Health and Social Care Bill

Baroness Pitkeathley Excerpts

Thursday 8th March 2012 Lords Chamber

[Baroness Jolly]

My Lords, I have a couple of amendments in my own name in this group, and I shall also speak to amendments in the names of my noble friends Lady Tyler and Lady Cumberlege.

We welcome the decision to set up a patient and public involvement organisation and network across England based on local authority geography and with HealthWatch England at the centre. It offers the possibility of real engagement for all stakeholders and the consequent improvement of health and social care services for all. However, there are still some areas for concern in relation to HealthWatch England, whose role is to engage with all the key national players—the Secretary of State, the NHS board, Monitor, the CQC and the local authorities to which I referred a moment ago. It is charged with providing the views of those in receipt of services, their carers and other members of the public, and also with offering advice to the key stakeholders to whom I have just referred. It will thereby be influencing the Secretary of State mandate, commissioning practices, the process of registration of providers and the authorisation of clinical commissioning groups.

However, there is a deficit in the Bill. There is no representation on the HealthWatch England board of a local voice. Reports may be sent by local healthwatch organisations and they may be read, but there is no one on the board of HealthWatch England who can tell it as it is at a local level. The board, as with all other boards, is charged with making decisions involving running the organisation but, without a local perspective, it runs the risk of being metrocentric, south-east based and out of touch. Therefore, I support Amendment 224 in the name of my noble friend Lady Cumberlege and, as a good Liberal Democrat, I of course welcome elections run by STV.

The relationship between HealthWatch England and local healthwatch organisations has to be pivotal to the success of this proposal, and one certain way to cement that is with the presence on the HealthWatch England board of members of local healthwatch organisations, as we have just discussed. However, another way would be to use Amendments 229A and 234ZA in the name of my noble friend Lady Tyler. These allow for local healthwatch organisations to have a power to recommend to the board of HealthWatch England the reports that they think, from their local information-gathering, HealthWatch England should carry out, and HealthWatch England is bound to have regard to these recommendations. This should help to avoid situations such as Winterbourne and Mid Staffs. An effective local healthwatch organisation would have confidence that its advice would be considered and acted upon by HealthWatch England, precipitating early intervention and service improvement. It would also allow HealthWatch England the opportunity to spot national patterns, determine their significance and take appropriate action.

I have an amendment in my own name which concerns specialised services commissioned by the board—in particular, those for rare and complex conditions. Here, I need to declare an interest as chair of the Specialised Healthcare Alliance. I should be very grateful if my noble friend could clarify how it is envisaged that information can be collected about these services, how patients and carers can have confidence in a local healthwatch organisation dealing with issues with which they might only rarely get any concerns, and how HealthWatch England can put these scarce data together in a useful and timely manner for stakeholders. That will need careful management and crystal-clear guidance to ensure that the information gathered and the advice based on that information find their way to the board. Many people with such conditions are keen to hear the Minister’s response and I would welcome total clarity from her in that regard.

[Baroness Pitkeathley]

My Lords, I wish to speak in support of the powerful case made for the independence of HealthWatch England by the noble Lord, Lord Patel, and by noble friends on these Benches. It is a mystery to me why, in the face of a genuine commitment by successive Governments to public and patient involvement, we have made such a mess of it thus far. I am not one who looks back on the work of community health councils as some kind of nirvana. As someone who was briefly a chief officer of a CHC, I know that they were very patchy and variable in quality. However, they had a strong national voice, and I pay tribute to my noble friend Lord Harris of Haringey in that regard.

Since then, we have struggled. I think that the failure of the Commission for Patient and Public Involvement in Health has made successive Governments frightened of setting up one of these national organisations. It has put them off having a national body to support local groups, to help them to develop successfully and to help them when they are in difficulties, as well as provide a national, challenging voice for patients. Will HealthWatch England, as currently envisaged, be this missing national body? I am afraid that at present the answer is certainly no. As a committee of the CQC—an organisation for which I have the highest regard—it will not be independent or accountable to the patients and public it represents, and its links with local healthwatch organisations, which we will discuss later, will be very variable and often not sufficiently robust for them to be in full receipt of the amount and range of information that they need. We simply must have a proper governance structure with an independent, publicly appointed chair. Surely the independence of the whole organisation is essential to how it will provide the strong voice for patients that everyone involved say they want.

[Lord Warner]

My Lords, it gives me great pleasure to follow that sterling contribution by my noble friend Lady Pitkeathley. The real problem with the Government’s approach is that they really have not properly defined the functions of this body. One of the great strengths of this amendment is that it sets out what the functions of a truly independent body should be in this area. I make no defence of the previous Government’s attempts to wrestle with this idea, but I think that we have continued to go backwards in this area since the days of community health councils, despite their patchiness.

I was very optimistic when the Government made their first announcements about healthwatch, and I was a great supporter of the brand name that they had created, which I thought was very powerful. Unfortunately, the functions that they have given it and the way they have set it within the CQC do not enable it to live up to the strength of that brand.

I was full of admiration for the creative way in which the noble Baronesses, Lady Cumberlege and Lady Jolly, loyally tried to make the sow’s ear a bit more of a silk purse. However, it really does not cut the mustard. I think that we need to pay attention to the points made by my noble friend Lord Whitty, who emphasised very well the extent to which the model that the Government are pursuing has failed in a number of other areas of public policy. The Government should learn from that evidence and rethink this matter before we get to Third Reading.

I have one other point which concerns the rather spirited exchange that we had in Committee with the noble Baroness over the issue of campaigning. I shall return to that for a few moments. The whole point of having a body like healthwatch is to enable it to join forces with other people when there is a serious challenge to the public interest and to patients’ interests in this area and allow it to campaign. I cannot see how it can be very easy for a committee of the CQC to join in that campaign. I asked the noble Baroness whether it would be able to campaign and, to her great credit, she said that yes, it would. Most of us who have knocked around the public sector for any length of time would find it very difficult to believe that a committee of the CQC would be able, despite what the noble Baroness says, to join in a campaign that was highly critical of the CQC. We need to be clear on whether it can campaign; and if it can, I would like, as the noble Baroness said, a very convincing explanation of how it will be able to when it is sitting within the structure of the regulator and it is the regulator's deficiencies that it is campaigning against.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Tuesday 6th March 2012 Lords Chamber

[Baroness Pitkeathley]

My Lords, I was delighted to add my name to this important amendment which builds on several amendments we have discussed in your Lordships’ House with regard to the integration of health and social care. The central point of the amendment is to place a duty on the Secretary of State to secure improvement in the quality of social care services provided by local authorities. It goes on to set out the means of doing so.

These proposals are based on those of the Dilnot commission, of which my noble friend Lord Warner was such a distinguished member and about which there is such consensus among all those who work in or are in receipt of social care. If only the coalition Government had managed to achieve such a consensus about all the proposals in this Bill, we would have saved a lot of time and be a lot more content. There is consensus around the proposals and everybody understands what the social care system is in need of. As we have heard from my noble friend, the system is starved of cash, failing to meet the volume of need, unfair—a lottery—and confusing and difficult to find your way around, especially if you are frail, elderly and confused.

The existing consensus is that the future funding of social care has to be based on a combination of individual and state responsibility and contribution, and that we must achieve a lasting settlement. We have mentioned many times before in your Lordships’ House that the Health and Social Care Bill fails to address the most pressing of all health problems: how to deliver affordable and effective social care for our growing elderly population—a view endorsed, I remind your Lordships, by the Health Select Committee in a recent report.

It is extremely worrying that rumours are circulating that the White Paper on social care, responding to both the Dilnot proposals and the Law Commission proposals about legislative reform in this area, is to be delayed. This would be a huge disappointment as well as a missed opportunity. Moreover, it would renege on the commitment given by the Minister for social care in another place when he said only four months ago that,

“social care has languished and rested in the ‘too-difficult-to-do’ box for far too long. We are the Government who are committed; we see the urgency and the need”.—[Official Report, Commons, 10/11/11; col. 181WH.]

I hope that the Minister will today repeat that commitment in response to this amendment.

We should remember, too, the advantages which would be delivered by accepting this approach. We would spend existing resources—which everybody agrees are short—better. It would improve integration of health and social care systems. When people’s need for social care is not met, they turn to the NHS—resulting in increased numbers of emergency admissions or delayed discharges. The inconsistency between fully funded NHS care and means-tested social care hampers delivery of an integrated care system. Recent statistics from the Department of Health show an 11 per cent rise already in the number of hospital bed days lost to so-called bed blocking, so that costs have risen extremely fast.

In addition, the rights and responsibilities of individuals and agencies would be clear to the public if the Government accepted this approach. If people were clear about their future personal liability, they could plan how they would meet care costs up to the level of the cap, wherever that were placed. We would also stimulate the care market to provide more choice for families and incentives for business. The Dilnot report and its proposals have been called a once-in-a-lifetime opportunity. We cannot and should not miss that opportunity. I support the amendment.

[Lord Skelmersdale]

My Lords, the House seems to have gone remarkably silent after those two introductory supporters of this particular amendment. As some of your Lordships will remember, when I returned from Northern Ireland as the ex-Minister responsible for health and social services, I came as a great fan of combined health and social services. Yet I discovered in my experience there that it would never, ever work unless you had one organisation in total and utter control. This may seem like a Second Reading speech, but it is not intended to be. The Secretary of State mentioned in the amendment means any Secretary of State, and currently we have two Secretaries of State. That is why the notable ambitions of this amendment—and they are notable—will always fail. Therefore, I encourage my noble friend, until a higher authority than himself, senior as he is, gives the imprimatur to take social services away from local government, to resist this amendment.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Wednesday 29th February 2012 Lords Chamber

[Lord Beecham]

My Lords, as the noble Baroness might have said, but did not quite, Public Health England has been conjured out of the ether rather than having been approached in the way one might normally have expected as regards a subject to be included in the Bill. The body constitutes a significant change of policy and direction which ought to have brought before us by the Government and not left to the noble Baroness and others to raise as a consequence of their failure to do so.

It is instructive to look at the comparison between the executive agency model which the Government have chosen to adopt and the special health authority model to which my amendment refers. I say immediately that I agree entirely with the noble Baroness’s analysis of the situation as it will obtain under the Government’s proposals—not legislative proposals—in terms of the independence of the organisation. I share many of her doubts about other aspects, including the impact on the income which is currently derived—to the extent of, I think, £150 million a year—by the existing organisation: namely, the Public Health Agency.

The critical definition of the role of Public Health England was provided in a debate in the House of Commons by the Minister of State, Paul Burstow, who said:

“In legal terms, Public Health England and the Secretary of State are the same thing, and Public Health England will not be provided for in primary legislation”.—[Official Report, Commons, 7/9/11; col. 412.]

That set the tone of what has subsequently emerged as the Government’s policy. There are Cabinet Office guidelines on the attributes of executive agencies. They are effectively threefold. The first is that an executive agency is independently accountable within the government department. Secondly, an executive agency has to be financially viable. Thirdly, and critically, executive agencies should be,

“clearly designated units … which are responsible for undertaking the executive functions of that department, as distinct from giving policy advice”.

One would imagine that the giving of policy advice in the area of public health would be a prime function of the body charged with the responsibilities that we anticipate will fall to Public Health England. As an executive agency, it would not be in a position to offer that critical element which is so indispensable to a proper development of policy and monitoring of policy in this arena.

As to the structure of the organisation, the noble Baroness has rightly referred to the curious proposal that the chief executive will establish an advisory board. Public Health England’s Operating Model states:

“The Chief Executive will establish an advisory board to provide external challenge and expertise”.

I stress “external”. The most recent document, with the snappy title Building a People Transition Policy for Public Health England, states in terms that:

“Staff in Public Health England will be civil servants whose conduct will be governed by the Civil Service Management Code”.

It goes on to say, as the other document indicated, that there would be,

“an advisory board to provide external challenge”,

and the,

“current intention is that the chief executive will chair the board, which will”,

as the noble Baroness indicated,

“include at least three non-executive members”.

That is the model that the Government seem to prefer. However Public Health England will have a huge role. Its incorporation within the department will virtually triple the size of the department. It will have enormous responsibilities, ranging from managing disease outbreaks to running specialist reference laboratories and regional laboratories, and providing—critically—information and intelligence support in respect of, for example, cancer registries and public health observatories. These are massive responsibilities and there will be no legal or constitutional separation from ministerial control.

In this arena, as we debated and determined when we were talking about the position of directors of public health within local government, there is a critical need for independence. I am grateful to the Government for reinforcing this—it is to be seen in the arrangements made for local government. However, what is good for local government in this respect does not appear to be good for central government because that independence is patently lacking. I will allude to the position of staff as civil servants a little later.

Contrast that model of the executive agency with the position of special health authorities. They are defined as,

“health authorities that provide a health service to the whole of England”.

They are exemplified by the National Blood Authority, and,

“are independent, but can be subject to ministerial direction”.

There are 10 such bodies at the moment, including the Health Research Authority, the National Treatment Agency and the NHS Litigation Authority. Ironically, they will include the NHS Commissioning Board when it is formally constituted. The employees are public servants, not civil servants, and are not therefore subject to the Civil Service Code. That has some interesting implications.

I must refer to the recent case of Professor John Ashton of Cumbria—a distinguished director of public health who had the temerity to join 400 of his professional colleagues in writing a letter, under the auspices of the Faculty of Public Health, critical of the Government’s proposals in this area. He received a rebuke from the primary care trust that employs him. I do not know whether or not he is right, but he believes that it may have been instigated by the department. I know that the Secretary of State has indicated that he had no role in it, and the noble Earl seems also to be indicating that the department had no role. I accept that of course, if that is what is being said. However, it is interesting that the primary care trust nevertheless felt obliged to take the step of rebuking Professor Ashton and calling him to a meeting. If that is indicative of how a serving, distinguished and leading public servant in the realm of public health is treated under the present dispensation, one wonders what would happen under the regime that is being established, which will be even less accepting of the independent nature of the role of its chief officers.

The question of independence remains very much at issue. I concur with the questions raised by the noble Baroness in Committee about income-raising. We received some rather broad assurances that all would be well. Half of the Health Protection Agency’s income is raised externally—as I said, in the region of £150 million. The Government said that they would set up a mechanism to ensure that income-generation activities of the Health Protection Agency can be maintained. When the Minister replies, perhaps she can tell us how far the Government have got in developing proposals to establish that mechanism.

Finally, when we were debating this in Committee, the argument was advanced—it has also appeared in other places—that because the function is not limited to England, because there are implications for disease control and the like which cannot be confined within the national borders and potentially reach to the territories of the devolved Administrations, somehow we cannot establish it as a special health authority. That seems to me to be hardly an insuperable obstacle. Have any approaches been made to the devolved Administrations to see whether they would have any objection to there being a special health authority? I should have thought that they might prefer a special health authority, given that it would not be, as Mr Burstow, described it, simply a manifestation of the English Secretary of State. I may be wrong, but I wonder whether the Government have taken any steps to ascertain the views of the devolved Administrations. If it were not unacceptable to them, I can see no objection to creating a special health authority for that purpose.

Although I warmly endorse the thrust of the amendment moved by the noble Baroness in having an independent chair, I would go a step further to have a completely independent special health authority in place of what the Government propose. She clearly wants to discuss matters further. I hope that the Minister can give an assurance that she will take the matter away to consider it. I apprehend that it is unlikely that the noble Baroness will seek to take the opinion of a fairly empty House tonight, but there might be an opportunity at Third Reading. This is too important a matter to be left in abeyance for a decision to be reached by default.

I commend the amendment moved by the noble Baroness, but seek to extend it in the way that my amendment describes. I beg to move.

[The Deputy Speaker (Baroness Pitkeathley)]

It may be for the convenience of the House if I point out that, as Amendments 162A and 162B are amendments to Amendment 162, we have to dispose of them first and then come back to Amendment 162.

[Baroness Masham of Ilton]

My Lords, I support Amendment 162, moved by the noble Baroness, Lady Cumberlege. It is vital. The Health Protection Agency is admired across the world. It does vital work and important research. We cannot afford to lose something which is so effective. I see no reason why it should not have an independent chairman. It is also a very interesting idea to have a special health authority. When we were taking evidence on the Select Committee on HIV, the Health Protection Agency said that there were many concerned people not just in England but across the world, because they depend on our advice. That is why independence is so important. We cannot lose something so good.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Monday 27th February 2012 Lords Chamber

[Lord Patel]

My Lords, I have put my name to Amendments 38C and 143 and support them very strongly. They cover the issues that we raised in Committee and which need to be addressed.

The Government’s intention in the Bill is clearly stated: they want to see better quality of care and outcomes, particularly for patients with long-term conditions. I spoke at length about this in Committee and will not repeat myself. However, in brief, a patient who suffers from a long-term condition will get better care and outcomes only if that care is individualised and integrated from primary care, through acute care to community care. If we are to do this, we need some guidance in the Bill itself as to who will be responsible, how it will be done, who will give the guidance and how it will be monitored. I do not mean by Monitor, but how whether it is happening will be monitored. It is for this reason, if no other, that I strongly support these amendments. I agree with my friend, the noble Lord, Lord Warner, about hoping that the Minister will be able to accept these amendments or the principles behind them; and, if he cannot accept them, that the Government support them by tabling their own amendments at a later stage.

[Baroness Pitkeathley]

My Lords, I, too, will speak strongly in support of these amendments, to which I have added my name. In spite of my major misgivings about the content of the Bill when it was originally published, I remember being delighted by its title because it had “social care” up there with “health”. Did this mean, I thought to myself, that at long last health and social care were to be given equal status? At long last, was there to be a proper recognition that the patient experience of being ill, disabled or in need of care is an integrated one? The Bill was supposed to be about making the patient experience better—less confusing, and more effective and efficient from the point of view of the patient—so I was hopeful.

In more than 40 years of working at the margins of health and social care, I have seen two experiences constantly repeated. The first is of patients always being surprised, distressed and horrified by the lack of integration between health and social care. Since they cannot put their own needs into two separate boxes, they are surprised that the services seem to be provided in separate boxes. They are further distressed by having constantly to give their details and history to different people, having to undergo unnecessary repeat tests and yet still being left alone or reliant on their families to negotiate between the NHS, social care agencies and local authorities, not to mention voluntary and private sector providers.

The second experience which has been constant in my life is the seeming commitment of all those who work in the system to how important integration is to the delivery of proper patient-centred care. Indeed has anyone in your Lordships’ House or anywhere else ever heard any professional say that there are benefits to care which is not integrated? Yet that is what we continue to deliver and there seems little hope of the Bill in its current form rectifying and ensuring a joined-up approach. Indeed, I fear for the practice manager or the social worker who has to interpret the new diagrams of the system to an elderly and confused patient or client.

My noble friend quoted the Health Select Committee, which said:

“Although the Government has ‘signed up’ to the idea of integration, little action has taken place to date. The Committee does not believe the proposals in the Health and Social Care Bill will simplify the process”.

The committee further said that the reforms in the Bill were built on the hope that GPs, hospitals and local authorities will respond to payments for working together. These amendments are about more than hoping for the best. They make practical proposals, first, about defining integration which, as the Law Commission found, is not easy. It will surely not be difficult to agree, as the Law Commission did, around contributing to or promoting the well-being of the individual. That would cover not only health and social care but housing too. That separation, as your Lordships are well aware, has always been a problem.

The proposals about annual reporting and business planning to check progress are also very practical and taking into account the levels of integration in setting tariffs is also very important. It is of the utmost importance that we take the opportunity given by the Bill to move the reality of integration forward in a way which will make a radical difference. The benefits to the patient, the client and the carer are obvious but there are benefits to the community and society which are similarly significant, since integration clearly delivers more effective and efficient care. There is lots of research evidence about this. For example, Turning Point identified that for every £1 spent on integrating health, housing and social care, £2.65 was saved. This is not only better for patients but provides better value for money. What is not to like in these amendments? I hope the Government will accept them.

[Lord Mawhinney]

My Lords, it would be very courageous for anyone in your Lordships’ House to argue that there was no benefit to the patient in trying to have as integrated a service as possible. I am not that courageous. It is a good place to start. Having said that, I do not believe that these amendments are the answer or that they move forward the argument for integration. I searched through these proposed new clauses and I find no mention of any legal responsibility on the local authority, the social care agencies or anyone else. They are entirely directed to health bodies. That imbalance struck me as being a pretty poor starting point if you are genuinely interested in trying to produce integrated services.

Your Lordships will know that, even before the introduction of the Bill, there were various attempts to integrate services in various parts of the country. I happen to be a reasonably well-informed individual in respect of one of those attempts. It is one thing to say to the PCT, the cluster, or whatever is the latest development in that area that it has responsibilities to integrate with the local authority, just as it will be a different thing to say that a local commissioning group has to integrate with the local authority if some attempt is being made legally to define the role of the health component but there is no commensurate attempt to deal with the legal framework with regard to the providers of social care. I know of one example of attempted integration in this country that is foundering because the health component is seeking to shift its deficit on to the local authority. Sometimes the quality of those who serve in one is so different from the quality of those who serve in the other that no right-minded person who was dealing with his or her own money would invest in a partnership that was as skewed as those that exist up and down the country.

I started where I did because I do not wish to be interpreted as being against useful, appropriate and constructive forms of integrated provision. I have taken a view throughout the Bill that it ought to be for the benefit of the patient. It would be courageous to suggest that some appropriate form of integration would not be of benefit to the patient. However, these skewed and flawed amendments are not helpful and certainly do not beat a path to the future for the benefit of patients.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Monday 13th February 2012 Lords Chamber

[Baroness Oppenheim-Barnes]

My Lords, I am obliged to my noble friend Lord Faulks for provoking me into thanking him for having read the proceedings of our earlier debate on a similar amendment, in which I spoke at length about the total impossibility of someone with money and influence bringing a case against a doctor or a hospital in a situation that was completely black and white. I went into this detail only to convince those who—quite rightly—want this candour that it will not result in an “open sesame” for bringing cases in which a mistake has been made or completely bad treatment has been given.

I would also say that I wish anyone trying to deal with the General Medical Council the best of British luck, because it is not easy. It is a long process, and it involves a great deal of information being given. Even when the consultant involved has said, “I am very sorry, I have made a mistake, I have failed”, the GMC still does not find it necessary to criticise that surgeon in any way at all.

On the amendment, my noble friend the Minister was kind enough following the last debate to circulate to those who had participated a note from the NHS giving details of the steps that it takes after a mistake has been discovered: dealing with patients in counselling, apologising, all the important things that we would expect it to do. However, one thing was missing, and I hope that my noble friend will feel kind enough to grant it; it did not say that in such cases the NHS was required to circulate throughout the health service what accident had happened or what mistreatment had taken place, so that it could warn in advance that special care must be taken in the future.

[Baroness Pitkeathley]

My Lords, the noble Lord, Lord Faulks, speaks with his extensive legal experience, which I certainly could not match, but I have very extensive experience of working with patients and their families. It is in that respect that I support this amendment. I particularly support what noble Lords have said about seeking culture change in the NHS.

One thing that gets in the way of that culture change is the anxiety about why patients want candour and the truth. My experience is not that they seek redress or even want to pursue legal action—time and again any consultation with patients will show you that that is not their aim. Their aim, almost always, is to achieve closure after a distressing incident. What a patient said to me a year or so ago is typical: “I just wanted them to admit that something had gone wrong and say sorry. I knew it could not bring my brother back but it would have helped us come to terms with it”. That is what patients are seeking and that is what this amendment will help to achieve. We can all agree that if we are to achieve more culture change, we must move towards a greater degree of openness throughout the NHS.

[Lord Newton of Braintree]

My Lords, I am tempted to chip in—rather unwisely, no doubt, as usual—by the last two speeches. If it does not seem paradoxical, I must say that I agree with almost every word of both of them.

I certainly share the view of the noble Baroness, Lady Pitkeathley, and have some experience in having chaired three NHS health trusts since 1997, that there are too many cases in which an apology, together with an assurance that action will be taken to make sure it does not happen to anyone else, as well as achieving closure in the individual case would have made a material difference. I would add that ingredient to what she said. Indeed, I could give examples of where I spent hours of doing exactly that in one of my capacities with some parents who had experienced a tragic loss. I endorse that and I think that she is right. I also endorse her comments about not quite recognising this as a common feature in health trusts.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Wednesday 8th February 2012 Lords Chamber

[Lord Laming]

My Lords, may I briefly add my thanks to the Minister and the Constitution Committee? Its second report was particularly helpful. To follow the point made by the noble Baroness, Lady Williams, it is right to see Amendment 5 in the context of some coherence over how this accountability will work, not just at ministerial level but at board level. There will be further amendments. At this stage, suffice to say that the Constitution Committee looked at these matters in the broadest possible way to ensure that—whether in terms of autonomy or commissioning—there would be a coherence to the way in which accountability would continue to be established in the National Health Service; and, in particular, that those responsible for commissioning and other important work follow through their tasks in relation to ministerial accountability to Parliament.

The second report of the Constitution Committee was a model of how such matters can be dealt with coherently, succinctly and very clearly. We are indebted to the Minister for giving us the opportunity to consider that more carefully; and to the Committee for its work, which took us forward enormously and has brought us to where we are today. I am grateful and I support the amendment.

[Baroness Pitkeathley]

My Lords, far be it from me to cast a pall over the House of Lords at its best. I join others in being glad about the consensus and in congratulating the Constitution Committee. I also congratulate the Convenor on the part that he played in getting the consensus. It is a privilege to follow him.

I join the noble Baroness, Lady Williams, in hoping that the consensus can continue but I have to remind the House of how the Bill is viewed out there. It is deeply unpopular with many of the people who will be required to make it work. They will make it work because that is what the workforce of the health service does and always has done in the most difficult of situations. However, it is looking to us to make those difficulties as few as we possibly can. Therefore, in congratulating ourselves on reaching where we have on this issue, let us remember the task before us.

[Baroness Young of Old Scone]

My Lords, I am afraid that I will be even more discordant. I do not want to denigrate the congratulations that have been offered to the noble Baroness, Lady Jay, and her colleagues and the process that has been gone through to reach agreement on this amendment. However, I share the view of the noble Baroness, Lady Pitkeathley, that we must not forget not only how deeply unpopular the Bill is but that it is flawed.

I had not intended to speak on this amendment but I cannot let the moment pass as I think that the noble Baroness, Lady Jay, referred to a spirit of improvement that she was seeking in moving this amendment. However, we have to remember that the improvement is a bit like trying to paint the face of a harlot; at the end of the day, it is still the face of a harlot, no matter how improved. We are seeing real impacts on healthcare in this country as a result of the Bill, as we speak. I come from a background of having run health services for 20 years. I have also been the regulator for health and social care and am now part of a patients’ organisation. Patients are telling me that we are seeing the fragmentation of responsibility for the commissioning of healthcare and that services are suffering as a result of the financial squeeze; for example, diabetic specialist nurses are disappearing and patient education is being cut. The things that are important for the quality of care are being removed.

I am experiencing a huge loss of momentum in getting any change implemented in the care for people with diabetes. Whenever I speak to the Secretary of State, he tells me that it is no longer his responsibility and that I should talk to the NHS Commissioning Board. However, when I speak to the NHS Commissioning Board, staff say, “We are still working out how we do this”. When you talk to clinical commissioning groups, they are still not clear about the framework in which they are operating. Therefore, we are losing one, two or three years of headway on issues where there needs to be real improvement for patients.

Because of the preoccupation with reform, we are seeing a lack of real focus on the task in hand, which is how we make the health service more efficient. The Minister and the Secretary of State have repeatedly told me that these reforms will deliver that necessary improvement in care and efficiency. However, my experience over 40 years leads me to believe that that is not the case. In saying that, I am not making a political point; I speak from my knowledge of what is happening in healthcare. We will continue to try to improve the Bill because we are good and honest toilers in the House of Lords, but we are trying to improve something that is deeply flawed.

Health: Stroke Care

Baroness Pitkeathley Excerpts

Monday 30th January 2012 Lords Chamber

[Baroness Pitkeathley]

My Lords, I thank my noble friend not only for securing this debate but for the wide-ranging way in which she introduced it. Her personal experience as a carer enriches our debates, and it is on the care experience that I want to focus in the few moments available to me.

I want to bring to your Lordships’ House Olivia, who looked after her husband, Ronald, when he suffered a massive stroke. She said:

“He spent four months on a stroke ward where little was done to rehabilitate him; he was lucky if he got 10 minutes of physio a day and even less input from speech and occupational therapists”.

She felt that the care he was receiving was so poor that she would take him home, and she thought that she would be better off doing that. Within days of taking him home, she felt that his condition had improved, and Ronald also received support there from district nurses and a physiotherapist. Olivia had to fight to get information and support. She said:

“It took months to determine what help we might be entitled to. I was passed from department to department, we were subjected to assessment after assessment and review after review, answering the same questions over and over again, the various departments procrastinating over every decision”.

She is still convinced that she made the right decision to care for Ronald at home, but the lack of support for her meant that she had to give up paid work to care, and suffered then from stress and depression, providing round-the-clock care. The impact of both people losing their incomes forced them to sell their home and go into sheltered rented accommodation. Your Lordships may think that that is an extreme example but it is not. It is a common experience in some families.

One of the great difficulties about a sudden onset condition such as stroke is that carers have little time or opportunity to plan for caring responsibilities. Intensive support, or reablement as we often call it now, following hospital discharge, can make the difference between a more rapid recovery and the need for ongoing long-term care. Not only is it crucial to support the independence of the stroke sufferer but for family members, too. Many families can juggle short periods of intensive caring and ongoing lower levels of support with paid work. They are very willing to do that, and to juggle it with other family commitments. But the lack of rehabilitation services can extend the length and intensity of the caring responsiblities of families. Evidence from Carers UK shows that many families are at risk of longer-term penalities: falling out of work and risking isolation, ill health and financial hardship.

In addition to support with personal care and mobility, stroke survivors often experience communication difficulties and changes in behaviour. That, too, can lead to stress and strain in the caring relationship. When the Minister responds, I hope that he will acknowledge the importance of caring families and address specifically the latest developments to support the Olivias of this world, as well as the Ronalds, who are the sufferers, particularly in respect of the unacceptable variation in levels of support available to them.

NHS: Transition Risk Register

Baroness Pitkeathley Excerpts

Wednesday 18th January 2012 Lords Chamber

Asked By

[Baroness Pitkeathley]

To ask Her Majesty’s Government whether their risk assessment of their proposed National Health Service reforms will be published before the Report stage of the Health and Social Care Bill commences.

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

My Lords, the Government are appealing the Information Commissioner’s decision that the transition and strategic risk registers should be released, for the reasons explained in my recent statements to the House. The tribunal has initially fixed the oral hearing for 2 and 3 April, but my department is urgently discussing with the tribunal how the case may be expedited further. Regrettably, however, it is not possible for this to take place before Report commences.

[Baroness Pitkeathley]

My Lords, the Minister’s reply will be disappointing to many Members of this House, who believe with the Information Commissioner that,

“there is a very strong public interest in disclosure of the information, given the significant change to the structure of the health service the government's policies on the modernisation will bring”.

Moreover, the noble Earl himself is, I know, on record as saying that he is anxious to get the matter decided as speedily as possible. Are the Government considering a delay in the timing of Report, so that the House can have before it all the information that it needs to ensure that this important Bill is subject to detailed scrutiny, which is such a significant function of your Lordships' House?

[Earl Howe]

My Lords, I understand the noble Baroness’s disappointment. As I have said, my department has made strenuous representations to ensure that this process is concluded as speedily as may be possible, consistent with the need for both parties to assemble the necessary evidence and present their cases properly. In answer to her second question, of course we have considered the timetable for Report in the context of this process, but we have concluded that if the Bill is to go through its full passage by the anticipated time of the end of the Session we need to start Report at the beginning of February. So, regrettably, our conclusion is that the start of Report cannot be delayed.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Monday 19th December 2011 Lords Chamber

[Lord Patel]

My Lords, I have my name on these amendments. Of course, we have had an opportunity to discuss integrated care at length at other times. However, I agree that integrated care and the delivery of it is one of the key challenges in the Bill. I agree with what the noble Lord, Lord Warner, said. To a patient, integrated care is the care they need: primary care, secondary care, social care and care in the community.

What leverages will there be for the commissioners to promote the integration of health and social care? They will have the budget, but what other incentives will they have? There is some evidence that contracting of provision of care to a population, particularly the elderly, the frail and those with complex diseases, will require much more care but also use more resources and services. It is not only value for money, but improved patient experience and patient outcomes. How will the commissioners be encouraged to do this? Does the Minister think that three separate outcomes frameworks in health, social care and prevention will help or hinder integration of care? There is also an issue about who will lead this change, if we think that this is the key challenge in the Bill. I agree that putting a clear definition of what we mean by integration, or what a patient means by integration, into the Bill will give a clear message to all those who commission and deliver the care, to know exactly what they have to do.

[Baroness Pitkeathley]

My Lords, my name is on Amendment 332. As other noble Lords have said, the Committee hardly needs reminding of our previous debates about the integration issue, or of the importance of health and well-being boards to the interests of patients. It is too easy, as the noble Lord, Lord Warner, has reminded us, for those delivering care to think that they are delivering an integrated service, because they are talking to each other—although it is not as common across services, in fact, as we might like to think—or because they are making joint plans, or they have made some kind of structural change, to give a nod to integration. What matters is how the services are received. Are they received by the patient in a way that is coherent and co-ordinated to the patient and to their family and carers?

The services will be delivered by a variety of providers—more, it seems to me, than the two arms the noble Baroness, Lady Murphy, reminded us about; that is, not only by health and local authorities but also by third sector organisations, particularly for those with long-term and chronic illnesses; by charities, by social enterprises and of course across the private sector. However the health and well-being boards end up being constituted in a particular area, it seems to me that some of the members at least will be patient representatives. They will be in an ideal position to monitor the patient’s response to service delivery and that it is indeed being integrated across all those services. It is very good news that the Future Forum is now working on integration. Will the Minister assure the Committee that the report, which I think he said would be available in January, will be available to the House by the time of our Report stage?

--- Later in debate ---

[Baroness Finlay of Llandaff]

My Lords, I support the amendment. It raises a very important issue, namely what happens when an error occurs. At the moment, there is an enormous disincentive for the pharmacist to do what one would say is the right thing, which is immediately to contact the patient, or their family, carer or nursing home, to try to put an immediate stop to the further use of that medication and to do all they can to correct the error. In the law as it is written at the moment there is an in-built incentive to a pharmacist to attempt a cover-up, to weigh up whether the error is a major or minor one or one which they might just get away with, or perhaps even to make a phone call that fudges the issue and tries to cover up the fact that they have made a dispensing error, and to reclaim the medication in another way.

In addition to the importance of a spirit of openness, there is an actual safety issue here. We know from looking at medicine and nursing that when you make it easier for people to admit immediately that they have made an error and to do all they can to correct that error, they are much more likely to handle things in an open and honest way and to learn from it. Certainly I say to all my junior staff, “I know that you will make mistakes. The only thing that I will hold against you for the whole of your career is if you do not immediately notify whoever is the consultant covering you at the time. Mistakes will happen, but you must let people know immediately and take every step to correct them”. I do not see why we should be treating pharmacists in law in a way that works against that type of principle and which is inappropriately punitive.

[Baroness Pitkeathley]

My Lords, I, too, support this amendment. I remind the Committee of my role as chair of the Council for Healthcare Regulatory Excellence, which has an oversight role with the General Pharmaceutical Council. We believe that single dispensing errors should be treated in a proportionate way that still prosecutes those who have been negligent or have committed a deliberate act but does not penalise pharmacists who want to declare a dispensing error in the interests of patient safety—and I very much agree with the noble Baroness, Lady Finlay, that this is about patient safety.

In the interests of patient safety and public protection, we of course expect the regulator to be able to co-operate with other agencies if it is aware of a pattern of repeated single-dispensing errors that might reflect wilful and deliberate acts with the intention of harming patients. In those circumstances, there would of course still be recourse to criminal prosecution. With these exceptions, I very much support this amendment.

[Baroness Jolly]

My Lords, I, too, support this amendment. I have some personal experience that I can bring to bear, and it was not until I was reading through the amendments a week or so in advance that I put these things together. Some years ago my mother became really ill with a very strange set of symptoms and no one could work out what the problem was. Eventually her GP came round. Like many people of that age, she takes several drugs. He sat down on her bed, took out her box of drugs from her bedside table drawer and went through them. There was one drug that she should not have been taking at all. It was completely wrong and should have been taken sparingly, not three times a day. My mother lives in a small town and the GP knows the pharmacist well, so he high-tailed down to him straightaway to find out what exactly the issue was. In this case, the dispensing pharmacist was unaware that there was a mistake.

It was really quite interesting to see how it had all happened. The medicines were all stored on a shelf in alphabetical order by drug name, not brand name. The drug in question was adjacent to my mother’s normal drug, and both were generics produced by the same pharmaceutical company. The narrow little rectangular boxes looked the same, so the pharmacist had picked the wrong one off the shelf, popped it into the bag with the rest and it had gone home. My mother, whose sight is not what it was, had taken them all out of their boxes and popped them all into her pill box. The deal was done, it was really very easy, and the whole thing was completely indistinguishable.

Fortunately my mother recovered once it was sorted out. It was a regular, well-known, high-street pharmacy, and it was absolutely excellent. It wrote a letter immediately saying that it was going to instigate a clinical governance review. It then wrote again to tell us exactly what it had done, including changing its methods of storage and ensuring that someone double-checked all drugs before they were bagged-up. This had been a mistake, but there is absolutely no doubt that it was completely negligent, and also avoidable. However, it was not criminal. There was no malicious intent. It could have been terrible, but mercifully it was not. The employer spoke to the pharmacist who admitted exactly what she had done once they had worked it all out. The pharmacy took proportionate discipline, and that is what we as a family wanted. We wanted something to happen, for it be arranged that the mistake could not happen to anyone again and for anything that happened to be professional and proportionate. That is what happened. As a result, I totally support the amendment that my noble friend has tabled with the support of the Royal Pharmaceutical Society.

Health and Social Care Bill

Baroness Pitkeathley Excerpts

Monday 19th December 2011 Lords Chamber

[Baroness Meacher]

My Lords, I support the opposition of the noble Lord, Lord Hunt, to Clauses 206 and 208 to 211 standing part of the Bill, and will also speak to Amendment 338B. The noble Lord, Lord Hunt, has elaborated these issues extremely comprehensively and powerfully. I want to avoid duplication and will therefore concentrate on a few specific concerns that, for me, are the most serious, although the matters raised by the noble Lord, Lord Hunt, are also important to me.

Social work carries onerous public protection responsibilities that, to my mind, differentiate it importantly from the other professions regulated by the Health Professions Council. One issue that highlights that problem is the registration of social work students referred to by the noble Lord, Lord Hunt. This and other key matters are left to regulation under Clause 208 without any clarification of what that will mean in practice.

It is important to bear in mind that social work students have direct and unsupervised contact with vulnerable people, including children, whose lives may be at risk. That is rather different from the contact that other professionals tend to have with individuals. Following an impact assessment, the GSCC, not surprisingly, concluded that compulsory student registration was necessary. At present, the GSCC makes grants to the universities providing social work training. Those grants are conditional on the registration of students. The result is that 95 per cent of students are in fact registered. I am not sure what happened to the other 5 per cent, but in essence it is a form of compulsory registration of students.

As a result, any serious complaint about the conduct of a social work student can be referred for investigation by the GSCC. Although the number of serious complaints is small, it is larger than that of complaints about other professions. It is very important that these individuals are picked up early before they can do any severe damage to young children, or indeed other children. If a student is found guilty of misconduct and dismissed from their course, they cannot simply go across to the other side of London or to Newcastle and register on a different course, as this will be picked up by the GSCC. However, that will be lost in the new system. This system of student registration seems to be an important safeguard in public protection.

As I understand it, the HPC is consulting on whether the registration of students should be purely voluntary, as it is in the other health professions regulated by the HPC and as mentioned by the noble Lord, Lord Hunt. The concern is that the consultation includes all the health professions, which of course will say that registration does not need to be compulsory, and indeed it does not for these other professions. Any social work professional will recognise the importance of the compulsory registration of students, but of course they will be outnumbered by all the other professions. As a result, social work registration is likely—in fact, almost certain—to become voluntary. I understand that Paul Burstow, the Minister in the other place, has some concerns about this. Can the Minister tell the Committee what progress has been made to ensure that social work registration remains, de facto, compulsory under the student arrangements?

It is worth flagging up that Northern Ireland, Wales and Scotland will continue to have compulsory registration of social work students, and England will be out of line if this provision goes ahead. As a result, inappropriate students—potentially dangerous social workers—will come across the border into this country and practise. Do we really want that to happen?

Another issue is the assessed and supported year in employment—the ASYE. This is not yet in place but has been recommended by the Social Work Reform Board and is supported by the GSCC. I understand that senior social work professionals do not expect the HPC to introduce the assessed and supported year for newly qualified social workers because they want a common system for all professionals, as alluded to by the noble Lord, Lord Hunt. This provision is not necessary for professionals without a public and child protection responsibility.

Again, there is a problem here because of the differences between social work on the one hand and all the other professions on the other. As someone who practised social work—albeit briefly and many years ago—I fully appreciate the importance of a year immediately following qualification when social workers carry a lighter case load and receive support with more hands-on supervision to enable them to consolidate their knowledge. You could say that this was all a bit heavy-handed if it were not for the public and child protection duties of these workers. However, it really is important that those people know what they are doing and that they do not miss high-risk cases.

The GSCC wants the assessed and supported year to be a registration requirement in the future. Northern Ireland has this system. Of course, this would need to be tied in with some control over the number of social work trainees, but in my view it is a very important matter. What are the Minister’s plans in this regard?

My third area of concern is the standard of social work training. Those at the head of the GSCC would agree that we need more, rather than less, rigorous regulation of social work training. Social work standards set by the Department of Health have already fallen over a period; certainly they are quite unrecognisable to me. I think all of us who are aware of the Baby P report would agree with that assertion. We can expect these standards to fall further under the HPC because, as the noble Lord, Lord Hunt, mentioned, the HPC has basic standards across all professions at roughly NVQ level 3—not a degree level and not, in my view, a sufficiently high level—and just a few generic standards for each profession. It is not looking for intellectual rigour and does not have practice standards. Its focus is on outputs, which we all recognise and think are a thoroughly good thing. However, we all know that outputs based on book learning without any fieldwork requirements will miss absolutely essential elements of effective social work professional practice. The Social Work Reform Board is setting higher standards but these will not be regulated. Only the most basic standards set by the HPC will have that regulatory framework.

The Government are, I believe, leaving it to the yet-to-exist College of Social Work to promote excellence in social work. The BASW is challenging the establishment of the college, I understand. Will it exist and, if it does, will it be delayed? If so, for how long? I gather that even when it does exist, the college will be toothless—it will have no powers to regulate training at all. It may set standards of excellence but it will have no powers to ensure that those standards are met. Does the Minister agree that social work standards need to rise, not fall? If so, will she agree to take away these concerns and consider how best to ensure meaningful progress on the issue? That is vital to the protection of children and to avoid more Baby P scandals, with huge embarrassment to the Government. I trust that the Minister will take this seriously.

Finally, I ask the Minister what will become of the GSCC code of practice for social care workers, which is another group altogether. It is important that this code of practice is retained as an element in the standards framework for social care. This is all about standards and the quality of provision. Will this code of practice be hosted by Skills for Care in the interim before any registration of these workers, or will it be lost? I reinforce the point made by the noble Lord, Lord Hunt, about the spurious financial justification for the abolition of the GSCC. I, too, understand that, financially, keeping the GSCC would stand up perfectly well—it could be self-funding on a similar basis to the HPC. I hope that the Minister will be able to explain this.

Very real risks arise from this planned merger. England will move out of line with its neighbouring countries, and we will reduce standards and safeguards in a profession at the front line of child protection. Is it really too late to rethink this high-risk plan?

[Baroness Pitkeathley]

My Lords, I have interests to declare other than being chair of the Council for Healthcare Regulatory Excellence in that I chaired the advisory body that led to the setting up of the General Social Care Council, and I was its first chair.

It is not for me to question the Government’s decision on these matters, but I draw your Lordships’ attention to the fact that neither the decision nor its implementation have been easy for those involved. I pay the warmest possible tribute to colleagues at the General Social Care Council and the HPC for the way in which they have dealt with this difficult situation. In particular, I acknowledge the role of the oversight group, which is chaired by Harry Cayton, the chief executive of the CHRE, and consists of colleagues from both organisations and other interested parties. However difficult those discussions may have been at times, the professionalism and commitment of those involved to the safety and interests of the end users of social workers’ work have been exemplary, as has been the commitment to ensuring that there should be as little disruption as possible to their functions during any transition period. Thanks to that professionalism, these reforms will allow for the greater integration of health and social care regulation through the renamed Health and Care Professions Council. Regulation by the HCPC—I shall have to get used to the new initials—will extend regulation to the competence of social workers, as well as to their conduct, and thus improve public protection.

I have some concerns about the proposals for the governance of the HCPC, as they do not reflect the general direction of travel in recent reforms across professional regulation. These have emphasised and focused the regulator’s governance and operations on the primary duty of public protection, not of professional representation. Historically, allowing reserved places for particular professionals in councils and committee structures was thought to be damaging to public confidence in regulators and in their decisions about standards and fitness to practise. These proposals might therefore represent a step backwards and not demonstrate good governance principles for professional regulation.

The HPC has a strong track record in taking on new registers, and has established quality assurance mechanisms to facilitate appropriate input from professional expertise, where appropriate. I hope that we shall be able to see that this is an important development, and one that protects all those professions, as well as, most importantly, the public, in the integration of social care and health in the way that we have been calling for in so many debates during the course of this Bill.

--- Later in debate ---

[Baroness Barker]

My Lords, I have a great deal of sympathy with what the noble Lord, Lord Walton, has said. If noble Lords look at A Vision for Adult Social Care, a document published by the Government last year, they will see that the principles underpinning health and social care have been set out perhaps more clearly than they have been for some considerable time. I do not think the problem is that the principles are not there or are not known; it is that the training that brings those principles to life for a practitioner is not there.

I am torn on this issue. I listened to the noble Baroness, Lady Pitkeathley, and I was persuaded by what she said. I know of organisations which use staff who are not registered but who are exceptionally well trained and have very high standards. If the Government are reluctant—I am sure that my noble friend will again say that they are—to go down the path of full registration, I would understand that position if my noble friend would give a commitment to the development of training. That would go a long way to meeting the point to which I think all noble Lords are trying to get; namely, that the training of people involved in the direct care of those who, usually, have long-term conditions is of a high-enough quality. That is the most helpful thing that my noble friend might be able to say.

[Baroness Pitkeathley]

My Lords, in response to the two noble Lords from the Cross Benches who have spoken, the thinking of CHRE, which is to become the Professional Standards Authority, on the accreditation of voluntary registers is quite well developed. We would be very happy to participate in any meeting of the kind suggested.