National Health Service

Baroness Wilkins Excerpts

Thursday 8th January 2015 Lords Chamber

[Baroness Wilkins (Lab)]

My Lords, I thank my noble friend Lord Turnberg for securing this debate. I want to concentrate on the future of the spinal cord injuries unit. I declare an interest, having been spinal cord injured at university in the 1960s. Last year, I returned to the national spinal injuries centre at Stoke Mandeville Hospital to do four months of unsolicited in-patient research, having broken both my legs. The scene is depressing. I found that the speciality in which we led the world is pinched and demoralised. The result is a pointless waste of NHS money as well as of precious lives. Even in this sorry state, the relief to have been found a bed there after 10 days in a general hospital was overwhelming. I cannot thank the noble Earl and my noble friends enough for all their appeals to secure me that bed. Such help should not be necessary, but I will be undyingly grateful.

It is tragic that the demand for the spinal injury service far outstrips the supply, yet bed numbers have been and continue to be cut, leaving newly injured people in district general hospitals. Twelve spinal beds at Stoke have been changed to general use since September 2013 and, despite continual assurances, have still not been returned. Nationally, as of 6 January, 151 newly injured people that we know of are being treated in general hospitals by non-specialist staff, at the risk of developing complications such as urinary tract infections, pressure sores and psychological difficulties. The most vulnerable patients are those high-level tetraplegics who need ventilation to assist with their breathing. Currently, 19 ventilated patients are waiting to be admitted to specialist care, with an average waiting time of six weeks. Their intensive care beds cost around £1,500 per night, 50% more than a ventilated bed in a spinal unit.

Delayed discharges badly frustrate the optimal use of spinal units. The situation at the Salisbury Odstock spinal unit is not unusual. One patient has been awaiting discharge for more than two years, and another for more than a year. They are occupying spinal beds that cost £500 to £600 a night. We know that the drastic cuts to social care and the appalling lack of accessible housing have caused bed-blocking but, as I found, so has the intransigence of the CCGs. To protect their own budgets, CCGs refuse to accept the spinal centres’ advice and insist on their own assessments when the patient is almost ready for discharge. A completely unnecessary delay then ensues in organising care packages and essential equipment. In some parts of the country the local CCG will not even take the unit’s advice on providing the appropriate wheelchair. Instead, a patient has to be transported, with an escort, to their local wheelchair centre, with all the costs that that involves. As a result, there are considerable delays and in some cases rehabilitated patients have even been discharged home on stretchers to wait for a wheelchair at home—what a waste.

The situation with delayed discharges has now reached such a critical level that the All-Party Group on Spinal Cord Injury is about to conduct an inquiry into the causes and to make recommendations. I ask the Minister, first, to support that inquiry and, secondly, who now is in a position to be able to do something about this? The spinal centres have no power to compel the CCGs to address these issues; neither, it appears, does NHS England.

NHS England directly finances spinal injury as a specialism but the money is not ring-fenced. The centres will tell you that up to half their budget is absorbed by their host trust before it reaches them. Would it not be better if the NHS funding went direct to the spinal centre, which could then pay the host hospital for the services it uses?

Underlying all these issues is a general downgrading of spinal cord injury as a specialism in its own right, which must have Ludwig Guttmann turning in his grave. Currently there are consultant vacancies right across the service due to the lack of suitable candidates. Sadly, once we aligned our specialist medical training with Europe, spinal cord injury became part of the medical specialism of rehabilitation rather than a specialism in its own right. There appears to be no clear mechanism to ensure sufficient numbers of spinal consultants or adequate nursing staff and therapists to meet the need. Is anything being done to change this?

At Stoke Mandeville the trust has merged the spinal unit into a specialised services directorate along with haematology, pathology, sexual health and miscellaneous others. As a result, the spinal unit is managed by senior managers who have no knowledge or experience of working with spinal cord injury. I found that the staff feel neither valued nor supported. As a result, key staff have left, with the loss of their invaluable specialist knowledge, skills and expertise. When we have such a shortage of staff, surely it is vital to retain the ones we have.

Finally, whichever party wins the general election, will the new Government recognise that our world leadership role in this area of specialist medicine is now being sacrificed because the management of the service is driven by concern with local issues? Will they develop a strategic vision once again to keep the UK in the forefront of the care, treatment and rehabilitation of people with spinal cord injuries?

Independent Living Fund

Baroness Wilkins Excerpts

Monday 12th May 2014 Lords Chamber

[Earl Howe]

My Lords, the noble Baroness will know that she and I had a very useful meeting last week and I, with my honourable colleague Norman Lamb, undertook to her that we would give that proposal serious consideration, which we will certainly do. I will be in touch with her in the coming weeks to arrange a further discussion about this. We are absolutely committed to co-production in this and to involving stakeholders wherever possible.

[Baroness Wilkins (Lab)]

My Lords, given that the Government have set the national eligibility criteria at a level that will not provide sufficient support for independent living, will the Minister say whether and how the Government will monitor the level of unmet need of the transferred ILF clients if elements of their package are not eligible for local authority funding?

[Earl Howe]

My Lords, 94% of ILF users receive support from both the ILF and the local authority. Local authorities will assess those who are transferring from the ILF. If a person is assessed as not having eligible needs, the Care Bill provides authorities with a power to meet those needs, and they do so. Authorities should also advise on what preventive services, information or advice, or other support may be available in the wider community to help them achieve their particular outcomes.

Care: Older People

Baroness Wilkins Excerpts

Wednesday 7th May 2014 Lords Chamber

[Earl Howe]

My Lords, as the noble Lord is aware, specialised services are the responsibility of NHS England. We have charged it in the mandate and through regulations to make sure that there is comprehensive specialised cover for mental health services and other services throughout the country. For less specialised services, we expect the parity of esteem principle to apply, and CCGs are being held to account by NHS England to achieve that.

[Baroness Wilkins (Lab)]

My Lords, what is the Minister’s response to the recent Nuffield Trust report, which warns that the Government are now “flying blind” in planning services for vulnerable older people because there is no way of assessing the true impact that social care cuts are having on their lives? Does he agree that the recent abolition of the Independent Living Fund, with no ring-fencing of the transferred resources, will only exacerbate the social care crisis?

[Earl Howe]

My Lords, the Government are not flying blind on this issue. Social care has remained a priority for us, which is why in every year since 2011 we have invested significantly from the NHS into social care, and with a health benefit, as I mentioned earlier. That has enabled councils to give relative protection to social care in implementing their savings. The noble Baroness shakes her head, but the figures are very clear. Spending on adult social care services has been protected to a much greater degree than other service areas. One cannot expect them to be wholly protected. Local authorities have reduced spending on other services by a good deal more than they have on adult social care services.

Ageing: Public Services and Demographic Change Committee Report

Baroness Wilkins Excerpts

Thursday 17th October 2013 Lords Chamber

[Baroness Wilkins (Lab)]

My Lords, I, too, congratulate my noble friend Lord Filkin on securing this debate and on his committee’s excellent report warning us that the Government and society are woefully unprepared for the ageing of the UK population.

Like many fellow noble Lords, I am one of that cohort known as the baby boomers. However, we have not just arrived; we have been around a long time—long enough for successive Governments to prepare for. By 2031, I shall be 85, when there will be twice the number of people of that age than in 2010. Yet, as the report says,

“no government so far has had a vision and coherent strategy”,

to ensure that our society is ready for ageing. Government, central and local, can no longer keep their heads buried in the sand.

It is the report’s reflections on loneliness and isolation on which I want to concentrate today. Citing the deleterious impact of loneliness on the quality of life and the health and well-being of the old, the report sees this as,

“one of the biggest risk factors for people needing care and support”,

and the group most affected is older women who mostly live alone.

In their response to Ready for Ageing?, the Government acknowledge the huge impact of social isolation and persistent loneliness on people’s health and well-being in later life. However, they then go on to suggest technology, touch-screen tablets, e-mails and video conferencing as a remedy. This surely was dreamed up by a 25 year-old, totally unaware of the realities of being an 85 year-old woman living on her own in frail health in 2030. Loneliness requires human contact, touch and empathy, and the everyday stimulus of news and gossip. It requires people whose presence does not depend on the state of a local authority’s budget.

I have spoken a number of times in this Chamber about cohousing—a way of living that combines today’s aspiration for the autonomy of our own home with being within a supportive community. It is a model well established in continental Europe, where senior cohousing communities are encouraged by various Governments also faced with rapidly ageing societies. They are based on a range of ages over 50 and are a self-help model—fundamentally a means of prevention, harnessing the energies of younger cohorts of older people to address their own futures and help others.

I declare an interest in that I am a member of Cohousing Woodside, a group working with Hanover Housing Association to develop a senior cohousing community in Muswell Hill. I am also partner to one of senior cohousing’s main advocates in the UK.

I first spoke of the struggle to establish senior cohousing in the UK in the debate on the Queen’s Speech in 2003, mentioning OWCH, the Older Women’s Cohousing project, a low-income group of women Londoners aged between 50 and 80, all living alone. For five years they had been meeting regularly, building the social capital which is the essence of cohousing. They aimed to be, and are, a living demonstration of how older people can band together to address the challenges of ageing. My noble friend Lord Warner, then the Minister, was very encouraging in his reply to the debate. But that was 10 years ago, and those people are still waiting for their homes to be built. One of the founder members is now 84, and living up a flight of 27 steps. Thankfully, Hanover Housing Association has seen the benefits of cohousing and taken action. It is now about to build the OWCH community in Barnet, the first senior cohousing community in the country, due for completion in 2015. In what will be an age-proofed, low-energy, lifetime homes standard environment, which they will manage themselves, they will operate as friendly, supportive neighbours. This insightful initiative by Hanover sets an example that others should follow.

This model of cohousing deserves much greater official support and encouragement in a housing and planning system where the cards are totally stacked against it. Hanover’s enterprise in promoting it is to be applauded and lessons need to be learnt from the 14 groups around the country struggling to develop senior cohousing. The authorities must be shaken out of their torpor by the report of the noble Lord, Lord Filkin, and start to take radical action. So much could and should be done. The Government could do much to offer incentives to developers and local authorities. For instance, they could provide public land from public housing sites.

Cohousing is obviously not the answer to societal ageing, but it is one answer, and one that makes full use of the assets of our older population.

Care Bill [HL]

Baroness Wilkins Excerpts

Monday 29th July 2013 Lords Chamber

Although I have gone on for quite a while, this is but a brief summary of a highly complicated case. Putting together the various elements reveals the dangers that we are walking into—dangers of which only some people appreciate some parts. A proper and detailed OBR investigation of the facts and the trends would throw enormous light on this issue and, even more importantly, lead to action.

[Baroness Wilkins]

My Lords, I, too, speak in support of the amendment in the name of my noble friend Lord Warner. I have said before that I warmly support the principles behind the Bill and the modern framework that it provides for social care. However, there is a world of difference between principle and delivery, and many things determine that difference.

Money is not everything, but the lack of it can mean the difference between certain misery and a chance of happiness, between one’s health deteriorating at an unnecessary rate and being maintained at its possible best, and between mere existence and feeling wholly human. Little will change for the better unless social care is adequately funded—and not just by funds transferred from an increasingly strained health service. As has been reiterated many times throughout the debates on this Bill, social care is in crisis. In the past few years, as the Care and Support Alliance has shown, many tens of thousands of people have lost vital services as a result of tighter eligibility criteria. Their needs have not changed; they have simply been redefined out of care, leaving them in many cases more isolated and, in some cases, at greater risk. The strain on family members has also increased as a result.

At Second Reading I raised the fears of the more than 20,000 disabled people with high support needs who have been funded by the Independent Living Fund to live independent lives. They fear a return to institutional care now that the fund has closed and the funding responsibility transferred to local authorities. I asked the Minister then for a reassurance that their fears were not justified and that the transition funding would not finish after one year. Sadly, he was unable to give any such reassurance, so the situation for more than 20,000 severely disabled people threatens to become much worse. As we know and have already heard, local authorities have been required to implement swingeing budget cuts for some time, most recently a cut of 10%. Can the Minister give that reassurance now? His department must have calculated the funding that local authorities require.

On 18 July, the Government launched the Caring for our Future consultation on reforming what and how people should pay for their care and support. This important document is over 100 pages long and covers a complex set of questions that are difficult for most of us to get our heads around unless we are specialists in the field. What plans do the Government have for making sure that people using care and support services and their carers are fully involved in the consultation and given the necessary information and support to make a constructive contribution?

There is no doubt in my mind that we must take a clear-eyed look at what funds would be sufficient for the aspirations of the Bill to be delivered. If we are to meet this once-in-a-generation opportunity to craft a care system that meets the real current and future challenges, we should remember that by 2030 the number of people aged over 85 is set to double; that is, a 6% increase every year on the 2013 figure. Are we prepared to aim for a decent level of well-being rather than accepting that thousands of our fellow citizens will live—and die—in misery?

[Baroness Bakewell]

My Lords, I endorse and support the amendment in the name of my noble friend Lord Warner. We have been watching a very impressive Bill go through this stage. If it is not funded properly, the political and social fallout in terms of the disappointment of an entire generation will be catastrophic. That generation will simply lose the trust that it puts in our capacity to legislate for the needs of society. That is what is at risk and why we need this review of the funding. I have not been a part of the debate so far and I will simply speak to one particular aspect of it, the postcode lottery.

Last week, the Office for National Statistics issued figures for life expectancy which show clearly the disparity between the north and the south. The lowest life expectancy for men is in Blackpool; for women, it is in Manchester. The highest life expectancy is in Dorset. That is not at all surprising. Dorset has the highest number of care homes in the country and has pioneered an outstanding care policy throughout the county based on early intervention and the reabling of people who fall ill. The county has found that this saves money and lives, and citizens are living longer because of it. It is exemplary.

It is not the same in the north of England. I was at a conference recently of the Local Government Association and I was constantly made aware of the pressures that councils in the north are under to trim their funding. Various statistics exist, but it is clear that the budgets of local authorities have fallen considerably. As was debated at the conference, the result is that the eligibility criteria are being squeezed across the north. It made me realise that councils in the north find it laughable that the cap of £72,000 for care should have any meaning for the citizens who live there. The outlook in the north is totally different from that in the more prosperous south. It is not as clear-cut as that, but I am generalising because it is important to grasp how fundamental the difference is. What I want to ask the noble Earl is this: does the funding under the Bill adequately address the increased disparity of care across the country?

--- Later in debate ---

[Baroness Wilkins]

The noble Earl says that that transition funding has been taken into account. Can he also confirm that that is for beyond one year? Or is it only for that one year?

[Earl Howe]

I will come back to the noble Baroness on that question.

I take the point of the noble Lord, Lord Hunt. It could clearly be a source of resentment on the part of a self-funder if they find out through the transparency of the arrangements that we are putting in place that they are paying more than the cost of somebody else’s care. I can tell the noble Lord that we have given thought to that. It has been discussed with the LGA. I would be happy to flesh out the substance of our discussions, but we want to avoid a situation that gives rise to that kind of resentment.

The noble Baroness, Lady Wilkins, asked what plans the Government have to make sure that service users and carers are able to contribute fully to the consultation on funding reform. We intend to arrange a series of consultation events around the country to engage with those who use services, their carers and their families. We will also work with stakeholders to make the best use of their networks and local groups to make sure that we consult as widely as possible.

The noble Baroness, Lady Bakewell, asked a particular question around what she termed the “postcode lottery”, and, of course, I understand the force of that phrase. She asked whether the funding of the Bill adequately addresses the disparity of care and support across the country. The short answer is that the Care Bill provides for national eligibility criteria. That, of itself, will provide greater transparency and consistency for people across the country. I do not think that we will ever completely get away from variation in what local authorities are prepared to consider adequately meets the needs of individuals and we will see some independence of decision-making, whatever we do. However, I firmly believe that the Bill brings us much closer to greater consistency and fairness.

On top of the spending-round announcements, I believe that the Bill will have a positive effect on the NHS by strengthening joint working between health and care and support. For example, Clause 3 requires local authorities to exercise their functions with a view to ensuring integration between health and care. In addition, Clause 2 creates a clear legal duty on local authorities to ensure the provision of preventive services. We want a service that reduces dependency, as well as supporting those who already need care and support, rather than just waiting for people to reach a crisis point. By slowing and preventing the development of care needs, the onset of health conditions or the loss of independence, we believe that preventive care can increase quality of life for individuals, while having the potential to provide longer-term financial savings to the public purse. It is only with this greater focus on prevention and integration that both the NHS and care and support can respond to the financial pressures of an ageing population.

The noble Lord, Lord Lipsey, took us forward to 2025 and beyond and referred to the shortage of workers in the social care workforce predicted by the King’s Fund. Of course, we agree that reforming care and support to make it sustainable for the future will require more capacity and greater skills in the workforce. That is why we stated our ambition in the Caring for Our Future White Paper to double the number of apprenticeships in social care to 100,000 over five years. We are now working with stakeholders to make that ambition a reality.

The noble Baroness, Lady Campbell, speaking powerfully about the areas that she knows best, said that disabled people feel that they are losing their independence as a result of funding cuts, and, indeed, there is a fear that the country unwittingly may be breaching Article 13 of the UN Convention on the Rights of Disabled People. A local authority’s overriding duty under the Bill is to promote well-being. This includes control by individuals over their day-to-day lives, including the way in which care and support is provided. We are confident that the well-being principle captures the outcomes that affect an individual’s independence. We should always keep going back to that principle, not least in the context of the rights that people feel they have—and do have—under the UN convention.

In so far as I have not answered questions from noble Lords, I will, of course, follow up this debate in writing. For the time being, I hope that, for the reasons I have outlined, the noble Lord, Lord Warner, will agree to withdraw his amendment.

Care Bill [HL]

Baroness Wilkins Excerpts

Monday 22nd July 2013 Lords Chamber

[Lord Wigley]

I would like to put on record my support for the points made by the noble Baroness, Lady Campbell, and those just made by the noble Lord, Lord Low. I wish to speak to the two amendments in my name in this group; Amendments 92ZZAG and 107. These are probing amendments to try to get something on the record with regard to the way in which care issues covered by the Bill and which have cross-border implications between Wales and England will be handled in the future.

Although Clause 112 says that the Bill extends to England and Wales, the Bill is ostensibly to do with care provision in England only, which is why I have exercised a self-denying ordinance and not imposed my opinions on the House or the Committee in recent weeks—other than at Second Reading when I flagged up these matters, which I wish to pursue today.

There are two distinct issues although they can in some circumstances be linked. The first relates to the people who move between Wales and England and England and Wales and how differing care regimes in the respective countries will affect their entitlements. I am talking about people who move voluntarily and not those who may be placed by local authorities or a health authority. The second relates to the funds associated with this Bill and how they impact on the two respective countries, and to that extent the Bill certainly has implications for Wales, Scotland and Northern Ireland.

I first remind the Committee that the social care dimension is a wholly devolved subject, and the policy in Wales may be totally different from that in England. The National Assembly is now considering draft legislation which no doubt will lead in coming months to the evolution of a new statute in Wales. The Welsh Government have a commitment to a new system that is fair, affordable and sustainable within a Welsh context. The legislation being considered in Wales is likely to increase the number of services where people can claim a direct payment from local councils; introduce national eligibility criteria that may be different from those in England; create portable assessments within Wales that do not extend to England as I understand it, and establish a national adoption service and allow council officers greater powers in helping those suspected of being at risk.

In Wales there is a substantially greater proportion of older people—greater than any other country or region in the UK. I also maintain in that context that the GVA levels in Wales are in some areas 40% below the average levels of the UK. The financial profile against which any new policy is set will inevitably be different between Wales and England. They will also have to allow for the fact that disability levels are significantly higher in Wales. Wales has already set a cap of £50 a week on charges for home care. The Welsh Government have, wisely to my mind, waited to see the sums involved in England before deciding on the best policy for paying for care in Wales.

There has been pressure on the Welsh Government from Age Cymru and others pressing for a lower cap in Wales than in England and there has been talk of caps of £23,000 and £35,000, which is the figure recommended by Dilnot. There are serious questions about how the Care Bill in England may affect Wales and vice versa, both in terms of whether there is any full Barnett consequential accruing to Wales from the £1 billion cost of the package in England, and with regard to the entitlement of people who have moved informally—not by placement but informally—between the two countries. For example, what is the portability of assessments of need made in Wales for people who move to England and vice versa—not cross-border placements but those who move voluntarily?

To put it simply, what is the position of Mrs Jones who lives in Prestatyn and goes into residential care in Prestatyn? At the behest of her daughter who lives in Chester she moves to a residential home over the border to be closer to her grandchildren. Will the cap operational in Wales or in England be applicable? Likewise, what if Mrs Smith experiences exactly the same problem in the converse direction? Who will explain the situation and the implications of the situation to both Mrs Jones and Mrs Smith before they decide to move?

Incidentally, the definition of “ordinarily resident” in Clause 38(1) seems to be inadequate to deal with the situation of someone who may move from supported accommodation in one country to another as the location at which she or he lived prior to coming into supported accommodation might be totally irrelevant—for example, if they lived for a period with their daughter in, say, Dublin, Brussels or the Isle of Man.

There is then a question about the duty of the health research authorities covered by Clause 98 of co-operation between England and Wales. Clearly the duty of co-operation needs to be considered, not only in the context of the health authorities but in the general context of these amendments, but who will enforce that duty? What will be the fundamental long stop to ensure that Mrs Jones and Mrs Smith are not caught in the crossfire between the policies of two Governments?

I do not know whether any of the government amendments in this group have an implication for the question I am raising but I would be grateful if the Minister can address these issues so that between now and Report I can discuss them with colleagues in Cardiff to ensure that when the final legislation goes on to the statute book everyone will know exactly where they stand.

[Baroness Wilkins]

My Lords, I strongly support the amendments of the noble Baroness, Lady Campbell, and the noble Lord, Lord Low. The noble Baroness has been very keen in pursuing these issues for the past five years and her tenacity has been outstanding. I am sure we all recognise that. She has argued comprehensively and excellently for these amendments. We all know that there is huge stress in moving home and, if you are a person in need of care, that stress is beyond words. As the noble Baroness said, it is a monumental risk. I hope that the Committee will wholeheartedly support these amendments.

[Lord Hunt of Kings Heath]

My Lords, I, too, congratulate the noble Baroness, Lady Campbell, on her amendments and on her persuasive advocacy in this area. We debated the issue of equivalent services at Second Reading and the noble Earl said in his response that he felt that when people move from one local authority to another their circumstances are, in many cases, likely to change and that after a move it would not always be appropriate for them to have services equivalent to those that they had before. However, the noble Baroness has answered this point—her amendment has moved on—and she is not asking for an equivalence of services but an equivalence of outcome. That is a very important difference that noble Lords ought to mark. It is a persuasive case. Of course it is not possible to say that a new local authority must provide exactly the same services in the same way, but it must be right to strive to ensure that the outcome for the person who has moved is the same. I have a great deal of sympathy with her amendments and support those which are designed to ensure a smooth transition.

The noble Lord, Lord Low, made an interesting contribution in relation to ordinary residence and the number of disputes that currently arise in relation to it. As he said, Clause 38 and its associated regulations are welcome. However, he is surely right to seek to ensure that the regulations give absolute clarity and I would welcome the Minister’s reassurance on that.

I welcome the intervention of the noble Lord, Lord Wigley. He should not feel inhibited from intervening in Bills which he thinks apply only to England. His experience is welcome and I hope that he will continue to take part in our debates at future stages of the Bill. I have always found cross-border issues complex. No doubt the Minister will now move many amendments to deal with the issue. However, the substantive point is that, as the four countries of the UK seem to be going their separate ways in relation to health and social care, it is important that we ensure that people moving to and from different parts of the UK are able to do so without a gap in services. In that sense, I welcome the noble Lord’s intervention.

My Amendment 92ZZADA is concerned with the circumstances of carers in relation to a move from one authority to another. Essentially, the amendment requires the second local authority to provide a written explanation where the cost to the second authority of meeting the carer’s eligible needs is different from the first. That explanation should be provided to the carer, the adult needing care and any other person to whom the carer asks the authority to provide an explanation. I am seeking to mirror for the carer the requirement contained in Clause 36(10) to explain the difference in the cost of meeting the eligible needs of an adult when they move from one authority to another.

Perhaps I may probe the Minister about what would happen in a scenario where a carer receiving local authority support moves to a new local authority area but the person receiving care does not. Does the Bill cover this situation? Would a review of the support plan of the carer and the care plan of the person being cared for be triggered? Essentially, on the issue of portability, I want to ensure that the circumstances relating to carers are as well understood as they are to the person making the move. If the Minister cannot specifically respond to that point, perhaps she will write to me between now and Report stage.

Care Bill [HL]

Baroness Wilkins Excerpts

Tuesday 16th July 2013 Lords Chamber

[Lord Touhig]

My Lords, I support Amendments 88M and 92ZZM in the name of the noble Lord, Lord Low of Dalston, and myself. Assessments must be carried out by assessors with the necessary training and expertise to understand the needs they are assessing. This point has been made time and again in this Chamber. The noble Lord, Lord Low, also referred to the Autism Act. The Department of Health has provided clear direction that autism training is essential for community assessors to ensure that the needs of adults with autism are fairly assessed. Here I declare an interest as a vice-president of the National Autistic Society. The noble Lord, Lord Low, also told us of the too few local authorities that have awareness training in place— 70 out of 152 local authorities have still not got a proper awareness training in place as part of their equality and diversity training.

Crucially, a National Autistic Society survey found that one in three social workers did not have a good understanding of autism. This is, in part, because adults with high-functioning autism or Asperger’s syndrome can have less obvious, hidden needs that can be hard to pick up in any assessment. That is why the assessor must have the necessary training and expertise. Failure to assess needs can mean that autistic people and others with disabilities are denied the support they need to live independently. As we all know, this makes it much more likely that in later life they will have a significantly greater need for support.

We are simply asking in these amendments to ensure that the needs of people with autism and other conditions are expertly and properly assessed. In that way, one can ensure that people will have a good quality of life—the sort that we in this Chamber take for granted. We are not asking for much and I hope that the Minister will agree with that.

[Baroness Wilkins]

My Lords, I strongly support this group of amendments. The consolidation of the care and support legislation into one Bill is very welcome but not if it lessens existing essential provision. As both noble Lords have clearly described, the initial assessment of someone’s needs is critical and must be carried out by someone who is appropriately qualified and understands the impact of the impairment and the types of support that are needed. As we have heard, the Bill does not provide the same requirement as the current statutory guidance. I therefore hope that the noble Earl will recognise the critical importance of specialist assessment for people in these groups and allay the concerns of organisations such as Sense and the RNIB.

[Baroness Wheeler]

My Lords, I do not have a great deal further to add on this issue, given that we fully supported this approach in the earlier debate on our amendment. The noble Lord, Lord Low, and my noble friend Lord Touhig have made their case powerfully for the need for specialist expertise in assessing people with complex care and support needs—for example, deafblind people, people with autism and those with profound and multiple learning difficulties.

As the noble Lord, Lord Low, pointed out, the draft Bill originally provided for the regulations to specify the circumstances in which a person with expertise in a specialised matter must carry out the assessment on behalf of the authority. However, this was altered in the published Bill, with the only requirement being consultation with a specialist. Noble Lords are right to consider this to be a retrograde step and I look forward to the explanation from the Minister on this and an undertaking to reinstate in Clauses 12 and 27 the current approach, as the amendments propose.

--- Later in debate ---

[Baroness Wilkins]

My Lords, I strongly support this amendment. If the Government do not agree with the intention behind the amendment, it is clear that they accept, no doubt at the Treasury’s insistence, that the social care crisis should continue for years to come. As we have already heard, the social care system is currently failing to support four out of every 10 disabled people of working age to do the basic things in life such as washing, dressing, eating and getting out of the house. The proposed national eligibility threshold will do nothing to change this. The cap on care costs for these people will be a fiction; unless their needs are assessed to be at the equivalent of “substantial” under the current FACS criteria, they could well spend a small fortune paying for care, none of which would count towards the overall cap.

The public would be shocked to learn that the level of needs spelled out in the amendment in the name of the noble Baroness, Lady Grey-Thompson, is not covered by the cap on care costs. The Government envisage that people whose needs are below the proposed national eligibility threshold will be helped by the universal preventive services covered in Clause 2. However, as the Care and Support Alliance points out, many of these services have already been axed in the cuts or are at risk of closure. The £2 billion funding is very welcome, but we need the Government to be clear with the public that they are endorsing the continuation of the social care crisis unless a major shift of resources takes place.

[Baroness Jolly]

My Lords, I, too, am delighted that these amendments have given us the opportunity to debate the eligibility criteria and I echo the comments of noble Lords who know better than I do how this will affect them. Eligibility is a critical issue, which affects both disabled people and older people with care needs—disabled people account for one-third of the people affected by the Bill and elderly people the other two-thirds.

The Joint Committee warmly recommended the introduction of a national minimum eligibility threshold as a key way of resolving the current postcode lottery in social care. The new eligibility framework and national threshold proposed in the Bill will go a huge way to alleviate the lottery of care and will be vital in ensuring that there is more clarity and consistency in the provision of care for disabled people and the elderly in England.

The focus on well-being in the Bill was hugely welcomed by the committee. This principle is the thread that runs through the Bill and will ensure that the care system not only delivers basic support but promotes older and disabled people’s independence, allowing them to realise their potential through participating more fully in their communities. This is a bold vision for the future and one that could truly revolutionise the care system. It is therefore key that these two elements of the Bill work seamlessly together so that the well-being principle is at the forefront of the Government’s mind when considering who will be eligible for care, something that the committee explicitly recommended in its report on the Bill.

However, as the Government have rightly recognised, social care is not merely about allowing people to “survive” but about enabling them to live full and independent lives. The Bill explicitly places a duty on local authorities to provide care that promotes the well-being of individuals. In a conversation yesterday with the Minister for Care and the noble Baroness, Lady Grey-Thompson, it was acknowledged that the draft regulations, which have already been referred to in this debate, were just that—draft. Much more can and needs to be done to make them asset or strength-based. Can my noble friend ensure that the work on the draft regulations proceeds at pace so that they are fit for purpose and meet the needs and requirements of all within the scope of the Bill? Can he also ensure that any work involves those from the sector and expert Members of this House?

Care Bill [HL]

Baroness Wilkins Excerpts

Tuesday 16th July 2013 Lords Chamber

[Lord Sharkey]

My Lords, I shall speak briefly to my Amendment 92ZZS. Its purpose is to ensure that the direct payment system works well. In particular, it would ensure that all parties to the decision to use direct payments fully understood the implications of that decision.

I raised this matter at Second Reading because I was concerned that some successful applicants for direct payments may underestimate the difficulties involved in administering those payments. I was concerned that there was no clarity about exactly how local authorities would make the decision about who was and was not a suitable recipient for direct payments. For example, it is likely that many in receipt of direct payments will want to employ people directly. Will they understand how very complicated it is to employ even one person? How will they find out? Exactly how will local authorities assess their ability to do this, and will people properly understand any contractual arrangements they may enter into? Who will help them understand? Exactly how will local authorities assess their likely abilities in this area?

I suggested at Second Reading that a way of dealing with this was to give local authorities an obligation for friendly oversight of the administration of direct payments for an initial period of six months or so. In his very thorough and helpful letter of 5 June to those who spoke at Second Reading, the Minister pointed out that Clauses 31 and 32 set out that, before a direct payment is made, the local authority must be satisfied that the adult or someone nominated on their behalf is capable of managing the direct payment. He felt that these and other provisions in Clause 4 should ensure that direct payments are used appropriately.

I am sure that these provisions will be very helpful, but they would be more helpful if the local authority had to explain to applicants on what basis their capability was being assessed and the exact criteria for assessment. It would be more helpful still if the explanation was in written form and followed by discussion with the applicant. That is what my Amendment 92ZZS would put in place. It simply requires the local authority to make known in writing and discuss with the applicant the criteria that it uses to satisfy itself that the adult is capable of managing a direct payment. This would have the effect of bringing about a proper discussion of the implications for the applicant of managing direct payments and provide a proper and informed basis for the local authority to make a judgment. I hope that it would also ensure that the criteria for judgment were clear, understandable, user-friendly and completely transparent. Making this simple change would greatly improve the chances of correctly matching direct payments with those who understand the implications and can effectively manage the system. I very much look forward to hearing the Minister’s thoughts on the matter.

[Baroness Wilkins]

My Lords, I speak to Amendment 92ZZSA, which stands in the name of the noble Baroness, Lady Campbell of Surbiton. The amendment seeks explicit clarification from the Government that nothing in the Bill lessens the strong duty on local authorities to offer direct payments to those requiring care and support services. A right to request direct payments is a welcome encouragement to those who would like to arrange their care and support with the autonomy that direct payments bring. However, it should not undermine the duty of local authorities to offer direct payments as enshrined in the Health and Social Care Act 2001 and regulations. It would be unhelpful to shift the onus on to individuals to know about and request direct payments and away from local authorities’ duty to offer them.

In general, case studies in this area show that where people already have a care package and then want to convert to direct payments, a battle is often involved. Care services recipients need a clear indication that direct payment is one of the support options available. The Bill requires local authorities to tell an adult which, if any, of the needs can be met by making direct payments. It is vital that local authorities understand that they must always provide information about direct payments. This information must include how to request one, the conditions, and advice and brokerage services.

Local authorities need to provide support to help the adult to manage direct payments. As the Bill stands, they can refuse a request if the adult has no help available to manage the payments. Could the Minister make the Bill’s intentions clear in this regard? It is important that the rights and duties enshrined in the original Act, which have proved so beneficial to many disabled people, are not, as it were, lost in translation, and some reassurance on this matter would be very welcome.

Care Bill [HL]

Baroness Wilkins Excerpts

Tuesday 9th July 2013 Lords Chamber

[Lord Best]

My Lords, we come now to a group of amendments, five of which are in my name and the names of my noble friends Lady Wilkins and Lady Tyler. These five amendments have the same underlying purpose—namely to give greater prominence to the crucial role that housing can play in preventing and reducing the need for health and social care services. The amendments have been prepared by the Care and Support Alliance, which is composed of more than 70 organisations that support and represent older and disabled people. I am particularly grateful to the National Housing Federation, which has helped bring these amendments together and given excellent briefings to interested Members of your Lordships’ House.

The Bill has been welcomed by those organisations, and they note with approval that the definition of “well-being” in Clause 1 covers “suitability of living accommodation”. Also, in relation to the duty on local authorities to meet needs for care and support, Clause 8 includes reference to such assistance being provided “at home”. However, these passing references to the place where many elderly and disabled people spend almost all their time do not do justice to the significance of housing to enabling people to live independently.

The Bill takes highly significant steps to integrating health and social care services, but downplaying the housing element—the third leg of the stool—will undermine the legislation’s good intentions. The Age UK report, Stop Falling: Start Saving Lives and Money, notes that falls cost the NHS around £4.6 million every day and that around half of the people over the age of 80 suffer a fall each year. It makes clear that it is accidents in the home, or on the icy step outside, that so often lead to hospitalisation. Cold and damp premises are equally likely to be the cause of a deterioration in health. Once in hospital, if the home to which the patient should return is totally unsatisfactory, their discharge will be delayed and/or there will be a swift readmission to hospital when the home fails them. Informal family carers cannot cope with someone’s care needs if they are battling with the inadequacies of a home that has unmanageable stairs or cannot accommodate a wheelchair.

The case has been made for the financial benefits of getting the housing service right. The National Housing Federation’s new report, Providing an Alternative Pathway, for example, shows that housing for someone with dementia in a self-contained flat in an extra-care scheme provided by a housing association can cut the cost of their care by up to 50%, allowing them to live more independently with care and support on-site, rather than in a costly residential care home. Currently, the UK is spending £9.43 billion on housing those with dementia in care homes, so housing alternatives can have a huge impact on health budgets.

Often the ideal housing solution for so many of us as we grow older is a move to a more manageable home with very low heating bills, no stairs or steps, but with high standards, space, light and ventilation. As a wonderful bonus, when an older person downsizes, a much needed family home, probably with a garden, comes on to the market for the next generation. I declare my interest as chair of Hanover Housing Association, which endeavours to build accommodation of this kind, which is in turn likely to be the best place for care and support services to be delivered. The housing provider can supply the back-up, not only through emergency call systems—now much enhanced by new technology—but in personal terms in acting as helper and ally in securing care services. Age-friendly housing developments for older people also protect against loneliness and isolation for the resident through ensuring a sociable, companionable environment.

However, the great majority of people will stay put in their family home. A joined-up care and housing service can make this possible. Sometimes very minor adaptations are all that are needed to extend people’s independence and autonomy. Handrails that are discreetly and strategically placed can prevent falls in the home. Long-armed “D” taps for people with arthritic hands can reduce the occupier’s need for costly help. Introduction to a “handy person” service can get these things fixed. Arrangements to pay for a defunct central heating boiler to be revived can end the misery of choosing between being freezing cold and spending a fortune on an electric bar heater which may well be unsafe. This investment in the home can keep people well.

Home improvement agencies, often called “care and repair” services, can organise access to disabled facilities grants for items like stair lifts or the installation of walk-in showers, making life so much easier for family carers as well as for the person themselves. It is good to note, in the spending review, the transfer of resources from the Department of Health to fund a planned 20% increase in the budgets of disabled facilities grants.

All these measures that prevent the need for more costly care services achieve very rapid payback as well as transforming people’s lives. If a patient cannot be discharged from hospital for a couple of weeks because their home cannot take them back, the NHS will incur costs of well over £5,000—money that could have been so much better spent fixing the home and preventing a series of unnecessary and unwanted hospital stays. Avoiding a move into residential care for a couple of years will save tens of thousands of pounds.

Each of these amendments covers a different clause in the Bill and inserts a housing dimension to the very welcome measures already therein. First, Amendment 80 addresses Clause 2, which focuses on preventing or delaying a person’s need for care. It seeks recognition that housing is a crucial part of a preventive care service.

Secondly, Amendment 81 is particularly significant. It adds housing to Clause 3, covering promotion of integration of care and support with health services. It is interesting to note, in this context, that in Scotland this holistic view of integration is now taken. The relevant Scottish guidance says:

“It will be important that, in bringing … health and social care closer together, partners ensure that housing services (including those provided by housing associations and the third sector, as well as by local authorities) are fully included in the integrated approach to service planning and provision, and that health and social care planning and local housing strategies are mutually supportive”.

So says the Scottish guidance. Sadly, our Health and Social Care Act 2012 does not explicitly reference housing, and a framework for engagement was neglected in that Act’s guidance. This has led to a very patchy involvement with housing by the new health and well-being boards. Some are examplars of engagement with housing providers in a three-way partnership, while others seem blind to the significance of this element in the equation.

Thirdly, Amendment 86 covers Clause 4 and relates to information and advice. Again, this is a very important amendment. The Joint Committee that looked at the Bill strongly recommended that local authorities provide information and advice on the housing options available in their area. However, although the Government have incorporated the need for independent financial advice, the recommendation from the committee to include housing has not been taken up. This amendment, by including housing options in the Bill, should ensure that local authorities provide the requisite information on specialist and adapted housing in their area, on ways for people to get their home adapted, and on the ways in which people can cover the costs of home improvements.

Fourthly, Amendment 87 seeks to improve Clause 5, which is concerned with the diversity and quality of local services. It extends the definition of care and support services to ensure that local authorities include specialist housing, accessible housing and housing-related support in their mix of services.

Finally, Amendment 88 addresses Clause 9, which relates to the assessment of an adult’s needs for care and support. It is intended to make sure that local authorities pick up on whether adaptations to a home are needed or whether a move to more specialist housing would be best. Assessing the housing requirements of the individual is a vital part of the process of seeing what is best for that person and how their lives can be improved. The amendment seeks to make sure that this ingredient in the process is covered as a matter of course.

I hope that the Minister will feel able to take on board the kind of changes to the Bill which these amendments advocate. The report last year from the All-Party Parliamentary Group on Housing and Care for Older People, Living Well at Home, spelt out the case for the three-way integration of health, social care and housing. The White Paper published prior to the Bill promoted the theme of including housing more centrally in the future of social care. The House of Lords Select Committee report, Ready for Ageing?, highlights the housing requirements of older people. The pre-legislative scrutiny committee, so ably chaired by Paul Burstow MP, took this forward with strong recommendations for a higher profile in this Bill for the housing dimension. The 70 organisations in the Care and Support Alliance, which have a real understanding of the needs of older and disabled people, believe passionately that these changes would greatly improve the Bill. I beg to move.

[Baroness Wilkins]

My Lords, I strongly support the amendments which have been so expertly described by the noble Lord, Lord Best, and to which I have added my name, as well as Amendment 87ZC in the name of my noble friend Lord Hunt of Kings Heath.

This is an important group of amendments. In combination, they will help to ensure that housing is at the forefront of decision-makers’ minds when providing for an individual’s care and support needs. The person will be supported in a way which makes them the least dependent on health and social services only if housing solutions are properly taken into account. However, that element is all too often ignored, and dependency is ensured.

I well remember a dispirited social worker who described the effects of a two-year delay in providing an arthritic lady with lever taps. In the mean time, she had to have considerable support to wash and cook and objected strongly when that support was taken away because she was now able to turn on the taps. However, it helped to convince the council to clear their backlog of occupational therapy cases.

It is so often the case that the housing element ensures that a person can maintain their greatest independence and be enabled to live their life to the fullest extent they can. Housing solutions have to focus on the individual—ensuring that the person is at the centre of the services and not the system. There are numerous examples of how, when housing, health and social service professionals work well together, people are able to regain a control over their lives which can all too easily be lost when social or health care are seen as the only options.

Care Bill [HL]

Baroness Wilkins Excerpts

Tuesday 9th July 2013 Lords Chamber

[Baroness Browning]

My Lords, I speak to Amendments 88B and 88N in this group. The noble Lord, Lord Touhig, has added his name to Amendment 88B, which is about the need to co-ordinate between two pieces of legislation: this Bill and the Children and Families Bill, which is also going through the House. It focuses on assessment, particularly at the time of transition from children’s to adult services. That is a very sensitive time, and the Minister will not need reminding that it was the weakness in the system of transition that prompted the initiative for the introduction of the Autism Act. There is much well documented casework about young people on the autistic spectrum who move from children’s to adult services that gives us a great deal of cause for concern. As the noble Lord, Lord Low, has just pointed out, if people do not get their correct assessment and services at the right time, they simply move on to more serious deterioration in their condition. Just looking at the bottom line, it is usually a crisis management situation, which is not good for the individual and certainly costs the statutory services a lot more money than it would have done if the transition had been smooth and matters had been dealt with properly.

Amendment 88B therefore calls on the Government to consider how this new system of SEN reforms in the Children and Families Bill will fit with the changes that are proposed in this Bill. Appropriate planning and support in the move to adult services is very important, and it is important that these two areas are co-ordinated. There is a danger that they could be done quite separately from each other, which would not be in the interest of the individual concerned. Under the Children and Families Bill, some young people—for example, those with autism—will be able to access an assessment for the new education, health and care plans, which of course will replace what we used to refer to as statements, up to the age of 25. This creates a clear overlap with care assessments under the Care Bill, which the same young people with autism may be eligible for from the age of 18. It is very important that the two systems of assessments and plans talk to each other.

In particular, that means that when a local authority carries out a needs assessment, as in Clause 9 of the Care Bill, it must ensure that it is co-ordinated with any assessment for an education, health and care plan that may also be under way under a separate piece of legislation. I have mentioned autism—I am sure that will not surprise my noble friend—but of course it will apply to young people with other conditions as well. However, this is particularly important for the autistic community because we know that it is during that move from the structure of full-time education in school into adolescent and adult services that you start to see a great deal of change in the individual, as the structured routine of the day starts to move to more adult choices and ways of doing things, including education.

I therefore hope that my noble friend can reassure me tonight that these two pieces of legislation will be compatible, that discussions have taken place between the two departments to make sure that there is no overlap, and that that famous word “seamless”, which I have heard so many times related to transition from children’s to adult services, will genuinely mean “seamless”. I spent 18 years as a Member of Parliament but did not see much that I would recognise as seamless. We have the opportunity to make this seamless. I hope that my noble friend will assure me that that will happen tonight.

I will speak very quickly to Amendment 88N. I tried with an earlier amendment to get my noble friend to agree that social work-qualified staff played a greater role in providing information. I will now have another go, as when he replied earlier I got the hint that he did not seem to accept my argument. I will try again in terms of their role of assessment, which is much more narrowly defined in Amendment 88N. That amendment ensures that information and advice are not only proportionate, but that the local authority must employ social work-qualified staff to provide the information and advice in cases where present or foreseeable needs are classified as complex. Of course, this goes into regulation, which is what this part of the Bill requires.

I hope that my noble friend will look more kindly on this particular recommendation because these are complex needs or—and this is important—foreseeable complex needs, so you are dealing with some of the most difficult cases. You are almost certainly looking at cases where there is some lack of capacity for a start, as well as people with multiple diagnoses and those with very complex situations. It is important that social workers are there. I am asking a Minister with responsibility for health to recognise that unless we in this House bring social work and healthcare together in statute, whatever our best intentions, it will not happen. Again, from all that casework I dealt with—I raised this at Second Reading—as a Member of Parliament, when somebody sat in my surgery and said, “What you need is to get all these people together round a table”, I, the MP, could never work out why nobody ever took responsibility for it. By bringing into regulation the role of the social worker, you make some progress in ensuring that in these very complex cases things are not only speeded up but that there is a much better outcome.

[Baroness Wilkins]

My Lords, I will speak to Amendment 88A. This amendment relates to Clause 9, which requires a local authority to carry out an assessment where an adult may have needs for care and support. The clause sets out things that the local authority must consider, for example the outcomes the person wants to achieve in their day-to-day life. There are similar provisions in Clause 10 in relation to a carer’s need for support. There is, however, an anomaly between Clauses 9 and 10. Under Clause 10(6), the local authority also has to take account of whether the carer works or wants to work, and whether the carer is taking part—or wants to take part—in education, training or recreation. That provision is missing from Clause 9, while in other respects the two clauses closely mirror one another. Surely the same provision as Clause 10 proposes in relation to carers should apply to people in need of care and support? While many of those with a need for care and support may be elderly, or may not be able to—or want to—work, others will want to. Many will be interested in education, training or recreation. This is an important gap that sends an unfortunate message about the ability or desire to work of those with needs for care and support.

Of course, it may be that the Government will argue that this is covered by Clause 1(2)(d), which includes in the concept of well-being,

“participation in work, education, training or recreation”.

If that were so, however, presumably the separate provision for carers in Clause 10(6) would not be needed.

I understand that overwhelming evidence exists that carers are often forced to withdraw from education or employment. That may well be why the Government felt they should include the emphasis on these things in relation to the assessment of carers’ needs. Possibly there is not as much evidence in relation to disabled people, and, as I have said, many social care users are older people. That does not mean that they will not be interested in education, training, recreation or even work. One in three people who use social care services are disabled people of working age.

In the recent report The Other Care Crisis by five disability organisations, the researchers found that time and again disabled people told them that the right care and support was critical in finding and sustaining work, studying and keeping fit or enjoying the arts. How can you hold down a job if the hours and type of support you are provided with take no account of a course you may be studying or of a job? What if the job starts at 9.30 am but your carers do not come to get you up until 9 am, or they turn up at different times each morning because of short-staffing?

Carers UK and others have rightly worked very hard to show the impact of caring on employment chances. As I say, this may well be the reason why the Government has included Clause 10(6). The Government may simply not have realised, however, how this would come across to users of social care services who wish to work. I hope the Government will want to rectify this anomaly.

[Baroness Meacher]

My Lords, I shall speak to Amendments 88SA, 88SB and 92ZZCZA, all of which are designed to ensure that parents who have care and support needs receive sufficient services to ensure that the caring burden on their child is not such as to impede their education and well-being.

Young carers are, of course, children and young people under 18 who provide regular and ongoing care and emotional support to a family member who is physically or mentally ill, disabled or misuses substances. The 2011 census identified 178,000 young carers in England and Wales; an 83% increase in the number of young carers aged five to seven years old; and a 55% increase in the number of eight and nine year-old children caring. I find these numbers staggering. We are talking about a lot of children of a very young age caring for a very considerable number of hours each week.

Why are the amendments important? Apart from a concern for the well-being of children, the issue is important for taxpayers. Young carers whose parents do not receive the support they need have poor educational and employment outcomes and suffer from negative health, with obvious cost implications for the Treasury. These amendments and the resulting early intervention could alleviate those problems and avoid crises, family breakdown and child protection issues, which, again, are a tragedy not only for the family but for the taxpayer and society.