NHS: Midwives

Baroness Wall of New Barnet Excerpts

Monday 17th March 2014 Lords Chamber

[Earl Howe]

My noble friend is right to draw attention to the attrition rate. NHS England is focusing on this very closely. It is not always possible to predict the attrition rate because midwives leave practice for varying reasons—for instance, to take a career break. It is, however, very important that the motivation of midwives should be maintained. There is a great deal of work going on to ensure that we do not lose highly qualified and skilled midwives from the NHS.

[Baroness Wall of New Barnet (Lab)]

Does the Minister accept that the issue is trying to work out how many vacancies there are? The ratio that is defined in the area depends on the hospital. For instance, Barnet and Chase Farm Hospitals, of which I am chair, has 30 births to one midwife, whereas in other parts of London it could be 28 or fewer. What we have tried to do, in looking at whether we should have a lower ratio, is work with the midwives’ associations. I think it is difficult to establish the number of vacancies because that ratio dictates what is paid for.

[Earl Howe]

The noble Baroness is quite right. Helping commissioners to reduce unwarranted variation in service delivery is one of the key roles of the maternity and children strategic clinical networks, as I am sure she is aware, which are being established and supported by NHS England. Clinical commissioning groups are responsible for commissioning maternity services locally, but they work with local authorities and in conjunction with provider partners to give assurance that processes and service specifications are in place which ensure that midwifery staffing is appropriate for the locality.

Health: Midwives

Baroness Wall of New Barnet Excerpts

Wednesday 5th March 2014 Lords Chamber

[Earl Howe]

My Lords, any bridging loan requires to be repaid, and that is one of the issues that we are looking at.

[Baroness Wall of New Barnet (Lab)]

My Lords, following on from the question from the noble Earl on the Cross Benches, I am sure that the Minister is aware that most trusts—this is certainly the case in the maternity unit at Barnet hospital—now have a community midwife at the birth, and that midwife follows the mother home and stays there for as long as the mother needs support. Therefore, there is one-to-one care from a midwife, not necessarily during the delivery but certainly in the care that the mother receives when she goes home.

NHS: General Practitioners

Baroness Wall of New Barnet Excerpts

Wednesday 26th February 2014 Lords Chamber

[Baroness Wall of New Barnet (Lab)]

I follow on from the question of my noble friend Lord Hunt and the Minister’s acknowledgement that the effectiveness of primary care needs to be improved. I agree with what the Minister said about the improvement in some GP services, but still many individuals come to A&E at all times, whether the surgery is open or otherwise, which makes things very difficult. For instance, Barnet Hospital received 117 ambulances yesterday, which made it extremely difficult to deal with people who had walked in, who probably could have had their treatment somewhere else.

[Earl Howe]

The noble Baroness is quite right. The NHS is seeing an extra 1 million patients in A&E compared to three years ago. Despite the additional workload, it is generally coping very well although we know that departments are under strain. This is not just about A&E, as the noble Baroness will be aware, but about how the NHS works as a whole: how it works with other areas, such as social care, and how it deals with an ageing population and more people with long-term conditions. Dealing with all that means looking at the underlying causes, and that work is going on at the moment in NHS England.

NHS: Walk-in Centres

Baroness Wall of New Barnet Excerpts

Tuesday 10th December 2013 Lords Chamber

[Baroness Wall of New Barnet (Lab)]

My Lords, the noble Earl suggested in his response earlier that part of the problem might be that the commissioners felt that they were paying twice. Obviously, GPs are paid for the people on their lists; those same people could use the call centre and they would have to be paid again. How does this fit with the view—certainly the view on the policy—that you can belong to any GP throughout the country, which is exactly what should happen and, if it did, we would not have this dilemma? Walk-in centres are hugely important. I assure the House that, from the point of view of the provider trust, they are absolutely vital to stop people coming into A&E and possibly being admitted.

[Earl Howe]

My Lords, I would not deny for a second that walk-in centres had a role in many places, and indeed the fact that so many are still open is proof of that. However, it is a mixed picture. Those centres that have closed are in many cases ones where doctors locally have perceived that, in one form or another, there is adequate provision for patients, whether through pharmacies, GP surgeries or community services of a different kind.

NHS: Clinical Commissioning Groups’ Funding of Treatment

Baroness Wall of New Barnet Excerpts

Tuesday 12th November 2013 Lords Chamber

[Lord Harris of Haringey (Lab)]

My Lords, 55 years ago—

[Baroness Wall of New Barnet (Lab)]

My Lords, as chair of one of the many trusts that are in financial difficulty—

[Baroness Royall of Blaisdon (Lab)]

I suggest that we hear from my noble friend Lord Harris.

Health: Local Healthwatch Organisations

Baroness Wall of New Barnet Excerpts

Tuesday 5th November 2013 Lords Chamber

[Earl Howe]

I am grateful to my noble friend. The first annual report from Healthwatch England was laid before Parliament on 9 October and it outlined some encouraging progress at both a national and a local level. There are already examples of the impact that local Healthwatch is having—for example, the work of Healthwatch in Peterborough, which is looking at how to improve health outcomes for offenders. My noble friend mentioned autism. I am aware that Healthwatch Cornwall uncovered a gap in the services meant to deliver a diagnosis of autism in children. That work resulted in a really practical solution so that families could access a diagnostic service without losses to other services in the area.

[Baroness Wall of New Barnet (Lab)]

My Lords, will the noble Earl acknowledge that, certainly from the point of view of people who are working on the ground, the process we are going through is somewhat different from that set out by my noble friend, with whom I hate to disagree? There are obviously challenges at the moment, particularly in A&E, as the noble Earl is aware, but many of the changes have brought a lot of good news for health trusts, and my own in particular. However, the Healthwatch bodies—certainly locally where my trust is involved with them—need some support and guidance about what they are meant to achieve. It may seem odd but there is still some ambiguity about who is doing what. We are working with them as an acute trust to make sure that we can link with them, but there needs to be more clarity about their role.

Care Bill [HL]

Baroness Wall of New Barnet Excerpts

Monday 21st October 2013 Lords Chamber

[Baroness Gardner of Parkes]

My Lords, I do not want to speak before whoever supports the noble Lord, Lord Hunt, in his amendment, so I will sit down and speak after the noble Baroness.

[Baroness Wall of New Barnet]

My Lords, I did not intend for that to happen. Noble Lords may find this quite tedious, but I want to follow both the theme and the specifics of the amendment moved by the noble Lord, Lord Hunt. As to the theme, his statement that things are difficult out there today is quite an understatement. Things are hugely difficult. I spent the morning with the TDA in my trust and heard very difficult messages around performance and, more importantly, around finance.

On the specific point about the suggested skill mix and the way of dealing with it in the Care Quality Commission, when we had our Care Quality Commission representative for Barnet and Chase Farm with us a couple of months ago—on a routine visit rather than an impromptu one—she set aside a session to talk to people about healthcare assistants. She got the same message that I have tried to impart to noble Lords on several occasions that the regulation of these people is hugely important. She was trying to understand what difference it would make. Patients who came in to listen at the event could not understand why healthcare assistants were not regulated in that way—although some thought that they were. There is also confusion about who they are and what role they play.

Healthcare assistants and nursing assistants are hugely important to the skill mix, but what they do and what they are able to do is paramount to being able to understand how their contribution to the skill mix really fits. I support the amendment. It can ensure that we once and for all deal with what it really means to be a healthcare assistant, what they can do and how they are regulated.

[Baroness Emerton (CB)]

My Lords, I rise to speak to Amendment 159 standing in my name and in the names of the noble Lords, Lord Willis and Lord Warner, and of my noble friend Lord Patel. Amendment 159 is about safeguarding patients. I championed safe staffing levels during the proceedings on the Health and Social Care Bill and during the proceedings on the Care Bill to date but failed to get my amendments accepted following a firm rebuttal by the Minister. Therefore, it was with a slightly doubtful mind that on 29 July, before we left for the Summer Recess, I put my name to the amendment before us today.

I then began nine weeks of reflection on whether I should or should not withdraw my name. I want to share the experiences of those nine weeks that have left my name on the amendment. I resolved to try to convince the Minister and noble Lords that if we wish to meet the challenges of high-quality, safe care acceptable to patients and their families in hospitals, we cannot ignore the contents of this amendment, set out under four headings. It recognises that it is only a small part of a very comprehensive Bill focusing on the acute hospital provider but it is nevertheless important that patients should be assured that all the measures that are taken will ensure their safety and the high quality of delivery of care to their satisfaction, resulting in a short length of stay, less likelihood of infection, reduced readmission rates and lower mortality rates.

Surely there is a cost-effective and care-effective way forward, despite the challenges it brings with it. The need to consider staffing levels in the community is equally important if we are to achieve an integrated service from primary healthcare and community care as well as from the acute providers in hospitals. Before the Recess I was involved in discussions about staffing levels with a number of very senior nurses, academics, the Royal College of Nursing and other organisations. The Bruce Keogh report focused on the seriousness of the situation, identifying 14 hospitals with high mortality rates and low staffing levels. That was quickly followed by the publication of the report by Professor Don Berwick, also just mentioned, on the safety of patients, which again referred to low levels of nursing staff as being a problem, but not measured against an evidence-based level.

The group of senior nurses formed themselves into the Safe Staffing Alliance, chaired by Elizabeth Robb, the chief executive of the Florence Nightingale Foundation, who had personally experienced introducing care bundles for five long-term conditions, which led to a dramatic reduction in mortality rates, and who was a member of the Keogh commission. The alliance busily engaged itself in examining the research evidence available internationally, and within the UK, on staffing levels. Its statement says:

“Under no circumstances is it safe to care for patients in need of hospital treatment with a ratio of more than 8 patients per registered nurse during the day time on general acute wards including those specialising in care for older people”.

Very soon after that, Robert Francis spoke to the CQC and referred to his original recommendation on staffing levels. He said, “So much of what went wrong in our hospitals is likely and indeed was in many regards the case in Stafford, due to there being inadequate numbers of staff either in terms of numbers or skills. The evidence given to my inquiry however was not sufficient to persuade me that there should be a minimum across the board staffing level, and I know not everyone agrees with that conclusion. But I could only act on the evidence I had and I was after all only dealing with the event arising out of a particular hospital so the inquiry for all the breadth in the end had limitations. However, evidence has been put forward to me since from the Safe Staffing Alliance to suggest there is a level below which it should be regarded a service is not safe, not that’s the adequate level of staffing but the level below which you cannot be safe. It does seem to me that it’s evidence that is worth consideration and therefore ought to be considered somewhere with regard to whether there is some sort of benchmark which at least is a bit like mortality rates an alarm bell which should require at least questions to be asked about whether it is possible for a service to be safe given whatever the staffing situation is. I just ask you to consider that as being a potential way to show real support for staff, some of whom are working in really challenging circumstances”.

In an interview reported in the press on 8 October, Robert Francis discussed the possibility of services being shut down if insufficient staffing levels were evident.

During September, I met directors of nursing from the teaching hospitals called the Shelford Group, who were grappling with staffing problems but in slightly different circumstances from those in other NHS trusts and NHS foundation trusts. I also discussed the issue with the director of nursing at Salford Royal NHS Foundation Trust, Elaine Inglesby, who gave evidence to the Health Select Committee that demonstrated clearly that the whole hospital was engaged in the safe staffing project. She had been able to implement the suggested staffing levels by using the acuity and dependency tools supplied by the Association of UK University Hospitals and using the ratio of one registered nurse to eight patients as a minimum, based on the evidence from Southampton University, King’s College London and the National Nursing Research Unit. Evidence suggested that there was a need for three registered nurses on night duty.

In this hospital there is a safe staffing steering group to support ongoing development. The introduction of a white board on every ward or department indicates the number of nurses and grades on each shift. This is posted so the patients and visitors can immediately identify how many staff at what grade are on duty at any time. There is a daily safe-staffing teleconference on daily rotas meeting each morning at 8.30. This looks at the morning, late and night shift and presents a true picture of ward and department nurse staffing. Obviously this is an ongoing development project involving the board members and the staff of the whole hospital. To date it is working to the satisfaction of patients, families and, above all, the staff involved.

During this time, I also noted the media and varying reports of events demonstrating failings in service delivery because of low staffing levels, including the reports of warning signs from the Royal College of Nursing and other organisations. I also listened to patients’ experiences, where shortage of staff appeared to be a major concern. The need for so many trusts to seek overseas recruits because of shortage was reported last week. There are also records from the Patients Association, which has received many complaints on staff shortages during this time.

I then went on holiday myself and reflected back over the eight weeks. I came to the conclusion, while declaring that I am a long-retired nurse not on the NMC register, that I could do nothing but support the amendment and continue campaigning for the future safety of patients. I hope I have persuaded the Minister. Although this amendment is only a very small part of this large Bill, because of the ramifications for the safety of patients in hospitals who rely on 80% of their care being given by nurses, we owe it to the nurses and to the patients they serve at least to acknowledge and accept the words of the amendment so framed to allow the flexibility required to meet patient need but avoid high risk to the delivery of care. I trust the Minister will respond accordingly to the amendment.

--- Later in debate ---

[Baroness Wall of New Barnet]

My Lords, I, too, welcome the announcement, and I am sure that the noble Earl is not surprised at the depth of feeling I have in welcoming it. I see this as a step towards regulation. He might baulk at that but, as the noble Lord, Lord Willis, said, regulation is important for us, and I have been asking for it for a long time. However, I also have felt: what is it we are regulating in the sense of the absolute ultimate? So I think this gives us a very clear and descriptive way in which that can be measured.

I echo what the noble Lord, Lord Willis, said about “may”. That must be “must”, please, because “may” gives such a lot of flexibility that we may go back to exactly where we are right now if people are not required to carry this out. I very much agree that regulation helps in bringing value into the skill mix. My noble friend Lord Hunt referred to an aside by his colleague sitting alongside him. As somebody who is involved in skills heavily, whether it is NVQ level 1, 2 or 3—which I am sure my noble friend Lord Young was referring to—I know from the work that I have done with Skills for Care that the aim is that between level 2 and 3 will be competent level because obviously it depends very much on what people start with.

A final point, which the noble Lord, Lord Willis, picked up on and which we have in industry as well, is how we measure the skills and experience that people already have when we try to ascertain where they fit in. One of the dispiriting things that we find elsewhere is that, when people are asked to take a level 2 or 3, no recognition is made of what they have already gained while they have been doing the job. Skills for Care knows how to cope with that in the way that the skills levels are drawn up.

I thank the noble Earl very much. I spoke before about being tedious. I am sure that the way in which he has pursued this issue has nothing to do with me or other people being tedious; it is because he has a belief in it.

[Baroness Emerton]

My Lords, I, too, thank the noble Earl the Minister for what he has said. I think I have probably been more of a pain than anybody on this subject. I thank the noble Earl very much for the assurances that he has given.

I have one or two very quick questions. He knows that I have a thing about Skills for Care and Skills for Health. Who is going to decide the membership of those groups? I am concerned that in teaching skills each individual care worker will want to have the background knowledge to support their skill. It is no good just teaching someone a simple skill without having the knowledge behind it. It reminded me that 63 years ago I was a St John Ambulance cadet. I did an elementary first-aid course where a doctor taught elementary anatomy, physiology and treatment of first aid. I then went on to home nursing and was taught by a registered nurse how to look after patients in the home, provide good nutrition and prevent bed sores. I think probably what I knew at the age of 11 is more than what some of our healthcare professionals know today. What will be the professional input into Skills for Health and Skills for Care? Who will do the syllabus, the curriculum and the teaching? Presumably Health Education England and the NMC will give the backing to that. If we could have that assurance, it would keep me quiet for a little longer.

Care Bill [HL]

Baroness Wall of New Barnet Excerpts

Monday 29th July 2013 Lords Chamber

[Baroness Masham of Ilton]

My Lords, I, too, support these amendments. People in the community definitely need better facilities. There is no doubt that people should have choice. My husband would have liked to have died at home. Sadly, that option was not available because he needed an antibiotic in a drip. He died in an A&E department. I therefore greatly support these amendments.

[Baroness Wall of New Barnet]

My Lords, I, too, wish to support the amendment presented by the noble Lord, Lord Warner. I want to focus particularly on the first part of the amendment and I support completely the sentiments within that. One of the points made by the noble Baroness, Lady Jolly, was very important. It is important to try not to have the elderly patients in the hospital so that their right to die wherever they want to be is where they are before they have to come in. The context here is not just the money. The noble Lord, Lord Warner, is absolutely right to point out that it is hugely expensive. I think that it is more than £3,000 if an elderly person is in hospital and dies in hospital. It is very much evidenced by the fact that they very often feel quite degraded by the lack of privacy when they die in hospital. By definition, it is not the same as being at home or, even, I would suggest a hospice, where people have very good experiences. The evidence provided by the noble Baroness, Lady Jolly, and the noble Lord, Lord Warner, is absolutely crucial.

I can tell the Committee from first-hand experience that people also say this to us. I declare an interest in Barnet and Chase Farm Hospitals. If I or anyone else in the hospital goes around the wards, the patients tell us that they would love not to be there to die. Certainly, the nursing staff would love them to be in a better, more dignified place to die. It is a hugely important part of any of the social care we are looking at.

[Baroness Pitkeathley]

My Lords, I, too, wish to speak in support of the amendments and to endorse what the noble Baroness, Lady Jolly, said about the recommendations of the Joint Committee. I want to use the opportunity also to consider the needs of family carers as well as those of the person who is dying. I want to emphasise that it is very important that carers are informed about the likely stages at the end of life and that they, too, are able to prepare for the death of a loved one. This includes ensuring that families are well informed when making decisions about where their loved one dies. It has been said by all noble Lords that most people wish to die at home. However, this can put extra pressure on carers, which should be discussed with them by health professionals. These health and care professionals may need further training to ensure that they are identifying and considering the needs of carers at the end of life.

More than 300 carers who have experienced the death of the person they cared for shared their experience as part of this year’s report for Carers Week, which is called Prepare to Care?. Nearly half said that they had not had time to plan about the death. One third of carers stated that they had not given this enough thought and wished that they had planned it better. As one carer said:

“Although you can be aware end of life is coming you have to balance this out with keeping up hope and being positive for the person you care for. Also you just don’t have the time to think ahead. With hindsight I can see that the signs that end of life for the people I was caring for was approaching, but as a carer in that situation at the time I could not see them. I wish the GP had spent some time with me to discuss these things”.

We must bear the carers in mind.

If I may, I would like to say a word about the aftermath for carers of the death of a loved one. Carers often become isolated as result of caring and find it very difficult to maintain social networks and hobbies. When caring comes to an end, so do the carer’s services. The carer is left without any social or emotional support. I never forget the carer who said to me, “I am expected to go from the graveside to the job centre”. Sometimes we expect that of carers. If we could support carers more, I think that more of them would be willing to be part of the team providing end-of-life care and thus gain the advantages which have been so clearly set out by noble Lords.

Medical Litigation: Impact on Medical Innovation

Baroness Wall of New Barnet Excerpts

Monday 15th July 2013 Lords Chamber

[Earl Howe]

I cannot give my noble friend a figure for that, but I can tell him that mediation and arbitration are increasing features in cases of this kind. We are very keen for that mechanism to grow, because the more that cases get into the hands of lawyers—I say this with great respect to noble Lords who are lawyers—the higher the bill to the NHS and the more distress there is to patients and families.

[Baroness Wall of New Barnet]

My Lords, I congratulate the noble Lord, Lord Saatchi, on linking these two important issues of innovation and litigation. I worry that the innovation that has become part of the Liverpool care pathway has had the reaction that it has. We understand today that there is going to be a cessation of that care pathway, because people are reporting being tarnished by it, whereas many patients have had great experiences and families’ involvement in that. It concerns me that we will either stop something because there is an issue about it or stop innovating.

[Earl Howe]

I share the noble Baroness’s concern, but at the same time I recognise that the noble Baroness, Lady Neuberger, and her expert group have done a very thorough job of work. It is now up to the Government and the whole medical community to consider and reflect on the conclusions that the noble Baroness has reached. One thing that she has said is that her decision is not a recommendation to move away from best practice in end-of-life care.

Care Bill [HL]

Baroness Wall of New Barnet Excerpts

Tuesday 9th July 2013 Lords Chamber

[Baroness Barker]

My Lords, I wish to speak to Amendment 82A, which is in my name in this group, and to support the amendments in the name of the noble Baroness, Lady Greengross. For well over a decade, we have had evidence that the recovery rates for people being discharged from hospital during the week, through to people being discharged on Friday, vary enormously. There has been evidence in abundance for the past decade that the failure to integrate care plans for people leaving hospital with community services leads to their readmission into hospital as an emergency—and in some cases, to their death. All the factors that contribute to that should not be news to anyone who has ever read about delayed discharge.

At the heart of our failure to really look after older people who go in and out of hospital is not just the failure to carry out assessments at the proper time but the failure to share that information with all the relevant people along a care pathway. It has been interesting, particularly over the past year, to begin seeing something of a change taking place both in health and social care. One of the driving factors behind that are the shared outcomes frameworks to which health, adult social care and mental health now have to work. The fact that we have the five overarching domains and that each of them is working to performance indicators below them is beginning to have a real influence, not just on high-level strategic planning but on front-line work.

We have always known that there have been excellent examples of integrated care. Where care works well, it works fantastically well and where it does not, it is just a disaster. The trouble is that we can never really pinpoint and identify where that will happen, other than that the systems that work well are always those which have the patients at their heart, involved in the planning process as well as being recipients of care.

My Amendment 82A is prompted, as I think noble Lords will know from last week, by the Christian Scientists—the people who, as part of their belief system, wish it to be known that their care should not involve medical treatment because that is incompatible with their beliefs. Beyond that small group of people, whose beliefs I do not share, it is important to register in all this that when we are building systems that assess the needs of older people there has to be within them a point at which older people can dissent, particularly if quite forceful medical decisions are being made about their care. Sometimes we get incredibly enthusiastic in our support of doctors and manage to let that take things over completely.

The noble Baroness, Lady Greengross, has highlighted the key points that we need to focus on because, at the end of the day, integration depends entirely on all the different care providers in the pathway working to common information. If we cannot start now to develop those systems, we will not achieve what has proved for so long to be that elusive solution to integrated care.

[Baroness Wall of New Barnet]

My Lords, I also support all these amendments, particularly in relation to the previous discussion of getting older people out of beds that they are blocking, as I think the noble Baroness, Lady Greengross, put it. That is perhaps an inappropriate word but, in reality, those are the facts. The care plan that everybody has talked about is important, and hugely effective when it works. I have to admit that in my own hospital—I declare my interest as chair of Barnet and Chase Farm Hospitals Trust—it does not always work. Very often, the breakdown with the local authority can come from the start of the agreement on a care plan—what will happen to the individual, how many X-rays they will have, where they will go at the end and so on.

One of the good things in the new system—there are several—is the CCGs. The relationship between clinical commissioning groups and local authorities is proving, in the very short time that it has been working in my area, effective. The more pressure on commissioners in terms of getting hospitals running better, the more interest they have in making sure that local authorities are doing their bit as well. That partnership, in my view and my experience of the past months, has been working much better, which, for us, is a very good thing.

[Baroness Gale]

My Lords, I will speak to Amendments 92ZZEA and 92ZZEB. Clause 22 is titled:

“Exception for provision of health services”.

Subsection (1) is crucial, as it sets out the legal test for when NHS continuing care or registered nursing care should be provided and when the means-tested social care system may lawfully provide for nursing care.

Recently, I have been listening to people give evidence to the APPG on Parkinson’s, which I chair and which has been conducting an inquiry into NHS continuing care. Listening to the witnesses, it has become very clear that there are often lots of problems with the health service and social care services arguing over funding. People are having difficulty accessing continuing care under the NHS and have to get over lots of barriers. It is quite heartbreaking to hear the problems that people are having.

The wording of Clause 22 still carries a potential risk for those who self-fund their care. There are various provisions in the clause that allow local authorities to arrange for health services that should be provided by the NHS. Once councils start delivering healthcare, when they traditionally used to deliver means-tested and chargeable social care, there is a risk that someone—somewhere in the system—will mistakenly conclude that the council can charge for those services. There is a need to ensure that self-funders are not exposed if they are found to be eligible for NHS continuing care, or registered nursing care, and the package of delivery is with the local authority. These matters were raised by the Joint Committee scrutinising this Bill but have not yet been addressed.

In legal terms, local authorities are prohibited from providing anything authorised or required to be provided under the NHS Acts. This means that social services cannot provide care home accommodation if a power or a duty to provide the accommodation exists under any of the NHS Acts. Clause 22 has narrowed this down to just “required”, for example by omitting the “power” or authorisation provision. That leaves local authorities able to provide accommodation that the NHS has a power to provide. I believe that disputes and confusion have occurred between councils and the NHS over continuing care, and this seems to be a recipe for more. The Bill should be amended to prohibit local authorities providing a service or facility that is authorised or required to be provided under the NHS Act 2006.

My amendment would mean that local authorities would be prohibited from providing health services that are authorised or required to be provided under NHS Acts. My aim is to make it clear who can deliver what, so as to avoid self-funders being at risk, however small that risk might be, of having to pay for care that they should be getting free.

Clause 22(4)(a) also states that a local authority may, despite the prohibitions, arrange for care home accommodation with nursing care if it has consent to do so from the clinical commissioning group. This may also put self-funders at risk of being charged for services that should be free.

These amendments would introduce an explicit clause that sets out that, where a local authority provides services on behalf of a clinical commissioning group, the authority may not recover the cost from the individual whose needs are being met. I trust I have set out clearly why these amendments are needed and I hope that the Minister will agree with me.