Care Bill [HL]
Baroness Tyler of Enfield Excerpts(13 years, 1 month ago)
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Lord Touhig
My 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.
Baroness Tyler of Enfield
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.
Baroness Wheeler
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.
Care Bill [HL]
Baroness Tyler of Enfield Excerpts(13 years, 1 month ago)
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Baroness Masham of Ilton
My 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.
Baroness Tyler of Enfield
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.
Baroness Greengross
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.
Health and Social Care
Baroness Tyler of Enfield Excerpts(13 years, 2 months ago)
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Baroness Tyler of Enfield
To ask Her Majesty’s Government whether they will consider linking the separate outcomes frameworks for health and social care.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
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.
Baroness Tyler of Enfield
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?
Earl Howe
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.
Care Bill [HL]
Baroness Tyler of Enfield Excerpts(13 years, 2 months ago)
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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(13 years, 5 months ago)
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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(13 years, 7 months ago)
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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(13 years, 8 months ago)
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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(13 years, 10 months ago)
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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(14 years, 1 month ago)
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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(14 years, 2 months ago)
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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.