sending copies of their annual report to the Secretary of State also seems eminently sensible. Looking at safeguarding annual reports across the country would allow the Secretary of State to see the national picture as well as to monitor what works and what does not. Guidance can be issued where worrying trends are observed and good practice shared. This is about leadership at a national and strategic level, which could help to tackle the abuse and neglect of the most vulnerable members of our society. I do not think it is about extra bureaucracy.
Mental and Physical Health: Parity of Esteem
Baroness Meacher Excerpts(10 years, 7 months ago)
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Baroness Meacher (CB)
I should like to begin with a very brief response to my noble friend Lady Murphy. The answer to this debate, in my view, is not a redistribution of resources from the secondary mental health services to the primary but, rather, to seek to focus resources on to or into NICE-recommended treatments in both the primary and secondary sectors. An enormous amount can be achieved if we really focus on that objective.
Despite having worked in the secondary mental health services for about a quarter of a century, on and off, I shall concentrate my brief remarks on the lack of parity of esteem in the availability of treatment for children with mental as against physical disorders. I applaud the Government for at least introducing the objective of parity of esteem. I think it is fair to say that we have never had it before.
I have the benefit of access to the draft of a new book on mental health to be published by my noble kinsman Lord Layard and David Clark. You could say that I have access to insider information without which I should not be making this particular speech but doing something completely different.
The need for psychological treatment services for children is overwhelming. Indeed, the evidence suggests that the incidence of emotional and behavioural problems in 15 and 16 year-olds approximately doubled between 1974 and 2004—a 30 year period, of course—and has remained fairly stable since. Today, about 10% of 15 and 16 year-olds suffer with emotional or behavioural problems.
We now have a situation where these problems can be resolved but, tragically, generally they are not. My noble kinsman Lord Layard has talked about the undertreatment of adults, but for children the situation is equally bad. We know that nine out of 10 children with a physical illness will be treated. As my noble kinsman mentioned in relation to adults, only a quarter of children with a psychological problem will be treated. We are talking about children who are just not treated for a problem.
In 2010, Britain’s Royal College of General Practitioners conducted a survey of its members. One question was: “When children are suffering from depression or another disorder requiring specialist psychological therapy, are you able to get them the treatment within two months?”. The results were truly appalling. Only 6% of GPs could get the service they needed for their child patients within the specified time. The timeframe is important, just as it is for physical illness. We have maximum waiting times for specialist treatment for physical conditions, but none for depression and anxiety. Can the noble Earl give the House some reassurance that the Government will extend maximum waiting times to psychological therapies for children, not only for adults?
I applaud the coalition Government’s establishment in 2010 of a new priority for early intervention for children at risk. That followed the release of figures for the number of suicides. However, within two years there were cuts in half of our mental health services, which have surely undermined the Government’s objective. Again, can the noble Earl give the House any assurance about reversing that trend?
Why is our failure to prioritise children’s mental health so important? The answer is simple. Children with mental health problems go on to become adults with mental health problems. Surely it is better to treat children when the problems arise, rather than waiting for them to waste years of their lives in misery and unable to contribute effectively to society. That is obvious from the point of view not only of the individual but of the taxpayer. Our failure in this field is extremely costly. To give just one example, a child with a conduct disorder will cost the taxpayer roughly £150,000 more than if the child did not have the behaviour disorder. We can look at it the other way. If we spend £7,500 on a child with a behaviour problem, the cost is absolutely zero if a mere one in 20 of those children is helped. Of course, the figures are much better than that.
Some might think that the reason that the Government do not invest in those treatments is that they do not work, but we now know that, for children too, there are psychological treatments that have been shown to be effective. The treatments are very similar to those recommended for adults—cognitive behavioural therapy, in particular, and interpersonal therapy—for the common mental disorders. For conduct disorder, however—the single most common mental health problem in childhood —there is now a well established treatment, which is structured parent training. One of the biggest trials in England showed that after seven years the children whose parents had this treatment were 80% less likely to be defined as having oppositional defiant disorder than those not treated. This is a huge success rate. Even for the most difficult children, multi-systemic therapy has produced good results. So there are effective treatments available, if only they are commissioned, for our children. In 2008, however, less than half of children’s services were implementing NICE guidelines—hence my point at the beginning of these short remarks. In another survey, half the therapists said they use CBT for less than one fifth of their patients.
The Minister, as always, knows all these arguments. It will be very encouraging if he can give some assurances to the House today that improvements are being made to the availability of NICE-recommended psychological therapies for children. We are, of course, aware of the IAPT programme for children. I hope the noble Earl can assure the House that this programme will reach all our communities in sufficient depth to ensure that nine out of 10 children with psychological problems can be helped, just as their friends with physical problems are helped in nine out of 10 cases.
Care Bill [HL]
Baroness Meacher Excerpts(10 years, 7 months ago)
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Baroness Meacher (CB)
My Lords, I support the amendments of the noble Baroness, Lady Greengross. She is so right in saying that people very often have no idea what questions they need to ask and what services they may be entitled to and therefore this aspect of the Bill is far more important than it sounds.
However, I shall speak to Amendment 21 which, in a way, takes us a step further and would ensure that vulnerable people with current or foreseen complex needs receive information and advice in a way that they can understand; also that the information and advice takes full account of their complex personal position. This may sound simple enough, but, in fact, an untrained person with a leaflet on local services, probably including lots of irrelevant information, is quite likely to leave someone more confused than they were before the visit. In fact, if local authorities do not want people to find their way to services that they need, a rather weak and unstructured approach to information and advice is probably the best way to achieve that result, but in the longer run, such a cynical approach will be highly costly.
My few remarks are based on a briefing from the College of Social Work, which has had the benefit of input from front-line social workers, managers, recent directors of adult care and academics, all of whom are very conscious of and concerned about the efficient use of resources. They would not say lightly that one should be developing a service such as this for information and advice unless it were really important. For people without dementia or other disorders which make it particularly difficult to comprehend the world around them, information and advice can probably be provided by less trained people without any great loss.
As was said in Committee, the aims and principles of the Bill are welcome. The College of Social Work is concerned, however, that many of these principles will not be fulfilled in practice. We hope, with the aims and principles in mind, that the Minister will agree to some further clarification in the Bill, or in regulations, on the key role of skilled social workers in supporting and protecting some of the most vulnerable people in society through their involvement at the information and advice stage.
Key stakeholders were grateful that, in Committee, the noble Earl, Lord Howe, recognised the point of this amendment. He said that,
“some authorities have also used qualified social care staff as the first point of contact and have found that this can be effective, efficient and timely, helping people to the care and support that will help them most”.
At that stage he envisaged that,
“guidance will set out the clear expectations of what the local authority’s service should cover or what it should seek to do in order to ensure that the information and advice is sufficient”.—[Official Report, 9/7/13; col. 216.]
The aim here is to ensure, by including the appropriate wording in the Bill or in regulations—I fully accept that having it in regulations would be perfectly satisfactory—that professionally qualified social workers will be deployed in sufficient numbers, including at the information and advice stage, for people who really need that level of expertise. As I have already said, those with complex needs may be a relatively small number of people. This should ensure that these particularly vulnerable people are put in touch with the most appropriate services for them. This could avoid the need for more intrusive and expensive interventions at a later stage.
Lord Lipsey (Lab)
I shall make most of my remarks on the subject of advice and information on Amendment 20, which is a more broad-brush amendment, but I shall just comment on the government amendments in this group, on advice—that is Amendments 16, 17 and 19. I remind the House that I speak as the unremunerated president of SOLLA, the Society of Later Life Advisers, which accredits, to a gold standard, advisers who can help old people on financial matters.
It would be churlish not to say that the government amendments mark a small step forward, in that for the first time they represent a recognition that independent financial advice can be necessary. To that extent, I welcome them. However, I have to say right away that it is impossible to read the briefings we have had without realising that they have caused great disappointment, particularly among financial service people who are determined to get this right. The Equity Release Council says that the government amendments do not go far enough.
In trying to put my finger on the point, yes, they recognise independent advice and financial advice, but they do not recognise the need for that advice to come from people who are properly qualified to give it. It is not enough to have Tom, Dick and Harry advise in this field. It is not enough, even, for local authorities to send people to see people who they may think are quite plausible advisers, such as Citizens Advice: they do not know the complications involved in giving financial advice, particularly to people who have got some money and need to make sure that it will provide them with the care in a home that they want. They need proper, regulated financial advice, given by advisers who can be called to task by the Financial Conduct Authority if the advice they give is not sufficient, who have to follow the rules set by it and must have the kind of qualifications required by it. Therefore, in my view the Government are some way short of what is required in these amendments. It is to repair that lack that I shall later move Amendment 20.
Lord Hunt of Kings Heath
My Lords, we shall come to Amendment 20, in the name of my noble friend Lord Lipsey and that of other noble Lords, including me, in a moment. However, I want to ask the noble Earl about the point raised by the noble Baroness, Lady Barker, in relation to independent advocacy. The noble Baroness raised a pertinent point about what responsibility there is on a local authority to engage with the advocate. I hope that the noble Earl will provide the House with more information. Clearly, this is a step forward, which is to be welcomed, but one needs some assurance that the advocacy system will work effectively. It would be helpful to know what the noble Earl’s department thinks might be the appropriate response of a local authority where an advocate has come to the fore.
I have a great deal of sympathy with the amendment of the noble Baroness, Lady Greengross. It is one thing to provide information support grudgingly; another to be proactive in doing so. Perhaps the noble Earl would comment in particular on Clause 4, because there is a world of difference between Clause 4(1), in which a local authority must,
“establish and maintain a service for providing people in its area with information and advice”,
and Clause 4(2), which goes on to describe what type of advice. This does not assure us that a local authority will be effective in doing so. I should be grateful if the noble Earl would explain how this will be monitored. Will the Government have a role in reviewing the effectiveness of local authorities in providing that?
If one is resident in an area where the local authority does not seem to provide an effective information and advice service, what recourse does one have? I assume that there would be judicial review and the ombudsman, but those are heavy-handed approaches and it would be helpful to know whether the Government have thought through ways in which members of the public can draw attention to failures to provide effective information and advice in some local authority areas.
That might pick up on the amendment relating to the use of professionally qualified social workers. My noble friend Lord Warner, with a great deal of experience, has suggested that even in areas where there are complex needs, a qualified social worker need not necessarily provide this support. None the less, one wants some assurance that sufficient provision for support will be given. Again, it comes back to the issue of how we will monitor the performance of local authorities.
Baroness Meacher
My Lords, perhaps as a point of information in response to the noble Lord, Lord Warner, I should clarify that my amendment does not suggest that qualified social workers should provide financial advice, for example. The important point about the role of these qualified social workers is that they are used to co-ordinating services for people and would be well aware of the need for financial and all sorts of other advice. Therefore, in relation to people with very complex needs, they are in a good position to make sure that all the bits of the jigsaw are actually provided. That was the objective behind the amendment.
Earl Howe
My Lords, let there be no doubt at all that in the Government’s view high quality, accessible information is vital if we are to realise the aims set out in this Bill. We heard some excellent arguments in Committee about financial advice, advocacy, accessibility and signposting to other sources of information and advice. I hope that the amendments we are tabling today, and the commitments that we can give about our work with the sector on statutory guidance, will persuade noble Lords that we have listened to what we heard in Committee and have acted accordingly.
The noble Baroness, Lady Greengross, has tabled two amendments, Amendments 13 and 18, which state that local authorities should facilitate access to information and advice and that they should be accessible to those who would benefit. Amendment 21, tabled by the noble Baroness, Lady Meacher, proposes regulation-making powers which specify when social workers should provide information in complex cases. Following consultation, we made clear that information and advice must be accessible to those who have a need for them in relation to care and support. It says exactly that in Clause 4(4). Local authorities will have to meet the information needs of all groups, including those who often find it most difficult to access information, such as those with sensory impairments, people from BME backgrounds, people who are socially isolated or who have complex conditions. We are absolutely clear about that.
“Accessible and proportionate”—the words that we use in the Bill—also mean ensuring that information and advice are available in the right format, in the right places and at the right time. A vital aspect of this is making them available face to face and one to one, by phone, through leaflets and posters as well as online. When appropriate and most effective, that advice should be given directly by a qualified social worker. There will be other occasions when information and advice are best and most appropriately provided by others. We are working with all interested parties on what this means in practice and on translating this into the statutory guidance.
Amendment 18, tabled by the noble Baroness, Lady Greengross, seeks to ensure that information should be accessible and proportionate to those who would benefit. We consider this amendment to be unnecessary. The duty to provide information and advice applies to a local authority’s whole population—including those who would benefit from that. Each local authority will need to tailor the service to its population’s needs. I can confirm to the noble Baroness that the detail about how to do this will be covered in statutory guidance, and we are working with stakeholders, including carers and user groups, to make sure that we get this right.
The Government have also listened carefully to concerns expressed about the provision of information and advice on financial matters. We have in response tabled Amendments 16 and 17, which seek to make clearer the active role that local authorities have. Amendment 16 requires local authorities to have regard to the importance of identifying individuals who would be likely to benefit from financial advice. This encourages a more active role for local authorities to consider whether people would benefit from financial advice. Amendment 17 means that local authorities must seek to ensure that adults understand how to access information and advice on the range of financial options available to them.
There are various options for people who could benefit from financial advice relating to care and support, both regulated and non-regulated. Our amendments highlight the importance of ensuring that people understand how to access the variety of advice available independently from local authorities. They mean that local authorities must seek to ensure that adults understand how to access the different financial advice available to them, thereby supporting people to make informed choices.
A particular point that I want to bring out here is that the Government do not believe it would be appropriate to require local authorities to make direct referrals. For the most part, local authorities do not possess the necessary expertise, and there is a risk that a referral leading to poor advice could bring a significant burden of accountability on to the local authority. We will work closely with stakeholders as we produce the statutory guidance to understand how different types of financial advice, including regulated financial advice, might be of benefit for people in different situations, as well as the active role of local authorities within this.
Amendments 14 and 19 seek to simplify and clarify Clause 4 and to respond to specific concerns raised in discussion in Committee. Amendment 14 simply re-words Clause 4(2)(d) in a more concise and understandable way. This makes the clear and unambiguous statement that the information and advice service must cover how a person can access independent financial advice on matters relevant to the meeting of needs for care and support. Amendment 19 responds to concerns raised about the potential confusion, particularly in the financial services industry, over the term “independent financial advice”. The amendment clarifies that the term means financial advice independent of the local authority.
Care Bill [HL]
Baroness Meacher Excerpts(10 years, 7 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(10 years, 10 months 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(10 years, 10 months 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.