Health and Social Care Bill

Baroness Wilkins Excerpts

Wednesday 16th November 2011 Lords Chamber

[Baroness Massey of Darwen]

My Lords, I shall speak to Amendment 97. I agree with the noble Lord, Lord Ramsbotham, about the need for communication skills, but this set of amendments is really all about improving services for children. It is interesting to note that so much has been said during our debates on the Bill about the importance of the co-ordination of services of all sorts, but I would suggest that nowhere should services be better co-ordinated than those for children. That is absolutely crucial to success. I was interested to read the letter sent by the noble Earl, Lord Howe, after our previous sittings. He kindly circulated a series of paragraphs which stated on children’s issues that:

“We are determined to build in children’s health explicitly and clearly throughout the new system, including through the mandate … We want the NHS to play its full part in safeguarding and promoting the welfare of children and we expect the NHS to continue to improve processes for protecting children”.

I welcome those words, but I will seek further reassurances from him on their validity.

In amending Clause 20, I want to ensure that the Secretary of State will publish an annual mandate specifying the objectives that the NHS Commissioning Board must seek to achieve. This amendment would require that the mandate includes objectives related to improving services for children.

Children and young people are significant players in NHS services. Children account for around 40 per cent of the workload of GPs while making up 19 per cent of the population. Around 26 per cent of those attending A&E departments are children. Every year, about one in 11 children receives specialist out-patient care in hospital, while one in 10 to 15 is admitted for in-patient care. All these are key statistics. However, I suspect that while children and young people make significant use of NHS services, they and their families are often let down by a health system that is incoherent and affords only a low priority to child health services. I want to see this improved. Noble Lords may remember that Sir Ian Kennedy, when reviewing child health services, concluded that there was a,

“varying quality of services … with a large number in need of significant improvement”.

He also said that children were given a low priority when compared with adults, that they often received inappropriate or poor quality treatment or had to travel long distances. He identified a lack of co-ordination between the NHS and other services such as education provision. The question of co-ordination between services is something which comes up all the time. He also pointed out the low investment in services for the early years and a failure to provide safe environments within NHS settings.

I realise that there are particular challenges for children and young people with complex needs. Often little attention is given to how the system delivers for disabled children and young people, but I shall leave it to my noble friend Lady Wilkins to address that. The support group, Every Disabled Child Matters, highlights the range of challenges faced by disabled children and their families in securing good healthcare, but again I shall leave the detail to my noble friend.

The NHS mandate must include priorities for child health. This would ensure that tacking these issues is made a priority within the health service. It is appropriate to include objectives for children's health, because child health services operate on a separate system to those of adults, with separate structures and relevant partners. For example, children receive support from a wide range of child-specific professionals, such as health visitors, community paediatricians, children's nursing services and specialist treatment centres. So again the issue of co-ordinating according to age comes up strongly.

The difference between child and adult health structures is very much demonstrated when disabled young people make the transition from child to adult services, as indeed when other children make the transition to adult services. Without specific objectives for the issues in the system for children's health, there is a concern that the mandate will be ineffective in achieving change for children and young people. So I hope that the Minister will be able to respond positively to this. I suggest that the Government should amend Clause 20 to ensure that the NHS mandate sets out priorities for improving services for children and young people. They should also publish a policy statement setting out how it envisages the revised reforms will deliver improvements for children’s health in general.

[Baroness Wilkins]

My Lords, I speak to the amendments to which I have added my name, and urge the Minister to ensure that speech, language and communications needs are treated as a core public health issue in this Bill.

As the noble Lord, Lord Ramsbotham, said, communication is a basic life skill which underpins everything we do, particularly in this House. Good communication means that we connect with other people; we share ideas, thoughts and emotions and forge the relationships which all people require. Indeed, UNESCO believes that effective communication is one of the 10 core life skills that all human beings should have if they are to thrive.

Speech, language and communication needs are the most common disability experienced by children or adults, with over 20 per cent of the UK population experiencing problems at some point in their lives. These difficulties often start from birth. It is sobering to note that in some parts of the UK, particularly areas of social deprivation, upwards of 50 per cent of children are starting school with poor language skills, and poor language is linked to poor behaviour in young children. Two in every three language-delayed three year-olds have behaviour problems. Problems in later life follow with poorer employment prospects.

The earlier that any communication difficulties can be identified, the earlier solutions can be found, and the earlier help can be delivered. The centrality of communication is why this group of amendments focuses on establishing effective joint working and integrated commissioning for speech, language and communication needs. It requires the NHS to work in close partnership with education providers and local authority children's services. This is by far the most effective way of working. It also emphasises how important it is to deliver help early.

Amendment 81A to Clause 12 requires the NHS Commissioning Board to conduct an assessment of pre-school age children's communication skills. The impact of communication problems and their significance underlines why we believe that their assessment should be directed centrally by the board and not left to the local discretion of clinical commissioning groups. Last year's review of children's services within the NHS conducted Sir Ian Kennedy found that GPs, who will be the lead commissioners for clinical commissioning groups, have little or no experience of paediatrics as part of their professional training. Indeed, GPs often have a limited understanding of children with speech, language and communication needs. Central direction and support from the NHS Commissioning Board is vital in this. Further amendments within the group underline this point by requiring clinical commissioning groups to exercise their functions with a view to improving communication skills in children and young people. They must do so in close partnership with education or children's services. Currently people with speech, language and communication needs all too often miss out due to the divide in commissioning between health and education services.

This divide can mean that resources in terms of skills and equipment are not used effectively. Integration is vital to maintain and improve outcomes. The final two amendments within the grouping also address the necessity for integrated working by the new health and well-being boards when seeking to advance the health and well-being of the local population of the area they serve. If we are to move forward and ensure that all children and young people with communication problems are given the support they need to address them, then I would urge acceptance of these amendments.

--- Later in debate ---

[Baroness Barker]

I thank the noble Lord, Lord Hunt, for drawing attention to a very important point that I think has been missed and in some cases distorted, which is that our debates so far have been about the powers of the Secretary of State and we have ignored a number of other elements that have a direct bearing on that, such as the mandate. That appears to have passed by people like 38 Degrees completely. I thank him for drawing it to our attention but I will resist the temptation to get into the detail of that this evening.

[Baroness Wilkins]

My Lords, Amendment 92A is tabled in my name and those of the noble Baroness, Lady Hollins, and the noble Lords, Lord Rix and Lord Wigley. It would make explicit the responsibility of the NHS Commissioning Board and clinical commissioning groups to be compliant with the public sector equality duty, as set out in Section 149 of the Equality Act 2010.

Section 149 states that a public authority should,

“take steps to meet the needs of persons who share a relevant protected characteristic that are different from the needs of persons who do not share it”,

as part of the duty on it to advance equality of opportunity. This essentially makes provision for such public authorities to be subject to making reasonable adjustments for individuals who may have specific or different needs as a result of factors such as age, disability and religion or belief. In the context of this amendment, the healthcare bodies concerned and the healthcare professionals who work in them would be required to take the necessary steps so as to offer appropriate care to people with these protected characteristics.

In particular, I am speaking about the provision of reasonable adjustments for disabled people, particularly those with a learning disability. People with a learning disability will often have particularly complex healthcare needs and therefore require specialist interventions in order to have them appropriately met. These interventions are about health professionals adopting a change of attitude towards disabled patients and not making assumptions as to their quality of care which would not be made towards non-disabled patients. For example, the use of hospital passports can help to provide key personal information about an individual’s medical details and, as importantly, details about how they communicate so that health professionals can better understand the patient’s individual needs and communication requirements. Additionally, learning disability liaison nurses can help to provide specialist support and guidance to medical professionals when treating someone with complex needs.

These measures are more often than not achievable, reasonable and proportionate, and help to ensure that health professionals are treating disabled patients with the dignity and respect they are entitled to. Whether this is for planned or non-planned admissions, it is necessary for the NHS to make adequate provision for patients with disabilities. This can be achieved through better disability and learning disability awareness training for all staff so that they can better understand the needs of such individuals who may be in their care.

A 2009 poll conducted by ICM on behalf of Mencap found that a third of healthcare professionals have not been trained in how to make reasonable adjustments for a patient with a learning disability.

At this point, Baroness Northover continued the speech for Baroness Wilkins.

This can lead to poor treatment and can exacerbate existing healthcare inequalities. The same ICM poll indicated that almost half of doctors and a third of nurses said that people with a learning disability receive a poorer standard of healthcare than the rest of the population. The Mencap report Death by Indifference in 2007 also revealed the premature and avoidable deaths, in the NHS, of six patients with a learning disability. Since then, a further 60 families have been in contact with Mencap with similar experiences to this. It is therefore particularly important for the NHS Commissioning Board and clinical commissioning groups to be fully aware as to their responsibilities and obligations under the public sector equality duty.

It is very important that disabled patients and their families can be expected to be treated in the NHS without being the victims of prejudice and discrimination. The amendment tabled in my name and others’ sets out specifically the requirements on these bodies to adhere to the public sector equality duty. They would safeguard disabled patients against malpractice, mistreatment and neglect in the NHS.

[Baroness Hollins]

My Lords, I am delighted to have this opportunity to support the amendment of the noble Baroness, Lady Wilkins. The noble Baroness has eloquently put forward the case for reasonable adjustments and has given good examples of reasonable adjustments that people need and why they are so important for people with a learning disability. I fully endorse her sentiments on this issue. I am also speaking for my noble friend Lord Rix, who was unfortunately unable to stay this evening.

It is vital, under the new arrangements, that health professionals and the various health bodies that will be created are fully aware of their legal responsibilities when treating disabled patients. As the noble Baroness said, this is particularly relevant for people with a learning disability who continue to experience large health inequalities and who are at a disproportionate risk of experiencing epilepsy, mental health problems and premature death. Not only do people with a learning disability experience poorer health outcomes, but they also receive fewer routine immunisations and blood pressure checks and have poorer access to cervical and breast cancer screening programmes.

In response to an earlier group of amendments to this Bill, tabled in the name of the noble Lord, Lord Rix, on day 3 in Committee, the Minister gave many assurances as to why it was not necessary to mention disability or learning disability specifically in the Bill. He cited NICE quality standards, Monitor, the NHS outcomes framework, Clause 12 of this Bill, clinical advisory groups, the duty of clinical commissioning groups to involve and consult people “appropriately”, the annual report by the Secretary of State and, above all, the public sector equality duty.

My noble friend Lord Rix and I are both extremely grateful to have heard all of these assurances, put forward by a Minister who is both sympathetic and determined to be as helpful as possible. But we cannot imagine patients with a disability, especially those with a learning disability, being conversant with all these facts, and perhaps even having to visit their GP or local hospital with a vast compendium of their entitlements tucked under their arms to place in front of the health professional—who, as we know, may have been inadequately educated in their responsibilities with respect to the requirement to make reasonable adjustments—before they receive adequate and correct treatment.

The amendment of the noble Baroness, in one simple and effective move, would bring together all of the Government’s good intentions in this area and remove any ambiguity or uncertainty, by making it 100 per cent clear as to the importance of public bodies in the NHS meeting their obligations under the public sector equality duty, not just for disabled people, but for all of the protected characteristics.

The Minister stated in reply to earlier amendments by my noble friend Lord Rix that the Government’s starting point,

“is that people with a learning disability are people first”.—[Official Report, 7/11/11; col. 18.]

He will not be surprised to hear that my noble friend and I fully concur with that view.