Care Bill [HL]

Baroness Wheeler Excerpts

Tuesday 9th July 2013 Lords Chamber

[Baroness Tyler of Enfield]

My Lords, I add my support to Amendment 88B and point out that, while it is in the name of the noble Lord, Lord Tyler, on the Marshalled List, it should have my name attached to it.

Both my noble friend Lady Browning and the noble Lord, Lord Touhig, have presented a cogent case. I am not going to say anything other than it is important that we have properly co-ordinated arrangements for the transition process and the assessment as young people move between children’s and adult services. Certainly, like my noble friend Lady Browning, my experience is that far too often, in far too many cases, it is far from seamless.

I also support the three amendments to which the noble Baroness, Lady Meacher, has just spoken on young carers. The separation of adult and children services proves a real structural barrier, in my experience, to supporting young carers. Simply improving guidance and the other methods that have been tried before will not ensure the clear accountability that is needed for supporting the whole family. I know that the Minister has spoken before in Committee about the importance that the Government attach to the family approach—a view that I share—but a recent evaluation carried out by the Children’s Society found that the professionals involved believe that the law must be changed so that there are clearer levers for the provision of care and support in a way that sustains the whole family, and clearer lines of responsibility and accountability for both adult and children services.

We have discussed this both at Second Reading and in Committee. It needs a fully joined-up response and, while I understand and accept the Minister’s argument that most of the heavy lifting, if you like, in this area will be done in the Children and Families Bill, these amendments are needed in the Care Bill to ensure that adults’ needs are met sufficiently so that children and young people are protected from inappropriate caring, and that we have proper joining-up and co-ordination, not simply between services on the ground but between these two important pieces of legislation.

[Baroness Wheeler]

My Lords, the issue of assessment is an important part of the Bill and key issues have been raised which need to be carefully considered by the Government to ensure that the Bill gets these provisions right.

As we know, the Bill extends the right to be assessed for care and support to self-funders and their carers which, in the estimation of major social care charities, will involve nearly 500,000 additional assessments being undertaken by local authorities on top of those for people whose care is provided by them.

We support the extension of entitlement to assessment to self-funders and their carers but we join with noble Lords who are concerned about whether local authorities can possibly carry out this major undertaking in the realities of the current funding crisis and the other duties being placed on them. It is vital that we hear from the Government whether they consider extra resources will need to be made available to support these new duties and whether the noble Earl is confident that the current funding settlement will enable the duties to be performed effectively.

Our Amendments 87J and 88D address the concern that noble Lords and care and support organisations have raised over including in the Bill the requirement—as part of the assessment—to consider whether and to what extent the adult’s or carer’s own capabilities, or any support available from family and friends, could contribute to achieving the outcomes identified in the care plan. It is a very important issue.

Clauses 9(4)(d) and 10(5)(f) were not part of the consultation on the draft Bill, which followed the Law Commission’s advice on making a clear distinction between consideration of care and support needs and how these needs should be met. Support from families and carers should be considered as a way of meeting needs rather than as a reason for deciding the person does not have needs.

The approach in the Bill runs a huge risk of the assessment not recognising the vital contributions of carers and the extent of needs if the carer is unable to provide care. The clauses, as they stand, blur the distinction between an assessment being about what the needs are and the ways of meeting them because they look at how needs can be met other than through the provision of services before any decision about eligibility has been made. They also raise concerns that a carer might be pressured into providing care that they do not feel able to provide—or even that the adult may be pressured into receiving care from a family member. I hope that the Minister will recognise the importance of these two paragraphs being deleted.

Instead our Amendments 92ZZF and 92ZZL propose putting the issue in other parts of the Bill where the vital distinction we are making will be clear. We are seeking to insert new subsections into Clauses 24 and 25 to retain the aim of a capability-based approach being properly considered—in other words one that draws on a person’s own abilities and available social networks. Our amendments would require this process to take place after needs have been defined and not before.

The proposed new subsection refers to the local authority duty to provide information and advice to people not eligible for care and support. It adds to the advice and information requirement to discuss with the person who has been assessed whether they have the individual capabilities or social or community resources that can help them achieve the outcomes they want. Clause 25 deals with the care and support or support plan for people eligible for support, and our amendment again would ensure that the individual’s capabilities and social or community resources are considered at this stage after assessment. This is vital to ensure at least some protection against either the carer or adult needing care being pressured into a caring relationship they do not want, or is inappropriate.

Our Amendments 88P and 88PA deal with the concerns raised under this and in a later group to ensure that assessments are undertaken by persons with expertise, in line with current guidance and practice. Amendment 88P provides for the local authority to be satisfied that the assessment of needs of the adult and carer have been appropriately and proportionately considered by an appropriately skilled or qualified assessor. The intention of Amendment 88PA is to tighten the duty on local authorities to consider preventive support following the determination of eligibility. We want to ensure that local authorities do not use unreasonable justification for refusing to provide or arrange for preventive support and consider what preventive services would or would be likely to benefit an adult.

The current guidance recognises the need for flexibility in certain circumstances on who undertakes the assessment, and this needs to be retained. For example, my local authority is in the last processes of undertaking effectively new assessments of existing clients under the transfer to self-directed support and personal budgets. As noble Lords will know, I am a carer and my partner has long-term health and care needs after suffering a major stroke. Our recent assessment was undertaken by a very competent member of the personalisation team who is not a qualified social worker but a former care assistant, so she fully understood home care support. However, she had access to a qualified social worker care manager for advice to whom we could also refer if we needed. I stress that this was an assessment of a care plan in operation for six years, and under a process that was not originating the plan but viewing it from the personalisation perspective. We both found the new, but demanding process— 44 page forms, as I might have mentioned before—very helpful in giving new perspectives on issues, such as risk when I am not at home or contingency arrangements if I am hospitalised, or fall under the proverbial bus. Most carers just cross their fingers and hope that it would never happen for their own and the cared-for person’s sake, but the assessment experience was a positive opportunity to take stock and a worthwhile experience, which I hope we are still feeling good about when the personal budget allocation comes.

Nevertheless, my point is that the original assessment was conducted by a qualified social worker with full understanding of care requirements for major stroke recoverers, and that assessment has stood the test of time six years on. Had this assessment been a first time assessment, however, it would have been vital to have had a qualified social worker, plus any specialist advice on stroke, if needed. Amendments 88A and 88DA tabled by the noble Baroness, Lady Emerton, require the local authority to involve the relevant health practitioner in the needs assessment for adults and carers under Clauses 9 and 10. We agree that they should be involved where their specialist skills are needed and that this will help ensure better integration of health and social care, and overall better patient care.

I also support Amendment 88 from my noble friend Lady Wilkins, which provides for the local authority to have the same duty under Clause 9 for adult assessments as is given in Clause 10 for carers’ assessments. This is a logical amendment and I hope the Minister will recognise that.

We have also had three important amendments tabled by the noble Baroness, Lady Meacher, which have been added to this group and which we support. These reinforce our messages in the debate in Committee last week on young carers—namely that adult assessments need to meet the needs of the adult, so that children are protected from inappropriate caring. The noble Baroness has stressed how important this is and I look forward to the Minister updating us on the developments over the interface between the Care Bill and the Children and Families Bill in respect of young carers and parent carers.

Finally, I would stress how important the assessment process is. The Government’s discussion document on eligibility recognises that they are an integral part of the system. As we have seen, there are many separate aspects related to assessments, and it is a pity that, in this instance, we have had to lump them all into one big debate. I would therefore urge the Minister, even if he does not agree with the very strong case presented by noble Lords for including these matters in the Bill, to undertake to take the issues of concern away and review this part of the Bill so that there can be full confidence in the legislation underpinning this important issue.

NHS: Association of Medical Research Charities Report

Baroness Wheeler Excerpts

Thursday 27th June 2013 Grand Committee

[Baroness Wheeler]

I, too, congratulate my noble friend Lord Turnberg on securing this debate, especially his timing following hot on the heels of our scrutiny of the Health Research Authority under the Care Bill. My noble friend is a much respected and tireless champion for research and innovation, leading to improved quality care for patients, and we in our party rely strongly on his expertise and support.

My noble friend and other noble Lords from across the House between them ensure that the importance of research and innovation to the NHS is kept to the fore, by this debate and, for example, in recent debates by the noble Lord, Lord Kakkar, on the impact of the EU healthcare in the UK and the concern over the UK losing its global allocation of clinical trials, and in the powerful debate earlier this year of the noble Lord, Lord Saatchi, on medical innovation, which reinforced the need to deal with the regulatory burden, to which noble Lords have referred, and to speed up the availability of innovative treatments.

Like other noble Lords, we welcome the progress on speeding up research approvals made by the HRA through the single portal of entry and single application procedure and bringing together the various research ethics committees. However, the point about the need for progress in getting the local R&D committees of NHS trusts singing from the same hymn sheet is well made and I look forward to the Minister updating us on the action that the Government are taking.

Like other noble Lords, I congratulate the AMRC on its excellent report and the accompanying survey of healthcare professionals’ views on the importance of research to the NHS and to staff working for it. Under the Care Bill, the need for Health Education England to ensure that research and innovation are incorporated into education and training for healthcare staff was a major theme, echoing the Joint Select Committee on the Bill on this issue. All NHS staff need to be able to make use of research throughout their careers and should be equipped with the tools to understand and support research and to assess and use evidence to inform their decisions when caring for patients or supporting clinical staff.

As noble Lords have pointed out, the association’s survey showed the challenges to be faced. The good news was that staff overwhelmingly recognised the value and importance of research, but the barriers to taking part in research, identified by the majority of staff surveyed, including doctors and nurses, was deeply worrying. It is clear that these barriers of lack of time, problems over funding and support and the difficulties of navigating regulation have to be overcome, particularly the need to develop stronger support among GPs to become personally involved in research. After all, they are such an important gateway to spreading the message to get patients interested and involved in research. As my noble friend put it, there is still much to do at the coal face. This is where the ARMC report is so valuable. It offers an authoritative but very practical vision of how the goal of having every clinician a researcher and every willing patient a research participant can be progressed and achieved, as well as how the leadership and support that the NHS staff need can be developed and built into a service-wide research culture.

The case studies in the report are particularly informative, providing examples of excellence and best practice in cancer, arthritis and other key research areas of patient consultation and involvement, and of building staff support and confidence about participating and using research findings so that they can show their patients the benefits of them taking part.

In the context of this debate it is important also to reflect on the progress being made on the UK life sciences and the innovation, health and wealth strategies, the central aim of which is for innovation to become the NHS’s core business. No one reading these reports and the recent one-year reviews can be in any doubt of the dramatic pace and scale of change in the medical and life sciences, such as the breakthrough in genomic medicine, which is changing fundamentally the way disease is diagnosed, prevented and treated, and the progress on regenerative medicine, which are all breathtaking to a lay person such as myself.

There are important developments on the service side, too, as part of the high impact innovation programme, such as in wheelchair design. Can the Minister update the House on progress on implementing the strategies? I could not find any details on the website about further review reports or of the Government’s response to the MHP Communications review of the strategies, which charted good progress but also some continuing problems, including implementation of NICE technology appraisals by NHS trusts and the poor level of awareness of the IHW strategy; only 30% had discussed the strategy at board level. How are these issues being addressed?

Finally, on the association’s vision, I would reinforce the need to keep our foot on the pedal to ensure that we continue to be a world leader in clinical research. We must ensure that CCGs in the absence of SHAs and PCTs continue the focus on research and do not allow it to diminish. The AMRC vision highlights the need for leadership and guidance to CCGs to promote research; to encourage NHS managers so that they understand the value of research and actively support it through their management decisions and processes; and to ensure that all parts of NHS support research, including primary care and all non-NHS providers. I look forward to the Minister’s response updating the House on the Government’s actions to ensure that real progress is made on all these fronts.

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

My Lords, I begin by thanking the noble Lord, Lord Turnberg, for having tabled this debate. He has spoken with both authority and passion about Our Vision for Research in the NHS, the report by the Association of Medical Research Charities. The Government welcome the report; it is a challenging and insightful contribution to the debate on optimising the research potential of the NHS.

It is now more than seven years since the National Institute for Health Research was established in April 2006. The NIHR has a wide-ranging role that is central to our debate today. It provides the framework through which the Department of Health can position, maintain and manage the research, research staff and research infrastructure of the NHS in England as a national research facility. Indeed, together, NIHR people, facilities and systems represent the most integrated clinical research system in the world—driving research from bench to bedside for the benefit of patients and supporting economic growth.

My noble friend Lady Sharp referred to the importance of clinical trials, and of course, that is centre stage for the NIHR. As a result of the NIHR, large numbers of patients have the opportunity to take part in research. In the past financial year, more than 630,000 participants were recruited to trials and studies hosted by the NIHR Clinical Research Network Portfolio, and more than 99% of NHS trusts were involved in the recruitment. During the whole of 2013-14, the NIHR is promoting the fact that, “It’s okay to ask” about clinical research. We want everybody to get involved—patients, medical professionals and the public to support the campaign.

In March 2013, the Government published the revised NHS constitution, which contains a pledge to inform patients of research studies in which they may be eligible to participate. The pledge aims to give people better access to the potential benefits of participating in research studies, including clinical trials. We have already improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I just say to the noble Lord, Lord Aberdare, who spoke very powerfully about pancreatic cancer and the need to enlist more patients into trials for that condition, that the launch of the gateway was promoted through leaflets and other printed materials, including postcards and posters, and the gateway is also being actively promoted by INVOLVE, which is the NIHR-funded patients and public involvement body. In the course of just one month, May of this year, there were 11,570 visitors to the gateway website. Although not all of them will be related to pancreatic cancer, I hope that that gives an indication of the powerful influence that we hope the gateway will have in alerting patients to relevant studies.

Crucial to all this activity is the need to both protect and promote the interests of patients and the public in health research. That is why we established the Health Research Authority in 2011, and provisions in the Care Bill will give it added stability and independence. To my noble friend Lady Sharp I would say that the HRA has a programme of work to enable the implementation of a unified approval process and to support the authority in promoting consistent and proportionate standards for compliance and inspection. The programme includes a feasibility study with a number of pilots to test the effect of rationalising and combining elements of NHS study-wide review with elements of the research ethics committee review into a single HRA assessment. The findings are expected to identify and show how to release the potential to improve both study set-up times and the quality and consistency of ethical review.

The noble Lord, Lord Kakkar, very helpfully acknowledged that enactment of the Health and Social Care Act is a milestone for research in the NHS. It recognises the need to promote research and the use of research evidence and created unprecedented powers and duties at all levels to meet that need. The Government’s mandate to the NHS Commissioning Board—now NHS England—sets an objective to ensure that the new commissioning system promotes and supports participation by NHS organisations and patients in research funded by both non-commercial and commercial organisations, most importantly to improve patient outcomes, but also to contribute to economic growth.

The noble Lord, Lord Kakkar, specifically asked how CCGs will be held to account. The mandate asks for demonstration of progress against the five domains and all the outcomes indicators in the NHS outcomes framework. The framework document emphasises that vital to the quality and delivery of these outcomes will be continued research and the use of research evidence in the design and delivery of services at a local level.

NHS England welcomes the vision for research set out by the AMRC and shares its aspirations to empower patients to take part in research; to engage clinicians and other NHS staff; and to implement research findings to lead to better outcomes for patients and the public. Although NHS England is a new organisation, the NHS—as I do not need to tell the noble Lord, Lord Turnberg—has a strong existing culture of research, although we want to strengthen that culture. There is a wide wealth of research activity already taking place and considerable expertise within organisations. However, NHS England recognises there is further work to do to ensure that all NHS commissioning staff embrace a research culture, which was the theme of my noble friend Lord Saatchi’s excellent contribution, that they have access to research evidence and use it to inform commissioning decisions. It has recently recruited a team to lead the research agenda and develop and implement its research strategy. It is anticipated that a draft strategy will be in place by autumn this year, when extensive consultation with key stakeholders and partners, including patients, will be undertaken.

The noble Lord, Lord Turnberg, and my noble friend Lady Sharp rightly referred to the vital role of clinical commissioning groups within the new system. Through their formal declaration of compliance, all these groups have confirmed that they understand and will comply with their statutory responsibilities regarding promoting research. They have also confirmed that they are committed to following the policy of ensuring the NHS meets the treatment costs for patients taking part in research funded by government and research charity partner organisations. Alongside NHS England, Health Education England has responsibility for promoting high quality education and training that is responsive to the changing needs of patients and local communities. It will work with stakeholders to influence training curricula as appropriate.

HEE will work to build a workforce that is research-literate, with the skills and confidence required to diffuse the latest ideas and innovations. HEE will establish mechanisms to ensure that ongoing engagement takes place with a wide range of partners. This will include building relationships with academic health science networks and academic health science centres to align education with research and innovation. The noble Lord, Lord Turnberg, referred to the role of LETBs, which are responsible for commissioning education and training and securing quality and value from education and training providers. Indeed, they will need to ensure that the education and training that they commission is in line with national objectives, which include building a flexible workforce that is receptive to research and innovation. HEE and the LETBs are working with the NIHR to ensure appropriate investment in education and training, to develop clinical academic careers and to increase the number of staff accessing academic careers programmes across all clinical and public health professions.

I say to the noble Lord, Lord Rea, that the NIHR supports a wide range of programmes for research training and career development. The purpose of these is, self-evidently, to create the next generation of researchers focused on people-based research. The programmes provide support for the academic training paths of all healthcare professionals and other key disciplines involved in health and social care research, including, importantly, general practice. The NIHR is actively building research in general practice—for example, through its School for Primary Care Research. Through its integrated academic training programme, the NIHR has already taken a lead in reversing the decline in clinical academic careers.

The noble Lord, Lord Turnberg, spoke about investing in research, and of course I very much identify with the need to do that. As part of the commitments announced by the Government yesterday to invest in Britain’s future, the department will provide £150 million of capital investment in 2015-16 to fund health research infrastructure in the areas of dementia, genomics and imaging.

As regards clinical excellence awards and the consultant contract, discussions are ongoing between the UK government health departments, NHS employers and the BMA about changes to the consultant contract. The aim is to agree a heads of terms next month and to move to detailed negotiations. I will write to the noble Lord with further details about that.

My noble friend Lord Selborne spoke very powerfully about data from the NHS. One million people have some form of contact with the NHS every 36 hours. That produces, as he rightly said, a staggering amount of data, which can be used to drive forward research into new treatments. The NHS is in a unique position in that sense. We can draw on linked datasets on a scale unprecedented elsewhere in the world. Provided that we ensure confidentiality and privacy for individual patients, the opportunities for research and innovation are vast. In April last year, we established the Clinical Practice Research Datalink, which enables access to anonymised patient records to support the development of novel treatments. I can reassure the noble Lord, Lord Turnberg, that the CPRD is working with the NIHR primary care research network to recruit more GP practices to contribute their data to the CPRD’s data assets.

The clock is moving against me, so noble Lords will have to forgive me if I do not cover all their questions today but I undertake to write to those noble Lords whose points I have not covered—and there are many. I hope that the noble Lord, Lord Turnberg, in particular, has gained a sense of the importance that the Government attach to promoting research in the NHS, and a sense that we need, and have, a whole-system approach to this agenda, which is so vital for the future health and prosperity of our nation.

National Health Service (Direct Payments) (Repeal of Pilot Schemes Limitation) Order 2013

Baroness Wheeler Excerpts

Thursday 20th June 2013 Lords Chamber

[Baroness Wheeler]

My Lords, I thank the Minister for his comprehensive explanation of the background and purpose of the order. We recognise that it is a technical amendment, but this is nevertheless a good opportunity to be updated by the Minister on the consultation on the extension of direct payments for healthcare and how the learning points from the pilots are to be translated into the revised regulations. Labour is fully supportive of extending personal health budgets, having pioneered them in social care through our personalisation and transformation of social care agenda, and set the ball rolling into 2009 on the PHB direct payments pilot.

It was also right to focus on exploring the use of PHBs and direct payments where people had the highest needs, such as those with long-term health and mental health conditions and who access the NHS most frequently. The pilot group covered CIPD, diabetes and long-term conditions, mental health and stroke and patients eligible for NHS continuing care. Labour was particularly concerned that PHBs do not stop at physical health but also include people with learning disabilities.

The national rollout target for PHBs to be extended to 56,000 people by April 2014 is challenging but is necessary to boost the take-up of PHBs across the country, as is the NHS mandate provision for every patient who will benefit to have the option of a PHB by 2015. Is the Minister confident that in the current circumstances, the resources will be available to support achieving these targets?

The pilot evaluation concluded that the majority of budget holders and their carers reported positive impacts of PHBs on patients—on health and well-being, care and other support arrangements for family members. As we know, PHBs have the potential to improve quality of life and satisfaction for both patients and carers, including psychological well-being. Helping patients design packages of care and support from clinicians, primary and secondary care and community health services also helps to provide joined-up integrated care, as the Minister pointed out, and in many instances has led to a reduction in the number of hospital visits. This is exactly where we need to be in terms of future service provision.

As a member—like many Members on all sides of both Houses—of the Westminster Health Forum, I recently chaired a specialist conference on PHBs which was attended by staff, providers and practitioners from across health and social care. The forum conferences are a valuable exchange between experts and staff on the ground including, in this case, those who are part of the multidisciplinary teams supporting and delivering PHBs. There was strong support for PHBs but it is clear, as the Minister said, that we are still very much in a learning process about their development. As usual, as you would expect, there were many questions and answers about some of the implementation, monitoring, accountability and evaluation issues.

I should like to finish by asking the Minister three questions on the issues that arose. First, there were widespread concerns at the conference that the evidence on the impact and effect of PHBs needed to be sharpened up in the future evaluation process. The pilot evaluation showed that there did not appear to be an impact on health status per se. Can the Minister explain whether there are plans in the rollout to assess possible measurements of health improvements, although of course we recognise that these can be hard to achieve in long-term health conditions?

Secondly, a number of GPs at the conference spoke about the challenge of getting wider GP buy-in to PHBs. Can the Minister update the House on discussions with the Royal College of GPs and the BMA on addressing this important issue? The college’s guidance on PHBs was especially commended by conference participants.

Finally, there was widespread concern about how PHBs will be taken forward by commissioners, health professionals and service users. Can the Minister update the House on advice planned or issued by the Department of Health in this respect?

[Earl Howe]

My Lords, this is most definitely one area of policy where all sides of the House are at one and I am grateful to the noble Baroness for her comments. She is right that the pioneering work on social care budgets was carried out during the previous Administration and gave us—and her own Government in 2009—sufficient confidence to institute these pilots for healthcare. I am pleased that she is as gratified as I am that the pilots have been a success, although as I emphasised earlier, we still need to feel our way in rolling them out.

The noble Baroness mentioned specifically people with learning disabilities and I agree with what she said. Although the number of people with learning disabilities involved in the pilot was small, it is clear from their stories that people with learning disabilities and their families benefited from the flexibility and control offered by personal health budgets. As the final report on Winterbourne View identified, personal health budgets have the potential to improve commissioning for people with complex needs and challenging behaviour. Many people in out of area placements, or who are at risk of such placements, are funded entirely through NHS continuing healthcare or have some NHS funding. These groups could be offered personal health budgets as the basis for a person-centred approach, meaning that they could have more control over where they live and the care they can access. It is that kind of intangible benefit—the noble Baroness asked about health benefits—that is very difficult to capture metrically, but it is nevertheless an important factor.

The noble Baroness asked me about resources and whether they will be available. As I mentioned earlier, personal health budgets are not about new money, they are about using existing money more effectively. Funding for budgets will need to be found from within normal NHS allocations and how that is done will be a decision for local CCGs. The personal health budget toolkit contains learning from the pilot programme on this and more information will become available during the early rollout phase as Going Further Faster sites consider sustainability issues. NHS England will be publishing guidance to help CCGs consider how to introduce direct payments for healthcare and personal health budgets on a local level in a sustainable way.

In answer to the noble Baroness’s question about health outcomes, it might be helpful to run through some of the findings from the pilots, which I think show that we can hold our heads up and say that they benefit people. First, we are clear that personal health budgets are cost-effective. They improve or maintain outcomes and reduce costs or are cost-neutral. These results are particularly true for people eligible for NHS continuing healthcare and people with mental health problems. When personal health budgets are implemented so that the person has choice over services and how they receive the budget, the cost-effectiveness increases. People can choose to meet their needs in different ways through lower-cost interventions, for example by training their personal assistants to carry out some health tasks, such as changing dressings. This means that people’s needs can still be met but in a different way, and perhaps in a way which is less stressful for them.

Personal health budgets also clearly resulted in an increase in the quality of life. The study found that effects were greater when people had budgets of more than £1,000, and this generally applies to people who have higher levels of health need, as I mentioned earlier. People benefited more from personal health budgets when there were fewer restrictions in place around what they could spend the money on and how they received the budget—that is, having a choice of a direct payment, a third-party budget or a notional budget. I hope that that is helpful to the noble Baroness in answer to her question.

In answer to the noble Baroness’s further question, I can tell her that the review will include a review of whether the budget is meeting the individual’s needs. That is clearly an important factor. We need to make sure not only that the money is adequate but that the plan itself and the money that goes with it are in step with each other. As regards the Royal College of General Practitioners and wider GP buy-in to personal health budgets, we have been very careful to engage with the royal college at all stages. We met them in conference last week to discuss their role going forward. It is important, as the noble Baroness stressed, that we engage GPs in this process, and I hope that we can continue that active co-operation with them.

Care Bill [HL]

Baroness Wheeler Excerpts

Monday 10th June 2013 Lords Chamber

[Baroness Finlay of Llandaff]

My Lords, for many years in medicine, there has been a move to try to ensure training in the community, but its implementation has been woeful. It has not been instigated as rapidly as people have been campaigning for over many years. I hope that the Government will look favourably on the spirit behind the amendment, although, in an odd way, the wording may be a little too restrictive. It is a very important move to ensure that, as more patients are moved out to be cared for in the community, community services can deliver what they need. With very sick people in the community, a different skill set will be needed from that which is currently available.

[Baroness Wheeler]

My Lords, I support my noble friend Lord Warner’s amendment. There will of course be further debate on integration in the wider context of the Bill, but the amendment is important because it underlines that Health Education England must have the strategic overview and understanding of the workforce requirements across the boundaries of health and social care if it is to undertake its role effectively.

Our stakeholder meetings have shown that there is considerable concern among stakeholders on that issue. They want the links between HEE and the social care sector to be more explicit. The noble Earl’s reassurances last week in that regard concerning Clause 88 were helpful, and I look forward to hearing from him further on how HEE is to work with integrated care delivery. I hope that he will concede that my noble friend’s cross-reference in his amendment to Clause 85 is necessary, because it links the HEE’s duty in Clause 88 to have regard to promoting integration to its key role of ensuring that there are sufficient skilled healthcare workers available.

The Health Education England mandate acknowledges that the future needs of the NHS, public health and care system will require a greater emphasis on community, primary and integrated health and social care. HEE is essential in that. Staff must be trained and developed in the skills that are transferable between different care settings and in working in cross-disciplinary teams in a range of different health and support settings. It must also work closely with the social care sector by developing common standards and portable qualifications across the NHS, public health and social care systems. The local LETB role, linking up with the health and well-being boards, is particularly important in that respect.

It is worth briefly mentioning two recent reports on integration, both of which, among other things, reinforce how much awareness and understanding of each other’s roles must take place for integrated services to happen and to be delivered. The shared commitment statement under the National Collaboration for Integrated Care and Support was drawn up by an impressive mix of national partner organisations, including government departments, the HEE itself, regulatory bodies, the Association of Directors of Adult Social Services, National Voices and other stakeholder groups. It pledges to help,

“local organisations work towards providing more person-centred, coordinated care for their communities”.

There is not time to go into detail, but National Voices’ A Narrative for Person-centred Coordinated (“Integrated”) Care, which sets out what integrated care and support looks like from an individual perspective, for both the cared-for and for carers, is a powerful vision for the future. It underlines how closely staff across primary, community, NHS and social care will have to work if this is to be achieved. The section of the narrative on communication describes professionals talking to each other, and patients always knowing who is co-ordinating their care, always being informed about what is going on, and having one point of contact. This in itself would be nirvana to most patients, service users and carers.

The recently published Nuffield Trust report, Evaluation of the first year of the Inner North West London Integrated Care Pilot, looks at developing new forms of care planning for people with diabetes and people over the age of 75. It underlines the importance of staff having a high level of commitment to the pilot and to the care planning process in particular. Initial results show that work on care planning and multidisciplinary groups resulted in improved collaboration across the different parts of the local health and social care system.

On public health, the HEE mandate itself states:

“The health of people in England will only improve in line with other comparable developed countries when the entire NHS, public health and social care workforce genuinely understands how their services together can improve the public’s health”.

Does the Minister accept that the HEE mandate supports the case for the Bill to include an explicit reference on the overall strategic context?

HEE’s role is to provide national leadership for workforce training, planning and development, ensuring that we have skilled, committed staff in the right place, in the right specialities and numbers. We need to meet these challenges of the future and of the changing face of healthcare provision. How to ensure an integrated approach to education and training across the NHS, public health and social care is a very strategic issue. I hope that the Minister will reassure the House on this by responding positively to the amendment.

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

My Lords, integration between health and social care is a strong theme of the Bill, and the Government take it very seriously. I very much agreed with a great deal of what the noble Lord, Lord Warner, and others said on that topic.

First, to deliver integrated care, it is important that local planning is aligned and is mutually reinforcing. That applies also to the planning of education and training. As Members of the Committee are well aware, the future needs of the NHS and the public health and social care system will require a greater emphasis on community, primary and integrated health and social care than in the past. An understanding is required of working in cross-disciplinary teams and working to break down barriers between primary and secondary care.

The mandate the Government published a couple of weeks ago gave Health Education England a clear remit to ensure that it trains and develops a workforce with skills that are transferable between these different care settings. The amendment of the noble Lord, Lord Warner, seeks to amend Clause 85 to require HEE to have,

“regard to the promotion of integration with care and support provision”,

when it performs its duty under that clause of ensuring that there are sufficient skilled healthcare workers for the purposes of the health service. As the noble Lord is well aware, Clause 88, which lists the matters that Health Education England must have regard to in exercising its functions in Clauses 85 and 87, already includes a requirement at subsection (1)(h) that Health Education England must support,

“integration of health provision with health-related provision and care and support provision”.

Subsection (1)(i) requires Health Education England to support staff to be able to work across different settings. These provisions were added to the Bill at the recommendation of the Joint Committee following pre-legislative scrutiny. Although Health Education England does not have a direct remit for the social care workforce, it will be expected to work closely with the social care sector at local and national level to ensure that workforce plans align with the training and development of the healthcare and public health workforce.

To support the development of this integrated approach, Health Education England needs to work with partners across health and care to develop common standards and portable qualifications. This must make it easier for staff to work and move between settings and should build on existing work, such as skills passports and national minimum training standards. Health Education England will work closely with the sector skills councils, Skills for Health and Skills for Care, nationally and through the local education and training boards, to ensure that workforce development is co-ordinated and integrated.

--- Later in debate ---

[Baroness Jolly]

My Lords, I thank the noble Lords, Lord Turnberg and Lord Patel, for helping me with these amendments. The noble Lord, Lord Willis of Knaresborough, is unwell and may not be returning to us in time to help with the Bill. His twin passions are training and research, and Amendments 37 and 39 to Clause 90, which are all about the functions of LETBs, completely underpin that. I would be doing him a disservice if I did not ask the Minister to explore these areas when he sums up.

It is critical not only at a national level, with HEE, but at a local level, with the LETBs, that this area is not forgotten. Staff must understand not only the implications but all aspects of research. That must be plugged in at HEE and, with these amendments to Clause 90, at the LETB level.

[Baroness Wheeler]

I strongly support this group of amendments, the case for which has been ably made by my noble friend Lord Turnberg, the noble Lord, Lord Patel, and the noble Baroness, Lady Jolly.

The importance to the NHS of research and innovation has come under close scrutiny and debate in the House in recent times, under the Health and Social Care Bill, in the powerful debate of the noble Lord, Lord Saatchi, earlier this year, and in the debate that we almost had in the name of the noble Lord, Lord Kakkar, on the life sciences industry’s important contribution to healthcare and to our economy.

Under the Health and Social Care Act, Labour fully supported placing duties on the Secretary of State, the NCB and CCGs to promote research. Indeed, my noble friends Lady Thornton and Lord Hunt proposed amendments to that Bill reinforcing the importance of research, and we were pleased to work with noble Lords across the House in strengthening these provisions. That is why amendments to Clause 86, which deals with quality improvement in education and training, are so important.

Amendment 17 deletes the current reference to HEE needing to promote,

“the use in those activities of evidence obtained from the research”,

and replaces it with a proactive reference to using this,

“evidence to ensure the rapid uptake of innovations into practice”.

Amendment 20 underlines the need for HEE,

“to secure that research and innovation are incorporated into education and training”.

This was a recommendation of the Joint Committee, which we fully support. All NHS staff should be equipped with the tools to understand and support research and to assess and use evidence to inform their decisions when caring for patients or supporting clinical staff. They also need to be able to make use of research throughout their careers—a point that my noble friend Lord Turnberg made strongly—and be familiar with the NHS research infrastructure, which can provide further help and support.

The recent survey by the Association of Medical Research Charities showed the challenges to be phased in in this regard. Some 91% of staff surveyed, including doctors and nurses, identified the barriers that they had experienced to taking part in research. Lack of time was the predominant reason given by respondents. Other reasons included funding, practical support and difficulties in navigating regulation. GPs are an important gateway for getting patients involved in research, but although a majority of GPs believes that it is important for the NHS to support research into treatments for their patients, only 32% felt that it was important for them personally to be involved. As AMRC emphasises, we still have a long way to go if the Government’s goal of every clinician being a researcher and every willing patient a research participant is to be achieved.

Amendment 32 to Clause 87 adds promoting innovation and research in clinical practice to the matters that the HEE should have regard to—a logical and crucial next step in our support for innovation and research under HEE’s national functions. Amendment 37 on the local functions that LETBs exercise on behalf of HEE makes the important cross-reference between Clause 90 and Clause 86, rather than Clause 84, on the issue of ensuring that there are sufficient skilled healthcare workers promoting research and the use of research evidence in the health service. We believe that if LETBs are performing other duties of behalf of HEE under Clause 90, there is no reason why they should not also promote research, obviously within the LETB area. Amendment 39 would confirm in legislation that HEE’s research duty applies to LETBs as a main function, and we strongly support that.

Throughout the debates on innovation and research, we heard continued concerns and frustrations at the often painfully slow, complex and bureaucratic process of getting innovation in care and treatment adopted in the NHS. There was frustration, too, that existing processes and pathways, such as conditional approval in the named patient schemes and the opportunities under existing legislation, are not being fully used. In the January debate, the Minister reminded us that it took an estimated 17 years for only 14% of new scientific discoveries to enter day-to-day clinical practice. That is why these amendments to ensure that HEE actively promotes innovation and research and carries that through in the education and training of healthcare workers needs to be supported by the Government. I look forward to the Minister’s response.

Care Bill [HL]

Baroness Wheeler Excerpts

Monday 10th June 2013 Lords Chamber

[Lord Rea]

My Lords, I must apologise for not moving this amendment in its proper place on the first day in Committee. That was due to a misunderstanding on my part, and I apologise.

I put down this probing amendment to draw attention to the importance and relevance of interprofessional education in preparing different health and social care staff to work well together. It is recognised across the board that caring for the increasing proportion of the population with long-term problems requires teamwork. This will be more effective and economically efficient if the different members of the team understand the role and approach of other members of the team with whom they need to collaborate, be they social workers, nurses, physiotherapists, pharmacists or doctors. At present, each healthcare worker may have no proper conception of the abilities and skills of those in another discipline, and that may lead to inefficient working, inappropriate decisions and learning by trial and error, if at all. One thinks perhaps of Stafford.

The duty to promote integration is much used in legislation but is mainly directed to administrators at a high level. For example, in last year’s Health and Social Care Act the NHS Commissioning Board and clinical commissioning groups were directed to take note of the need for integration, and in this Bill promoting integration is a requirement on local authorities. In Clause 88, in which this amendment sits,

“HEE must have regard to … the desirability of promoting the integration of health provision with health-related provision”.

The detail of how integration is to be achieved is left to the bodies concerned, although there may well be, and certainly should be, guidance, which I have not seen but which is perhaps to be published later. Perhaps the Minister can fill me in here. My amendment could perhaps be considered when formulating such guidance.

Interprofessional education needs to be carried out at educational or training institutions for clinical and social care professionals but also in continuing postgraduate education. Therefore, it is not only to Health Education England but to the General Medical Council, other professional bodies, royal colleges, universities, postgraduate deans and LETBs that this amendment is directed.

I do not have much time to describe the details of how IPE works, and this is not the right place to do so. Suffice it to say that it is not something I have invented off the top of my head but is a recognised discipline, led in this country by CAIPE, the Centre for the Advancement of Interprofessional Education. It has branches in several countries on both sides of the Atlantic and has produced a number of publications describing the method and the institutions that have adopted it. It has also commissioned several evaluative studies which have confirmed its effectiveness. CAIPE is in touch with the Department of Health, and positive discussions have taken place. The Minister will probably know about them. In fact, I understand that CAIPE is due to meet Health Education England to discuss possible future collaboration. Interprofessional education is up and running in at least five universities, including Leicester, De Montfort, Bristol, Sheffield Hallam and Aberdeen.

I am aware that there are plenty of problems involved in getting different professions to receive co-ordinated education, not least logistics and timetabling. Students may not at first appreciate the need for understanding and co-operation, so do not always take kindly to what they may see as a diversion from their task of learning the skills needed for their chosen profession. However, once they meet each other, understanding can grow. Directors of education need to be convinced of the benefits of IPE. Its benefits are summarised well in a recent WHO task force report:

“After almost 50 years of inquiry, there is now sufficient evidence to indicate that interprofessional education enables effective collaborative practice which in turn optimizes health-services, strengthens health systems and improves health outcomes ... In both acute and primary care settings, patients report higher levels of satisfaction, better acceptance of care and improved health outcomes following treatment by a collaborative team”.

I shall be most interested to hear the Minister’s views on IPE and whether he agrees that it deserves to be more widely used in the National Health Service. I beg to move.

[Baroness Wheeler]

My Lords, I shall make a brief intervention in support of the desire of my noble friend Lord Rea to draw our attention to the importance of interprofessional education if we are to develop health and social care staff’s mutual respect, understanding and knowledge of each other’s professions that will bring about the collaboration, joint working and integration of care and support that we need. My noble friend describes this as staff knowing “how the other half lives”—in other words, staff knowing about each other’s services and how they operate, and being aware of boundaries, interdependence on achieving outcomes and competing agendas. He commends IPE because it provides an established model of collaboration and co-operation on the ground.

The amendment refers back to our earlier debate on integration and the need for multidisciplinary teamworking, and it will also be relevant to the debate that we will come to shortly on the importance of continuing professional development for healthcare workers. It adds promoting the use of joint IPE for clinical and social care staff as a matter that HEE must have regard to in relation to its responsibility for promoting the integration of healthcare and health-related provision.

My noble friend helpfully sent me a considerable amount of background information on his amendment in which, as a former HR professional, I was genuinely interested. It included extensive research by the Centre for the Advancement of Interprofessional Education, which my noble friend referred to, supporting the effectiveness of interprofessional education and training. My noble friend also referred to discussions between CAIPE and Health Education England to explore HEE’s role in taking IPE forward and embedding it in professional curricula. This is to be welcomed. Two-thirds of UK universities with two or more undergraduate programmes in health and social care include IPE, so these discussions will be helpful. These programmes cover a wide range of professions, including nursing, social work, physiotherapy, pharmacy, clinical psychology and radiography—all professions that are increasingly required to work flexibly across different care settings as part of multidisciplinary teams.

The Nuffield Trust evaluation of the first year of the inner north-west London integrated pilot that I referred to earlier underlined the importance of staff in multiprofessional teams having a high level of commitment to the pilot as a key factor in improving collaboration across different parts of the local health and care system. However, the evaluation also reminds us of the international evidence that integrated care takes years to develop and that a minimum of three to five years is needed to show impact in relation to patient experience and outcomes. Culture change, moving from silo to collaborative working among professionals, is a slow process, however committed we are to trying to make it work. I look forward to the Minister’s response to my noble friend’s amendment.

[Earl Howe]

My Lords, if I may say so, the noble Lord, Lord Rea, has explained his amendment in a very compelling way. Amendment 31 seeks to amend Clause 88(1)(h) so that Health Education England must have regard to the promotion of joint interprofessional education of clinical and social care staff where appropriate. As he is aware, much of the ground on these issues was covered in our earlier debates, when I hope I was able to reassure noble Lords that the Government take this issue very seriously. Clause 88 of the Bill, in listing the matters that Health Education England must have regard to in exercising its functions, is clear that Health Education England must support integration between health and care, and support staff so that they are able to work across different settings in health and social care.

In establishing Health Education England with a multiprofessional remit with responsibility for the development of all the professions, the Government have reinforced the importance of planning and developing staff in an interprofessional manner. As I mentioned, this approach is reinforced further in the Government’s mandate to Health Education England, which places a clear requirement on Health Education England, where appropriate, to develop multidisciplinary education and training programmes. I hope the noble Lord will agree that that is very much consonant with the principles that he was propounding in his contribution.

We entirely appreciate the importance of close working between the professions. I am sure that that is something Health Education England will consider carefully. I will write to the noble Lord if I can add any useful detail once I have had a chance to investigate further the issues that he raised and once I have discussed them with my officials.

However, I point out, as the noble Baroness, Lady Wheeler, did in our earlier debate, the importance of the recent commitment entered into by 12 of the national leaders of health and care, who signed up to a series of undertakings on how they will help local areas to integrate services. This was the document Integrated Care and Support: Our Shared Commitment—the first ever system-wide shared commitment. That document set out how local areas can use existing structures such as health and well-being boards to bring together local authorities, the NHS, social care providers, education, housing services, public health and others to make further steps towards integration. The ambition here is to make joined-up and co-ordinated health and care the norm. It works towards the first ever agreed definition of what people say good integrated care and support looks and feels like. That will be developed by national voices. There will be new pioneer areas around the country, to be announced in September of this year. One of the 12 partners of that shared commitment is Health Education England.

I hope that the noble Lord will be reassured by what I have said. I am entirely in tune with the spirit of his remarks. I will be happy to write to him if I have further and better particulars to impart, but for now I hope that he will feel able to withdraw his amendment.

Care Bill [HL]

Baroness Wheeler Excerpts

Monday 10th June 2013 Lords Chamber

[Baroness Wheeler]

My Lords, we support the amendment. Our amendment on this issue relating to Health Education England’s national role in planning education and training for healthcare workers was considered last week. We were, in particular, keen to probe the role that LETBs will play in that important area.

The amendment would ensure that the annual reports of LETBs specify how they propose to support continuing professional development in that area. We strongly support that. The amendment specifies the medical professions, but it is applicable across the healthcare workforce. CPD is about ensuring that structured learning continues throughout one’s career, with clear objectives set and progress logged and regularly reviewed. CPD complements formal training and enables practitioners and other staff to acquire new knowledge and skills, as well as to maintain and improve their standards across all areas of their practice.

The HEE mandate has a small subsection on supporting the professional and personal development of the existing workforce, underlining the importance of HEE leadership and work with LETBs, but that aspect is far from being given the importance that it needs in the mandate—the point made by the noble Lord, Lord Ribeiro. There is of course emphasis elsewhere in the document on the workforce needing to be flexible and receptive to research and innovation, but CPD is wider than just keeping up to date and applies to values, behaviours and the ability to understand how one’s working role relates to the wider service, as we heard during our earlier debate on integration.

I could not see CPD addressed in any depth on the HEE website, although we join other noble Lords in welcoming the general, across-the-board progress that HEE has made in its new role so far. HEE recognises that providing leadership and ensuring greater transparency in the investment that employers make in their workforce and in supporting and championing multidisciplinary and professional CPD is a strategic priority. Does the Minister agree that HEE needs to step up and develop its CPD strategy as a major priority, and does he accept that the mandate needs better to reflect the importance of CPD?

The HEE website also mentions that it will be allocating a limited amount of central funding for LETBs to invest in CPD, particularly for staff employed at Agenda for Change bands 1 to 4 and equivalent staff employed as part of primary care teams in general practice, community pharmacy and other community-based employers.Does the Minister have any further information on how the Government expect HEE to take this forward with LETBs?

Last week I mentioned the recent member survey by the Royal College of Nursing on CPD, showing how varied the time allocated by NHS trusts is. It is worth going into the findings in a little more detail today. The survey found that in the past 12 months almost a third of respondents had received no CPD that was provided or paid for by their employer. By sector, just a third of respondents in the NHS received no training in the past 12 months, compared to just under a quarter of those working in the independent or voluntary sectors. Just over a third said that the amount of CPD provided had decreased in comparison to the previous year, while 45% said that it had stayed the same.

Interestingly, overall, members working in the NHS were more likely than those working in the independent and voluntary sectors to report that the amount of CPD undertaken had decreased. Obviously, CPD is a mix of both employer-supported and resourced training and personal development learning resourced by the individual, either in their own time or with their own money. However, the RCN survey shows a very worrying trend in the importance employers place on providing CPD. Can the Minister comment on this and on how the problem can be addressed in the future? Is he confident that HEE or LETBs will have the resources to address this problem?

Our earlier amendment was similar to the wording that the Government included in the original Bill but subsequently deleted. I am sure the Minister will explain his thinking behind this and, as the noble Lord, Lord Patel, fully expects, delight us all by announcing that he has decided to put the CPD wording back in.

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

My Lords, I make no apology for repeating my firm belief that the staff working in our NHS and public health system are the health service’s most precious resource. We must do all we can to ensure that staff have and continue to have the right values, training and skills to deliver the very highest quality of care for patients.

Clause 93 requires local education and training boards to publish an education and training plan for each financial year. The education and training plan must set out the local education and training board’s proposed investment in its current and future workforce for the following year. Note the word “current” in this context. In developing an education and training plan, the Bill makes clear that a local education and training board must consult with and have regard to the local priorities of, among others, the NHS and health providers and the commissioners that it represents.

The noble Lord, Lord Patel, asked what level of funding is attached to CPD in the NHS. The answer is that investment in CPD is really a decision to be taken locally. As I indicated, local providers and commissioners are best placed to decide what ongoing professional development their staff need. It will be their job to feed that in to the LETB as the local education and training plan is developed. I have already spoken in reply to an earlier group of amendments about the importance of continuing professional development, and the leadership role that Health Education England and local education and training boards can play in supporting this.

The noble Lord, Lord Patel, and the noble Baroness, Lady Wheeler, asked what happened to the reference to CPD in the draft Bill. The answer is that we widened the description in Clause 84(6) so that the Bill states that:

“HEE may, with the consent of the Secretary of State, carry out other activities relating to … education and training for health care workers”.

This still very much includes CPD. I emphasise that we consider this to be an important part of the way HEE may exercise this power. The NHS constitution sets out that staff can expect employers to invest in their development, and that all healthcare providers must take this issue seriously. Employers have a clear responsibility to provide their staff with the support and personal development they need, as well as access to appropriate training to enable them to fulfil their duties. However, Health Education England will play a crucial role in providing leadership in supporting employers in this area. The mandate sets out that Health Education England will work with LETBs and healthcare providers and commissioners to ensure that professional and personal development continues beyond the end of formal training to enable staff to deliver safe and high-quality health and public health services, for now and in the future.

--- Later in debate ---

[Lord Turnberg]

My Lords, the point of Amendment 63, which is in my name, is the need for the HRA to emphasise transparency in the reporting of clinical trials because patients and the public must have confidence that research in which they have been involved will be used in the best way to spread the message for the good of other sufferers. They have to know that results, whether negative or positive, are published. As my noble friend Lord Warner has said, it is particularly important if they are negative, for at least two reasons. First, it is to stop the unnecessary, wasteful repetition of the research by others who are unaware that it has already been done. Equally important is to prevent a bias in reports towards research that shows only that a new drug works when other, unpublished, research shows that it does not. This is particularly important when we consider what is called meta-analysis, whereby an analysis is made of all relevant published reports, brought together to provide a large database on whether a drug works or does not. If only the positive results are reported, we have a biased result at the end, which could result in all sorts of problems.

Open access to research data provides researchers with a much better picture of their field than if research results are held too closely to the chest, perhaps by researchers jealous of their findings or by drug companies fearful of rivals gaining an advantage. It is heartening to know that GSK seems to have learnt the lesson: it is the first pharmaceutical company to lead the way in transparency. Members of the Association of Medical Research Charities make it a condition of their grants that results are published. We are pushing on an open door and we just need the HRA to have some capacity to ensure transparency in NHS research.

[Baroness Wheeler]

My Lords, I support Amendments 58 and 63. It is right for my noble friends Lord Warner and Lord Turnberg and the noble Lord, Lord Patel, to press the Government on this important issue. As we have heard, the Joint Committee proposed including the promotion of transparency in research and ensuring full publication of the results of research—consistent with the preservation of patient confidentiality—in the Bill and we strongly support this.

This is our first opportunity to welcome the establishment of the Health Research Authority as a statutory body and we do so wholeheartedly. We recognise the vital importance of research and innovation to the NHS, the very real progress that is being made in these areas and the scale and pace of change in medical science. The HRA’s objectives not only promote and protect the interests of patients and the public in health and social care research but ensure that it is ethical and safe research, which inspires the public confidence that my noble friend Lord Turnberg spoke about.



Alongside other bodies, the HRA has a key role in promoting transparency, and we acknowledge that its recent guidance on how it will undertake this role sets out important measures that will go some way towards underlining that it takes its duty seriously. These include: gaining approval from research ethics committees before clinical trials can go ahead; a new timescale for registrations; the commitment to work with research funders and sponsors to set the standards for the publication and dissemination of research outcomes; taking steps to facilitate further analysis of detailed data; and plans to look at how patient consent forms can be amended to provide early consent and understanding on how data will be used, as well as how the HRA will be informed of the outcome of study findings.

There is no doubt that the HRA is committed to working with others to overcome barriers to transparency and create a culture of openness. The amendment and Amendment 63, which provide for the publication of research findings “fairly and frankly” and transparency in the reporting of clinical trials, would enshrine the HRA’s commitment in statute, and ensure that clinical research benefits patients and that the findings are available for others to learn and benefit from. As we have heard from my noble friend Lord Turnberg, the advice of the Association of Medical Research Charities to its members to ensure that there is a requirement to publish in the terms and conditions of all their research awards has played an important role in providing greater transparency and would be reinforced by greater HRA authority in this matter.

Finally, like other noble Lords, I received a valuable briefing from the National Advisory Council to the Thalidomide Trust on the need for transparency and a change in the law for the disclosure of clinical and healthy volunteer trial data in relation to the drugs available on the market. The briefing states:

“Adverse effects caused by drugs that are designed to lead to a health improvement can be difficult to prove, and easy for the pharmaceutical companies to dismiss ... At the core of the problem is the fact that the safety assessments of a drug, undertaken in clinical trials done prior to the drug’s launch, remain hidden once the drug is on the market. A patient experiencing adverse effects therefore has no access to data that could be used to prove their claim … the onus is on patients to prove it was a drug that harmed them rather than the company that already holds that evidence”.

The Thalidomide Trust proposes changes to the informed consent form to allow sharing of anonymised data and making data from clinical trials available and accessible to the public once a drug has been released on the market. The trust acknowledges that this is a difficult issue. Have the Government had any discussions with the trust on this matter? I should be grateful if the noble Earl would comment on this, either today or in a written response.

[Lord Phillips of Sudbury]

My Lords, perhaps the noble Earl will tolerate a short intervention. I was for 30 years a trustee of the charity the Public Interest Research Centre. I think I am correct in saying that in the 1970s and 1980s it was the only independent charity carrying out extensive research on the matters under discussion here. I agree with every word said by the noble Lords, Lord Warner and Lord Turnberg, and the noble Baroness, Lady Wheeler. There is, to some extent, a disparity of arms between the huge pharmaceutical companies and the regulatory authorities. Frankly, I see no harm and some potential good in the amendments to try to rectify the balance of power and to avoid a repetition of the example given by the noble Lord, Lord Warner, which is extremely sobering but by no means unique. A number of instances that we confronted in the 1970s and 1980s mirrored that example, if not on quite the same scale.

Health and Social Care

Baroness Wheeler Excerpts

Wednesday 5th June 2013 Lords Chamber

[Earl Howe]

Again, my noble friend asks an extremely good question. The year-on-year success of public health interventions to address non-communicable diseases, for example, will be measured through the public health outcomes framework. The department will incentivise some of the indicators in the public health outcomes framework through the health premium incentive scheme. Some of the indicators that will be selected may contribute to prevention of non-communicable diseases.

[Baroness Wheeler]

My Lords, on social care, the charity Mind has pointed out that many people with mental health problems are never properly assessed to see if they need social services, such as having somebody to help with admin or household tasks, or with washing, dressing or something meaningful to do during the day. Is the Minister confident that the outcomes framework is robust enough to measure this problem, and how does he think that local councils will be able to address this issue in the light of the £2.7 billion cuts that they will have had to their adult social care budgets by the end of this spending round?

[Earl Howe]

My Lords, the adult social care outcomes framework was put together with a great deal of help and support from local authorities, so we hope that there will be a great deal of buy-in to it. It has as its focus high-quality care and promoting people’s independence and well-being, and it enables councils to make comparisons, assess scope for improvement and measure progress against their own local priorities in adult social care. Therefore, the virtue of the outcomes frameworks is, above all, transparency and accountability, leading to improved quality of care as defined locally by councils.

Care Bill [HL]

Baroness Wheeler Excerpts

Tuesday 4th June 2013 Lords Chamber

Moved by

[Baroness Wheeler]

8: Schedule 5, page 107, line 22, at end insert—
“( ) HEE must exercise its functions consistent with the promotion of a comprehensive health service, giving equal consideration to the importance of physical and mental health.”

--- Later in debate ---

[Baroness Wheeler]

My Lords, I shall speak also to Amendment 10. These two amendments seek to make sure that Clause 84 and Schedule 5 specify the responsibility of Health Education England to ensure, throughout its work, the promotion of a comprehensive health service which gives equal consideration to the importance of physical and mental health and the health of people with learning difficulties. This parity of esteem, putting mental health on a par with physical health, must be a key principle carried through HEE’s work and in the education and training of healthcare workers, and it is important that the Bill specifies this. Why is that? It is because the lack of parity continues to have a massive impact. The most recent psychiatric morbidity surveys show that, despite theoretical parity under existing legislation, only a minority of those with a mental disorder in England receive any intervention, in stark contrast to other disease areas, such as cancer, almost all of which have some intervention.

Labour is proud that it introduced the NHS constitution and is pleased that it now has widespread support. However, we acknowledge that it did not go far enough in ensuring that parity of esteem was entrenched into the constitution. This is especially important as the growing number of NHS bodies and organisations established under the Government’s NHS reforms are all required to take the constitution into account in all they do.

Noble Lords will recall that parity of esteem was a hard-fought-for, last-minute inclusion in the Health and Social Care Act. It is vital because it is important to do everything that we can to ensure that this key NHS objective is taken seriously and is underlined at every stage. We welcome the steps in the HEE mandate recognising HEE’s leadership role in this, including a focus on the mental health workforce to ensure that there are sufficient psychiatrists and other clinicians and specialist staff working to build the values and skills to facilitate continuous service improvement, developing training programmes which ensure that all staff have awareness of mental health problems and how they may affect their patients, and ensuring that the mental health needs of people with long-term health conditions are addressed concurrently and not as an afterthought.

We particularly welcome HEE’s leadership role in providing, through LETBs, training programmes to support staff in diagnosing the early symptoms of dementia so that they are aware of the needs of patients, carers and families. Building skills among GPs is especially important in this respect, as we know that patients often go undiagnosed for years. The target for Health Education England of 100,000 staff undertaking dementia foundation-level training by 2014 is a challenging one but it must be achieved if the current appalling level of undiagnosed cases is to be reduced. While focus on dementia is welcome, we must also ensure that other debilitating mental illnesses are addressed with equal vigour.

The lack of parity of esteem for mental health under the current system is widely recognised and acknowledged. The website of the mental health charity, Mind, sums this up well in reporting on the experiences of people with mental health problems. As it says:

“One person told us they get immediate attention for slightly high blood pressure, but face indifference and long waits about their mental health needs unless they are suicidal. Others have told us that they experience far better treatment in A&E for physical symptoms than when they need emergency help in a mental health crisis or for self-harm injuries. This is not acceptable—an emergency is an emergency”.

My noble friend Lord Patel of Bradford reminded us during the debate on the Queen’s Speech that only 13% of NHS funds are devoted to the treatment of mental health issues. Against this backdrop we strongly welcome the Royal College of Psychiatrists’ report, Whole-person Care: From Rhetoric to Reality, commissioned by the Department of Health and the NHS Commissioning Board last year. It sets out how progress on achieving parity of esteem can be made by,

“changes in attitudes, knowledge, professional training, and practice”,

and makes key recommendations to apply across the NHS on equivalent levels of access and waiting times for mental health services, specifically in emergency and crisis mental healthcare.

The RCP report has a number of recommendations relevant to HEE’s remit and role. These include how HEE should as a priority support the development of core skills and competences in health and public health professionals; the need for the General Medical Council and the Nursing and Midwifery Council to review medical and nursing study and training to give greater emphasis to mental health; and integrating mental and physical health within undergraduate medical training. I would welcome the Minister updating the House on what action the Government plan to take on this important report, the timescale for the Government’s response, and how any of the report’s recommendations will be fed into the Bill.

Whole-person care is Labour’s agenda for the future. It would bring together physical health, mental health and social care into a single service to meet all of a person’s health needs. Ed Miliband, in announcing Labour’s commission on whole-person care, emphasised that:

“In the 21st century, the challenge is to organise services around the needs of patients, rather than patients around the needs of services. That means teams of doctors, nurses, social workers and therapists all working together”.

In his landmark speech on mental health last year at the Royal College of Psychiatrists seminar, he acknowledged mental health as the biggest,

“unaddressed challenge of our age”.

He went on to say:

“We have to confront the unspoken discriminations too. Like the vast inequalities in funding for research. Like the lack of training in mental health of many NHS staff – whether in GP surgeries, outpatient clinics or A&E. Eight out of ten primary care professionals say they need more training in mental health than they have”.

Amendment 12 underlines the importance of HEE working,

“with persons who provide health services to ensure an adequate provision of continuing professional development for health care workers”.

That is particularly important in view of the recent findings in a member survey by the Royal College of Nursing, which pointed to a worrying decline in CPD training. The noble Lord, Lord Patel, has an amendment on CPD under the provisions for LETBs, so we will pick up this issue then.

As we progress through the Bill, we will argue strongly for parity of esteem between mental health and physical health to be underlined and specified in the Bill as a guiding principle. When the RCP report on whole-person care was published in March, its president, Professor Sue Bailey, called on government policy-makers, service commissioners and providers and the public to think in terms of the whole person, both body and mind, and to apply a parity test to all their activities and to their attitudes. For Health Education England, this parity test for the planning, education and training of healthcare workers is crucial. Our amendments give force to the HEE mandate provisions on parity of esteem, and we hope they will be accepted by the Government.

[Lord Rix]

My Lords, I support Amendment 10, but I should like to clarify one or two points in the wording. It is possible for a person with a learning disability to have a physical health problem. It is also possible for a person with a learning disability to have a mental health problem. But that is not the main cause or even sometimes the basic cause for their particular condition, which is learning disability. I would therefore have preferred the wording of paragraph (a) of Amendment 10 to have been “learning disability”. The same situation arises in paragraph (b) of Amendment 10. People with a learning disability have a learning difficulty. That is natural. However, there are plenty of people who are not learning disabled who also have a learning difficulty. I would like to have seen Amendment 10 include learning difficulties and learning disabilities, but I actually support the general thrust of the amendment. I hope that if it is accepted the wording of a learning disability can be made quite clear.

--- Later in debate ---

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

My Lords, the health service is dependent on having the right numbers of staff, with the right skills and behaviours. Quite rightly, patients expect the people who deliver health services to be well supported and to have the right professional and clinical skills. To achieve this, we need a system that can attract people with the right values, give them the right career advice, support the development of excellent professional and clinical skills, emphasise the centrality of providing care with compassion, kindness and respect, and ensure a workforce that is responsive to changing needs and innovations in services. That, in a nutshell, is why we have established Health Education England and the local education and training boards.

Health Education England is already established as a special health authority and is already working to put in place requirements similar to those placed on it in this legislation. Establishing Health Education England as a non-departmental public body will ensure that it has the independence and impartiality that it requires to plan, commission and quality-assure education and training for the long term. As an NDPB, it will be accountable to the Secretary of State and Parliament for ensuring that there is an effective education and training system in place. The establishment of Health Education England has been welcomed, I am glad to say, by stakeholders across the health and education system. It has the support of the Health Select Committee and the Joint Committee that scrutinised the draft Bill. It is viewed as an important step forward in promoting the development of the healthcare workforce and driving up standards.

Amendments 8 and 10 seek to ensure that Health Education England gives equal consideration to physical and mental health in the delivery of its education and training functions. I have no quarrel with noble Lords bringing us back to that familiar theme, but primary legislation is not required for Health Education England to give equal consideration to the importance of physical and mental health.

To start with what I hope is an obvious point, in establishing Health Education England, the Government are making clear their commitment to the development of the entire health and public health workforce. One of the significant weaknesses of previous workforce planning and education commissioning arrangements has been the fragmented approach, with responsibilities scattered across different bodies and silo approaches taken to considering the development needs of different professions and services. Health Education England will be different. It will be responsible for the planning and development of the whole workforce, whether in primary care, secondary care, public health or mental health. Although it will retain a strong focus on the development of different professions, it will do so with a multiprofessional remit and perspective that promotes multidisciplinary education and training where appropriate.

I would like to take the Committee back to the Health and Social Care Act 2012, which places a clear duty on the Secretary of State to ensure an effective education and training system for,

“persons who are employed, or who are considering becoming employed, in an activity which involves or is connected with the provision of services as part of the health service in England”—

which is a very wide scope. That duty is very important. It reflects the importance of education and training in the NHS and public health system, and is a key duty underpinning the Secretary of State’s duty to ensure,

“a comprehensive health service designed to secure improvement … in … physical and mental health”.

The Bill delegates the Secretary of State’s education and training duty to Health Education England, giving it a clear and unambiguous remit for workforce planning, education, training and development across England. I hope that that conveys to the Committee the direct legal linkage between this Bill and the 2012 Act in respect of the parity of esteem issue.

Clause 88 requires Health Education England to have regard to the Government’s mandate to NHS England. It is appropriate that the education and training objectives are aligned to service commissioning objectives in this way. It is especially relevant in the context of this amendment because the NHS England mandate requires mental and physical health conditions to be treated “with equal priority” and to,

“close the health gap between people with mental health problems and the population as a whole”.

The Government’s mandate to the Health Education England Special Health Authority reflects this and requires Health Education England,

“to focus on the mental health workforce”.

I listened with care, as I always do, to the noble Lord, Lord Rix. I simply say to him that Health Education England can support better education, training and development for staff so that they can better support people with learning disabilities and difficulties. The core components of education and training for all staff should be to treat people with kindness and compassion and communicate well with all patients and carers. That, I hope, goes without saying, but it is particularly relevant to those with learning difficulties and disabilities. In saying that, of course I recognise that there are certain specialist skills that people in that field require.

Amendment 12 relates to continuing professional development. I absolutely recognise that the continuing professional development of healthcare workers is important. This is enshrined in the NHS constitution, which places a commitment on all employers that supply NHS-funded services to invest in this area and provide their staff with the support and personal development that they need, as well as access to appropriate training to enable them to fulfil their duties.

Health Education England will play a crucial role in providing leadership in this area. The mandate that the Government published only recently for the Health Education England special health authority sends out a clear message that the staff working in our NHS and public health system are the health service’s most precious resource. We must do all we can to ensure that staff have the right values, training and skills to deliver the very highest quality of care for patients. To support the development of the existing NHS and public health workforce, the mandate sets out that Health Education England will work with Local Education and Training Boards and healthcare providers to ensure professional and personal development continues beyond the end of formal training to enable staff to deliver safe and high quality health and public health services, now and in the future. This will include supporting those staff who may wish to return to training.

I hope that those remarks are helpful to the noble Baroness. To cover a number of questions that were put to me, the noble Baroness, Lady Wheeler, asked about the Royal College of Psychiatrists report. We very much welcome the report. The Minister for Health and Care Services will be attending the report’s launch on 19 June and will be setting out what the Government will do to respond to the challenge that the Royal College has articulated.

The noble Lord, Lord Warner, asked what Health Education England will do to address the issue of reliance on locums and agency staff, a very pertinent question. Health Education England can make a significant contribution in this area. Better workforce planning, linked to service and financial planning, is a key aim of the new system that should ensure less reliance on locum and agency staff.

The noble Baroness, Lady Wall, asked me what Health Education England was doing to support career development for healthcare assistants. The capability of care assistants, and public confidence in that group of workers, is of increasing importance. Health Education England will work with employers to improve the capability of the care assistant workforce, including those in the care sector, as well as the standards of training that they receive. Health Education England will develop a strategy and an implementation plan to achieve that, building on the Cavendish review, which will be published quite soon, and on work by Skills for Health and Skills for Care on minimum training standards. The strategy should cover job roles, recruitment, induction, training standards and transparency, as well as identifying opportunities for career progression. I hope that those comments are helpful to the noble Baroness.

[Baroness Wheeler]

I thank the Minister for his thorough response and for his reassurances on the Government’s intentions in respect of parity of esteem. The debate as to whether parity of esteem is inferred or assumed in legislation, or should be specifically included, will continue. We will be strongly supporting this issue as we move through the Bill, with the comments of the noble Lord, Lord Rix, on the need to ensure the inclusion of people with learning difficulties. I am disappointed that the Minister is resisting this issue of inclusion. It would underline the importance of parity of esteem as a guiding principle, ensure consistency with the Health and Social Care Act and reinforce the HEE mandate role in this respect.

Amendment 12 received strong support from my noble friend Lord Warner, the noble Lord, Lord Willis, and the noble Baroness, Lady Emerton. I welcome that. My noble friend was right to underline the particular importance of CPD in the light of the current challenges facing the service. I look forward to the fuller debate later on in the Bill on this. With that, I beg leave to withdraw.

Amendment 8 withdrawn.

Care Bill [HL]

Baroness Wheeler Excerpts

Tuesday 21st May 2013 Lords Chamber

[Baroness Wheeler]

I thank the Minister for his very thorough and comprehensive introduction to the Bill. When the Care Bill was discussed last week in our debates on the Queen’s Speech, there were six overarching themes in the contributions from noble Lords.

First, there was a general welcome for the reform and consolidation of social care law, which we on these Benches initiated and strongly support in so far as it achieves a fairer, simpler and more sustainable system—three factors against which we will be closely testing the Bill through scrutiny and amendment.

Secondly, there was deep concern that this would be at best a partial solution unless a new legal framework is introduced in the context of addressing current and future social care funding needs. Given the scale of this Government’s cuts to local authority budgets, the Bill’s measures put forward in this context risk raising expectations that cannot possibly be met.

Thirdly, the Government’s proposals in the Bill on social care funding do not meet the Dilnot commission’s fairness criteria. Many in care homes will die before the cap at this level is reached; houses will still need to be sold; the cap will not in fact limit the costs that elderly people actually pay for their residential care; and the Bill will not mean that pensioners get their care for free if they have income or assets worth up to £123,000. The squeezed middle—those pensioners on average incomes who have worked hard, proudly invested in a home and tried to save for their older age—risk missing out.

Fourthly, the Bill offers only a partial response to the recommendations of the Francis report to address failures in hospital and care support. What happened at Stafford Hospital was terrible and lessons must be learnt. Last week Jeremy Hunt referred to Part 2 of the Bill as,

“a vital element of our response to the Francis report”.—[Official Report, Commons, 13/5/13; col. 350.]

But in reality the Government have been disappointingly limited in their response to those vital issues identified by Francis. Where is the Government’s response to his concerns over safe staffing levels and the risks to safety and care? Where are Francis’s full proposals on the statutory duty of candour? Where is the regulation of healthcare assistants?

Fifthly, there were concerns that once again, like the Health and Social Care Act, this Bill will not in practice lead to better integration of health and social care. How will the Bill translate this into practice? How will the work of the Government’s consultation on integrated care, launched last week, inform our consideration of the Bill? Will it report in time for any legislative steps to be adopted? How will the institutions of the Health and Social Care Act—the health and well-being boards and Healthwatch England—link in with the care requirements placed local authorities? How will the marketisation and fragmentation of that Act align with any integrating intention in this Bill?

Sixthly, there was deep concern and dismay across the House that the Government have backtracked on vital commitments on public health, particularly on standardised packaging for cigarettes. The care crisis facing this country is not simply one of an ageing population but also one of co-morbidities and many more people living with long-term health needs. Public health plays an essential part in our response to those demographic changes, and is hugely relevant to issues dealt with under Clause 2 and to maintaining well-being.

So, the good news: the Bill is welcomed by Labour as an important first step towards providing a consolidated legislative framework for our social care system based on the excellent report of the Law Commission inquiry set up by Labour in 2009 to streamline and unify social care law. It implements 66 of the commission’s 76 recommendations, refocusing care and support on more patient-centred services better suited to people’s lives and needs, improving access to information and advice, strengthening the legal rights of carers, standardising eligibility criteria and establishing well-being as the guiding principle.

We strongly support that. It takes our work on patient choice and control forward. It builds on the progress that Labour made on key areas such as prevention, personalisation of services and carer recognition and support in our landmark National Carers Strategy. It also addresses much of the unfinished business in our pre-election White Paper on a national care service.

Like other noble Lords, I commend the pre-legislative scrutiny work of the Joint Committee. The Bill enjoys support among patient and carer organisations, staff, and service users and providers, but with the proviso that key improvements are needed to address what the committee itself identified as gaps and risks of unintended consequences. For completeness, we also welcome the proposals on Health Education England and the Health Research Authority, albeit with some significant issues to explore as we progress the Bill.

Now for the not-so-good news. On its own, the Bill will not go anywhere near far enough to tackle the crisis that is engulfing health and social care today. In addition to the crisis in A&E, now acknowledged by the Secretary of State, we have hospitals full to bursting, the discharging of patients becoming ever more difficult, handovers to social care services slower and subject to more disputes and a social care sector struggling to fulfil the demands placed on it. On the front line, thousands of nursing posts have been lost and many services are under pressure. In social care, the recent report of the Association of Directors of Adult Social Services lays bare the scale and severity of the financial squeeze on councils, who, by the end of this spending round, will have been stripped of £2.7 billion from their adult social care services, equivalent to 20% of their care budgets, as demand for services increases.

New rights to services and support risk being meaningless as council budgets are cut to the bone and people are faced with spiralling charges. Will the noble Earl tell the House whether the resources for local authorities to deal with the additional responsibilities placed on them by the Bill, including carrying out the extra assessments of the estimated 450,000 self-funders, will be made available, and whether it will be new money? Is it accounted for in the impact assessment? Is he confident that councils will have the trained staff to complete those assessments on time?

We welcome the delayed consideration of Part 1 until completion of the spending review, but can the Minister reassure the House today that his department has shared with the Treasury the representations of the Care and Support Alliance, which has stressed that,

“without appropriate funding for the social care system … the aspirations of the Bill will not be reached”?

Can he also give a commitment to the House that the regulations associated with Part 1 will be available in draft by the time of our consideration? Without them, our scrutiny of vital issues such as eligibility criteria will be severely hampered.

On Dilnot, it is disappointing that the Government have watered down the commission’s proposals, proposals which Labour believes represent an important step forward in beginning to address social care funding. When he announced the Government’s response to Dilnot, the Secretary of State made great play and emphasis that the plans were “radical” and would,

“transform the funding of care and support in England—bringing a new degree of certainty, fairness and peace of mind to the costs of old age”.—[Official Report, Commons, 11/2/13; col. 592.]

He matched that with a promise that that would guard against someone’s property being sold and their savings wiped out. However, a £72,000 cap—£140,000 for a couple— will not be enough to stop many people with modest properties, especially in the north of England, selling their homes to pay for care. Under the deferred payment scheme, councils loan people money to cover their care costs, which now has to be paid back with interest, most likely by selling the family home after the elderly person has died. Nor will the Bill cap the costs that elderly people actually pay for social care unless differing local authority care charges are addressed, which could make a difference to care now. The cap introduced by this Bill will be based on the standard rate that local councils pay for residential care, which on average is £480 a week; but 125,000 self-funders face weekly bills that on average are £50 to £140 more than this average council rate and in some areas far higher. This extra amount will still have to be paid and not count towards the cap.

The Bill will not mean that pensioners get care for free if they have income or assets worth up to £123,000. People will still get free care only if they have income or assets under the lower means-tested limit that is not being increased and will still be £17,500 in 2017. Those with incomes or assets between this figure and £123,000 will get a sliding scale of support from councils as they do now. Can the Minister confirm that this is the case?

On these Benches we remain to be convinced that the Government can provide answers on these fundamental aspects. Can the Minister not recognise that the Government are overselling what the impact of the Bill’s current provisions will be, particularly bearing in mind that nobody will be benefiting at all until 2020 at the earliest?

Finally, I turn to the some of the other questions that noble Lords will no doubt raise during the Bill’s passage, and I look forward to the Minister’s response to them. Will the change in the legal language around the continuing care and social care boundary of the NHS, shifted by the Bill, result in the possibility of more people having to be means tested for residential care? What are the Minister’s estimates of the number of people who will fall out of the system and become ineligible for support under these proposals? Have the Government assessed the overall impact on disabled users of social care also hit by cuts in their benefit entitlement and support? What consultation have the Government had with the insurance industry and pension providers about the likelihood of markets developing to help self-funders bridge the gap up to the £72,000 cap?

We welcome the introduction of well-being as the guiding principle but should this duty not also be placed on the Secretary of State? On integration and prevention, why does housing still get only limited consideration and mention throughout the Bill? On young carers, when will the Government make their position clear in addressing via this Bill the gap in the law? His colleagues have resisted attempts to amend the Children and Families Bill to this effect. Why have the Government reintroduced the issue of after-care services for people with mental health problems leaving hospital after a period of detention? We thought that this issue was settled under the last health Bill, but it seems not.

Lurking in the background as we speak today is the reality of a social care system on the edge of collapse. Social care is being left to decline. Labour supports the principle of capping care costs, but we stress that a bigger and bolder response is needed by Government to meet the challenges of our ageing population. Whole-person care is our vision for a 21st-century health and care system that brings together physical and mental health, and social care, into a single service to meet all of a person’s care needs. Our independent commission has already started its work on looking at how health and social care services budgets can be brought together. “Integrated services” means not just a series of area or service specific initiatives, but a way of working for a whole service.

We have a major task ahead of us to improve this Bill and we on these Benches will work hard to meet this challenge, and ensure that older and disabled people, and their carers and families, get the best possible deal.

Care Quality Commission

Baroness Wheeler Excerpts

Thursday 14th March 2013 Lords Chamber

Asked by

[Baroness Wheeler]

To ask Her Majesty’s Government what actions they propose to take in the light of the findings of the Care Quality Commission’s home care inspection review Not Just a Number.

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

My Lords, the Government were encouraged that almost three-quarters of the domiciliary care agencies inspected by the CQC for the review were found to be meeting essential standards.

As the regulator of health and adult social care, the CQC has a range of powers to ensure that services are safe and of good quality. The CQC has the Government’s full support to take firm action where it finds services are unacceptable or failing.

[Baroness Wheeler]

I thank the noble Earl for his response and welcome the CQC’s positive findings on the 75% of home care services it inspected. However, the 25% of failing providers are a cause for deep concern, particularly as regards the number of late or missed calls and their complete failure to have systems to document, assess or monitor the quality of care they are supposed to deliver. Where there is a live-in carer, late or missed calls can at least be managed in some way, even if the cared-for person cannot be got out of bed. However, if people are on their own, the consequences are deeply distressing and can be very serious. What information does the department have nationally across the sector about this very worrying issue? What action is being taken to address the problem? Should we not ensure that all providers are required to keep records of the numbers, reasons for and remedial actions taken for missed and late calls, including refunding charges to self-funders or to the local authority?

[Earl Howe]

My Lords, the noble Baroness is quite right: there is no room for complacency in this area. Care has to be right every time, not just three-quarters of the time. I noted from the CQC’s report that, although it recorded a number of common issues undermining the majority of good home care from a significant minority of providers, many of these were fairly minor. However, the noble Baroness has alighted on a very important failing among several of the agencies inspected. I do not have national information on late and missed calls but in the work that we are doing with local authorities, providers and, indeed, the CQC, all of whom share responsibility for driving improvement in services, this will inevitably be an area of focus for it.