Mental Capacity (Amendment) Bill [HL]

Baroness Thornton Excerpts

Committee: 1st sitting (Hansard): House of Lords
Wednesday 5th September 2018 Lords Chamber

I have been discussing this with general practitioners. I declare that I was on the safeguarding toolkit working party of the Royal College of General Practitioners. Safeguarding is different from liberty protection safeguards or a deprivation of liberty, but sometimes in people’s thinking they get muddled up and unclear, and it becomes particularly difficult when you are talking about people who are cared for in their own home. I am sure that we will come on to that later, but I would be interested to know whether the Minister agrees that the general thrust we should be taking is that the care plan must be appropriate for that person and constantly revisited, and that we must be able to make sure that all the views of those people who have the welfare of the person at heart, and who have been perhaps chosen by that person to speak for them when they can no longer speak for themselves, are respected.

[Baroness Thornton (Lab)]

My Lords, I will speak to Amendment 20, which is in my name on the Marshalled List and has been grouped with the amendment in the name of the noble Baroness, Lady Finlay.

During the briefing we had with the Bill team and the Ministers, my notes tell me that the first clause is a key change to the new regime, and that it is concerned with the portability of deprivation of liberty. I understand that the noble Baroness’s amendment makes sure that Section 4B—on the deprivation of liberty necessary for life-sustaining treatment or vital act—and Schedule AA1 are compatible with the provisions set out in the rest of the Bill and that they do not conflict with a valid decision to refuse care or treatment. The noble Baroness raises some important and substantial issues right at the beginning of the Bill and raises issues of conflicts which will need to be resolved.

Amendment 20 in my name comes from paragraph 15 of proposed new Schedule AA1 in the Law Commission’s draft Bill, quoting it exactly. It prevents the responsible body authorising arrangements for the cared-for person to reside in, or receive care or treatment somewhere, if those arrangements conflict with a valid decision by a donee of a lasting power of attorney or of a deputy appointed by the Court of Protection. As I say, the wording is exactly the same as that in the Law Commission draft Bill.

Under deprivation of liberty, a deputy and attorney may object to any deprivation of liberty and effectively block it, pending an application to the Court of Protection. I can see no obvious reason for excluding this from the Bill. The Government claim that it is already in the main provisions under the original Act—in Section 6(6) —but this is only the case where the basis for the deprivation of liberty is in “best interests”. If the basis for DOL is risk to others, that would not necessarily be the case, and so for the avoidance of doubt it is important to include this clause. If we do not, the risk of litigation on this point is probably quite high.

Deputies and donees should be able to refuse a deprivation of liberty, so this amendment seeks to ensure that the views of those donees and deputies, who have been appointed by the cared-for person to make the decisions in their best interests—as was eloquently outlined by the noble Baroness, Lady Finlay—are given appropriate weight with regard to where the cared-for person resides for care and treatment.

I am pleased to say that this amendment and what the noble Baroness, Lady Finlay, said, enjoys widespread support from the organisations who have found the time, even under the pressure we have all been under, to say that they support this. They include Mencap, VoiceAbility, Mind, the National Autistic Society, Liberty, Age UK, Sense and many others. The amendment looks at the clash or overlap between the different regimes that govern this area of law. I must ask why the Government did not adopt the Law Commission formulation. The Minister should be aware that I will return to that theme throughout Committee, because the Government seem to have cherry picked the Law Commission report, and some of the most important safeguards of liberty seem to have been omitted or watered down by the Bill.

[Baroness Browning (Con)]

My Lords, I refer to my interests in the register. I will pick up on two points that have been raised in the amendments, particularly the amendment in the name of the noble Baroness, Lady Finlay.

At Second Reading, I too raised my concern about the status of attorneys with lasting power of attorney, particularly over wellness and health. These are some of the most personal decisions. In some ways, I am more concerned about that than about attorneys who have power over the money. Money always seems a rather black and white matter—it either is or is not a good idea. But there are many shades of grey over health and, in particular, well-being. I should like to link this with decision-making and the other point in the noble Baroness’s amendment, about the need for qualified speech and language support to interpret and make sure there is a clear understanding of what “P”’s interests really are.

When you look at certain people with certain disabilities, particularly those with communication disorders—such as autism, learning disabilities and, of course, dementia—it is not always the case that they cannot express a view. But getting to that view—unless it is a real, life-threatening medical emergency—takes quite a long time. First, particularly those with autism and a learning disability, the individual has to be comfortable and familiar with the person asking the questions, however experienced. It is no good sending a stranger in for a five-minute cup of tea and a quick chat and thinking that person will then disclose their innermost feelings. How many of us would?

The point is that getting to that view might often be about something known for many years by someone who has been appointed as an attorney with a lasting power of attorney. I believe the two things are linked in those cases. We know from the Alzheimer’s Society that such a lot can be achieved for the quality of life and well-being of people with dementia and Alzheimer’s by giving enough time, when asking a question, to allow the person to process the information before they give an answer. Brain function is very different in these people. They need time to process the question they are being asked and to process how they will communicate the answer; it can take quite a long time.

This point was picked up quickly by the Alzheimer’s Society which says, for example, on a very simple matter, that when people with Alzheimer’s in residential care homes are asked whether they would like tea or coffee and do not immediately reply, they are processing the question and that can take a long time. They might prefer coffee today, but because they had tea yesterday, the answer may be quickly assumed—“I expect you will have tea, you always have tea”—before they can even process the information and the way they will communicate the answer.

How much more complex it is, and how much more time is needed when people are being asked more complicated questions about potentially life-changing decisions. This cannot be left only to someone with speech and language experience, important as that is, and such people need to be experienced. But people with a lasting power of attorney, who might have held an LPA for many years, and who know the individual extremely well, are in a prime position to act as an interpreter when important decisions are being made.

I believe my noble friend is aware of my view on this already. Those of us who served on the original Bill and its pre-legislative scrutiny many years ago know that a lot of thought went into the existing Bill on LPAs. To have one part of a Bill give rights to an individual through their attorney but then to diminish that in another part of the Bill, through amendment, seems not only wrong but seriously, morally wrong. I hope my noble friend will address this point when he replies to this amendment.

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The Bill makes sense in terms of cost-cutting, but like many other Members of your Lordships’ House I do not understand why many of the safeguards that the Law Society proposed needed to be retained have not been retained. If the Minister can explain that, and the strength of the connection back to the principles of the Mental Capacity Act, then perhaps his job in the next few days might be a good deal easier than it will otherwise be.

[Baroness Thornton]

I am grateful to my noble friend for tabling this clause stand part. It was necessary for a number of reasons. I am also grateful for the contributions that have been made because they bear out the reason why it was important to put down this debate. The first reason has been alluded to by many noble Lords and is the very unsatisfactory scheduling of the Bill. It means that noble Lords and stakeholders have not had sufficient time to consider the Bill and all its amendments for today. The vast majority were put down last week, and the Marshalled List became available yesterday. It was difficult for anybody to see whether the tabled amendments probed the Bill sufficiently and made all the improvements that noble Lords deemed worthy of consideration.

There is a lesson here about scheduling: if you have the Second Reading immediately before a recess, a sufficient number of sitting days must be given to allow noble Lords to table amendments and have the necessary discussions with stakeholders and each other. Getting almost 100 amendments tabled from a standing start when the House rose is pretty good going, and I congratulate noble Lords across the House for that. Some of us were emailing each other and the Public Bill Office from the poolside or the middle of fields during the Recess. However, people are playing catch-up, which does not bode well for a thorough-going scrutiny.

I congratulate the Bill team for managing to talk to noble Lords during the Recess, but in some ways they must have had an unsatisfactory time as well because we did not have the full list of amendments until Friday evening. As many noble Lords have said—it is clear from my mailbox too—in the last two or three days stakeholders are also playing catch-up and are expressing great concern about some aspects of the Bill. In a way, the frustration that that has raised is why my noble friend has tabled his amendment to oppose the clause stand part. That allows us not only to mention things that are not covered in amendments but to raise these points.

From my point of view, and from these Benches, depending on what the Minister says in his reply, we might need to raise issues of scheduling and time to consider some of the serious implications of the Bill, and possibly table amendments at the next stage that address some of the concerns raised in this debate—particularly the issue of care home managers. Notwithstanding the issues raised by the noble Baroness, Lady Finlay—she may well be right about people understanding the processes in the Bill—that does not alter the fact that we do not know who will authorise or whether it will work.

This links to my second point, which is about consultation. I would like to know where the care home manager’s role in this came from. It happened between the Law Commission draft Bill and this Bill. Suddenly, the care home manager is it, and I think that that might probably have been a surprise for some people—certainly for the noble Baroness, who did not hold back in her views about care home managers. On the consultation issue, it is clear from the Law Commission report that it did extensive consultation, leading to the creation of its draft Bill. There were something like 83 nationwide events and 583 written responses from interested persons and organisations. Some of those events were very significant indeed, with many stakeholders. Where did the issue of the role of care home managers come from? I should like the Minister to share that with us, as he must be aware of the level of disquiet about the expectations and the responsibilities that would have to be assumed by care home managers for the assessment required to authorise the deprivation of a person’s liberty when the person lives in their care home.

I also want to know the view of the CQC on this proposal. What is the view of the care providers, the ADASS and the LGA? They are all key stakeholders in that decision. I should be grateful to have the Minister’s take on the view of those important organisations on this proposal. I could not find the issue among the material circulated by the Minister or, indeed, in the letter he sent, which I found useful and informative.

My noble friend has done the House a favour in raising these issues and allowing a large number of questions to be asked at this stage, which might inform the next day’s discussion in Committee, the next stage of the Bill and perhaps also the discussions that we will need to have in the coming weeks.

[Lord O'Shaughnessy]

I start by agreeing with the noble Lord, Lord Hunt of Kings Heath, that of course extensive scrutiny is deserved for legislation of this kind, which we have achieved both at Second Reading and, for those who could not be there, in the second Second Reading debate that we have just had. That scrutiny is obviously reflected in the 100 or so amendments that have been tabled. It is worth using this opportunity, as the noble Baroness, Lady Finlay, did to some extent, to remind ourselves why we are here pursuing this legislation.

The noble Baroness, Lady Barker, asked why now? Well, in 2014, the House identified that the DoLS system was not fit for purpose and the Government tasked the Law Commission with completing its report into DoLS. It recommended that the current system needed to be replaced as a matter of pressing urgency. I will come on to the point about the discrepancies between the two approaches but, nevertheless, that was its view. The Government stated that we would do this as soon as parliamentary time allowed—part of the issue around scheduling is indeed “when parliamentary time allows”. It is important to use opportunities when they arise to do important things, even if it means that people have to work during the summer or holidays. I realise that that is not always ideal, but the scheduling, for example, of Committee over a long period—and we will then need to think about Report—should give lots more time for these kinds of discussion. I reassure noble Lords that we want to have and are open to those discussions.

The model that we have created is based on that developed by the Law Commission and, like the Law Commission, we want to increase the protection of some of the most vulnerable people in society, to protect their rights, not just in theory but in practice, and to improve access to justice. I confirm to noble Lords that we have worked and continue to work with a range of stakeholders to build on the Law Commission’s model and to produce a streamlined system. “Streamlined” is an important way of describing this, because the noble Baronesses, Lady Jolly, Lady Barker and Lady Murphy, talked about cost-cutting. This is in fact about creating a system that has the effect that we want with the budget that it is given; that is the point. As we know from the backlog, lots of people are being denied access to justice because of a system that is disproportionate in its application. That is what we are trying to solve, so that those cases that really do deserve the highest level of scrutiny are able to receive it. That really is at the heart of what we are trying to do. I emphasise that Nicholas Paines, the Law Commissioner who led this review, said that this Bill,

“will go a long way towards addressing the flaws of the current system and better protect the most vulnerable in our society”.

I would not claim at this point in the proceedings that it is perfect. I am sure that we can improve it, but it is important that we are doing it, that we are doing it now and that it has support from the Law Commission itself.

More recently, the Independent Review of the Mental Health Act: Interim Report, which was referenced by the noble Baroness, Lady Barker, and led by Simon Wessely, stressed the need for an,

“appropriate calibration between resources spent on delivery of care and those spent on safeguards surrounding the delivery of that care”.

That is what we are trying to achieve through this process. I reassure the noble Baroness, Lady Tyler, who was quite right to talk about the interaction and interface between the two Acts and how they operate that, while we are taking this opportunity to act now while we can, if there are future recommendations that mean there have to be further changes, we would be open to those. This will not be the last opportunity to make sure that the interface between the two Acts, once the reviews have been completed, could be amended, if that is what is necessary. It is important that we have acted now and that those 108,000 people currently in the backlog will have swifter access to justice—that is the main argument. That is my Second Reading speech summarised and repeated.

From what the noble Lord, Lord Hunt, has said, I do not think that he wants to remove this clause, not least because it would remove the new system while not stopping the repeal of the current system, and nobody wants that. At the heart of what the noble Lord spoke about is this focus on care homes, which I think is worth dwelling on. The system has been carefully designed to ensure that there is independence and proper accountability. Care homes will not authorise any applications. That will fall to a wholly independent responsible body—the local authority.

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[Baroness Barker]

My Lords, I hope that it is permissible for me to rise again. For the avoidance of doubt, will the Minister confirm that I understood him correctly? Is he saying that the role of the care home manager has not changed? I understand that, under the existing law, a care home manager may request that somebody’s capacity be assessed, but that assessment is not usually done by them. That assessment is done by somebody else. Is he saying that that is not going to change? I am sorry, but I think it very important that noble Lords understand what the Minister says.

[Baroness Thornton]

I understood that the Minister said “escalate”, which means that something changes. Perhaps when he is answering the question of the noble Baroness, Lady Barker, he could also explain the word “escalate”.

The Government may need to think about carrying out some form of assessment of the appropriateness and suitability of care home managers to undertake this task. If that has not been done, perhaps it needs to be done in the next month or so.

[Lord O'Shaughnessy]

In answer to the noble Baroness’s question, the point that I was making is not that the role of the care home manager will not change but that they are not being asked to do something of which they have absolutely no experience or responsibility for at the moment. As the noble Baroness, Lady Finlay, pointed out, care home managers are already required to make applications and to consider capacity and restrictions, so they already have a role. The distinction is that, as the Bill sets out, the assessments can be made within the care home itself—of course, not by a person with direct responsibility for care. That is one of the issues, of avoiding conflict of interest. In all cases, those will be authorised by the local authority. If there is any reason, through that authorisation, for concern—for example, of conflicting views between the person cared for and their family—then the AMCP, the mental capacity professional, will have the opportunity to decide on the right course of action. That is what I meant by escalate—not that there is a choice of whether to escalate authorisation to the responsible body, as that will happen in all cases, but that there is a further opportunity for consideration by an AMCP if there is any sense of this happening. We will explore in more detail in future groups whether there is a reason for further investigation, including, of course, speaking to the cared-for person, their family and others.

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Moved by

[Baroness Thornton]

2: Schedule 1, page 6, line 2, leave out “18” and insert “16”

[Baroness Thornton]

My Lords, we are moving to the issue of changing “18” to “16” and applying the provisions of the Bill to 16 year-olds. I have four points to make.

First, this amendment is supported by the LGA and the ADASS. Secondly, the GMC is concerned that, given that the Mental Capacity Act applies to people aged 16-plus, excluding those below 18 from the liberty protection safeguards in the Bill may leave an important gap in the liberty safeguards. Thirdly, the Royal College of Psychiatrists has pointed out that case law has established that the parents of children under 16 may give consent to what would otherwise constitute a deprivation of a child’s liberty where the matter falls within the “zone of parental responsibility”, but it has been held that a parent cannot give equivalent consent for a 16 to 17 year-old. It therefore argues that the Bill should be extended to 16 to 17 year-olds to provide them with better safeguards, as they are not served well at present.

Finally, the Law Commission looked at this in some detail. It was part of its remit from the Government that it should consider,

“the position of young people aged 16 and 17 (but not children aged 15 or younger). Most of the Mental Capacity Act applies to people aged 16 and over. However, the DoLS only apply to adults aged 18 and over. There are several legal provisions that permit the deprivation of liberty of children … Under section 25 of the Children Act 1989, a child who is being looked after by a local authority can be placed or kept in secure accommodation in England, provided for the purpose of restricting liberty. The Mental Health Act can be used to detain a person of any age suffering from mental disorder for the provision of medical treatment. Beyond these cases, the deprivation of liberty of a young person can be authorised by the Family Court or Family Division of the High Court under their respective inherent jurisdictions or by the Court of Protection”.

There is of course a complicating factor: namely, that,

“the Strasbourg court has recognised the right of parents—in certain cases—to consent to restrictions placed on their child which would otherwise amount to a deprivation of liberty”.

That refers to the Birmingham case, which noble Lords may well be familiar with.

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[Lord O'Shaughnessy]

I would like to thank the noble Baronesses, Lady Thornton and Lady Murphy, for tabling these amendments, which seek to apply the liberty protection safeguards to 16 and 17 year-olds in the same way that they apply to adults. Noble Lords have been absolutely right to point out, as they did at Second Reading, that in the Government’s response to the Law Commission report, we accepted in principle that 16 and 17 year-olds would be included in the new liberty protection safeguard system. I know that noble Lords are motivated not just get to get this right in general but also, as the noble Baroness, Lady Thornton, said, in relation to specific cases that are known to them, sometimes very close to home. I understand and sympathise absolutely with the desire to do that.

The noble Lord, Lord Touhig, is also right to say that it is something I said I would consider and would seek to bring further news. We are still considering this very actively. What is clear even from this brief debate is that, as the noble Baroness, Lady Tyler, pointed out, there are some critical interactions that we need to get right with other bits of the system. These include the role of parents, how the safeguards would apply to looked-after children, and interaction with processes such as the education, health and care planning processes for those with special needs and disabilities. As the noble Baronesses, Lady Murphy and Lady Thornton, reminded us, we need also to be mindful of the current court case.

At this stage, I repeat and underline our commitment to make progress and to offer the best possible protection for this group of vulnerable young people. Proper scrutiny and detailed thought is required, and that thought is ongoing. I recognise the arguments for including this group. Like all noble Lords, I want to make sure we get this right and get the interactions right, so that they do not end up being fixed subsequently by the courts, as the noble Lord, Lord Hunt, pointed out in a different context.

Our intention is to use the time between now and Report to continue having those discussions, both with noble Lords and with stakeholders throughout the sector, to make sure we can get this right. On that basis, having given the commitment that we will work hard to do what we can between now and Report to get the right outcome, I hope the noble Baroness will be prepared to withdraw her amendment.

[Baroness Thornton]

I thank the Minister for that. What can I say but, “Thank you, and let us hope so”?

Amendment 2 withdrawn.

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[Baroness Barker]

My Lords, I shall not detain the Committee for long but it is important to recap on a bit of history. The original legislation that came before your Lordships’ House on this issue—the Mental Incapacity Bill—was subject to the first ever pre-legislative scrutiny. In going through that then very innovative procedure, Members of this House and another place did a couple of things which at that time were game-changing. One was that we invited people who lacked capacity to come and give evidence to us. But we went further than that. When we produced our report, we invited them back to discuss with them what we had listened to and what we had changed. One of the first and most important things that we did was to change the title from the Mental Incapacity Bill to the Mental Capacity Bill. We also, for the first time ever, produced an easy-read version of a Bill.

I strongly support my noble friend Lady Tyler because this feels like a real regression in thinking. I understand that the term is there because somebody somewhere believes that it has a legal meaning. We came up against those same arguments all those years ago and this House led the way in getting lawyers and counsel to change their minds. I do not see a reason for us not to do the same again.

I wish to add one point. I vividly remember listening to the people whom we invited back to talk to us after we had produced our report. At this point, there were only Members of your Lordships’ House in the room—the Commons were busy and had not turned up. I remember one particular gentleman who said, “When I first saw this, I thought it was really rubbish, but actually you’ve done quite a good job”. I have to say that in all my years in your Lordships’ House I do not think that I have ever received a more sincere accolade. That is not to belittle anybody’s contribution to this, but I think that my noble friend has made a very strong point.

[Baroness Thornton]

These Benches support the amendment. As the noble Baroness, Lady Tyler, and others have said, the reference to unsoundness of mind is offensive to those with learning disabilities, dementia and brain injuries and their families. The noble Baroness, Lady Barker, has just demolished all the legal arguments for including the phrase in the Bill, and indeed a lot of organisations, including the Royal College of Psychiatrists, say that it out of place in today’s society. The GMC argues that it is not clear what added protection or benefit is achieved by using the term. VoiceAbility says that “unsound mind” is not used in modern psychiatry and that it could lead to debate in disputes. Therefore, I hope that the Minister will be as agreeable about this amendment as he was about the last one.

[Lord O'Shaughnessy]

I do hate to disappoint. I thank the noble Baronesses for introducing this point. We discussed it at Second Reading and I have huge sympathy with the concerns about this kind of language. Frankly, it is not the kind of language that we use. As the noble Baroness, Lady Murphy, pointed out, she has not diagnosed anyone as being of unsound mind for decades. It is a throwback and we are in the process of destigmatising mental health issues, as the noble Lord, Lord Cashman, pointed out. That is an endeavour that we are engaged in earnestly together. However, it is important to distinguish between the operational language used in care and the language used in the courts, and I want to discuss that.

This is not just about semantics; it is about terms that have established legal precedent and a jurisprudence based on their interpretation. It is worth discussing the consequences of deviating from a term that is in current use because of its role and the fact that the phrase is used in the European Convention on Human Rights. As the noble Baroness, Lady Tyler, pointed out, the term has not changed since the 1950s and the creation of the ECHR, and it has subsequently been used by the Strasbourg court. There is a risk, and it is worth recognising, even if it is one that noble Lords might be prepared to contemplate. The risk is that a different expression such as the one proposed by the noble Baroness, Lady Tyler—it is a perfectly reasonable starter for 10, as I think she called it—could create a gap for some people who need access to liberty protection safeguards but do not meet the criteria of having a disorder or disability of mind, although they would have met the criteria of unsound mind.

It is important to note that the Law Commission used this language. We have been accused of deviating from the Law Commission Bill but it used this language and we have copied it to ensure that the liberty protection safeguards are compliant with the ECHR and that there is no gap with people not being covered. This could include people with learning disabilities, brain disorders or disorders of consciousness. In essence, the problem here is not this Bill. In a way, the Bill has a problem because of the language that has not been changed since its creation in the ECHR.

Therefore, although I agree with the sentiment behind the amendment, new terminology would risk creating a gap for people between the ECHR and this proposed law, and we are all concerned to avoid such gaps. Any gap would require people to have recourse, instead, to the Court of Protection. Therefore, it is not the case that people would have no recourse; they would have recourse to the Court of Protection, but we know that the people being cared for and their families and carers can find that an intimidating and difficult process.

It is also important to note that the Court of Appeal has indicated that some people with certain forms of learning disability might not be considered mentally disordered under the definition put forward by the noble Baroness but would still be considered of unsound mind for the purposes of the convention. That is another reason why there is a risk of a gap. For example, there is a particular risk that some individuals with brain injuries, or certain disorders of consciousness, might fall within the gap.

At Second Reading I did say, earnestly, absolutely and honestly, that I wanted to take this away and consider it, because of the frankly unsatisfactory nature of the term when it comes to modern practice. We have also listened to the contributions of a range of stakeholders—a number of people are of course very interested in this, and not just in this House—and to the contributions of the Joint Committee on Human Rights to see whether it is possible to use better language. I know this is not something the House will welcome, but I have concluded that, although the term is regrettable, there is a risk in using alternative language of creating a gap. Between those who would be captured under the definition suggested by the noble Baroness, Lady Tyler—or, indeed, potentially any other definition—and those currently captured under the terminology “of unsound mind”—

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[Baroness Finlay of Llandaff]

My Lords, I have an amendment in this group that does not sit terribly well with the first two—but so be it. I will be brief. These attempts to define a deprivation of liberty are nobly submitted, but I worry about potential unintended consequences from the wording. I will not go through them in detail, but I hope that the Minister will assure us that this is something we can take away and look at. One difficulty is that one person’s imprisonment—a deprivation of liberty—might not be a deprivation of liberty to another, so this may be very personal in some aspects.

On Amendment 81 in relation to a “vital act”, I hope that the noble Baroness, Lady Murphy, will take reassurance from me—I do not know whether the Minister will agree with this or not—that anything done must be in a person’s best interest. Part of that is that it is a benefit and not a burden—or it may be a burden, but the benefits outweigh the burden. That has to be a fundamental principle in clinical decision-making.

The reason I tabled Amendment 82, which relates to an urgent authorisation, is that, looking through, I was concerned about unintended consequences from the way the legislation was written. I could see two, possibly—but they may be misplaced anxieties. First, in a true emergency situation, as a consultant in emergency medicine said to me, you just get on and do what you have to do. You do not go and look at paperwork. So, in an emergency situation, you may have to restrict somebody’s liberty to do what you have to do, which is in their best interest. You do not do something that is not in their best interest—and the last thing we want to do is impose any more bureaucracy or paperwork.

So I suggest that, possibly in the code of practice and not in the Bill, it should be clear that an urgent authorisation is an authorisation to begin longer-term care, but in an acute situation, in a clinical decision, nobody would expect people to even begin this process until we get to about 48 hours. I say that because a clinical decisions unit will normally have people staying in it for under 24 hours, as they may even on an acute medical ward, before being moved to a longer-term in-patient unit where their longer-term care may be assessed. Of course, we have people who have a transiently impaired capacity because of illness and the treatment of that will restore their capacity, such as the diabetic whose diabetes is out of control through either hyperglycaemia or hypoglycaemia, and things such as hypocalcaemia as well. None of those should be included.

The concern at the other end was that an urgent authorisation could be used for example to take a confused person with advanced dementia where care at home had completely collapsed. Possibly their main carer at home had suddenly been admitted to hospital. They would then have to be moved into a nursing home placement at great speed, but that may not be what they want and they cannot consent to it. They would have to be moved to that place, be in a placement and be assessed there. There needs to be some time limit so that this cannot linger on for months or years, with somebody saying, “Oh, well, they are here under an urgent authorisation”, rather than a longer-term authorisation. That is why I tabled the amendment. I accept that it is not perfect, but I hope it is something we can look at. It may be that the code of practice can clarify those issues.

[Baroness Thornton]

I have added my name to the amendment tabled by the noble Baroness, Lady Jolly, precisely because I thought we needed to have this discussion. That was exactly right. I would hate to choose between the two amendments, but this sets out when deprivation of liberty occurs:

“Arrangements that give rise to a deprivation of … liberty”,


are when the cared-for person is placed,

“under continuous supervision and control”,

they are “not free to leave” and the responsible body believes that it is in the cared-for person’s “best interests”. That is worth putting on the face of the Bill if at all possible.

The Joint Committee on Human Rights made a strong argument in favour of a statutory definition. I read its report and it seems absolutely right that that is what we should do. I would be interested to hear what one of the lawyers in our midst might have to say about this: whether they think that it would be a useful thing to do and whether the stabs we have made at it so far are helpful. We are interested in this discussion but we realise that this is the beginning of the discussion rather than something that may be appropriate right now.

When listening to the noble Baroness, Lady Finlay, talking about her amendment, it occurred to me that this is one of those occasions when technology is important. When you have an emergency admission, you need to be able to input the name of the person into a PalmPilot, which will tell you whether a DoLS is already in place and whether a do not resuscitate order has been made. Recently I have had experience of exactly this situation with a family member. Because the information was not readily available in an emergency, we ended up where we did not want to be. I just add that to the debate because I know that the Minister and his boss are very interested in technology and its uses in the health service. This is another of those occasions where it might be useful.

[Lord Woolf]

Perhaps I may respond by giving one lawyer’s view on the matter referred to by the noble Baroness, Lady Thornton. I should put on the record that I am a member of the Joint Committee on Human Rights and therefore was a party to the report, and of course I support it.

When the opportunity arises to deal with a situation where it is clear that a decision of the Supreme Court has had consequences which may never have been anticipated, it would sometimes be helpful if the judges had the opportunity to look at the matter again. If the sort of steps so ably advocated by the noble Baroness, Lady Murphy, were taken, I would suggest that serious consideration should be given to them as they could have a beneficial effect from the pragmatic point of view as well as on the point of principle.

I am sorry, but I ought to have added that I have a relative who could be affected by this legislation, and I declare that.

Mental Capacity (Amendment) Bill [HL]

Baroness Thornton Excerpts

Committee: 1st sitting (Hansard - continued): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I have added my name to the amendment tabled by the noble Baroness, Lady Hollins. As she eloquently said, the puzzle relates to paragraph 17 of new Schedule AA1 on consultation, which references those who must be consulted. The aim of the consultation is,

“to try to ascertain the cared-for person’s wishes or feelings in relation to the arrangements”,

but the paragraph does not specify that the cared-for person must be consulted. The Minister might just refer me to Section 4 of the Mental Capacity Act and say that it is covered there, but so are the provisions in sub-paragraphs (a) to (e) in paragraph 17(2)—they are all listed in the best interests test. Therefore, the puzzle is why the Government have decided that there should be no attempt, at least in statute, to seek the cared-for person’s wishes and feelings. We are already concerned that these measures are not focused on the interests of the cared-for person; they are about streamlining bureaucracy and saving money, and this rather lends to that suspicion. I hope that the Minister will be able to agree to the noble Baroness’s amendment, because it is a very important symbol of what this is really all about.

[Baroness Thornton (Lab)]

My Lords, this group of amendments tests the proportionate nature of the decisions being taken. Amendment 29 would put the views of the cared-for person at the centre of the assessment and ensure that adequate weight was given to their wishes and feelings. I have not been able to find in the Bill where that is expressed, and that is shocking and surprising. We have to see a clear statutory duty to consult the cared-for person, and the scope of that consultation must include their past wishes, feelings, values and beliefs. I invite the Minister to tell me whether he believes that the Bill as it stands achieves that, because I cannot see that it does. If this amendment is not agreed to, the Minister and the Bill team must think about how they can best make sure that the Bill reflects the need for consultation with the cared-for person.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

I thank noble Lords for tabling their amendments and for contributing to a debate that has continued the discussion that we had before dinner. It again gets to the heart of why we are here, which is to make sure that when people need to be deprived of their liberty, it is in their best interests to do so and that the restrictions are proportionate and necessary and so on.

I agree with the spirit of the amendments. It is important that we intend to, and do, safeguard the well-being, wishes and feelings of the cared-for person. Dealing with the first set of amendments, I take this opportunity to reassure noble Lords that the changes being sought are already required by law in several ways.

First, the European Court of Human Rights has made it clear that a decision on whether arrangements are necessary and proportionate must include consideration of the cared-for person’s wishes and feelings about the arrangements. It should also be noted that, as the noble Lord, Lord Hunt, pointed out, wishes and feelings are already a part of the first-stage best interests decision-making under Section 4 of the Mental Capacity Act and I can confirm, as I have done already, that the Bill does not change this. Furthermore, wishes and feelings will also be considered as part of the “necessary and proportionate” test, and the code of practice will provide further detail about how that will work in practice.

Going even further, as has been referenced by several noble Lords, we have created in this Bill a specific requirement to ascertain a person’s wishes and feelings in relation to the proposed arrangements through the duty to consult with anyone with an interest in the cared-for person’s welfare—first and foremost the person themselves, as well as their family, carers, friends, advocates, interlocutors or anybody with a substantive interest in their care. I believe that there is substantial legal protection, force and direction to make sure that the person’s wishes and feelings are considered first and foremost in any of these kinds of arrangements. As this debate has demonstrated, there are clearly lingering concerns that that is not the case, because of the existing framework, notwithstanding the enhancements through the duty to consult that we are introducing. However, I am eager to make sure that it is well understood, and to work with noble Lords so we can make clear that those responsibilities already exist, both in statute and—

--- Later in debate ---

[Lord O'Shaughnessy]

I take the points that the noble Baroness is making. Obviously we will discuss this further. But it is important to reflect on the new duty to consult. It is not a duty to consult everybody but the person, so it is not fair to say that there has not been an earnest attempt in the Bill to make sure that the person is fully consulted in the necessary and proportionate test, even if the noble Baroness does not like the precise way that that has been done. It is important to set that out.

[Baroness Thornton]

It is a spectacular omission not to mention the very person whose liberty is being restricted. I ask the Minister and the Bill team to remind themselves of Articles 5 and 8 of the UNCRPD, which mandate such consultations.

[Baroness Hollins]

This needs emphasis because of the culture of care that we have in this country. There is still such a paternalistic attitude towards the person, that not to emphasise it is to miss the point.

Obesity

Baroness Thornton Excerpts

Wednesday 18th July 2018 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, the noble Lord, Lord McColl, is nothing if not persistent in his determination to challenge obesity. Essentially, his message to eat less is the one that he has expanded on on many occasions. I agree with him that we definitely need a national approach.

I welcome the noble Baroness, Lady Boycott, to your Lordships’ House and I congratulate her on her maiden speech. She brings great experience, not least of the media, and indeed she was a hero of mine when she edited Spare Rib. I understood slightly less well her editorship of the Daily Express, but I think that that experience will bring great weight to our debates.

There have been some excellent contributions, as ever, and pertinent questions to the Minister about the Government’s progress on their obesity strategies, particularly for childhood obesity. We have also received many excellent briefings. I particularly enjoyed the contributions of my noble friend Lord Brooke—I congratulate him on his work with the BBC—and my noble friend Lady Massey, who called for an action plan. It is fair to say that we have not cracked this one yet. I think that we are slow in having any impact in our attempts to halt the growth of obesity rates and the related, and very expensive, health and social problems that follow.

There is an even greater and more serious societal problem here which will not necessarily be resolved by the exhortation from the noble Lord, Lord McColl, to eat less, and which might be only partly resolved by the Government’s obesity strategy. We have both an obesity and an eating disorder crisis, and in my view they are different sides of the same coin. Obsessive eating and self-hate, compulsive eating and body dysmorphia are handcuffs that women, but not only women these days, place on themselves and assume they have to escape from. There are assumptions that people are weak-minded, greedy and undisciplined. When Susie Orbach wrote Fat is a Feminist Issue 40 years ago, she said that there were specific realities to the conditions of both fat and thin that we were all chasing and escaping through our eating. She was right then and she is right now. If the Minister and the noble Lord, Lord McColl, have not read FIFI, I recommend that they do so when it is reissued.

We are now 40 years on and the pressures to be thin and to have no hair on your body except on your head, or this year to have very thick eyebrows or next year none at all, are not exclusive to women. Huge damage is caused by the pressures put on our girls and boys and our men and women by social media, the media and advertising campaigns, from stereotyping of all types and the misogyny illustrated by the #MeToo campaign, and the production and advertising of high fat, salt or sugar foods. Parents are constantly fighting a battle to either afford or persuade their children into a healthy lifestyle, and sometimes both. Who would have anticipated the explosion in non-food foods that contain chemicals and sugars that do not get metabolised by the body? Who would have linked obesity to class? There is no doubt that obesity is linked to social class, being more common in the routine and semi-routine occupational groups than managerial and professional groups.

We have what you might call a perfect storm. No doubt big action is definitely required, but that has to be accompanied by a greater understanding of the nature of the problem and the challenge that we face. Can the Minister request that his right honourable friend the new Secretary of State convene a summit that seriously addresses the issue of body hatred and body image, and the factors that create it and have led to this explosion in obesity and eating disorders? I also ask that his right honourable friend address the solutions to these huge societal challenges, which cannot just be left to public health and educational policy agendas alone. It is time to look beyond the strategies that the Government are pursuing at the moment.

General Practitioners: Indemnity Scheme

Baroness Thornton Excerpts

Monday 16th July 2018 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, the average GP paid indemnity costs that rose by 50% in a six-year period. That has had a knock-on effect of discouraging doctors from going into primary care and has been a factor in many leaving. It seems to me therefore that this is a matter of urgency, and so I am very pleased to hear that the scheme will be introduced in April next year. However, GPs are sorting out their indemnity insurance right now—they do it over the summer. What advice are the Minister and the Government giving GPs now to help them decide what the costs are? Given the shortage of GPs in this country, anything that the Secretary of State can do to encourage GPs into primary care would be a good thing.

[Lord O’Shaughnessy]

I agree with the noble Baroness’s final point. Indeed, one reason for sorting out this scheme is that we know it is a barrier to people joining the profession and, unfortunately, encourages them to leave it. There is of course an urgency, but nevertheless it is a complex discussion with commercial partners. I can tell her that we are talking to GPs themselves and their representative organisations to make sure they understand what is at stake, what we intend to do and that we intend to introduce the new scheme in April.

Mental Capacity (Amendment) Bill [HL]

Baroness Thornton Excerpts

2nd reading (Hansard - continued): House of Lords
Monday 16th July 2018 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I am very pleased to be speaking in this Second Reading debate. Although we might be missing a few of our known experts in this rapidly organised debate, we can anticipate full participation in the next stages of the Bill. The debate thus far has been informed and passionate, as one would have expected.

The maiden speech of the noble Baroness, Lady Barran, was a model of its kind, and I welcome her to the House. She brings great experience. As someone who has been involved for 20 years in this House working on behalf of women and abused women and on domestic violence, I welcome her to our cohort of people across the House who campaign on these issues. I look forward to working with her in due course.

We have had some excellent contributions. Many noble Lords have been asking pertinent questions, starting with the ones from my noble friend Lord Touhig. The noble Baroness, Lady Meacher, was very modest. She has a lots of practical experience dealing with these issues. Just because she was not here when we worked on the original legislation does not mean that she does not have a valuable contribution to make to this. I am also pleased to see the noble Baroness, Lady Murphy, back in her place. I am glad that she managed to fly home from wherever it was to take part.

I thank the Minister and the Bill team for organising the briefing we had last week. It was a packed meeting—and quite hot, it has to be said—and it showed the level of interest that there is in this small Bill. I also thank the many organisations and individuals that have sent us their briefs and their views on the Bill, and which are, at this moment, working to see how it might be best improved—Mencap, the LGA ADSS, Age UK, VoiceAbility, Sense, Alzheimer’s Society, the Royal College of Psychiatrists and the Royal College of Speech and Language Therapists, a doctor from Cardiff University called Lucy Series, who sent me an excellent brief, the National Autistic Society and so on.

This might be a small Bill, but it is one with potentially enormous consequences. It demands proper parliamentary scrutiny and, where necessary, amendments that will make it fit for purpose on its own terms. Anything short of this will be selling short the human rights of many thousands of vulnerable people in our country. As yet, like the noble Baroness, Lady Jolly, I am not confident that the Government have made enough time available for proper consideration of this important piece of legislation. We have experts in these matters in this House. I was witness to and a participant in these discussions—not key to them, as the noble Baroness, Lady Barker, was, but I was here—and I know from those debates how complex a challenge these matters are and that it is an issue that at the same time begs absolute clarity to serve justice for our most vulnerable fellow citizens.

I hope the Minister and the Bill team will know that we will be pressing for more time to be made available and that we will be doing it with all our support. Apart from anything else, the Minister needs to address the suspicion, which I have heard whispered, that the Government are seeking to hurry or bounce this Bill through the Lords in the summer to try to avoid the detailed and essential scrutiny that it deserves and that it would receive here. I am sure that that cannot be the case, but more time would probably dispel that terrible rumour.

As we can see, the Mental Capacity (Amendment) Bill amends the Mental Capacity Act to replace the DoLS framework, which, as noble Lords know, authorises the deprivation of liberty of people who lack the mental capacity to consent to their care arrangements in hospitals, care homes or other settings. Quite rightly, DoLS has been widely criticised as excessively complex and bureaucratic, as highlighted by the noble Baroness, Lady Barran, and by the noble and learned Lord, Lord Brown, in his great speech. I was shocked to learn that 70% are behind time. That speaks for itself. Also it is costly and offers inadequate protection for human rights.

Following the Supreme Court’s ruling on Cheshire West, which offered a broader definition of the deprivation of liberty, there are now some 230,000 applications for the authorisation of DoLS in England and Wales each year—I keep hearing different figures and I am rather confused, but it is an enormous number and there is a huge backlog. Local authorities are unable to keep up with the volume of applications, leaving them, in the words of the Joint Committee on Human Rights,

“having to work out how best to break the law”.

So it is costing a huge amount of public money, that is rising, and it is not doing its job.

So this is undoubtedly a timely piece of legislation; notwithstanding some of the reservations that some noble Lords have about this, I am fairly convinced that this is an urgent matter. The question we have to address here in your Lordships’ House is whether the Bill will do the job it is asked to do.

The Law Commission was asked to review the framework between 2015 and 2017. It consulted widely and came up with the new framework, the liberty protection safeguards, which offer more flexible and less bureaucratic means of authorising deprivation of liberty, channelling resources into situations where there are conflicts or concerns about a person’s care arrangements. It also included proposed amendments to the MCA’s best interest test, highlighted by my noble friend Lord Touhig and the noble Baroness, Lady Murphy, among others, and to promote supported decision-making to bring the MCA closer in line with the requirements of the United Nations Convention on the Rights of Persons with Disabilities.

The Law Commissioner, Nicholas Paines QC, said—and the Minister quoted him—that the deprivation of liberty safeguards are failing those they were set up to protect. He went on to say:

“We’re pleased the government agrees and we stand ready to work with them to implement these reforms as soon as possible”.


I have read the Government’s response to the Law Commission report, and it seems to accept the majority of recommendations contained—it is a 24-page document and I had some time at the weekend. However, the Bill we have before us today, while having the same title as the Law Commission’s proposed scheme, appears to have removed most or some of the important safeguards it proposed, as other noble Lords mentioned. That raises some serious questions, starting with whether the Bill complies with Article 5 of the European Convention on Human Rights and whether it moves the UK further away from compliance with the CRPD, instead of closer towards it. The Bill has major implications for the human rights of hundreds of thousands of people with dementia, learning disabilities, brain injury and mental health problems.

I am disappointed that there is no accompanying equality impact assessment. Paragraphs 16.1 and 16.2 of the impact assessment refer to equality matters. Basically, what they say is that there is no need for an equality impact assessment because,

“the new system will have beneficial impacts for older and disabled people”.

Surely that is a matter for examination, not something one can assume, particularly when we look at Article 5 of the European Convention on Human Rights. It seems to me that, if that is being diluted, it is very important that we have a proper, independent equality impact assessment, so I ask whether that can be supplied.

Noble Lords have raised many other questions during this debate. How does the Bill ensure that the cared-for person and those representing them have access to the information they need to understand and exercise their rights? Do the Government plan to secure the right of the cared-for person to participate in court proceedings concerning their liberty? Should the modern legislation—this was raised by many noble Lords—include outdated and stigmatising concepts such as unsoundness of mind? The noble Baroness, Lady Browning, is completely correct when she says that the Bournewood gap has not been plugged: I absolutely agree with her remarks on that. Why have the Government not taken forward the Law Commission’s proposals to bring the MCA closer in line with the United Nations CRPD? Why have the Government not chosen to require a written record of serious decisions that can be made under Section 5 of the Mental Capacity Act 2005 or introduce stronger procedural safeguards?

Perhaps one of the most significant proposals in the Bill is that care homes assume very significant new responsibilities for the undertaking and co-ordinating of assessments, and provide information about residents who may lack mental capacity to statutory bodies. The very helpful local authority DoLS co-ordinator who has written to several noble Lords says:

“I receive application forms from care homes, train care home staff and give advice about DoLS and MCA issues. Based on these experiences, I have concerns that at present, despite honourable exceptions, care home staff do not routinely have the knowledge and skills to assess mental capacity and consider whether restrictions are proportionate”.


We need to listen to his experience, as the noble Baronesses, Lady Finlay and Lady Hollins, highlighted. We need to ask what the mandatory training is going to be. The noble Baroness, Lady Hollins, is completely right: half a day is not sufficient.

Finally, a major recommendation of the Joint Committee on Human Rights is that there must be a statutory definition of what constitutes a deprivation of liberty in this context, but the Bill does not provide such a definition. The Bill team and the Minister have emphasised their consultation process and the organisations that support the Bill. The noble Baroness, Lady Jolly, referred to these. I am sure that is true. However, my inbox, like that of many noble Lords, is full of briefings which have serious concerns about the Bill. Our job in the coming period is to ensure that those are examined. Some clear themes of concern have been mentioned by noble Lords all the way through the debate. The Minister has two choices: either he can engage with the expertise and work with us all to improve the Bill, or he and the Bill team—I hesitate to use the example of the noble Lord, Lord Callanan—could dig their heels in and resist change to their small and perfectly formed Bill. I would counsel the former path.

NHS: Equitable Access

Baroness Thornton Excerpts

Thursday 5th July 2018 Lords Chamber

Asked by

[Baroness Thornton]

To ask Her Majesty’s Government what steps they will take to ensure that National Health Service patients have equitable access to the benefits of (1) artificial intelligence, (2) genomic medicine, (3) new drugs, and (4) innovative treatments.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O'Shaughnessy) (Con)]

My Lords, the NHS was founded on the principle of universal access and we are committed to making sure that that remains. To achieve this we are establishing a genomic medicine service to provide equitable access to testing across the NHS. We have commissioned the Topol review so that our staff can maximise patient benefits from technological advances and we are accelerating access to innovation across the country by expanding the role of academic health science networks.

[Baroness Thornton (Lab)]

My Lords, happy birthday to our NHS.

[Noble Lords]

Hear, hear!

[Baroness Thornton]

I thank the Minister for his detailed Answer. My Question concerns the future in the next 70 years. One of the key barriers to ensuring that NHS patients have equitable access to genomic medicine, new drugs and innovative treatment is the pressure on the workforce and lack of protected time for the workforce to develop research and to translate new research into practice. Some 25% of medics do research in their own time. This suggests a welcome hunger for innovation, but only 0.1% of NHS money is set aside for the adoption and spread of innovation. That seems modest. With the new funding agreement and the 10-year plan in preparation, will the Government support and enable our research base and ensure the continuation of clinical trials across the EU post Brexit?

[Lord O'Shaughnessy]

I thank the noble Baroness for her Question and join the whole House in wishing many happy returns to the NHS on its 70th birthday. She asked an extremely good question: how do we make sure that the NHS is equipped for the future and that everybody can benefit from the technological advances we are seeing take place? I point her in the direction of three issues. First, the National Institute for Health Research has more than £1 billion of funding and supports the translation of research into new technology every day. It is based in the NHS and uses NHS staff. I have also recently commissioned the department to look at the money spent on innovation, which we think is around £750 million in total, to make sure that it supports the uptake of effective medicines and treatments better than it does today, and to make sure that staff have time. Finally, in response to her last question, as we set out during the passage of the withdrawal Act, we will align ourselves to the clinical trials regulation as much as possible, whatever the outcome of Brexit.

Brexit: Reciprocal Healthcare (European Union Committee Report)

Baroness Thornton Excerpts

Tuesday 3rd July 2018 Lords Chamber

[Baroness Thornton (Lab)]

My Lords, I join other noble Lords in congratulating the EU committee on its report Brexit: Reciprocal Healthcare. I suspect it was no accident that the committee turned its attention to this matter early on in its considerations about the effects of Brexit. I congratulate the Government on turning around their response in three months. This is better than the last healthcare response, which took a year, so we should be pleased and congratulate the Minister. I thank the BMA and the Nuffield Trust for providing the most up-to-date information.

I proposed and supported amendments on these matters during the passage of the Brexit Bill most recently considered, so I looked at the record to see how it compared with the answers that the Government have given. I spotted some advances but, I am afraid, not many.

In preparing for this debate, I learned from IPSOS Mori that Brexit has now joined the NHS as the top two issues the public are most concerned with—for 46% and 44% of people respectively. Today we have a confluence; it seems that as time goes on, millions may be justified in their anxiety about both Brexit and health. We heard, as several noble Lords have mentioned —including the noble Lord, Lord Balfe, and the noble Baroness, Lady Janke—that the head of NHS England is preparing plans for the supply of medicines in the event that the UK crashes out of the EU without a deal. I suppose the first question, as reflected in this report, is what happens after the implementation period? What planning is being done for a no-deal scenario for reciprocal healthcare? Indeed, the noble Lord, Lord Ricketts, mentioned the human cost of that.

Two years for implementation is not so long. Just think how the last two years have flown since the Brexit vote, with so little progress. It is, of course, important, as other noble Lords have mentioned, that the negotiations so far have enabled the Government to achieve their aims for reciprocal healthcare in the first and implementation phases of negotiations. These include access to the European health insurance card for those visiting the EU on exit day and continued access to the S1 scheme for existing retirees living abroad. But does the Minister agree that the next phase of negotiations needs to secure ongoing access to EHIC and reciprocal healthcare arrangements, either through retention, or comparable replacement of existing reciprocal healthcare arrangements with the EU after Brexit?

Some 27 million people hold a UK-issued European health insurance card and 190,000 UK pensioners living elsewhere in the EU are registered to the S1 scheme. The Nuffield Trust has calculated that, if the 190,000 UK state pensioners signed up to the S1 scheme and, living within the EU, needed to return the UK to receive care, it would incur additional costs to health services of between £500 million and £1 billion per year.

This simultaneous increase in cost and demand would place even greater strain on the UK health and social care sector. There is some anecdotal evidence that indeed people are returning from France, Spain and elsewhere since the Brexit vote and the ensuing lack of assurance and clarity. Are the Government monitoring the numbers who are coming home already?

As reflected in this report, ending reciprocal arrangements may also require the application of existing cost recovery methods for non-EEA patients to EU and EEA patients in the UK, or the development of a new, alternative system. This could increase the complexity of the cost recovery process, so well described by the noble Lord, Lord Balfe, as well as the administrative burden on clinical staff. Does the Minister agree with the BMA’s long-standing position that doctors and clinical staff should be able to devote their attention to treating patients and not to recovering the cost of care?

If the UK loses access to these arrangements, or fails to agree comparable alternatives, it could severely impact on the healthcare arrangements of UK and EU nationals and place additional strain on our already stretched NHS. Healthcare affects all of us who travel, work and live in Europe and, just as we might legitimately expect post-Brexit that we can take for granted the supply of the most up-to-date, clinically approved medicine and remedies, we expect to continue to travel and work all over Europe and for our healthcare to be assured, without having to take out insurance. On a scale of 1 to 10, with 10 being the most likely, what is the Minister’s best estimate of this being the case post the implementation period?

The ease with which people can continue to do what they are used to doing is what will colour how people will judge whether Brexit is succeeding and whether it has been worth while. In many ways, the most important recommendations in this admirable report, most of which I agree with, are those which concern clarity and transparency. Recommendations 5 and 6 concern free movement, and recommendation 11 asks if reciprocal healthcare will be included in the objectives set out by the Government, which we hope will emerge in a White Paper, with white smoke, some time next week.

This paragraph also concerns our children and grandchildren and their ability to work across Europe, which will be curtailed, as was so well explained by the noble Lord, Lord Jay. He said we have a long way to go and he is absolutely correct. The problem is, we have a long way to go but we do not have a great deal of time. I thank noble Lords for their usual high-quality contributions and I look forward to the Minister’s reply.

Health: Endoscopy and Bowel Cancer

Baroness Thornton Excerpts

Monday 2nd July 2018 Lords Chamber

[Lord O'Shaughnessy]

The noble Baroness is right to highlight the importance of waiting times. The 62-day standard is unfortunately not being hit at the moment. The NHS has pledged to get back on that standard this year. We are also piloting a faster, 28-day diagnosis standard in five areas at the moment with the idea of rolling that out so that there is a higher standard of care and fewer people have to wait longer.

[Baroness Thornton (Lab)]

We should probably be grateful that the Minister did not choose to bring a FIT as a visual aid, as his honourable friend did on the “Andrew Marr Show” yesterday. I welcome the Government’s announcement that that test will be in introduced in England in the autumn, but will the Minister confirm that all eligible people will receive the FIT kit in the autumn rather than through a phased introduction across England? How long will that take?

[Lord O’Shaughnessy]

I will not be rummaging around in my pocket to reveal something; nobody wants to see that. My understanding is that FIT will be introduced from the autumn and the intention is to get national coverage. I do not believe that it will be achieved immediately, but I will write to the noble Baroness with the specific timeframe.

Nursing and Midwifery (Amendment) Order 2018

Baroness Thornton Excerpts

Monday 25th June 2018 Lords Chamber

[Baroness Thornton (Lab)]

I thank the Minister for his excellent explanation of this order, which provides the Nursing and Midwifery Council with the necessary legal powers to regulate the nursing associate profession. On these Benches, we will be supporting the order, and I thank the Nursing and Midwifery Council and the RCN for their excellent briefs.

We are ready to accept that the creation of nursing associates is a welcome addition to building capacity. Some of us who are long in the tooth—there may be one or two in the House today—will remember SRNs and SENs and wonder whether we have gone full circle to move forward. However, I accept that there is some urgency to get this on the statute book because, initially, 2,000 nursing associates were training at 35 Health Education England test sites, with a further 5,000 starts planned for this year. The first nursing associates will qualify to apply for registration with the NMC from January 2019, so I accept the urgency to implement this order.

The Minister says that the nursing associate role is a defined care role to act as a bridge between unregulated healthcare assistants and the registered nursing workforce. Now that that role has been created, we agree with the Royal College of Nursing that,

“there must be absolute clarity that the nursing associate … is not a separate profession, but a new role within the nursing family that works under the delegation of the Registered Nurse”.

It went on to ask for “urgent guidance” to be published on “the precise relationship between” nurse associates and registered nurses,

“in terms of delegation and accountability”.

I hope that the Minister has taken that on board.

It is important to recognise that this new role is not the answer to the huge workforce challenges faced by the NHS and the social care system. Last week when the Government announced their funding proposals for the NHS, and the creation of a 10-year plan, many noble Lords said—we agreed—that it would be meaningless if this does not cover healthcare workers and social care workers together, given their importance in the future of our healthcare and social care system. Given that Health Education England has had its budget slashed, that we have a huge decrease in healthcare workers from the European Union, and the soon-to-be-removed—I hope—ridiculous visa system for non-EU health workers, the fact is that more nurses are leaving the profession than joining it, and there is a demographic challenge in that one in three nurses is due to retire in the next decade. In that context there is a well-founded anxiety that nursing associates could be used as a substitute for registered nurses.

Also in that context, has this new role been thought through, or is it a quick response to nursing shortages, with unfilled nursing posts which, as we know, are at a record high? Linked to that, how do we ensure that this new role does not impact negatively on the social care workforce? The head of Health Education England has highlighted that problem.

The role of a nursing associate was created before this SI was even introduced. Has there been enough time to consider the standards and levels of training for nursing associates to be registered with the NMC? I have to say that I am comforted by two things. One is the comprehensive brief from the NMC which suggests that it is on top of this, and indeed the notes accompanying the amendment order itself. I want to raise two things with the Minister, which are on page 5 of the accompanying notes and concern the cost-benefit impact analysis and the regulation of the nursing associates. Two risks are identified:

“First, there is a financial risk that the agreed initial set up costs escalate beyond those currently agreed with NMC. Second, the unquantified costs mentioned above relating to setting up and/or amending existing nursing associate courses as well as the accreditation of education providers”.


Those risks need to be mitigated before this moves forward in an orderly fashion. Finally, I think that there is provision in the order to take account of European Economic Area nursing associates, but I understand that this is not a uniform description or role that fits the narrative across the board. Will the Minister also comment on that?

[Lord Willis of Knaresborough (LD)]

My Lords, I rise from the second Bench—I am not quite trusted to be on the front yet—

Childhood Obesity Strategy

Baroness Thornton Excerpts

Monday 25th June 2018 Lords Chamber

[Baroness Thornton (Lab)]

I thank the Minister for repeating the Statement. The last time we discussed childhood obesity in your Lordships’ House it centred on chapter 1 of the Government’s policy, which scored a C-minus at best among noble Lords. Today we have chapter 2, which we can probably score as a C. It offers 13 consultations, a review and a great deal of promotion.

My questions are as follows. First, does the Minister believe it is possible for voluntarism to deliver even in the generous time the Government have given themselves to reduce childhood obesity? For example, Alpro soya growing-up milk contains unnecessary fructose and sugar, but the packaging will tell you it is good for your child, particularly if your child is lactose intolerant, where there are fewer choices. Will that be on the noble Lord’s agenda for legislation or persuasion, and what would be the timeline? Secondly, given that the evidence is clear, why does the Statement not include a proposal and a timetable for legislation and regulation to ban the advertising of high fat and sugar content products on TV and social media? When will we see a draft Bill?