(11 years, 4 months ago)
Lords ChamberI rise to speak to my amendments in this group and to support the amendments of the noble Lord, Lord Patel, to which my name has been added.
I have tabled Amendments 93B, 100A and 104ZZA because I am concerned about the wording in Clauses 56 and 61, which may risk preventing the provision of services, and that the references to families and friends or others suggest a reliance on carers that is inconsistent with other provisions in the Bill and with the intention that a decision on eligible needs should be carer blind. That the provision should be carer blind is an important and welcome commitment by the Government in this part of the Bill.
My amendments seek to remove the reference to assessment of the capabilities of a child, a child carer and a young carer and the support that family members could provide to meet a child’s need for care in Clause 56, a parent’s need for support in Clause 58, and a young carer’s need for support in Clause 61. Similar amendments tabled by the noble Lord, Lord Hunt, were debated when we discussed Clauses 9 and 10.
The references to the capabilities of a child, a child carer or a young carer and any support likely to be available to the child from friends, family and others should be removed. There could be an undue reliance on family and friends to provide care and support, and voluntary support from family and friends will not be properly planned for or sustainable and will not be subject to checks or review. Family and friends may not be willing and able to provide support but there is a risk that they will be relied on regardless of their own wishes. There is no check in the law and there are no provisions for this in the legislation. Carers could easily be pressurised to provide care and the vital contribution that they make may not be recognised. Those of us who deal with carers all know how often they are pressurised, sometimes quite subtly. The implication is, for example, that they will have to give up their job in order to provide care for the particular person needing care.
I am also concerned, as a member of the Joint Select Committee, about Clauses 56, 58 and 61. They were not part of the consultation on the draft Bill and this is quite a substantial departure from the process set out in it and recommended by the Law Commission. The new parts which have been added to Clauses 56, 58 and 61 blur the distinction between consideration of needs and ways of meeting needs, other than through services at the stage of assessment, before any decision about whether the child, child carer or young carer have eligible needs. The assessment process should show what the needs for care and support are before consideration is given to how those needs will be met.
Carers UK—I declare an interest as its vice president—has tested the wording of these clauses on a number of front-line workers and their belief is that practice will be adversely affected. The distinction is important because if consideration of needs does not precede consideration of ways to meet those needs, there is a danger that needs will be defined with regard to whatever support is available and could result in children, young carers and parent carers finding it more difficult to access statutory care and support as a result of assumptions being made about the informal support that is available. These amendments seek to remove any risk that family and friends will be unduly and inappropriately relied on to provide care and support to the child, child carer or young carer, and to ensure that care and support needs are properly met following an assessment of needs and before considering the potential input of others.
The amendments tabled by the noble Lord, Lord Patel, to which I have added my name, emphasise the importance of the transition period to parent carers and disabled young adults and the vulnerability of both groups. I have little to add to his very eloquent presentation. It is sometimes remarkably difficult to focus the attention of policy-makers on the needs of parent carers. I have often been puzzled as to why that is. I think it may be about the very decided views that we all have about parental responsibility.
However, we must understand that the responsibility we gladly take for our non-disabled children is very different from what we expect from the parents of a child with special needs. These parent carers can find themselves providing care for many years and often at the very heavy end of caring—for example, someone who has severe mental and physical disabilities may need lifting and continence care—and for 24 hours a day. Do I need to point out that keeping such people engaged in caring by giving them enough support to stop them breaking down makes very sound economic as well as moral sense? At no point is this support more important than the transition stage, as the noble Lord, Lord Patel, has so eloquently reminded us.
My Lords, I will speak to Amendments 92BA and 104ZA. My noble friend Lady Browning and the noble Lord, Lord Touhig, whose names are also attached, are not in their places.
I welcome the attempt in the Bill to tackle the issue of transition from children’s services to adult social services and to try to make it work for young people. Clauses 55 to 63 undoubtedly present an important step in the right direction. However, some improvements are needed to ensure that the Bill provides the appropriate legal basis for the smooth transition for young people from children’s services to adult services that I am sure we would all like to see, and to remove the cliff edge that has been referred to in this and previous debates.
First, Amendment 92BA relates to Clause 63, which is about the continuity of services and is designed to ensure that if adult care and support is not in place by the time the child reaches 18, the services they receive under other legislation will continue until adult care and support is put in place. The potential for this change to benefit young disabled people making the transition to adulthood is very much to be welcomed. However, the benefits outlined in Clause 63 apply only if a request has been made for a child’s needs assessment by the time that child turns 18. The concern remains that some young people will not be able to benefit from this protection because they or their parents or carers will not be aware that they need to request an assessment by the time they are 18. Therefore, the amendment would ensure that every child who is receiving support under the relevant legislation and is likely to continue to have a support need after the age of 18 receives that assessment and the benefits that flow from it.
With regard to Amendment 1042A, as I have said in some of our earlier debates on the Bill, there is an overlap in the jurisdiction between this Bill and the Children and Families Bill, which specifically relates to social care for young people entering adulthood. The proposed new education, health and care plans, which the Children and Families Bill sets out to introduce, are at the very centre of this debate. If the aim of the current legislation is to create a better, joined-up system—as I think it should be and I am sure that other noble Lords agree—it is vital that the Care Bill makes reference to these EHC plans.
I will briefly explain that important link between the two Bills. At the same time as the Care Bill aims to bring adult social care into the 21st century, the Children and Families Bill aims to create a new joined-up system of support for children and young people with special educational needs between the ages of nought and 25. Plainly, with the Care Bill applying to adults from the age of 18 and the Children and Families Bill setting out the framework for children and young people up to the age of 25, there is an overlap in the 18-to-25 age range. It is vital that these plans are able to talk to each other if we are really to have the sort of integrated system that we all want, and if we are to achieve that desired goal of a one-stop shop of services that young people can access when they need them.
I support many of the other amendments in this group, but shall not spend time going through them.
My Lords, I support Amendments 92B, 92C and 92D, which are also in the names of the noble Baroness, Lady Pitkeathley, and the noble Lord, Lord Patel, who have spoken eloquently on this matter. I declare an interest as the chief executive of Turning Point, which provides health and social care to many young people in the process of transition. I know, as we all do, that transition can be a very delicate process if not done well. Young people slip through the net between children’s and adult services and begin their adult lives without adequate care and support, which risks deterioration of physical and mental health, and the escalation of need to the point of crisis. That is both immoral and expensive.
The Bill goes a long way to improve the current situation. I am pleased to hear that Ministers informed the House during an earlier session that discussions between the Department of Health and the Department for Education about the links referred to between this Bill and the Children and Families Bill are already taking place. These transition amendments offer an opportunity for us to go further—it is quite rare for a Bill to offer an opportunity to do something quite brilliant for young people—and to ensure that all young people receive support under other legislation. That support is likely to continue after young people reach 18 and they will receive an offer of a needs assessment from their local authority. Importantly, this process will begin in good time.
This includes those young people—or their families and carers, as has already been mentioned—who have not themselves requested an assessment. It is an important addition to recognise that there may be cases, as mentioned by the noble Baroness, Lady Tyler, where a family just does not realise that they need to request an assessment. Good transition is about helping to ensure that local authorities are better prepared to meet the needs of young people. If assessments can be conducted earlier, so long as this is what young people and their families want, care and support can be in place sooner, and there is less risk of people’s needs escalating to the point of crisis.
I hope that the Minister will agree that the assessment process needs to begin in good time, and that he can assure the House that those who do not themselves request an assessment will also be able to benefit from the improvements that this Bill offers.
(11 years, 5 months ago)
Lords ChamberMy Lords, I add my congratulations to the noble Baroness, Lady Hollins, on initiating this critically important debate. As the title of the debate states—it bears repeating—we are today discussing the health inequalities of a particularly vulnerable group, highlighted by the confidential inquiry into the premature deaths of people with learning disabilities. I speak today not because of any specialist knowledge but because of my interest in health inequalities, of which this is such a stark example, and I am grateful to the National Development Team for Inclusion for its briefing.
I am sure we can all agree that many of the findings of the report were horrifying. I will not repeat the statistics that many other noble Lords have already given the House. Suffice it to say that nearly three times as many people with learning disabilities die avoidably than die among the general population. Like many noble Lords, I find this shocking. Surely the issue should be treated with the same seriousness and urgency as responses to the appalling events at both Winterbourne View and Mid Staffs. The latter led to the highly influential Francis report and the immediate implementation by government of some of its key recommendations.
I will first make a few points on the factors leading to this vulnerability and these premature deaths. The confidential inquiry found that a fifth of people with learning difficulties experience significant difficulty or delay in diagnosis of their illness and that, as a result, there is often too little proactive care for this group and too many crisis-driven responses. It found a lack of reasonable adjustments to help healthcare, particularly in basic things such as attendance at GP surgeries and clinics; that GP referrals often do not mention learning difficulties; and very limited hospital flagging systems. Additionally it found that poor record keeping is creating problems and that, in some instances, even “do not resuscitate” orders in patients’ records have been found to be inappropriately or poorly documented. As others have said, there was poor adherence to the Mental Capacity Act and, finally, the inquiry identified poor co-ordination of care across and between different disease pathways and service providers, which failed to understand the episodic nature of care provision. That is only a few.
We know a great deal about the problem and we cannot continue to allow one group of people, those with learning disabilities, to experience such drastic healthcare inequality. It is because I know that the Government have such a strong commitment to reducing health inequalities that today I ask the Minister to consider immediate action in the specific areas on which I will focus my contribution. I am encouraged to do so in the knowledge that the Care and Support Minister, my honourable friend Norman Lamb, recently said:
“It is not good enough that people with learning difficulties are at a greater risk of dying earlier due to poor health care. … We are making progress on improving standards of care but we have to go further and keep driving forward our plans”.
I could not agree more.
First, regarding the confidential inquiry’s concern about a lack of adherence both to the Mental Capacity Act and the Equality Act, outlined by other noble Lords today, will the Minister clarify the Government’s plans to address this concern? Secondly, while details about the deaths of people with learning disabilities identified by the inquiry illuminate the severity of the problem, they only provide a snapshot. As anyone who has taken at least a basic course in statistics knows, cross-sectional data—what the confidential inquiry has assembled—cannot tell us as much as longitudinal data.
The confidential inquiry recommended that the Government should create a mortality review body and has offered three different models for doing so in subsequent discussions with the department. This would provide a critical ongoing lens into the mortality of people with learning disabilities. Will the Minister explain the Government’s plans and timetable for creating such a body?
Thirdly, the confidential inquiry also describes the current healthcare situation as one largely driven by crisis, with a lack of evidence of sufficient forward planning. Will the Minister provide his reaction to this assessment and say how forward planning can be improved?
Finally, on the care of those with learning disabilities, the only support currently available to clinical commissioning groups and local authorities is provided through the Learning Disabilities Specialist Public Health Observatory, which is part of Public Health England. This work involves a specific work strand on promoting learning and on sharing that learning with the wider sector and local areas. It is very important that this work continues and, given the number of people with learning disabilities who are supported both through social care and who live with their families, that this work programme includes specific action to support social care, understands the action needed to reduce premature deaths and works alongside action targeted at family carers. Will the Minister say what support the Government intend to put in place to ensure that local areas are able to implement the recommendations of the inquiry?
I finish by suggesting some additional practical actions for the Government to consider to try to improve the current situation. First, they could identify those people with learning difficulties who are afraid of seeking medical assistance and provide them and their carers with support and training now, before the need for urgent medical treatment arises. Secondly, they could offer a named healthcare co-ordinator to all people with learning difficulties with two or more long-term conditions and to those who live unsupported or with minimal support in the community with one or more long-term conditions. This would be akin to the Government’s recent proposals to refresh the NHS mandate, including by providing a co-ordinating clinician for the non-hospital care of another very vulnerable population—the elderly. This is something I very much support.
Thirdly, the Government could require all health and care services to assess and document the reasonable adjustments that individuals with learning disabilities need to access healthcare equitably and to share this information with providers so that people with learning disabilities are properly identified and providers have the duty to ensure that these reasonable adjustments are made. It must be possible to co-locate community learning disability nurses into GP practices to work alongside GPs.
Finally, will the Government consider requiring all acute hospitals to have at least one learning disability liaison nurse in post? These are just practical and specific examples—we have already heard others today and I am sure that we will hear more. I look forward to hearing the Minister’s response to these and other points.
(11 years, 5 months ago)
Lords ChamberMy Lords, I do not wish to duck the fact that this is a very difficult area to define. We all know that we want to achieve parity of esteem. It depends on ensuring not only that mental health services are given their fair share of the budget but that the right treatments are delivered to the right people, and that everyone in the country has access to appropriate treatments. We are currently firming up with NHS England what the right metrics are in order to judge whether they have met that aim. I will write to the noble Lord with the latest news on that front.
My Lords, I am sure that the Minister is aware of the growing trend for eating disorder clinics and hospitals to treat much younger children and, indeed, boys with eating disorders. Given this, what additional steps does the Minister think need to be taken to ensure that everyone involved—children’s services, primary schools and others—are spotting these signs, particularly in boys, where stigma is often attached to acknowledging these things, to ensure that effective treatment is quickly available?
My noble friend is absolutely right. The figures that I have before me show that by far the largest number of cases occurs in the age group 10 to 17. We are working on raising awareness of mental health problems, including eating disorders, and on providing support in schools. Particularly, we have provided £3 million of funding over two years to the BOND Consortium, which is led by YoungMinds. The aim of that is to build capacity in the voluntary sector to support the access that schools have to local services. We are also producing an e-portal tool for children’s and young people’s mental health, which we hope will be delivered next year.
(11 years, 5 months ago)
Lords ChamberMy Lords, I will be very brief in speaking in support of Amendment 88B. Certainly, I very much welcome the opportunity to improve access to the right support for young people with autism. I have met many young people with autism who have found that times of change, such as the transition from school to adulthood, are very challenging. It is the time when families need the appropriate planning and support to move from children’s services to adult services. In recent times I have talked to quite a few young people and their families who tell me that life at the time of transition, as they move from young people’s services to adult services, is like standing on a cliff edge.
The noble Baroness, Lady Browning, made a very powerful case that she articulated very well when she said that there would be considerable overlaps between this Bill and the Children and Families Bill. It is important that these two systems talk to each other. They must not operate in silos or we will never, as the noble Baroness, Lady Browning, said, ever get round the table and sort these things out. That makes common sense and I hope the Minister will recognise that—although, when I was growing up my mother used to say to me, “Son, in life, you will find that sense is not that common”. However, I hope that in this case it will prove to be and that the Government will see the reasonableness of these proposals.
My Lords, I add my support to Amendment 88B and point out that, while it is in the name of the noble Lord, Lord Tyler, on the Marshalled List, it should have my name attached to it.
Both my noble friend Lady Browning and the noble Lord, Lord Touhig, have presented a cogent case. I am not going to say anything other than it is important that we have properly co-ordinated arrangements for the transition process and the assessment as young people move between children’s and adult services. Certainly, like my noble friend Lady Browning, my experience is that far too often, in far too many cases, it is far from seamless.
I also support the three amendments to which the noble Baroness, Lady Meacher, has just spoken on young carers. The separation of adult and children services proves a real structural barrier, in my experience, to supporting young carers. Simply improving guidance and the other methods that have been tried before will not ensure the clear accountability that is needed for supporting the whole family. I know that the Minister has spoken before in Committee about the importance that the Government attach to the family approach—a view that I share—but a recent evaluation carried out by the Children’s Society found that the professionals involved believe that the law must be changed so that there are clearer levers for the provision of care and support in a way that sustains the whole family, and clearer lines of responsibility and accountability for both adult and children services.
We have discussed this both at Second Reading and in Committee. It needs a fully joined-up response and, while I understand and accept the Minister’s argument that most of the heavy lifting, if you like, in this area will be done in the Children and Families Bill, these amendments are needed in the Care Bill to ensure that adults’ needs are met sufficiently so that children and young people are protected from inappropriate caring, and that we have proper joining-up and co-ordination, not simply between services on the ground but between these two important pieces of legislation.
My Lords, the issue of assessment is an important part of the Bill and key issues have been raised which need to be carefully considered by the Government to ensure that the Bill gets these provisions right.
As we know, the Bill extends the right to be assessed for care and support to self-funders and their carers which, in the estimation of major social care charities, will involve nearly 500,000 additional assessments being undertaken by local authorities on top of those for people whose care is provided by them.
We support the extension of entitlement to assessment to self-funders and their carers but we join with noble Lords who are concerned about whether local authorities can possibly carry out this major undertaking in the realities of the current funding crisis and the other duties being placed on them. It is vital that we hear from the Government whether they consider extra resources will need to be made available to support these new duties and whether the noble Earl is confident that the current funding settlement will enable the duties to be performed effectively.
Our Amendments 87J and 88D address the concern that noble Lords and care and support organisations have raised over including in the Bill the requirement—as part of the assessment—to consider whether and to what extent the adult’s or carer’s own capabilities, or any support available from family and friends, could contribute to achieving the outcomes identified in the care plan. It is a very important issue.
Clauses 9(4)(d) and 10(5)(f) were not part of the consultation on the draft Bill, which followed the Law Commission’s advice on making a clear distinction between consideration of care and support needs and how these needs should be met. Support from families and carers should be considered as a way of meeting needs rather than as a reason for deciding the person does not have needs.
The approach in the Bill runs a huge risk of the assessment not recognising the vital contributions of carers and the extent of needs if the carer is unable to provide care. The clauses, as they stand, blur the distinction between an assessment being about what the needs are and the ways of meeting them because they look at how needs can be met other than through the provision of services before any decision about eligibility has been made. They also raise concerns that a carer might be pressured into providing care that they do not feel able to provide—or even that the adult may be pressured into receiving care from a family member. I hope that the Minister will recognise the importance of these two paragraphs being deleted.
Instead our Amendments 92ZZF and 92ZZL propose putting the issue in other parts of the Bill where the vital distinction we are making will be clear. We are seeking to insert new subsections into Clauses 24 and 25 to retain the aim of a capability-based approach being properly considered—in other words one that draws on a person’s own abilities and available social networks. Our amendments would require this process to take place after needs have been defined and not before.
The proposed new subsection refers to the local authority duty to provide information and advice to people not eligible for care and support. It adds to the advice and information requirement to discuss with the person who has been assessed whether they have the individual capabilities or social or community resources that can help them achieve the outcomes they want. Clause 25 deals with the care and support or support plan for people eligible for support, and our amendment again would ensure that the individual’s capabilities and social or community resources are considered at this stage after assessment. This is vital to ensure at least some protection against either the carer or adult needing care being pressured into a caring relationship they do not want, or is inappropriate.
Our Amendments 88P and 88PA deal with the concerns raised under this and in a later group to ensure that assessments are undertaken by persons with expertise, in line with current guidance and practice. Amendment 88P provides for the local authority to be satisfied that the assessment of needs of the adult and carer have been appropriately and proportionately considered by an appropriately skilled or qualified assessor. The intention of Amendment 88PA is to tighten the duty on local authorities to consider preventive support following the determination of eligibility. We want to ensure that local authorities do not use unreasonable justification for refusing to provide or arrange for preventive support and consider what preventive services would or would be likely to benefit an adult.
The current guidance recognises the need for flexibility in certain circumstances on who undertakes the assessment, and this needs to be retained. For example, my local authority is in the last processes of undertaking effectively new assessments of existing clients under the transfer to self-directed support and personal budgets. As noble Lords will know, I am a carer and my partner has long-term health and care needs after suffering a major stroke. Our recent assessment was undertaken by a very competent member of the personalisation team who is not a qualified social worker but a former care assistant, so she fully understood home care support. However, she had access to a qualified social worker care manager for advice to whom we could also refer if we needed. I stress that this was an assessment of a care plan in operation for six years, and under a process that was not originating the plan but viewing it from the personalisation perspective. We both found the new, but demanding process— 44 page forms, as I might have mentioned before—very helpful in giving new perspectives on issues, such as risk when I am not at home or contingency arrangements if I am hospitalised, or fall under the proverbial bus. Most carers just cross their fingers and hope that it would never happen for their own and the cared-for person’s sake, but the assessment experience was a positive opportunity to take stock and a worthwhile experience, which I hope we are still feeling good about when the personal budget allocation comes.
Nevertheless, my point is that the original assessment was conducted by a qualified social worker with full understanding of care requirements for major stroke recoverers, and that assessment has stood the test of time six years on. Had this assessment been a first time assessment, however, it would have been vital to have had a qualified social worker, plus any specialist advice on stroke, if needed. Amendments 88A and 88DA tabled by the noble Baroness, Lady Emerton, require the local authority to involve the relevant health practitioner in the needs assessment for adults and carers under Clauses 9 and 10. We agree that they should be involved where their specialist skills are needed and that this will help ensure better integration of health and social care, and overall better patient care.
I also support Amendment 88 from my noble friend Lady Wilkins, which provides for the local authority to have the same duty under Clause 9 for adult assessments as is given in Clause 10 for carers’ assessments. This is a logical amendment and I hope the Minister will recognise that.
We have also had three important amendments tabled by the noble Baroness, Lady Meacher, which have been added to this group and which we support. These reinforce our messages in the debate in Committee last week on young carers—namely that adult assessments need to meet the needs of the adult, so that children are protected from inappropriate caring. The noble Baroness has stressed how important this is and I look forward to the Minister updating us on the developments over the interface between the Care Bill and the Children and Families Bill in respect of young carers and parent carers.
Finally, I would stress how important the assessment process is. The Government’s discussion document on eligibility recognises that they are an integral part of the system. As we have seen, there are many separate aspects related to assessments, and it is a pity that, in this instance, we have had to lump them all into one big debate. I would therefore urge the Minister, even if he does not agree with the very strong case presented by noble Lords for including these matters in the Bill, to undertake to take the issues of concern away and review this part of the Bill so that there can be full confidence in the legislation underpinning this important issue.
(11 years, 5 months ago)
Lords ChamberMy Lords, today is bowel awareness day. I have been chairing a reception for bowel care this afternoon. Two of the speakers had disabilities: one with multiple sclerosis and one a tetraplegic, paralysed from the neck down. Both needed bowel care and they both said that dignity and respect were so important. Amendment 78ZA should therefore be a must for the Bill. There are many important amendments in this group, including those on well-being and companion animals, which I support. Happiness is something we should all aim for.
My Lords, I add my support to Amendment 78ZA, to which my name is also attached. The noble Lord, Lord Bichard, has already spoken very eloquently of the reasons behind the amendment. Dignity and respect are absolutely fundamental pillars of well-being, which is why I would like to see these words spelt out in the Bill. Well-being is unattainable without dignity and respect as central components. In saying this, I am conscious that the public’s opinion on this matter is one of pessimism and distrust of the current social care system. In a recent survey, only 26% of the public felt confident that older people receiving social care are being treated with dignity. If the public do not trust their loved ones in the hands of the social care sector, what hope is there that well-being is being promoted?
We have recently seen and heard of shocking failures in the care of older people in both the health and social care sectors. These very harrowing examples serve to illustrate the importance of enshrining dignity and respect as a critical part of well-being in order to try to change the culture among care workers in the health and care sectors, to ensure the transformation of services that this Bill is intended to bring about and to have the sort of compassionate care that we all like to see. Dignity will also be very important when it comes to secondary legislation and specifically to the eligibility criteria. It is vital that these criteria have regard to the well-being principle. I am happy to be corrected about this if I am mistaken, but the draft feels very health-and-safety-oriented and does not mention dignity at all.
I would have liked to add my name to Amendment 79 about including well-being as part of the Secretary of State’s duty, the reasons for which have already been set out very clearly. The very wide-ranging definition of well-being, set out in The Care Bill Explained, makes it absolutely clear that for the well-being principle to be made a reality it would need to be the joint responsibility of a wide range of partner agencies, nationally and locally. Government action on key issues such as welfare, transport and housing are likely to have a very distinct impact on well-being at an individual level.
We rightly hear a lot about the importance of joining up health, social care and wider services: horizontal integration, if you like. For any system to work as it is intended and to be fully aligned it must be, as I said at Second Reading, vertically integrated as well to make sure that everyone, from the Secretary of State downwards, has the same objectives and is pulling in the same direction.
My Lords, I support Amendment 78ZA. Six years of serving on the Equality and Human Rights Commission taught me that if we embedded dignity and respect into the training of staff we would avoid many of the tragedies we have read about. This applies, right across the board, to staff in health, social care and housing. It is essential that we take dignity and respect as very serious elements of the training of all staff who come into contact with frail and vulnerable people.
(11 years, 6 months ago)
Lords Chamber
To ask Her Majesty’s Government whether they will consider linking the separate outcomes frameworks for health and social care.
My Lords, we will improve outcomes only if all parts of the system work together with a common purpose. The three outcomes frameworks have been and continue to be increasingly aligned, reflecting the joint contribution of health, public health and adult social care to improving outcomes. The frameworks form the basis for integrated working locally. They support local partners across the health and care system to identify shared responsibilities, pursue shared goals and improve outcomes for their communities.
I thank the Minister for that helpful reply. I certainly welcome the efforts that have been made to align more closely the various outcome frameworks, in particular the sharing of particular outcome indicators on premature mortality. Given the new duties that are now on the Secretary of State, the NHS Commissioning Board and clinical commissioning groups to reduce health inequalities, and indeed the current inequalities in the incidence of conditions such as cancer and survival rates among deprived groups, what evidence is there that using these common outcome indicators will result in more integrated services such as smoking cessation, leading to real reductions in health inequalities?
The essence of the answer to that is that improved outcomes will be achieved only when all parts of the system work together. If you have shared measures within the outcomes frameworks and measures that are complementary to each other, you will shine a light on areas of inequality and inform local and national action to advance equality. This focus on outcomes rather than processes enables an innovative approach to health and care services that is driven essentially by the needs of the local population. I will just add that local Healthwatch has a role to play in working with partners to make sure that the views of vulnerable and seldom heard groups in the population are heard.
(11 years, 6 months ago)
Lords ChamberMy 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.
(11 years, 9 months ago)
Lords ChamberMy 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.
(12 years ago)
Lords ChamberMy 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?
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.
(12 years ago)
Lords ChamberMy 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.