Care Bill [HL]

Baroness Tyler of Enfield Excerpts

Tuesday 21st May 2013 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I start by saying how very strongly I welcome this Bill, which I also see as a landmark piece of legislation, addressing one of the key social policy issues of our time. After decades of putting this issue in the “too difficult to deal with” box, and with earlier reports gathering dust on shelves, this Government, in very difficult economic times, are finally establishing the architecture which will allow for the capping of catastrophic social care costs—something that has created fear for many families up and down the country. Many people deserve credit for getting the Bill to this stage—including, of course, my noble friend the Minister—but I, too, particularly want to pay tribute to the outstanding work and tenacity of my honourable friends Paul Burstow and Norman Lamb in getting both the policy and the legislation to this stage.

I see this legislation—and the surrounding guidance and regulations—as having the ability and potential to transform the lives of many of our fellow citizens for the better. All my other remarks will be made within this context and reflect my wish to strengthen the Bill still further. Also, I will focus in particular on issues affecting carers, who contribute so much to their loved ones, families and to society, but who too often go unnoticed and unvalued. However, I do not claim to do so with anything like the same degree of expertise as that of the noble Baroness, Lady Pitkeathley.

There is much to welcome in the Bill and the recent changes which have been made as a result of the excellent pre-legislative scrutiny undertaken by the Joint Committee mean that it offers an ambitious and positive vision for the future of social care. It is also an important consolidation of the existing social care law. It introduces for the first time new rights for carers, giving them the same rights to assessment and care services from local authorities as those they care for, which is something that I welcome. However, as so many others have said both in this House and outside, much of this will hang on the amount of funding that is available for social care, a matter that I suspect we will return to time and again.

I would like to highlight the following key provisions. I turn first to the new well-being principle, which is something that I strongly support, in particular the fact that carers are now covered by this important duty. Secondly, the new requirement on local authorities to ensure that there are sufficient care and support services to meet current and future needs is absolutely critical. Thirdly, we have the introduction of a national eligibility threshold for care services, alongside a new assessment process and eligibility criteria. This will make the way people are treated when they apply for care more equitable and easy to understand, including when they move away to different parts of the country. Fourthly, at the heart of the Bill are paving clauses to allow for the introduction of regulations setting out the level of the cap on social care costs and changes to the care means test. This is of course the architecture, and there will be plenty of debate to come on the appropriate level of that cap. While I very much welcome the increased level of the care means test, which has already been announced, I hope that as the economy improves and more resources become available, it will be possible to reduce the level of the cap to something more akin to that suggested by Andrew Dilnot. Finally, there is to be a duty on local authorities to provide information and advice, again with the explicit inclusion of carers. This is important as currently far too many carers feel that they have missed out on financial support as a result of not getting the right information and advice early enough.

During the passage of the Bill I will want to focus on four particular areas, and I shall say something briefly about them now. I turn first to well-being. As I say, I am a strong supporter of the well-being principle underpinning everything that happens in social care, but like the Joint Committee and other noble Lords who have already spoken, I would like to see it extended to the Secretary of State so that the whole pack of cards is fully aligned. We hear much, quite rightly, about the importance of horizontal integration between health, social care, housing and other services. In my view, what I would call vertical integration within the care system is equally important, and I will be pressing for this to be incorporated in the Bill.

The second area is that of dignity. In recent times, we have seen and heard of shocking failures in the care of older people across both the health and the social care sectors. Moving forward, we need to see a major cultural shift to ensure that dignity is embedded in everything that happens, along with a positive attitude to ageing and working with older people, a point that the recent report on ageing from the Lords Select Committee on Public Service and Demographic Change, of which I had the privilege and pleasure to be a member, made loud and clear. Public confidence in the current social care sector’s ability to treat people with dignity is very low. A recent survey showed that only 26% of the public are confident that older people receiving social care are treated with dignity. We have a great opportunity here. The Care Bill could, for the first time, embed dignity in legislation as a core element of the well-being principle, thus placing it alongside other crucial aspects of well-being such as physical and mental health, and family and personal relationships.

I also want to add my voice to a pressing issue that unfortunately has gone largely unnoticed in recent legislation and to which others have already referred. Both the Care Bill and the Children and Families Bill represent commendable and critical efforts to improve the lives and enhance the rights of many people, but sadly, a particularly vulnerable group appears to have slipped through the gap between these two Bills. It remains mired in complex legislation and disadvantaged by limited rights. This group is young carers.

The 2011 census identified 178,000 young carers in England and Wales alone and a further survey taken by the BBC in 2010 estimated the number to be more like 700,000, with as many as 8% of secondary-school children providing moderate to extensive care. As a group, young carers are infamously hard to identify and evidence suggests that in many cases the carer tries to keep this part of their life secret. But although they may often be invisible, young carers and their rights are in serious need of attention. Evidence suggests that young carers are often rightfully proud of their roles and the invaluable contributions they make to their families and the lives of those close to them, but that does not mean that they do not encounter serious difficulties and disadvantages—a point made so eloquently by my noble and learned friend Lord Mackay of Clashfern. So while young carers work to look after the needs of another person, the system must work to protect them and their rights and well-being.

A very welcome aspect of the new adult carers’ right is that it strips away the requirement for adult carers to have to establish that they are providing both regular and substantial care, placing a duty on adult services departments to provide services to meet the assessed needs of adult carers. Young carers, on the other hand, have been left with what has been described as,

“a mishmash of relic semi-serviceable carers’ Acts”.

In certain cases young carers will be required to establish that they are providing regular and substantial care with higher thresholds than for adult carers. In other cases young carers will have to demonstrate that they are in a household that is receiving services, and even then will have only a discretionary entitlement to support. When scrutinising the legislation, the Joint Committee called for amendments to ensure that young carers get equal rights to assessments and support in law, both in this Bill and the Children and Families Bill currently before Parliament. In response the Government have made some limited changes aimed at easing the transition between adult and children services, both for young people receiving care and for young carers, and they are welcome. But these changes do not change the fact that young carers will have lesser rights to assessment and support than adult carers caring for adults. Nor does it go far enough in placing a responsibility on adult social care services to prevent inappropriate caring by children—something which I would like to see clearly included in the Bill.

To summarise, both the Care Bill and the Children and Families Bill present an important opportunity to simplify and clarify the law for young carers, to provide a clear interface between the two pieces of legislation and to ensure that young carers are not left with unequal rights compared with adult carers. It is imperative that the Government urgently address this rights imbalance in an even-handed way. I ask the Minister to give assurances that the Government will look at the issues I have highlighted in a fully joined-up way to ensure that all carers receive the same legal rights to assessment and support.

NHS: Mid Staffordshire NHS Foundation Trust

Baroness Tyler of Enfield Excerpts

Monday 11th March 2013 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I also pay tribute to the noble Lord, Lord Patel, for raising this critical issue. What happened at Mid Staffs was a terrible violation of the trust that the public invest in our NHS. Appalling accounts of patients being left to lie in soiled sheets for long periods of time, unable to reach their water or feed themselves, and being denied privacy and dignity even in death, reveal a frightening gulf between what we have the right to expect from our NHS and what patients there were exposed to. What underpins this disgraceful treatment of patients is the failure of the Mid Staffs foundation trust board which, in Robert Francis’s words,

“failed to tackle an insidious negative culture involving a tolerance of poor standards and disengagement from managerial and leadership responsibilities”.

Focusing on finance, figures and top-down operational targets, the trust board neglected its patients’ well-being and overlooked its most basic duty. In the short time available I would like to focus on the issue of governance and the critical role that it plays in bringing about the change in culture so desperately needed.

First, to outline very briefly the failings of the trust and the trust board, despite clear warning signs, the board and other trust members did not take in the severity of what was happening and gave little attention to the concerns coming from patients and staff. On top of a poor complaints system, those in charge ignored issues and were slow to react to matters, if they reacted at all. According to the report—I find this one of the most damning and chilling phrases—the trust’s culture was one of,

“self-promotion rather than critical analysis and openness”.

The perverse values and priorities of the senior leadership resonated throughout the organisation, generating a culture characterised by a lack of openness to criticism, a lack of consideration for patients and defensiveness.

The trust board and trust members had a responsibility to cultivate and uphold a positive culture that places patient care, high clinical standards and quality of practice as paramount priorities. Their blatant failure to do so is a clear signal that action must be taken and I give my full support to the recommendations in the Francis report. In particular, I highlight the importance of ensuring that governors receive proper training and guidance in their roles, with greater emphasis on their personal accountability. Quality accounts, which Francis talks about, with complete and accurate information on a trust’s level of compliance with the fundamental and enhanced standards of care should be made openly available on its website, be audited by the CQC and be accompanied by a signed declaration of all directors certifying the accounts’ validity.

I will draw very briefly on my own experience of chairing a public body. What I have learnt to be critical to effective corporate governance is that all board members should go out, be curious, ask questions and above all listen. All board members should go out on visits, talk directly to front-line practitioners without the management being present, ask to see service-user feedback, and ask what has been done about the issues raised which fall short of expected standards. The board recently reviewed all the service-user feedback to assess its adequacy, and looked at all the complaints, their nature as well as their number, how they were dealt with and how they were being fed in to a cycle of continuous improvement. I make this point simply to emphasise that this is not an add-on or a nice to-do. This is at the very heart of effective corporate governance. An interesting article from the King’s Fund, which was published just before the Francis inquiry report, looked at the way in which boards operate in the NHS. It concluded that behaviour in the boardroom is key to the effective management of quality.

It is only through efforts to create an open, transparent and accountable system of governance that a sustainable and fundamental change in culture will come about. I urge the Government to accept the report’s recommendations, and to take urgent action to instigate these much needed changes.

Health: Hearing Loss

Baroness Tyler of Enfield Excerpts

Monday 17th December 2012 Lords Chamber

[Earl Howe]

My Lords, I am sure the Health and Safety Executive will take my noble friend’s comments to heart.

[Baroness Tyler of Enfield]

My Lords, given the prevalence of hearing loss among our ageing population, will the Minister say what is being done to ensure that hearing loss is being effectively managed in residential care homes for the elderly? What steps are the Government taking to work with the regulator to ensure that providers are being held accountable for responding to the needs of people with hearing loss?

[Earl Howe]

My noble friend raises a very important point about care homes. There have been considerable improvements in services for people with hearing loss over recent years. The waiting times for assessment and treatment for hearing problems in adults have been considerably reduced. The health and social care reforms provide opportunities to improve services further. For example, two-thirds of PCT clusters have chosen adult community hearing assessment services as a priority area in which to extend patient choice of provider. We expect that work to continue when CCGs take over.

Social Care

Baroness Tyler of Enfield Excerpts

Thursday 29th November 2012 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I add my congratulations to the noble Baroness, Lady Pitkeathley, on being such an excellent and enduring champion in this area. I view the issue of how adult social care is provided to vulnerable elderly people and to those with disabilities as the pre-eminent social issue facing this country.

Integration has been a buzzword around health and care services for a long time. Overcoming the entrenched divisions between health, social care, housing and wider services is indeed a major challenge, particularly with the great financial pressures that we are currently under, which is very much the focus of this debate. It is important that we are realistic about some of the barriers faced, which include cultural barriers as well as those to do with separate funding and planning systems and separate workforce training—I could go on. We probably all agree that making a reality of integrated care is now an absolute imperative.

I talked about the need for realism. Despite what has been described as its optimistic modelling, the LGA’s funding outlook report confronts us with some pretty brutal figures, such as a £16.5 billion shortfall in funding by 2020. Of course these kinds of savings cannot come from efficiency alone. In my view, it will require a fundamental and system-wide reform. I am also clear that more money is needed. The Barnet graph of doom has been very effective in placing a spotlight on the very real dilemmas faced by local authorities; but equally, it must not lead to a complete counsel of despair. Through well co-ordinated services that look to prevention as well as crisis response, it should be possible to make some contribution to the efficiencies needed and certainly to achieve greater cost-effectiveness, for example by reducing emergency admissions or readmissions and by speeding up discharge from hospital to the community. Integrated care can no longer be reserved as somewhere for rhetoric but has to become a reality. How do we actually do that? The most important thing is getting the right financial incentives in the system, both nationally and locally.

The additional money that was announced in the last spending review for social care was welcome. I am well aware that £1 billion of that was redeployed from the NHS. However, the evidence that we have seen so far says that too often that money has to be used to offset budget cuts and to meet changing demographic needs rather than to promote integration. Ultimately, real progress should focus on aligning the whole of the £121 billion currently spent on health and social care around the needs of individuals, particularly by pooling some of the local budgets, and having shared budgets and a much more strategic assessment of the funding needs in the round.

I have talked about joining up statutory services, which I think is key, but I also want to draw the attention of the House today to the value and potential of our voluntary sector in tackling some of the important problems of isolation and loneliness, which have already been referred to by other noble Lords. If you ask older people which local services make the biggest difference to their lives, they point to lunch clubs, keep-fit classes and day centres. It is often through organised group activities that many older people keep active, make friends and stay engaged with the world around them. We know that problems of isolation and loneliness are not just emotional—they have a very real impact on people’s physical and mental health. Research shows that loneliness can increase the risk of heart disease, blood clots and dementia, and that it encourages people to exercise less, drink more and avoid going out. It can also mean that people are more likely to undergo early admission into residential or nursing care. The introduction of a new loneliness measure as part of the adult social care initiative is therefore a very welcome move. But how is this going to be achieved in practice? I would be very grateful if the Minister could explain the thinking in this area.

For many who take part, volunteer-led local services are rare, even unique, opportunities for social interaction in a friendly and supportive environment. By creating networks of people who are looking out for one another, local services can generate vital sources of informal care, with benefits which resonate across the health and social care services. Instead of an older person’s health deteriorating without anyone noticing before a crisis happens, these services can prompt earlier intervention and help prevent problems escalating.

Sadly, these schemes and activities often do not get the support that they need. Alongside the tightened local authority budgets about which we have heard quite a lot today, the emphasis on personalisation is inadvertently taking its toll on some such voluntary sector services. As we have heard today—not least from my noble friend Lady Barker—personalisation is a perfectly good principle and has many benefits, but it has also had some unintended results. Fragmented amounts of money are difficult to tack together and shared approaches can become much harder. So, yes, of course, we must start with the individual, but what that sometimes reveals is the importance of collective and inclusive approaches which benefit both the people involved and the public purse.

These services do not need to cost much. Largely dependent on local volunteers, such initiatives have got by up till now mainly on small grants from their local authorities. Age UK, which does so much vital work in this area, recently told me of a discussion with one director of social services whose first instinct had been to withdraw funding from her local daycare services provided by the voluntary sector to help make the books balance, but she then realised, when she looked at it more carefully, just what a cost-effective and crucial access point they offered. Not only did the service enable her to stay in touch with how the older people in her area were doing but it provided a platform for delivering key services.

As I said at the beginning of my speech, as funding is reined in, so the focus shifts to acute needs. Daycare services, under pressure to take on older people with illnesses such as dementia, become less suitable places for older people looking for a lower level care. Of course, it is no criticism of local authorities that, when resources are scarce and they are being reduced to their bare essentials, acute needs become the main focus.

I conclude by returning to the big picture. I chose to make the focus of my remarks today the often undervalued and underfunded contribution of the voluntary sector—it is dear to my heart—but the big picture is critical. As so many other noble Lords have said, there are two key issues for the Government to address: first, the current funding gap for social care and, secondly, the need to implement a long-term, sustainable funding settlement for social care. On the former, without further action on funding, even the basic and too often inadequate social care currently provided will no longer be available from local authority-funded care. On the longer-term issue, there is a wide consensus, which I strongly share, that the Dilnot proposals are the most credible and practical solution. Difficult as it is in the current financial climate, the Government must make a firm commitment in the next spending review to implement Dilnot. The time for talk and deliberation is over; it is now time for action.

NHS: Mental Health Services

Baroness Tyler of Enfield Excerpts

Monday 8th October 2012 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, it is always daunting to follow someone as eminent as the noble Lord, Lord Layard, in a debate on mental health, but that is what I will seek to do.

Like many other noble Lords this evening, I very much welcomed the Government’s mental health strategy, No Health Without Mental Health, which gave clear priority to a long-neglected area of health policy. The implementation framework for that strategy, which was published earlier this year, was equally welcome in ensuring that the strategy did not simply gather dust. Like my noble friend Lord Alderdice, I greatly welcome the £400 million that the Government have invested in improving access to psychological therapies—IAPT—as a key plank of the strategy.

While I am pleased that the NHS Commissioning Board has endorsed the framework, it is also vital that the board makes the implementation of the strategy one of its key priorities. Like the noble Lord, Lord Layard, I think that means that it should feature prominently in the commissioning board’s mandate and the NHS outcomes framework. I ask the Minister to update, and I hope assure, the House on that point.

However, even that will not be enough to make a reality of improved mental health services for all. More is needed and I want to pick out three things. First, the forthcoming changes in the commissioning arrangements give the potential for a greater focus on early intervention. This means commissioners in CCGs and the national commissioning board having access to the right level of mental health expertise, both to assess mental health needs and to commission the right services to meet those needs.

Secondly, the Government have stated their intention to introduce payment by results for mental health services. The first step here is the long-awaited development of tariffs for mental health services. I know that those involved in the development of tariffs have expressed concerns about the lack of clear guidance from the Department of Health and in some cases poor data and inadequate IT systems at a local level. This does not augur well. I think that the sector as a whole recognises the challenges that payment by results represents for the whole mental health system, but can the Minister update the House on what additional support the department is making available in this complex area? Thirdly, with the expansion into mental health services of payment by results, we also need to ensure that the outcomes for which providers are paid fit with the objectives of the mental health strategy and are aligned with NICE’s work on quality standards. In other words, it must all join up.

We all know that mental ill health cannot be tackled by NHS mental health services alone. It is crucial that others—we have already heard about them this evening: local authorities, employment, housing, and criminal justice—play their part. The new health and well-being boards will be vital in helping local government, the NHS and others, including the voluntary sector, to tackle the causes of ill health at source. I look forward to seeing well-being services set up, which would include occupational health, housing, smoking cessation, fitness centres and mental health services working together for new attitudes towards public mental health.

Like others, I mentioned the importance of IAPT at the beginning of my speech, and I recognise that we have already heard some differing views on this tonight. While I am a great supporter of the concept of talking therapies, my view is that the current policy does not adequately or accurately reflect the importance of providing a range and choice of counselling and psychotherapy to meet a range of needs. I recognise and welcome the limited expansion of IAPT from purely CBT models to include other models such as couple therapy for treating anxiety and depression in cases where relationship problems are also a factor—either a cause or a consequence of the depression.

However, specialist providers, particularly those in the voluntary sector, have found it very difficult to navigate their way through an IAPT commissioning process that was clearly designed with the statutory sector in mind—a point that I thought was made very compellingly by the noble Lord, Lord Wills. I believe that counselling and psychotherapy play a vital role in promoting good mental health and well-being, and in the treatment of mental ill health. In my view, current government policy still does not sufficiently reflect the role that counselling and therapy can and do play. I would like to see more collaboration and joint working in this area.

Finally, I draw attention to the importance of improved mental health services for children and young people, for if mental health services have long been seen as the Cinderella of health services generally, surely children’s mental health services are the Cinderella of that Cinderella service. Yes, the role of the NHS is crucial here, but so too is the role of schools and the voluntary sector.

We all know of the parlous state of the NHS Child and Adolescent Mental Health Services, known as CAMHS. In a recent survey of providers and commissioners conducted by YoungMinds, over half of respondents said that they intended to reduce their spend this year. The biggest cuts were in local authorities, with some slashing up to 25% from their budgets. On a more positive note, some 20% said that they were planning to increase their funding for CAMHS. All this can only exacerbate the existing, very large variations in availability, quality and timely access to these vital services. On top of these, many voluntary sector services, as we have already heard, are having to cut back or close down.

I welcome the new bond initiative funded by the Department for Education to increase the availability, quality and young-person focus of early intervention services that address mental health issues earlier. However, this is currently a limited pilot in five local authority areas. Equally, I welcome the new children’s IAPT pilot, again in a small number of areas. I ask the Minister what plans the Government have for rolling this out more widely.

Touching on a point made by the noble Baroness, Lady Meacher, while thousands of young people in Wales and Northern Ireland benefit from national programmes of school-based counselling, England lags behind as the only country without a commitment to these services. This leaves many young people in England without effective and accessible therapeutic support in schools, despite the fact that counselling is associated with significant reductions in psychological stress. The Welsh Government’s national school-based strategy, which has been externally validated, has been shown to be an overwhelming success, so much so that the Welsh Government are planning to make counselling in Welsh secondary schools a statutory service. With the clear benefits that it has demonstrated in improving attendance, behaviour and attainment in schools, surely providing access to school counselling could be one good use of the pupil premium in England.

Why have I made such a great play of children and young people’s services? Research has shown that huge costs to the economy are associated with mental health problems, which all too often begin in childhood and continue into adulthood. Perhaps I may give noble Lords a few facts. Half of all lifetime mental illness presents by the age of 14, contributing to the vast economic and social costs of mental health problems. One in 10 children under the age of 15 has a diagnosable mental health disorder. Rates of mental health problems among children increase as they reach adolescence. Between one in 12 and one in 15 children and young people deliberately self-harms. More than half of all adults with mental health problems were diagnosed in childhood, but—this is the crux of the matter—fewer than half were treated appropriately at the time. According to the then Department for Children, Schools and Families in 2009, 60% of children in care have some form of mental health disorder. This is an astonishing figure that calls for an urgent response.

In summary, mental health problems obstruct many key goals for children. I would welcome the Minister saying what more the Government are doing to join up policy effectively, particularly between the Department of Health and the Department for Education, in order to address the mental health problems of children and young people. It is a no brainer that we must do this. It makes sense socially, economically and morally.

NHS: Spending Formula

Baroness Tyler of Enfield Excerpts

Tuesday 3rd July 2012 Lords Chamber

[Earl Howe]

My Lords, we come back to the issue of age in this context. I say again that we believe, as did the previous Government, that age is the primary driver of an individual’s need for health services. The very young and the elderly, whose populations are not evenly distributed throughout the country, tend to make more use of health services than the rest of the population—the noble Baroness gave a very graphic and important example of where that applies. This principle is reflected in the most recent PCT-weighted capitation formula. As I said earlier, there are imbalances that, over time, we will seek to correct.

[Baroness Tyler of Enfield]

My Lords, accepting that —as the Minister said—we are where we are, could he explain what evidence base is being used to determine the allocation of resources to CCGs?

[Earl Howe]

My Lords, the funding formula is made up of a number of components, including capitation, deprivation, age, the number of young people not staying in education and the number of people over 60 claiming pension credit. I have a long list in front of me. However, ACRA, the independent body that I mentioned, is composed of a group of independent-minded people who are keen to take into account every relevant factor that bears on this question. If my noble friend wishes, I will write to her with a more detailed list of the factors that historically have been in the formula.

Care Homes

Baroness Tyler of Enfield Excerpts

Monday 28th May 2012 Lords Chamber

[Earl Howe]

My Lords, as I made clear earlier, there is already a test for those people who are in charge of a care home. The CQC has procedures to verify the acceptable status of such people. Furthermore, there are very strict rules under the Financial Services Authority regulations, which require company directors to pass a “fit and proper person” test. We are not sure what added value might be conveyed by a further test, as the tests are already there.

[Baroness Tyler of Enfield]

My Lords, given the very great anxieties experienced by care home residents and their families on this issue, what steps are the Government taking now to prevent another Southern Cross situation arising, in both intelligence gathering and strengthening the regulation and oversight of the sector?

[Earl Howe]

My Lords, the Government are working with the Association of Directors of Adult Social Services and the Care Quality Commission. We are gathering greater intelligence on the social care market and its major providers, which will be used to give early warning of impending problems. We will continue to meet regularly with the major care providers to discuss their trading performance, their financial situation generally and how they are addressing any issues which put pressure on their ability to continue trading.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Monday 19th March 2012 Lords Chamber

[Earl Howe]

My Lords, I will speak also to Amendments 9 and 10. The three amendments in this group share a common purpose in strengthening the duties on the NHS Commissioning Board and CCGs in relation to reducing inequalities. I am grateful to my noble friend Lady Tyler for highlighting on Report the need to ensure this, and I promised at the time to introduce the necessary amendments at Third Reading to achieve it.

New sections 13G and 14T place duties on the NHS Commissioning Board and CCGs to have regard to the need to reduce inequalities between patients with respect to their ability to access health services, and to the outcomes achieved for them by the provision of health services. As the Bill stands, the NHS Commissioning Board and CCGs must assess in their annual reports how they have discharged this duty. However, they are not explicitly required to plan for this and, in the case of CCGs, not specifically assessed on this in the board’s annual performance assessments. These amendments introduce explicit requirements on these points. They require the board to include in its business plan, and CCGs to include in their annual commissioning plans, an explanation of how they intend to discharge their inequalities duties. I remind noble Lords that CCGs will consult on their commissioning plans with those for whom they are responsible, and must involve each relevant health and well-being board in preparing and revising their plans.

The amendments also require the board to specifically assess in its annual performance assessment of CCGs how they have discharged their inequalities duty. So CCGs will have to set out in their plans how they will take account of the need to reduce health inequalities and report on how they have done this in their annual reports, which is of course already a provision in the Bill. Their performance on this will then be one of the factors taken into account by the board when it assesses their performance. Together, these amendments ensure that from the development of the plans to the reporting on their effects, having regard to the need to reduce inequalities will be given particular emphasis and importance by commissioners. I beg to move.

[Baroness Tyler of Enfield]

My Lords, I shall speak to government Amendments 7, 9 and 10, to which my name is attached, and in so doing I thank the Minister for tabling them. As he has explained, they all relate to health inequalities; I would like briefly to place them into a wider context. In doing so, given that this is Third Reading, I make one general point. My view from the outset has been that this Bill should be judged ultimately by the health outcomes it produces—essentially, whether and how it improves people’s lives, particularly the most vulnerable. Because so much of the debate over the past year has—necessarily, I guess—been about structures, I sometimes feel that we have rather lost sight of this fundamental point. One specific point that has not received enough airspace in our deliberations, perhaps until today, is about reducing health inequalities—or, put another way, doing something real about unequal life chances. At the very outset, I felt that the fact that this legislation contains a landmark legal duty for the Secretary of State to reduce health inequalities was really significant.

As the noble Earl has explained, as the Bill has progressed through its various stages this duty has been strengthened at various levels in the new structure, so that reducing health inequalities now runs through the whole fabric of the health system in a way that we have not seen before. I will not repeat precisely what these amendments do, because they have been very ably set out. Briefly, however, in relation to the requirement that each CCG’s performance is assessed each year by the board and includes the progress made in reducing health inequalities, we all know that what gets measured gets done. That is what makes this significant.

However, we should not look at these specific duties in isolation from other key aspects of the Bill on accessibility and integration. New duties to join up services between health, social care and other local services, such as housing and homeless support, will have a crucial role to play here. The role of health and well-being boards in promoting joint commissioning should enable more integrated services, particularly, for example, for older people and people with learning disabilities. Finally, the much stronger focus on public health—I greatly welcome its return to local authorities—will be key to tackling issues such as obesity, smoking, drug and alcohol abuse and sexual health, which make a real difference in reducing health inequalities. This all adds up to a much stronger package than we have had before. Of course, the proof of the pudding will always be in the eating, but this very welcome shining of the spotlight on health inequalities has the potential to be a game-changer for some of the most vulnerable.

However, in case noble Lords think that I am being too uncritical, I finish on a point of concern. Local authorities are well placed to tackle inequalities, due to their responsibilities for education, housing and other factors which impact on health. The current proposition for holding councils to account for this is through what the Government call a health premium, to give extra money to those areas that reduce health inequalities. We need to be careful that this does not simply reward those areas where it is easiest to tackle inequalities and divert money away from areas where more fundamental problems may slow down progress.

In thanking the noble Earl most sincerely for tabling these amendments and paying tribute to his strong personal commitment on these issues, I respectfully ask him whether he will keep the health premium under review as it is rolled out.

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Thursday 8th March 2012 Lords Chamber

Moved by

[Baroness Tyler of Enfield]

234ZA: Clause 182, page 180, line 28, after “Commission);“ insert—
“(ga) making recommendations to that committee to publish reports under section 45B(3) of the Health and Social Care Act 2008 about particular matters;“

Health and Social Care Bill

Baroness Tyler of Enfield Excerpts

Wednesday 29th February 2012 Lords Chamber

[The Earl of Listowel]

My Lords, I support the amendment of my noble friend Lady Finlay of Llandaff. I noted what my noble friend Lady Murphy said. The Minister is aware that I have a long-standing concern about less-than-mainstream services for children and families, particularly in the mental health area. It became apparent several years ago when considering legislation around safeguarding children that there was a great shortage of appropriate interventions for children who sexually harmed other children. The approach was very piecemeal across the country. I became aware of a service working in London with these children. A team with a psychiatrist, a couple of clinical psychologists and a couple of social workers helped children who sexually harmed other children. Its interventions prevented those children going on to become adults who sexually harmed children. A large proportion of children who are sexually harmed are harmed by other children.

This is a very important service, and what I have heard again and again over the years was how the service had struggled to find funding. It appealed to its primary care trust, which simply did not recognise the importance and value of what it did. My concern is that, in a climate where there is such a shortage of resources, the national Commissioning Board may be too far away from these very small services in local areas. Therefore, it is important to do all that can be done to ensure that clinical commissioning groups have the expertise to recognise the value of these niche services and do what they can to support them. I look forward to the Minister's response and hope that he will comfort me.

[Baroness Tyler of Enfield]

My Lords, I rise briefly to support Amendments 75 and 94, tabled and spoken to so clearly by my noble friend Lady Williams of Crosby, which are very important. The nub of the amendments is that they are designed to address the problem that we know still exists of a limited number of people who are not on GPs’ lists and who, as has been said, fall through the cracks and often—inappropriately—turn up in accident and emergency units. I can verify this because on a recent weekend I spent 12 hours in accident and emergency with two of my relatives. During that time, time after time people came in with needs that were real but which it was not for A&E to meet. Problems with access lead to some of the inequalities in health outcomes about which we on all sides of the House are very concerned.

When considering the Bill recently, the Minister agreed to new duties to ensure that CCGs and the national Commissioning Board include in their annual report details of how they have met their health inequalities duties. I very much welcome these changes to the Bill, but I am not convinced that this reporting after the event is going to be sufficient to tackle some of these very deep-seated inequalities, which often lead directly from difficulties in access to NHS provision.

Will my noble friend the Minister consider giving some very real teeth to the absolute imperative, as I see it, of universal provision—an absolute founding principle of the NHS, which I know is supported across the House—and see whether these duties could be extended in some way so that CCGs and the board also need to include health inequalities and issues of access in their commissioning plans and in the board’s performance assessment of CCGs? I would be very grateful if the Minister could reflect on this in his concluding remarks.

[Baroness Masham of Ilton]

My Lords, I have added my name to Amendment 96. These patients can have very complex and varied needs. Will the Minister give an assurance that they will not fall through the net between the Commissioning Board and the CCGs? There will be a great need to have excellent communication between the Commissioning Board and the CCGs. There is concern, as has been shown here today—and if there is concern here, my goodness, what will be the problem outside when funds have to be found for these patients? I implore the Minister to sort this out.

--- Later in debate ---

[Lord Adebowale]

My Lords, I support the amendment moved by the noble Lord, Lord Patel. I am grateful to the noble Earl for the time that he generously gave to me and the noble Lord to meet him and the civil servants. However, I was disappointed by the letter that we received following the meeting. I thought that we had driven home the point and had some sympathy from the noble Earl. I understand the need to tidy up legislation, which is an important thing to do, but I find it faintly disgusting that we are going to mess up people's lives. The legislation might be neater but lives will be made much messier.

I have just come from Manchester—from Turning Point’s offices there; and I declare my interest as the chief executive of an organisation that will be directly affected by the Bill—where we have a case of an elderly lady who has been with us for 14 months, at a cost of well over £100,000. We cannot get the NHS to pay it because it claims that it is the responsibility of the local authority, whereas the local authority claims that it is the responsibility of the NHS. That is the reality under the current legislation, even with, as the noble Lord pointed out, the provisions of Section 117.

We are told that, in tidying up, the proposed provisions will allow people who are discharged from mental health institutions to seek a judicial review if they are refused aftercare arrangements in co-operation with health and social services. I was astonished to read that in the letter. I do not know what planet the writer of the letter is on but I would welcome them to join my planet and actually visit and speak to people who are discharged from these institutions, and to talk to their families and friends, and then to come back and tell me whether they are in a fit state to seek judicial reviews against local authorities and the NHS. We must be real when discussing legislation that will affect the lives of real people who may not sit in this Chamber but who will cost us a fortune if we do not get this right.

It is with a very heavy heart that I support the noble Lord, Lord Patel, in his amendment. I hope that, at this late stage, the Government will see the obvious logic. Even in their responses to previous amendments they said that they wished to support the joined-up provision of health and social care. What better example is there of such provision than Section 117 of the Mental Health Act? It is as obvious as gravity. So we must insist—not to make a political point or reference to the Bill, but on behalf of people not in this Chamber who will cost the country dearly if we do not get it right—that the Government accept the logic of the amendment and just say yes.

[Baroness Tyler of Enfield]

My Lords, I support this important amendment. The whole basis of the Health and Social Care Bill is to place great emphasis on delivering integrated care as part of the needed reforms, and I am sure that we all support that. As the noble Lord, Lord Adebowale, has just said, though, Clause 36 in its current form will remove one of the few examples of genuinely joined-up service provision between local health and social services. A joint duty on aftercare services for these people, some of the most vulnerable in society, is crucial if they are not to have further lapses and become more and more marginalised. We talked earlier about people falling between the cracks, and that is the danger that we are in.

[Baroness Northover]

My Lords, I realise that noble Lords want to move on to other debates, so it might be opportune if I intervene now. We have always expressed sympathy for what the noble Lord intended in his original amendment. We listened carefully to the points put by the noble Lords when they came to see us, even if it seemed that we were not very responsive to what they were saying. We note the considerable emphasis that they place on retaining the duty of co-operation with the voluntary sector that is set out in Section 117. We realise that the clause removes the duty that is currently there, and that is clearly causing concern.

We do not feel that there is anything in the clauses that will bring in charging for any NHS or social care services that are currently provided free under Section 117, and the Government have no plans to bring in measures that would change the position on charging for Section 117 services. However, sometimes tidying up causes concerns. We are all used to dealing with the section as it currently stands and could continue to do so. We are nothing if not a listening team. The Government have therefore decided, and I hope that the noble Lord, Lord Patel, will be pleased, that we will not oppose his amendment. In the light of this, if your Lordships’ House agrees and wishes to accept his amendment, the Government will need to bring forward a few technical amendments at Third Reading to make a few consequential changes to the Bill to ensure that the amendment works properly in the amended 1983 Act. I hope that the noble Lord will be pleased that indeed we heard what he and his noble friend were saying.