Residential Care: Cost Cap

Baroness Wheeler Excerpts

Thursday 10th December 2015 Lords Chamber

Moved by

[Baroness Wheeler]

That this House takes note of the quality and viability of the residential care sector in the light of the Government’s decision to delay the implementation of the care cost cap.

[Baroness Wheeler (Lab)]

My Lords, when I was researching for this very important debate, amid all the statistics, press coverage and reports on the cliff-edge financial state of the sector and the impact of the spending review, the one figure that most stood out showing the frightening scale of the crisis in residential care was the Care England figure of £2.16 per hour. This princely sum is the average fee paid by local authorities in England to care home providers to care for residents unable to pay for themselves. Of course, there are other ways of coming up with an average figure across the sector, but I am sure that none of them would produce a very different amount. Care England represents large and smaller scale residential care providers and, as its press release prior to the spending review put it:

“You can’t provide quality care for £2.16 an hour, no matter who you are”.

According to the Public Accounts Committee, local authorities have faced a 37% overall funding cut in real terms since 2010. They have found it impossible to raise residential care fees to try to keep pace with increasing demand and costs. Data from the residential care industry analysers, LaingBuisson, show that 1,500 care beds have been lost in England this year and that councils gave an uplift in baseline fees of just 1.9%—lower than the estimated 2.5% increase needed simply to keep pace with care home cost inflation. Out of the 166 councils providing information, 53 made no uplift in fees, and the remaining councils had either given increases below the standstill band uplifts, or fee revisions within the standstill band.

The residential care sector is home to 425,000 residents in about 18,000 homes across the UK. One in six residents is over 85 years old, an age group set to double by 2035. Care home residents have a prevalence of long-term conditions, particularly dementia, stroke and diabetes-related conditions. Many residents can have up to six comorbidities. Some 70% of residents in the top three care home providers are publicly funded which makes them especially vulnerable to continuing pressure on council budgets. It is clear, therefore, that throughout the sector self-funders of care help to keep homes viable and in operation.

There is no underestimating the blow for people with long-term health conditions, their families and the providers of care that came from the Government’s decision in July to delay implementation of the cap on liability for care costs for four years. Some 35,000 people would have benefited from the cap immediately. The Government's spending review repeated their commitment to introduce the cap in 2019-20, but with no money allocated. Nor was there a commitment to use fully the previously allocated £6 billion funding allocation for the care cap to ease the growing crisis in day-to-day social care services instead.

Prior to the spending review, there was no shortage of press coverage, providers and social care organisations pointing out the dire state of the sector to the Chancellor. There was the precarious financial state of Four Seasons Health Care—Britain’s biggest care home group providing 21,000 beds in 470 homes. It is reported to be on the brink of financial collapse, struggling with debts of £500 million. Last month it closed seven in its words “loss-making and unviable” homes in Northern Ireland. The group has a looming £26 million repayment instalment due, part of £50 million a year it has to pay to service its debts, which it is currently struggling to do.

There were also two separate joint letters to the Chancellor. The first came from the five largest providers—Bupa UK, HC One, Four Seasons, Care UK and Barchester—warning that failure to raise funding would mean that,

“thousands of older people could be left without a home”.

Secondly, a letter from 15 social care and older people’s groups, including Age UK and the Alzheimer’s Society, underlining the urgent need for more central government funding. They predicted a £2.9 billion funding gap across domiciliary and residential social care by 2020 and that,

“up to 50% of the care home market will become financially unviable and care homes will start to close their doors”.

Finally, there was the very timely ResPublica study of the private residential care sector. It warned that the funding gap specifically for older people’s residential care by 2020 would be £1.1 billion, a third of which will be the cost of the national living wage and which could mean the loss of 37,000 beds. The failure and collapse of Southern Cross two years ago affected 31,000 people. Other private providers eventually provided replacement care for them, although not without huge upset and trauma for the people involved, their carers and families.

As ResPublica points out:

“Given the perilous state of the industry, there is no private sector provider with the capacity to take in the residents who would be affected by the loss of other providers’ beds. Consequently … the worst outcome is the most likely: that the vast majority of care home residents will end up on general hospital wards”,

costing the NHS £3 billion a year.

Moreover, while public attention has been on the large-scale providers, we know that 75 % of providers are, in fact, small, local organisations—small group homes run by small teams of owners and staff or, in many of the smaller homes, just by the owners themselves. The Local Government Association estimates that for residential and homecare contracts the national living wage will cost an additional £300 million in the first year, rising to £834 million in the second. Does the Minister acknowledge that small care homes will be the first to go to the wall if the cost of the implementation is not properly funded by central government? We applaud and welcome the introduction of the national living wage—it is vital to the future of social care, but it must be properly funded.

The spending review offers two solutions to all this, under the ironic heading “A sustainable health and social care system”. The first is to allow local authorities the power to raise council tax by up to 2% in their area from next year, to bring in £2 billion a year; the second is a £1.5 billion allocation from the better care fund for councils to access in two years’ time. This, we are assured in the spending review, will be enough for councils to shore up core services, increase residential care fees and pay for the implementation of the national living wage from April next year for 900,000 care workers. But how can this limited additional funding be anywhere near enough to address the scale of the problem facing us? Can the Minister explain to the House how this can possibly make the current failing social care system sustainable?

I am sure that the Minister will come back with a string of figures on the amount of money that has gone into social care, but the fact is that the detailed analysis from the LGA, the King’s Fund, the Nuffield Trust, the private, charitable and voluntary sector providers and the patient and user organisations such as Age UK, Independent Age and Carers UK all show that this is nowhere near enough. Will he undertake to provide detailed analysis of the Chancellor’s sustainability plan for social care? How much of the better care fund allocation is new money into the system, or is it just money shuffled about the system or taken from the NHS?

Earlier this week, the King’s Fund put the amount that could be raised by councils as, at most, only £800 million per year, which underlines that areas in the north, Midlands and inner London with the greatest need for social care will lose out because they will be able to raise too little income for the increase to have any impact. Care England’s response is that the 2% addition, even if raised across all councils, would not even touch the sides of the problem. The charity Independent Age has calculated that a 10% increase would be needed to plug the social care funding gap, which would of course not be locally acceptable.

Meanwhile, Four Seasons remains in a very precarious financial state. This weekend, we saw reports of the devastating consequences for families and their elderly and frail relatives in its Northern Ireland care homes, which are to be shut down with 12 weeks’ notice. Four Seasons is on course to sell 19 homes this year, which will result in their closure, and it has 12 homes under embargo and barred from taking any new residents until the quality of care improves. Can the Minister reassure the House that an impact assessment has been made, that the situation is being closely monitored and that contingency plans are in place in the event of Four Seasons’ financial collapse? Four Seasons is also selling homes to other providers, so what checks and measures are in place to ensure that the care and well-being of residents is the top priority in such sales? Does he acknowledge that this is likely to be part of a growing trend, as the smaller group homes struggle to survive?

This debate is also very much about the quality of care in care homes and the people who are cared for, their families and carers. This is the first debate focusing on the residential care sector that we have had in this House in recent years. I am most grateful that we have such a broad range of experience and insight among the speakers today, which will ensure that the full range of key issues facing the sector can be addressed, particularly the impact of the NHS on the rest of the sector. The ResPublica report makes a very telling comment. It says that,

“the residential care system … has been overlooked as a partner in the integration of care”,

and in developing person-centred care across the NHS and social care. Its report looks to care homes becoming the agents of early intervention and the management of chronic conditions, preventing those conditions escalating and individuals funnelling in to the acute sector, swamping A&E units and local hospitals.

The NHS Five Year Forward View has a number of care home vanguards—the first time that the sector has had specific projects and funding—which reflect some of this thinking on trying to promote enhanced health in care homes. The projects have tight criteria for joint working and integration with the NHS and social care on care planning, residents’ health and the management of frail and elderly patients. In a number of areas, funding has been partly used to pay a higher fee to care homes so that they can focus on improving care standards and paying staff more, with new and extended job roles. This will mean that they are able to provide the care that ensures fewer residents are admitted to hospital or become permanent residents, rather than being able to go back into their homes after a short period of care following hospitalisation.

The recent CQC report on the state of care shows, as usual, the extent of the excellent care that takes place in many care homes across the country by trained, caring, dedicated nursing and care staff, as well as the reality and scale of the challenges that need to be addressed. The CQC’s five tests—that care is safe, efficient, caring, responsive and well-led—have been used for care home inspections since October last year, focusing on homes for residents aged 65 and over. Of the 300 homes inspected, 50 were rated good but 125 were deemed inadequate and 125 required improvement. Almost half of the homes—49%—were in breach of Regulation 18 on staffing, and a third—32%—fell short of Regulation 13, designed to safeguard service users from abuse and improper treatment.

Staff shortages in nursing and care staff, and the needs to attract the leadership and management which a good care home manager provides and make social care an attractive career for young people and people seeking work, underline the importance of the national living wage. The key training gaps identified by the CQC covered the areas of dementia care, safeguarding, mental capacity and deprivation of liberty safeguards which seek to ensure that the care provider does not restrict the liberty of vulnerable residents. Social care is failing dismally to attract new and younger people into the sector. The National Care Forum’s recent survey showed that just over 11.5% of staff employed in its member organisations are under 25, while more than half are aged 45 or older. These are all issues that the national living wage, if properly funded, can begin to address.

As a carer myself, I would like to see residential care integrated much more into the care plan for people with long-term conditions living in the community, with regular respite care planned, dated and available as part of the care pathway—and as part of the medium and longer-term planning for the person being cared for, not seen as a last resort. Carers UK testifies to how hard it is to book respite care in care homes in advance as part of a planned package of support, because the sector has too much focus on responding to emergency care and placements and cannot give a definite yes if you want a short stay on a specific date. The answer is often “Ring us nearer the time”, which of course is no good at all.

I will end with one case study from my experience as a trustee of our local carer support charity, which sums up the current situation faced in many parts of the country. One of our 73 year-old carers had cared for her husband for four years, through stroke, incontinence and then dementia. She needed a hip replacement. He went into residential care near the couple’s home while she had the operation, but when she came out she realised she could not care for him any longer. He stayed in the care home for two years, publicly funded by the council, with our carer regularly able to visit and help with care and feeding. His incontinence problems got worse and he was catheterised, but frequently pulled the catheter off due to his dementia. District nurses could not keep visiting the home, so frequent hospitalisation took place from the care home until it said it could no longer care for his needs. He did not meet the NHS continuing care criteria and stayed in hospital for months while social services looked for a nursing home near to his wife so she could visit. Finally, he is now in a step-down bed in a nursing home, a specially fully-funded intermediate placement bed at full care home costs to free up an NHS bed. The home meets his needs and his wife can visit him regularly, but he cannot stay there and must be moved in the next few weeks to a social service placement within the council’s baseline fee. The search goes on.

Social care is in dire need of a strategic, ambitious, forward-looking strategy and vision like the NHS Five Year Forward View, which has broad cross-party support and support from stakeholders, even if there is concern and scepticism about how the future plan can be delivered in the face of the realities on the ground. Dumping on councils so that they have to raise the money and then take the blame is not a strategy. As this week’s joint letter in the Guardian from the CEOs of the King’s Fund and Nuffield Trust put it, the spending review provisions are:

“another setback for people who need social care … These are sticking plaster solutions and no substitute for adequate funding”,

that social care desperately needs now.

--- Later in debate ---

[Baroness Wheeler]

My Lords, I thank noble Lords for their contribution. I said in my speech that their experience and insight would produce a very thoughtful and thorough debate and a comprehensive picture of both residential care and the wider social care, and that proved to be the case. It is important to develop a clear view of the role we want the residential care sector to play in integrating social care and I hope this debate has helped that, particularly across the care pathway. There were a number of speakers on that theme. We have debated these things a number of times but this is the first time we have focused on residential care and I think that has been very helpful. Many noble Lords stressed that this debate was about people. My example of my local carer was very much in that vein and other noble Lords gave examples of good care in their own experience. That is very valuable and it is well to remember that. CQC underlines that there are many well-led homes that are caring, safe and efficient with trained and dedicated nursing and care staff, but equally it gives the other side of the picture and the problems that we need to address.

I thank the Minister for his thoughtful response. He did not have a chance to reel off some of the statistics I was expecting. I was particularly looking out for his comment on the assessment from the noble Lord, Lord Warner, that we have seen only £70 million of the £6 billion that was to be introduced for the social care cap. I did not hear that but he is going to write to us and that is very welcome. I was a bit disappointed that he was not able to give us some reassurances on the monitoring that is going on of Four Seasons and other care homes. I understand the need for confidentiality but I think we need to be reassured that the Government are keeping it closely under review, particularly the issue of replacement care. On the care cap, I am glad it is still a postponement. The Public Accounts Committee has called for an urgent and clear timetable on implementation and I think the Government ought to take heed of that. In my view the overall debate has shown the clear need for a strategic, ambitious, forward-looking strategy and I am pleased the majority of noble Lords supported that. With those comments, I beg to move my Motion.

Motion agreed.

Atrial Fibrillation

Baroness Wheeler Excerpts

Wednesday 4th November 2015 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I, too, congratulate the noble Lord, Lord Black, on securing this debate and pay tribute to his work highlighting the importance of early detection and effective management of AF. I also very much welcome the important walk-in clinic initiative he is promoting within Parliament, with AntiCoagulation Europe providing pulse checks to help prevent strokes and blood clots for people with AF, and hope that as many MPs, noble Lords and Parliamentary staff—if they are included—as possible will go along on 10 November.

I am also very grateful for today’s debate because it sets the scene for my own debate on 18 November on the updating of the now eight year-old national stroke strategy. The strategy runs out in April 2017 and today’s focus on AF underlines the priority it needs to have in the future strategy for preventing stroke and reducing the number of people who have strokes that could have been avoided.

As a vice-chair of the All-Party Group on Stroke, as well as being the carer of a disabled partner who had a major brain haemorrhage stroke in 2008, I am sure that noble Lords will understand why most of my remarks on AF will focus on stroke-related aspects. Better diagnosis and treatment through early detection and effective management of AF with an anticoagulant would result in the prevention of more than 4,500 strokes and 3,000 deaths across England each year. Untreated AF is a contributing factor in 20% of strokes in England, Wales and Northern Ireland, and, as we have heard, more complex disability can result from AF-related strokes.

We have heard a number of figures about the scale of the problem. The Stroke Association’s figure, cited by the noble Baroness, Lady Masham, is that an estimated 16,000 strokes could be prevented every year. The association hears many accounts from stroke recoverers about the devastating consequences of poor detection of AF, so it is worth putting on the record just two of those case histories.

David had a stroke at 62 which had a considerable impact on his life. He now has reduced mobility and this impacts on his job as an electrical engineer. David was not diagnosed with AF until after he had the stroke, and when discussing how to reduce the risk of having another stroke caused by AF, his GP seemed keen for him to take aspirin rather than an anticoagulant; that is, clot-reducing medication. However, David conducted his own research and then pressurised his GP into prescribing an anticoagulant drug.

Another stroke recoverer, Brenda, suffered a stroke thought to be caused by AF. She initially had a mini-stroke and was told by the hospital she was taken to that she had had an arrhythmia; there was no mention of AF. She went on to have a stroke 18 months later. Often AF is discovered only after patients are admitted to hospital with a stroke, and obviously by then it is too late. The Sentinel Stroke National Audit Programme found that only 28% of stroke patients known to have AF when admitted to hospital were on the anticoagulant medication they should have been on. The noble Lord, Lord Colwyn, gave this figure as 38%, I noticed.

Significant underdiagnosis and undertreatment remain, despite the incentives mentioned by noble Lords in the quality and outcomes framework, last year’s reissued NICE guidelines and the new quality standard on AF. It is imperative to address the low level of knowledge among GPs of the importance of early detection and the appropriate treatment of AF. The toolkit AF: How Can We Do Better?, developed by the Stroke Association for GPs and others in primary care, is one of a number of key actions that would lead to the increased awareness and understanding that are needed, particularly about the link between AF and stroke. Government support for NHS Improving Quality’s new GRASP-AF guidance on AF risk assessment and stroke prevention within GP practices would also make a significant difference.

How will the Government be supporting these initiatives? Does the Minister acknowledge that if swift and routine pulse checks were included as part of every GP visit, huge progress could be made and thousands of lives saved? Does he agree that the current low levels of awareness among health professionals are not conducive to developing better understanding among the public? Finally, I support the inclusion of indicators on detection and treatment of AF in the public health outcomes framework. Local health trusts need to be assessed on the efforts they are undertaking to prevent strokes and other major conditions that can arise from AF to ensure that vital opportunities to save lives are not missed.

Lyme Disease

Baroness Wheeler Excerpts

Thursday 22nd October 2015 Grand Committee

[Baroness Wheeler (Lab)]

My Lords, I, too, welcome the initiative of the noble Lord, Lord Greaves, in securing this debate, which we hope will play a helpful role in raising awareness and understanding about Lyme disease and facilitate the real progress and action that is obviously needed. Although we are talking about a relatively small patient population, it is important to underline that cases of the disease have quadrupled over the past 12 years, taking into account the latest NHS data and the fact that, as we have heard, many cases are not formally diagnosed or clear up without any treatment. It has been a comprehensive and expert debate and I look forward to the response from the Minister on the number of issues that have been raised. I do not intend to repeat them.

I also pay tribute to the work of Lyme Disease Action. Its developing work and improving relationship with the Department of Health and Public Health England is a sign of hope for the future and is to be welcomed and commended, as is its partnership with the Royal College of General Practitioners in working on, for example, online training for GPs. In particular, LDA’s help desk for patients and medics, helping to document cases, including test information, talking to laboratories about test results and offering GPs a conversation with the medical director, has led to the successful treatment of patients. Surely it is a model that needs to be taken forward across the NHS as it uses the expertise and knowledge built up by the LDA over many years and, if more widely adopted, would go some way towards addressing the lack of awareness about Lyme disease among many GPs and hospital doctors.

As we have heard, early treatment of Lyme disease is almost always successful but the best treatment in late-diagnosed cases is unknown and the resulting disability can become very severe and lasting with, frustratingly, no consensus on approach or treatment. I recently watched a DVD from the charity Canine Partners which showed how an assistance dog helped and supported a wonderful woman called Sue, who was diagnosed with Lyme disease 17 years ago and has suffered chronic fatigue, painful and stiff joints and muscle and back pain since then. I watched it because my partner had a major stroke seven years ago and he has an assistance dog, so I know first hand how helpful and vital assistance dogs can be for people with disabilities in supporting their independence. It would be good if we could all see that DVD now because it underlines the terrible cruelty of the disease for patients in the chronic state. Sue’s assistance dog is trained to wake her up in the morning because her extreme fatigue means that she has no time awareness of how long she has been sleeping; and, if she needs to rest during the day, the assistance dog is trained to keep an eye on her. It supports her in so many ways—by passing clothes to her for dressing, picking up the phone and so on. It is very good to watch that DVD, which shows the impact this terrible disease can have.

Noble Lords have commented on recent press coverage. One of the articles I read as background to this debate commented that,

“few diseases have aroused more emotional attention in the press and the public than Lyme disease”.

We saw this in the recent publicity, with the all main problems identified: the ongoing problems with diagnosis; patients going to private clinics for tests or travelling abroad to seek tests not available in the UK, or desperately searching for countries with greater knowledge and expertise on the disease than in the UK; and the firm conviction by patients that the disease can be transferred from human to human despite the strong scientific evidence so far that it cannot. These patients all felt that treatment for the disease had not worked for them and that is important. The major themes of this debate are about the overwhelming need for more data and research and I look forward to the Minister’s response on that.

On the issue of guidance for UK health professionals, I understand that there is a general acceptance by both PHE and LDA of a need for guidance for health professionals covering secondary care in particular. What discussions has the Department of Health had with PHE and NICE on this and can the Minister commit to ensuring that a work programme and timetable for such guidelines is produced in the near future?

I was interested to learn from someone who has a particular interest in the provision of specialised care—I do not have time to say why—that paediatric Lyme disease is within the scope of specialised commissioning whereas adult Lyme disease appears not to be. Can the Minister shed any light on the background and reasoning behind this situation and agree to look into the matter?

Social Care and Support: Funding

Baroness Wheeler Excerpts

Monday 19th October 2015 Lords Chamber

Asked by

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they propose to take to address the concerns about the availability of social care and support funding expressed in the joint statement Spending Review 2015: a representation from across the care and support sector.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, social care is a priority for this Government, which is why we have established the better care fund to join up health and social care. We recognise that there are pressures on the system and we welcome the joint spending review representations from the care and support sector in helping us to understand these fully. The representations from the sector will help inform spending review decisions. The review will be announced on 25 November.

[Baroness Wheeler (Lab)]

I thank the Minister for his response. I emphasise that this very stark submission to government represents the collective view on the deepening social care crisis from care providers, commissioners and national organisations from across the private, public and voluntary sectors. While understanding that the Minister will not pre-empt the spending review, will he at least reassure the House that, in making the very welcome decision to introduce the national living wage from April next year, the Chancellor fully recognises the estimated additional £2.3 billion cost of this for the social care sector? Does he honestly expect councils to be able to meet this cost if the scale of cuts made over the last five years continues into the future and the Government fail to provide any substantial extra funds?

[Lord Prior of Brampton]

As regards the position of the social care sector, “fragile” is putting it kindly. It is very difficult; there is no point making any bones about that. The increase in the living wage, which is long overdue and very welcome, will add to pressures on the sector. It was made very clear in the Five Year Forward View that the future of the healthcare system is very much tied up with the future of the social care sector. The noble Baroness can be assured that we have brought that to the attention of the Treasury and we are waiting for a favourable result in November.

Social Care

Baroness Wheeler Excerpts

Thursday 15th October 2015 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, today’s CQC report calls on health and social care providers to focus on ensuring that services have the right staff and skills mix to ensure that care is always safe. Does the Minister acknowledge the impact of the funding crisis on residential care and the commission’s concern at the delay in the introduction of the care cap until 2020? Both residential and daycare have high vacancy and turnover rates and a chronic problem in recruiting and training care staff, particularly under-25s. Would it not be outrageous if the Treasury kept the £6 billion and did not use it to try to address those issues?

[Lord Prior of Brampton]

The noble Baroness raises two interesting points. There is a recruitment and a training issue involved in many care homes. This is being addressed by the Government in two ways: first, by raising the minimum wage to the national living wage so that it rises to about £9 an hour by 2020; and, secondly, by the introduction of the care certificate which came out of the Camilla Cavendish report after Mid Staffs, which should improve training in the sector. The funding of local authority-provided care is the issue on which we are awaiting the outcome of the spending round discussions.

Health: Diabetes

Baroness Wheeler Excerpts

Thursday 2nd July 2015 Lords Chamber

[Baroness Wheeler (Lab)]

My Lords, I, too, congratulate my noble friend on securing this debate and on focusing on the key issue of how people with diabetes can be helped and supported to manage their condition. My noble friend has done a great service campaigning for improved diabetes care over a number of years and ensuring that this important issue remains an ongoing focus and priority for this House. As well as playing a significant role in the development of the strategy for diabetes care, he speaks from his personal experience as a diabetic and his contribution therefore is all the more valued and powerful for that.

This has been an excellent, authoritative debate and, at this stage, the stark facts relating to diabetes have been comprehensively covered by previous speakers. The 3.5 million sufferers could rise to 5 million by 2025 unless we are able to make substantial progress on achieving wider access and take-up of the education and management programmes we are discussing today. The most alarming statistics of all are that an estimated 24,000 people are dying each year when better management and care could have prevented their deaths; and that 10 million people are at risk of developing type 2 diabetes.

Like other noble Lords, I commend the excellent APPG report, Taking Control, which shows the way forward for addressing problems of access, availability and quality of diabetes education. I also pay tribute to the work of the diabetes think tank which, as we have heard, brings together key stakeholders and policymakers from the diabetes community. I was not able to attend its meeting this week but I read its pre-meeting documentation underlining the importance of the future plan for diabetes properly addressing the needs of people already living with the condition. That is really what today’s debate is about. Getting a better balance between this and action to prevent people getting diabetes is crucial and there is a wide recognition that in the past this balance has not been achieved. It stresses, for example, that repeatedly linking diabetes with obesity risks stigmatising people with type 2 diabetes and ignoring the needs of people with type 1 diabetes whose condition is not preventable.

The APPG report also underlines the importance of focusing on ensuring that everyone living with diabetes, whether type 2 or type 1, has the necessary skills and support to manage their own health and reduce the risk of devastating consequences and long-term complications. My noble friend Lord Harrison and other noble Lords have outlined the powerful case on the cost effectiveness of diabetes education and the importance of ensuring that the NICE guidelines and technical appraisal programmes on the provisions of education are adhered to. Patient education programmes help people with diabetes to understand more about their condition and to develop the skills needed to effectively self-manage their diabetes, as we have heard from noble Lords across the House.

Recent economic analysis undertaken by the York Health Economics Consortium, for example, showed that the DAFNE course for people with type 1 diabetes will pay for itself within four to five years due to the reduced complication rate expected from improved management of an individual’s diabetes. Patients with type 1 diabetes are monitoring and adjusting their treatments several times a day, making clinically significant decisions, so the absence of attending structured and ongoing education for these patients is particularly serious in terms of reducing the risk of serious complications resulting from poor management.

Noble Lords might have seen a recent feature article in the Health Service Journal which starkly brings this point home. It told of the experience of a 19 year-old student, who after a shock diagnosis of type 1 diabetes, was sent home from hospital with an injecting kit and practically no educational back-up. The result a week later was her first hypo. She said:

“The hospital wanted to see me inject myself before I went home to make sure I could do it. I was given a blood glucose monitor and a strips box, but broke it. I really felt I was on my own and I didn’t know what I was doing”.

It was not until three years later, when she moved to London, that she was offered her first structured education course.

For both type 1 and type 2 diabetes, the APPG report refers worryingly to the mountain of evidence it received from experts—including clinical staff, academics, academic health science networks and strategic clinical networks—calling for what it refers to as,

“the ongoing deadlock in the provision and uptake of diabetes education”.

GPs and hospital staff must be the advocates and champions of structured education programmes, but the APPG makes it clear that a significant culture shift in the attitudes of some GPs and other staff as to the importance and efficacy of the courses needs to take place.

These are key workforce development issues. Many doctors report concerns that aspects of training and development in the delivery of diabetes care beyond the hospital have not caught up with how diabetes care needs to be delivered today and in the future through different care models, and in settings away from hospitals and GP surgeries with multidisciplinary team involvement. For example, the APPG cites advice on identifying and using new diabetes technologies as “patchy at best”. Are the Government confident that Health Education England’s training and development strategies are able to address these key issues? Noble Lords have referred to the APPG’s concerns on the lack of emotional and psychological support and mental health issues, such as anxiety and depression, which are often experienced by people with diabetes. I look forward to the Minister’s response.

The noble Baroness, Lady Manzoor, spoke about the international perspective and particularly the key link between TB and stroke. Like her, I should like to talk briefly about diabetes and stroke in this country. Diabetes is a major risk factor for stroke and one-fifth of hospital admissions are for people with stroke, heart failure or heart attack. Having type 1 or type 2 diabetes almost doubles your risk of stroke and is a contributing factor to 20% of strokes in England, Wales and Northern Ireland. Good management of blood glucose, blood pressure and cholesterol is essential. The Cardiovascular Disease Outcomes Strategy acknowledges the common risk factors and the interlinking nature of cardiovascular disease—including coronary heart disease, stroke, hypertension and diabetes—and the fact that people with more than one CVD condition can often receive care from multiple and different teams in a disjointed way. Managing the diabetes condition in these circumstances can be particularly challenging.

I understand that NHS England is now reviewing the programme of work on CVD, but it is far from clear how they propose to take the Cardiovascular Disease Outcomes Strategy forward. How is the strategy to be implemented and how it will relate to NHS England’s prevention plans, including the National Diabetes Prevention Programme?

Support from carers, families and health professionals is key to successful self-management. People without carers or family support have especially to rely on a consistent and active two-way relationship with the health team members involved in their care. Caregivers play a key role in their family member’s diabetes management. They help the person they care for to make healthcare decisions and to stick to a care management plan. Helping carers to better understand the condition is vital. The access problems and postcode lottery situation in the local availability of education courses affects carers and family members as well as the cared for, so family-focused education is important, as are localised peer support programmes.

When researching for this debate, I saw another article about a young carer. It shows just what family members face in helping to support their loved ones. I am a carer and a trustee for our local carer support group in Elmbridge. The local community magazine reported a very moving interview with a 16 year-old carer who looks after her mother who has diabetes. She said:

“I’ve helped her from a young age, testing her blood sugar level and getting sugary snacks when she needs them. When the disease took its toll on mum’s sight, I also started shopping, cooking, collecting prescriptions. And I support her when she feels down … I love helping mum … but caring comes with responsibility and I often miss out on seeing friends. Plus if mum needs help and I have homework to do, the homework has to wait”.

The five-year forward review promises significant investment by NHS England in self-management and educational courses for people with specific conditions. I look forward to hearing from the Minister how this pledge is to be translated into addressing the challenges and problems for people with diabetes, their carers and families, as raised by the all-party group and noble Lords today.

NHS: GP Clinics

Baroness Wheeler Excerpts

Thursday 25th June 2015 Lords Chamber

[Lord Prior of Brampton]

My noble friend makes a very good point. Health Education England and NHS England have a return-to-practice scheme precisely to do as he suggests, making it easier for those who have temporarily left practice by going overseas, or taken time out, to come back to practice.

[Baroness Wheeler (Lab)]

How does the Minister see the plans for seven-day working going forward in the light of recent data showing that there is growing pressure on surgeries and that practice closures have resulted in one in four GPs now working as locums, who are increasingly forming an integral part of practice teams? Does the Minister see the new models of care and the transformation he refers to embracing these new forms of working, together with partnered and salaried GPs? We often hear the view that local and part-time working, particularly for women GPs, is one of the major causes of GP shortages.

[Lord Prior of Brampton]

The noble Baroness makes a good point. The old model, based largely around partners, often in small practices, is the one that I think will evolve over the next five years. We will certainly see many more salaried GPs coming into the workforce. The fact that there are now many more women doctors, who will wish to take time out to look after their children or for maternity leave and the like, means that the structure of general practice will change fundamentally. It may also mean more locums. I do not have a view on that particular aspect of the noble Baroness’s question.

General Practitioners

Baroness Wheeler Excerpts

Monday 22nd June 2015 Lords Chamber

Asked by

[Baroness Wheeler]

To ask Her Majesty’s Government what plans they have to increase the number of general practitioners.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, my right honourable friend the Secretary of State for Health announced on Friday the first steps of a new deal for general practice. This includes working to increase the primary and community care workforce by at least 10,000, including an estimated 5,000 more doctors working in general practice. We will do this through promoting general practice as a career, increasing training places, encouraging people to return and considering how best to retain staff.

[Baroness Wheeler (Lab)]

My Lords, first, I welcome the Minister to his first Questions in the House. I thank him for his response and for whatever role he played in bringing about Friday’s announcement, ready for this Question. The Health Education England incoming chair recently told the Guardian:

“GP recruitment is what keeps me awake at night”.

Under this new package, will he have to wait until 2020 to get a decent night’s sleep or will the Government take note of the urgent call from the Royal College of General Practitioners for a clear and costed plan, and a timescale for turning it all into reality, so that we can make progress from now onwards?

[Lord Prior of Brampton]

The noble Baroness will know that NHS England recently published its Five Year Forward View, which is a five-year plan for the future. It will encourage much more care, delivered outside hospitals, in the community, and that will require larger input from general practice. I am very pleased to tell the noble Baroness that we are committed to 5,000 more doctors working in general practice.

Care Act 2014 and Children and Families Act 2014 (Consequential Amendments) Order 2015

Baroness Wheeler Excerpts

Thursday 19th March 2015 Grand Committee

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)]

My Lords, this order, while detailed, has a simple overarching purpose: to make amendments to primary legislation in relation to England consequent to new laws already passed by Parliament, primarily the Care Act 2014, but also to a small extent the Children and Families Act 2014, as I shall explain.

Part 1 of the Care Act 2014 is a crucial step in delivering the commitments in the Government’s White Paper Caring for Our Future: Reforming Care and Support. It takes forward the recommendations of the Law Commission to consolidate 60 years of fragmented law into a single statute, refocusing the law around the person, not the service.

The order before us today is part of the final step in this process, disapplying current legislation for England which is to be replaced by the Care Act, and changing references to that legislation in other Acts to reflect the Care Act. For example, many of the core entitlements to social care services included in the National Assistance Act 1948 are disapplied for England by this order because they are to be replaced by the overarching duty and power to meet care and support needs included in Sections 18 and 19 of the Care Act 2014.

The Department of Health and the Department for Education have worked together to ensure that carer provisions have been extended in key areas. Part 1 of the Care Act introduces improved rights for adult carers caring for adults, including to assessment and support. Sections 96 and 97 of the Children and Families Act 2014 amend the Children Act 1989 to introduce significant new rights for young carers and parent carers respectively. These new provisions will work alongside those in the Care Act 2014 for assessing adults to enable services to co-ordinate their approaches to assessment and support for young carers and the people they care for.

This consequential order therefore makes some amendments which are in consequence of the new provisions introduced by the Children and Families Act 2014. Because the previous legislation relating to carers is being replaced by a combination of provisions in these two Acts, it makes sense to deal with the necessary consequential amendments in a single order.

The order also includes some savings provisions which are necessary for the purposes of transition from the old system to the new one. Essentially the amendments in the Schedule to the primary order “turn off” the old law in England but, in respect of those currently in receipt of services, the order enables services to continue under the old law until those people move over to the new system. These savings provisions will work with separate transitional provisions, to be made by another instrument, and will ensure a smooth transition for those currently in receipt of services under the present law.

Lastly, I briefly outline how this order fits into the broader context of statutory instruments under the Care Act. Subject to parliamentary approval of this order, we will, as I have mentioned, be making a further transitional order that will complete the temporary legislative framework for local authorities and partners to move from old legislation to the Care Act. Also subject to approval of this order, we will make a commencement order to formally commence the relevant provisions in the Care Act from 1 April 2015.

We have also laid before Parliament the Care Act 2014 (Consequential Amendments) (Secondary Legislation) Order, which makes similar amendments to secondary legislation as the order before us makes to primary legislation. This is subject to the negative procedure.

I hope that this standard exercise of ensuring legislative coherence will not prove controversial, so I commend this statutory instrument to the Committee.

[Baroness Wheeler (Lab)]

My Lords, I thank the Minister for his comprehensive introduction to the order. As we have heard, it is part of the final steps of implementing the Care Act and related aspects of the Children and Families Act in respect of transition for disabled children into adulthood and on parent and young carers. Contrary to previous form on such Care Act SIs, I do not intend to raise many issues. The SI is very much a technical instrument, potentially complex and involved. However, read in connection with the 2014 statutory guidance to local authorities on implementation and transition to ensure that current services can continue under the old law until the new legal framework applies, it becomes clearer and more intelligible, even to non-lawyers such as myself.

The key imperative, which we strongly support, is for local authorities to be able to manage the transition for existing people receiving care and support services and carers before 1 April 2015 in a practical, case-by-case way. Assessments, care plans and funding arrangements and services agreed under the previous legislation continue unless circumstances have changed, and in accordance with the established review procedures to ensure that arrangements comply with the new Acts.

The Minister knows that we share local authorities’ continuing concerns over capacity and resource issues to ensure effective implementation, and I would be grateful if he could update the House on the latest stock-take survey of local authorities’ readiness and their continuing areas of concern. I understand that the joint LGA/Department of Health/ADASS programme office will continue to monitor and evaluate implementation, as well as co-ordinating the consultation on phase 2 of the Care Act implementation on the care costs cap. I hope that regular updates and information on implementation can be provided over the critical April/May period, and I would be grateful for the Minister’s reassurance on that—even if only up until 7 May.

As the Minister said, the separate transitional order setting out the detail of the circumstances in which the new order is to apply is to follow shortly, so this is especially important. The Department of Health has undertaken to circulate the draft next week via its local authority and other networks before it is formally issued, to confirm the approach for both phase 1 and phase 2 of the Care Act implementation so that it can address some of the recent detailed queries and concerns from local authorities. That is to be welcomed, as I am sure that we all agree that the local authorities need all the help and support that they can get on what is a huge and complex implementation programme.

The department has also undertaken to share the draft with us, and I am grateful for that. However, publishing the final transitional order so close to the date on which the Care Act comes into force will cause considerable difficulties to local authorities. The Minister will know that the order cannot be published until after this SI has been passed in the other place, which will take place next Wednesday. Even if it is published immediately after Commons agreement, that is exactly a week before the changes begin to be implemented and there will be no real opportunity for parliamentary comeback on such a detailed and important implementation document. I recognise that much of the order content will have already been discussed with and communicated to local authorities, but receiving the final authorisation so late in the day presents even greater implementation challenges than already faced. What steps are the Government taking to mitigate that very difficult position?

Two other key issues arise from the statutory instrument. The first is that it formally sets out the position in respect of Wales concerning the Social Services and Well-being (Wales) Act 2014 in relation to adult social care law and to children. The enforcement date of that is currently intended to be 1 April 2016, but that is rightly up to Welsh Ministers. The SI provisions underline that any provisions disapplied in England to make way for the Care Act and the Children and Families Act continue to apply in Wales until such time as Wales brings in the Welsh Act. The Explanatory Note has reassured us that full consultation has taken place with the devolved Administrations in both Wales and Scotland. It also underlines that the order does not contain any provision which changes the current law as it applies to Scotland or Wales, and we welcome those assurances.

The second issue in the SI is in the detail of the Schedule setting out the consequential amendments to existing legislation on the provision of care and support to carers in England resulting from the implementation of the Care Act and the Children and Families Act. That has obviously been a major exercise in cross-government departmental working, and we fully recognise the scale and extent of the task that the department has had to undertake. It is to be congratulated on this work. It is also timely to remind ourselves of the pioneering work described in the Law Commission’s 2008 report, which set out the agenda for the reform of social care law. We have always strongly supported the need to update, consolidate and modernise social care legislation and the key principles of the Care Act, and have been committed to working closely with Members from across the House to ensure improvements and amendments to the Act.

Can the Minister update the Committee on the issue arising from the recent report from the Joint Committee on Statutory Instruments in respect of the drafting of paragraph 95 of the Schedule? The committee has said that the amendments to the Personal Care at Home Act 2010 made by this paragraph are not comprehensive and that consequential amendments are needed. This is an important issue and the department has undertaken to remedy this omission, so will the Minister ensure that the amendments are communicated to all interested parties and organisations as soon as possible?

[Earl Howe]

I am grateful to the noble Baroness. She asked about the local authority stock take. The results of the recent stock take in relation to implementation of the Care Act for January and February reported a positive picture overall regarding local authority preparedness. Specifically, the stock take’s headline findings reported that 99% of councils say that they are very or fairly confident that they will be able to deliver the Care Act reforms from April 2015, compared to 97% of councils in stock take 2 and 90% in stock take 1. Of the four authorities which reported low confidence in stock take 2, three are now fairly confident and one is very confident; one authority has gone from fairly to not very confident.

Seventy-five per cent of councils say that they are on track in 2015-16 in their preparations for the Care Act, the remainder being slightly behind. Confidence has increased on six out of 10 proxy measures from stock take 2 to stock take 3. The exceptions are self-funders, carers’ assessment costs and information, advice and advocacy.

We have already invested more than £5 million in developing a suite of support materials, learning modules and other tools to help councils implement the Act. This is in addition to £23 million of investment in regional and local support that we have provided this year.

The noble Baroness referred to the transition order and regretted the fact that, in her view, it had been published rather late in the day. We set out the approach to transition in the statutory guidance published last October. The joint implementation programme of the Department of Health, the Local Government Association and ADASS has supported transition conversations with local authorities since that time. We do not think that anything in the transition order will have come as a surprise to local authorities.

The noble Baroness referred to the JCSI report, which pointed out that a particular consequential amendment had been omitted from the order. We accept that paragraph 95 of the Schedule to the 2015 order should have amended Section 1(2) to (5) of the Personal Care at Home Act 2010. Failure to do so was an oversight. Those subsections make some prospective amendments to Section 15 of the Community Care (Delayed Discharges etc.) Act 2003. The issue here, however, is that the 2010 Act is not yet in force and there are currently no plans to commence it. The department will ensure that if the provisions of the 2010 Act are commenced, the necessary consequential amendments to Section 1(2) to (5) will be made in the same order using the consequential amendment powers in the Care Act 2014. In summary, while we regret the missed amendment, the omission has no practical effect, and we will have ample opportunity to correct it if the relevant legislation is ever commenced.

Gender-based Violence: Screening

Baroness Wheeler Excerpts

Monday 9th March 2015 Lords Chamber

[Earl Howe]

My Lords, the provision in the Serious Crime Act on controlling behaviour is one of the ways in which we have addressed that. The noble Baroness is absolutely right: abuse can take many forms. It can be physical, sexual, emotional or psychological. Thirty per cent of this abuse starts in pregnancy, and existing abuse may get worse during pregnancy or after giving birth. In the context of health and care services, the challenge is to alert staff to all those possibilities in a way that avoids them stereotyping the person sitting in front of them.

[Baroness Wheeler (Lab)]

My Lords, more than 26,000 women in the UK received HIV care in 2013. What are the Government doing to assess the relationship between women with HIV and domestic violence, so that effective counselling, advice and support can be given to the women at greatest risk?

[Earl Howe]

My Lords, NHS England is working with the Department of Health to identify the right pathways, access to and availability of psychotherapeutic support for victims of sexual abuse and, in that context, the risk factors at play for women who have HIV. It is vital that the support services that we have and the alerts in the system are sensitive to the issue which the noble Baroness raises.