Care Bill [HL]

Earl Howe Excerpts

Tuesday 21st May 2013 Lords Chamber

Moved by

[Earl Howe]

That the Bill be read a second time.

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

My Lords, it is a privilege to open this debate. Care and support are things that everyone will experience at some point in their lives, whether they need it themselves, know a family member or a friend who does, or provide care themselves. Yet today’s care and support system often fails to live up to the expectations of those who rely on it. While many have good experiences, the system can often be confusing, disempowering and not flexible enough to fit around individuals’ lives.

The Bill represents the most significant reform of care and support legislation in more than 60 years. The foundations of social law are based on principles that are no longer relevant in today’s society. This long-awaited Bill implements the recommendations of the Law Commission’s excellent three-year review, begun under the previous Administration, to pull together over a dozen different Acts into a single, modern framework.

The Care Bill also takes forward our commitments to reform social care. Through the Bill, we are clarifying entitlements to care and support to give people a better understanding of what is available, help them to plan for the future and ensure that they know where to go for help when they need it. The Bill will make a reality our vision for a system that promotes people’s well-being and focuses on the person, not the service. It makes preventing and reducing needs a priority, and empowers people to take control over their care and support. It introduces national eligibility criteria, bringing greater consistency and transparency of access to care across the country.

The Bill includes historic reforms to strengthen the rights for carers to access support, putting them on the same legal footing as those they care for. It emphasises the importance of integration and co-operation between care and support and other services, providing the flexibility for local authorities and care professionals to innovate and achieve better outcomes for people.

A new adult safeguarding framework will ensure that arrangements are in place to protect people from abuse and neglect. There are new guarantees for people receiving care whereby if they move from one area to another they will not go without the care they need. For the first time, the Bill clearly sets out that local authorities are responsible for the care and support of people in prison.

I am pleased that public consultation and pre-legislative scrutiny have demonstrated widespread support for the principles and approach to law reform in adult care and support. Indeed, I am very grateful to those present who have already provided helpful and detailed scrutiny in draft through a Joint Committee of both Houses. The Government have accepted the majority of the recommendations of the Joint Committee on the draft Care and Support Bill. The Bill now reflects the importance of financial advice as part of the care and support information service; there is a stronger focus on prevention in assessments and care planning; and we have extended the powers to assess children for transition before the age of 18.

We have accepted the recommendations of the Commission on the Funding of Care and Support, chaired by Andrew Dilnot. The current care and support system offers little financial protection for the cost of care, which for one in 10 people will be in excess of £100,000. Critically, the Bill will reform care and support funding by creating a cap on care costs, giving people peace of mind by protecting them from catastrophic costs. By introducing universal deferred payments, it will also ensure that people do not have to sell their home in their lifetime to pay for residential care. Following the failure of Southern Cross, the Bill clarifies local authorities’ duties to protect people’s interest in the event of the failure of a provider, and creates a new regime for financial oversight of larger care providers.

In the debate on the gracious Speech, a number of noble Lords expressed concern about levels of funding for care and support. This is of course a very important matter. As a nation we are living longer, which I am sure all noble Lords welcome. Managing the fiscal consequences of this will be a key challenge in the coming years.

We must recognise that for the foreseeable future government spending will be constrained. However, we are also aware that in many areas local authorities are finding new and innovative ways of spending their available funding to secure better outcomes. The Bill will help to ensure that the care and support system works as effectively as possible to make best use of the resources available. To draw an analogy, the legislation changes not the amount of fuel available but rather the efficiency of the engine. I look forward to hearing noble Lords’ views about how the framework set out in the Bill can do this even more successfully.

The report of the Mid Staffordshire NHS Foundation Trust public inquiry, led by Robert Francis QC, identified inexcusable failures in care that must never happen again. Between 2005 and 2009 many patients received appalling care, and the wider health system failed to identify and act on the warning signs. The Government’s initial response set out our commitment to ensuring that patients are,

“the first and foremost consideration of the system and everyone who works in it”.

It set out a five-point plan to ensure safe, compassionate care.

Most of the steps we need to take are about increasing cohesion and bringing about a change in culture across health and care. This is not about fundamental changes to the structure of our healthcare system. However, there are a number of limited but significant changes we need to make which require primary legislation. These are changes primarily to the way health and social care information is used to assess performance, and to the way poor performance is tackled.

Through the Care Bill we will introduce a ratings system for hospitals and care homes to give a single version of performance so that organisations and the services they provide can be compared like for like in a way that is meaningful to patients and the wider public. For while there is considerable information available on organisations providing health and care in England, there is currently no consolidated summary of how well they are doing. Aggregated ratings will help people choose the right services, and encourage organisations purchasing or providing services to improve them.

We will create powers so that the new Chief Inspector of Hospitals can instigate a single failure regime. A key finding of the Francis report was that the focus at Mid Staffordshire was on financial and organisational issues rather than the protection of patients and ensuring quality of care. A new failure regime, in which quality of care is as important as financial performance, will ensure that where quality of care is below an acceptable standard, firm action is taken to resolve it properly and promptly.

Robert Francis made a number of recommendations to promote openness in the health system. We will improve transparency and accountability by making it a criminal offence for providers of NHS secondary care to supply or publish false or misleading information about their own performance and outcomes. This will ensure that regulators, commissioners and the public have an accurate picture of the organisation’s performance, and enable the Care Quality Commission to detect quickly any signs of poor quality or safety and trigger the appropriate interventions.

The Care Bill also closes a loophole in the regulatory powers of the CQC. At the moment, if the CQC finds that a care home that is part of a large provider is not complying with registration requirements, the provider could close down the care home voluntarily in order to evade enforcement action by the CQC. In order to guarantee transparency of the regulatory system, the Bill will address this gap in the law to ensure that large providers operating a non-compliant service cannot avoid a record of poor care in this way.

These measures make limited but important adjustments to facilitate our response to the Francis inquiry. Together with changes we are making that do not require primary legislation, they will help bring about a revolution in the care that patients experience, rooting out unacceptable care, tackling failure promptly and effectively, and ensuring that the inspectorate and ratings framework inspires all hospitals to drive for continuous improvement.

Health Education England provides national leadership for the education and training of healthcare professionals. It supports a network of local education and training boards to enable local healthcare providers and professionals to take responsibility for planning and commissioning education and training in their area. The Health Research Authority was formed to protect and promote the interests of patients and the public in health research, and to streamline the regulation of research. The Care Bill establishes both HEE and the HRA as statutory bodies independent of the Department of Health, giving them the impartiality and stability they need to carry out their vital roles free from political interference.

I am grateful to noble Lords from all parties for their support for this Bill in the debates on the gracious Speech. I look forward to debates about the detail of the measures it introduces, and I am sure that improvements can be made. Fundamentally, the Bill delivers much needed and long overdue reforms that can and should be widely supported. The Care Bill demonstrates the Government’s commitment to ensuring a compassionate, integrated and sustainable system of health and care, built around the needs of individuals and the outcomes they want to see, for now and the years to come. I commend it to the House. I beg to move.

--- Later in debate ---

[Earl Howe]

I begin by thanking everyone who has spoken today. There have been some excellent and highly informed contributions from all sides of the House. Health and care matter to us all throughout our lives; the quality of the contributions today demonstrates how important the issues are in this Bill. I am grateful in particular for the welcome given to Part 1 of the Bill by many noble Lords. A large number of questions have been raised during the debate and I will endeavour to cover as many of them as possible in the time that I have. Unfortunately, there is unlikely to be time to address all of these issues but I will, of course, write to follow up on any unanswered questions.

I listened with care, as I always do, to the speech of the noble Baroness, Lady Wheeler, but I must confess that I was disappointed by the somewhat negative tone that characterised her remarks. Anyone listening to her could be forgiven for thinking that the Labour Party opposed the principles set out in the Bill. I was very glad to hear the noble Lord, Lord Hunt, correcting that impression. I hope that, at the very least, we can look forward to a constructive approach in Committee from all noble Lords opposite. As ever, I stand ready to work with the noble Baroness and the noble Lord, Lord Hunt, and indeed all noble Lords to ensure that we explore the Bill thoroughly so that we can, in due course, send it to another place in a form of which we can be collectively proud.

A number of noble Lords referred, unsurprisingly, to the funding envelope for adult social care. We recognise that the last spending review provided local government with a challenging settlement and that is why we took the decision to prioritise adult social care and provide extra funding to help local authorities maintain access to services. In the White Paper, we committed to additional support for social care over the next two years. However, it has to be remembered that local authorities ultimately have discretion over how they use their resources. Of course we agree that the level of funding available in future will have an impact on how far the reforms are realised, but noble Lords should appreciate that we have committed to funding the reforms set out in the Bill in full.

For example, as the noble Lord, Lord Lipsey, pointed out, funding reform will cost the Exchequer £1 billion a year by April 2019 and there will be an additional £175 million a year to fund the new legal rights for carers in 2015-16. I assure the noble Baroness, Lady Wilkins, that the needs of social care will be at the front of Ministers’ minds as we approach the spending review. However, noble Lords will understand the realities facing us. We cannot improve care and support by simply putting more and more money into the system, and in this financial climate it is therefore more important than ever that councils review their practices, drawing on the work of the sector’s efficiency programmes, to ensure that they are using their resources in the most effective and efficient way possible.

The noble Baroness, Lady Wheeler, and others criticised the level of the cap on care costs. It is surely to be welcomed that, for the first time, there will be a cap to protect people from spiralling costs, and that people will no longer have to live in fear that their home will be sold while they are in a care home or that all their life savings will disappear. The level of the cap is not set in the Bill, but will be set in regulations. Why do we propose to set it at £72,000? We want to strike the right balance between supporting people in paying for care and managing the public purse in a sensible, sustainable way. We believe that a cap of £72,000, which is equivalent to around £60,000 in Dilnot terms, along with the increase in the means test threshold to £118,000, achieves this balance. I was grateful for the broad support provided by the noble Lord, Lord Lipsey, in that context.

The noble Baroness, Lady Bakewell, in her characteristically eloquent and powerful speech, contended that the formula we have arrived at protects the wealthiest. The current system, as she knows, exposes those with few savings or modest housing wealth to the greatest risk of losing everything to pay for their social care. That is unfair and it needs to change. Yes, we are expanding the scope of the means test benefit so that more people will get help, but the vast majority of state support will be provided to the 40% of older people with the lowest incomes and wealth. This is about protecting people with the greatest lifetime care needs, not the greatest wealth.

The noble Baroness, Lady Wheeler, asked me to confirm the details of the sliding scale of contribution towards care costs. People with assets above the lower capital limit, which will be £17,000 from April 2016, will have to make some contribution to the costs of residential care. The sliding scale determines the amount they must contribute. Individuals are deemed to be able to contribute £1 for every £250 of assets above the lower capital limit. We are extending the upper capital limit to £118,000 in residential care, which removes the cliff edge in the current assessment and will result in a gradual increase in support towards an adult’s care costs.

I have noted the hopes and concerns of a number of noble Lords, including the noble Lords, Lord Rix and Lord Warner, and the noble Baroness, Lady Bakewell, around the eligibility threshold. There has been widespread support for a national eligibility threshold and noble Lords are understandably keen to see the regulations that set it. In determining the threshold, we must consider the funding settlement to local authorities; the national minimum eligibility threshold will be announced as part of the spending review on 26 June, and the regulations will follow. Indeed, in answer to the noble Baroness, Lady Campbell, and the noble Lord, Lord Hunt, we will make available a draft of the regulations under Clause 13 to provide for the national eligibility criteria in order to support debate of the Bill in Committee.

The noble Baroness, Lady Uddin, said in her powerful speech that care and support was harder to access for minority ethnic people. I would say to her in that context that information is central to ensuring equality of access to care and support, a point rightly made by the noble Lord, Lord Hunt. Clause 4 sets out clearly and places the duty on local authorities to provide information which is accessible to people needing care and support in the local community. The information must be accessible to those for whom it is provided. So, for example, it should be translated into the languages that are used in the area. The noble Baroness also said that a disabled person should be involved in decisions about how their needs are met and their personal budget is settled. Clause 25 sets out important new duties for the local authority to involve the adult in care planning and to take all reasonable steps to reach agreement with the adult or carer on how their needs are to be met.

My noble friend Lord Sharkey and the noble Lord, Lord Warner, expressed their concern that the Bill contains no provision for a right of appeal against eligibility decisions. The Bill sets out, for the first time in primary legislation, how eligibility decisions will be made by local authorities and the new right to a written record of the decision and the reasons for it. These are important new rights, which will promote transparency and aid decision-making. Where people are unhappy about a decision, there is an established right to make a complaint, which is set out in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. There is no need to set out another system in the Bill. I say to the noble Lord, Lord Hunt, that we will look at the existing complaints arrangements, including considering how best to provide for effective challenge to local authority decisions, in the light of the findings of the review of NHS complaints led by Ann Clwyd and Professor Tricia Hart and our consultation on the capped-cost scheme.

The noble Lord, Lord Patel of Bradford, drew attention to Clause 2(3) and the power to charge for prevention services. He was concerned about how people will pay for this. Local authorities already have the power to charge for preventive services. We do not expect this to be the norm for lots of simple preventive services but we think it important to retain the ability to do so. We intend to use regulations to ensure that services which must currently be provided free, including intermediate care and minor aids or adaptations, remain provided free of charge.

The noble Lord, Lord Sutherland, drew attention to the cross-subsidisation issue. Local authorities and individuals can pay different prices for care, as he well knows, and this can be because individuals have chosen premium facilities or because the local authority has negotiated a lower price in exchange for buying care for a large number of people. The Bill places new duties on local authorities to promote an efficient and effective market for high-quality care services. The local authority must ensure that it has regard to factors such as the sustainability of the market.

The noble Baroness, Lady Wheeler, asked how the Bill interacts with benefit changes. My department is in regular contact with the Department for Work and Pensions on the relationship between welfare reform and our proposals for care and support in order to understand the interaction and impact on people who use care and support, carers and families.

My noble friend Lady Barker asked whether the development of the deferred payment scheme would take into account existing case law. The answer is yes. We have committed to a universal scheme for deferred payments for people who need residential care. In designing this scheme we will of course take into account all relevant case law.

The noble Baroness, Lady Wilkins, spoke about the Independent Living Fund. Following the closure of that fund, we have committed to passing funding to local authorities in order to allow for ILF recipients to be brought into the mainstream care and support system. Final details will be announced as part of the spending round on 26 June.

The noble Lord, Lord Hunt, and the noble Baroness, Lady Wilkins, stated their view that the Bill does not do enough to reference the importance of housing to care and support. In actual fact, the Bill does a lot to recognise housing as a determinant of health and well-being. In response to comments during consultation and pre-legislative scrutiny, we have included “suitability of living accommodation” within the list of matters which well-being relates to in Clause 1. Clause 3 requires local authorities to integrate the provision of healthcare and support and health-related services, which includes housing, while Clauses 6 and 7 require local authorities to ensure the co-operation of their housing officers, both internally and with the authority’s “relevant partners”, in care and support.

The noble Baroness, Lady Donaghy, stated her view that Clause 8 should include transport as a way of meeting needs. I agree that the provision of transport is an important way of meeting people’s needs but we do not believe that there is any requirement to set this out in Clause 8. That clause provides high-level examples of ways of meeting needs so as to leave maximum flexibility to the local authority and the adult to agree on how their needs should be met. Of course, that could encompass transport.

The noble Baroness, Lady Wheeler, and the noble Lord, Lord Hunt, asked whether we had been talking to the insurance industry about the reforms. It is encouraging that many companies support the change. We have been talking to the industry. The Association of British Insurers has welcomed the announcement as a,

“positive step forward in tackling the challenges of an ageing society”.

My noble friend Lord Sharkey asked why the Bill does not implement Dilnot’s recommendations for an awareness campaign. Legislation is not required for that but the Government agree on the need to raise public awareness. The Government will adopt a strategic approach to maximising the public’s understanding of the new care and support system, and that is a crucial part of our plans to implement Dilnot.

My noble friend Lady Jolly and the noble Lord, Lord Patel, spoke about the proposal to legislate for free end-of-life care. The palliative care funding review recommended that social care should be provided free at the end of life. The Government are funding eight pilot sites to test this and other recommendations, which are gathering evidence over two years until 2014. Before making any decisions we want to consider the evidence collected from the pilots. I can, however, confirm that primary legislation will not be required to enable social care to be provided free at the end of life.

My noble friend Lady Browning spoke about autism and people with Asperger’s. The autism strategy and its statutory guidance mark a great step forward for adults with autism in England, as I know she acknowledges. What it does not do, however, is guarantee that everyone with a diagnosis of autism will receive support or services from local authorities. If your needs do not meet the eligibility criteria set out by your local authority you will not receive social care services. The Bill will ensure that you are given information about what other support is available in your local area. As local areas gain a better understanding of autism needs locally and develop autism commissioning plans, we expect local authorities to look more at the cost benefits of more low-level and preventive services such as befriending services or social skills training.

A number of noble Lords, including the noble Baronesses, Lady Pitkeathley and Lady Wheeler, my noble friends Lady Jolly and Lady Tyler, and my noble and learned friend Lord Mackay, referred to young carers. The boundaries between children and adult legislation ensure appropriate distinctions between what can reasonably be expected of adults and children. It is of course crucial that adult and children’s services work together to ensure that young people are not carrying out inappropriate caring roles or are disadvantaged in their education and losing their childhood because of caring. First and foremost, however, young carers should be seen as children and assessed in that context.

Several amendments to the Children and Families Bill on support for young carers were debated in the other place. My honourable friend the Parliamentary Under-Secretary of State for Children and Families, Mr Timpson, recognised that the effective identification of young carers and assessment of their needs for support are best achieved by children’s social care, health and education services working together and considering the whole family’s needs. He explained that he would reflect on the arguments put forward and the evidence from the National Young Carers Coalition. Ministers in his department are very happy to meet noble Lords who are interested in this area as the Children and Families Bill moves to this House. Officials are in contact with the National Young Carers Coalition and other key stakeholders as part of the consideration of the evidence that they have provided. I should say, however, that the Care Bill encourages local authorities to take a whole-family approach in assessing an adult, which means that adults’ needs for care and support are not seen in isolation from their family circumstances, including the contribution of young carers. Regulations about assessment procedures to be made under Clause 12 will put a duty on councils to have regard to the family of the adult to whom the assessment relates.

The noble Lord, Lord Rix, spoke about the transition into adulthood, and I completely agree that transition between childhood and adulthood is an important time when young people and their families are thinking about their goals and aspirations for the future. The Bill gives young people and child carers the right to request an assessment before they turn 18 in order to help them to plan for the transition to adult care and support in order for them to have the information that they need to prepare for their future. The Bill will ensure that no child reaching the age of 18 should go without the care and support that they need around the point of transition. It will require local authorities to maintain children’s services until a decision has been taken about whether they require adult care and support in place for there to be no gap. The Bill will therefore incentivise local authorities to focus more closely on the relationship between these services to improve the experience of transition for all.

The noble Lord, Lord Patel, said that care plans should be in place from the age of 14, and for five years thereafter. As he well knows, the difficulties that some young people and their families face as they move into adult care and support are well documented. The Care Bill aims to smooth the transition. It sets no restrictions about whether the child is already receiving a specific service under children’s legislation in order to request this assessment, nor does it contain any restriction or stipulation about the age of the child for whom the request may be made, or their proximity to their 18th birthday. Instead, the local authority must consider whether the individual child is likely to have needs for care and support after they turn 18 and whether there would be significant benefit in undertaking the assessment.

My noble friend Lady Barker said that Clause 9(4) needs to be clear that people’s needs are assessed on the basis of what their family can provide and not what they are expected to provide, so that there is no pressure on them. I completely agree with what she said. The assessment is to include whether any carer is able, and is likely to continue to be able, to provide care. The intention is also that the regulation supporting assessment will require the local authority to have regard to the needs of the whole family, as I have just mentioned.

The noble Lord, Lord Low, stated his view that Clause 12(1)(f) is weaker than it was in the draft Bill. I will write to him about that, but that is not our intention and we will look at that point. My noble friend Lord Sharkey referred to the Clause 9 duty to assess where it appears to the local authority that a person may have needs. He thought that might be too passive. The duty is worded on the basis of the existing duty that it will replace, Section 47 of the National Health Service and Community Care Act 1990. It implements the Law Commission’s recommendations on what should trigger the duty to assess, and it is not intended to be passive. In fact, we do not think that it is.

The noble Baroness, Lady Campbell, spoke powerfully about the portability provisions in the Bill. The Bill will ensure that no one should face discontinuity in their care and support when they move local authority area. This is an important reform which will improve well-being for many people who use care and support. The Care Bill will place duties on local authorities that will ensure continuity of care. This will provide clarity on which local authority is responsible, and should ensure that there is no disagreement between authorities which might result in disruption to a person’s care.

The noble Baroness asked why there was no requirement for equivalent services when somebody moves. We believe that when people move local authority area their circumstances are in many cases likely to change. They may be moving to be nearer family support or to take up employment, and their needs for care and support may also change. After the move it will not always be appropriate for them to have services that are equivalent to those that they had before. Moreover, equivalent services may not be available in the new area. The assessment process we are putting into legislation is very much focused on these needs, rather than service provision.

With the leave of the House I would like to continue for a little longer, because there are a number of questions which I hope noble Lords would be glad if I answer while I am on my feet. If that is not the wish of noble Lords, I will race through the rest of my remarks. My noble and learned friend Lord Mackay of Clashfern, my noble friend Lady Tyler and the noble Lord, Lord Warner, all referred to the duty in Clause 1 to promote individual well-being, and asked why the Secretary of State was not bound into that duty. I am sure that we will have debates in Committee on that point, but I only say now that the well-being principle in Clause 1 is intended to apply at an individual level, when a local authority makes a decision. This individual focus on the specific well-being and outcomes for that person is at the heart of the way that the Bill has been drafted. It is not intended to apply in a more general way. Given that we do not think it would be appropriate for the Secretary of State to be subject to the same duty, the Secretary of State does not make decisions at the individual level.

The noble Lord, Lord Patel of Bradford, and the noble Baroness, Lady Pitkeathley, asked why there was no mention of advocacy in Clause 24(2)(b). The Bill specifies that the information and advice service provided by local authorities,

“must be accessible to, and proportionate to the needs of, those for whom it is being provided”.

This allows for information and advice to be provided in a variety of ways, as is appropriate to the needs of the people who use the service. Information and advice provided by an explanation in a leaflet or on a website may be a sensible way of providing this service for many people, but other people may require individual discussion through their assessment and care support planning process, in a variety of depths from independent brokerage to advocacy.

The noble Lords, Lord Bichard and Lord Warner, and the noble Baroness, Lady Pitkeathley, referred to the key issue of integration, which again I am sure we will debate in Committee. Integration is about more than legislation. That is why my department has been working with national partners—NHS England, Monitor, the Local Government Association, ADASS and others—to empower local health and care communities to improve integrated care and support for their populations and to tackle the barriers to achieving this. This is described in detail in Integrated Care and Support: Our Shared Commitment, which was published last week and which I commend to noble Lords.

The noble Lord, Lord Wigley, asked about cross-border issues and whether a legislative consent Motion was required for issues to do with Wales. We do not anticipate any issues in this area. Legislative consent on matters applying to Wales has been sought from and agreed in principle by Welsh Ministers. Of course, this is subject to the tabling and agreement of a legislative consent Motion by the Welsh Assembly. The issue of cross-border placements is complex due to diverse charging systems and regulatory requirements across the UK. The exact details of cross-border residential placements will be tailored to the wishes of each Administration and we will create a bespoke set of regulations for each Administration to meet those diverse operational requirements.

The noble Lord, Lord Rix, expressed concern that, in relation to the safeguarding duty, there is no duty to assess based on the appearance of risk. He suggested that that was an oversight. It is not an oversight. The adult safeguarding duty to make inquiries in Clause 41 arises where the local authority suspects that an adult with needs for care and support,

“is experiencing or is at risk of abuse or neglect”.

The local authority duty is to make inquiries to decide what action should be taken. One such form of action is to assess the adult’s needs under Clause 9. The duty to assess needs arises where it appears,

“that an adult may have needs for care and support”,

and that would cover an adult who is at risk of abuse or neglect.

My noble and learned friend Lord Mackay said that social workers should not have to rely on bits of paper to know what they have to do and that there should be a code of practice. I totally agree that social workers should not have to look at lots of bits of paper. Guidance should be set out in single, clear, accessible volumes. The only issue is whether it has to be laid before Parliament each time it is changed. We do not think that that is necessary. Equivalent guidance to social workers on children’s social services is not laid before Parliament but is set out in accessible volumes and we plan to do the same. Our proposals will look and feel just like a code of practice and will have the same legal effect.

The noble Lord, Lord Patel of Bradford, drew attention to Clause 68 and the proposed definition of Section 117 aftercare. We noted that several mental health organisations were concerned that the consultation definition of aftercare was drawn too tightly. We therefore changed the wording to clarify that Section 117 services address needs “related to” as well as “arising from” the person’s mental disorder. We have also clarified that the purpose of Section 117 aftercare is to reduce,

“the risk of a deterioration of the person’s mental condition (and, accordingly, to reduce the risk of the person requiring admission to a hospital again for treatment for the disorder)”.

Various noble Lords, including the noble Lord, Lord Low, and the noble Baroness, Lady Greengross, asked about Clause 22. The boundary between the NHS and local authorities is critical to the way in which the law impacts on the services people receive. This needs to be as clear as possible so that the division between local authority care and support and healthcare, particularly continuing healthcare, is more easily understood. The current law is especially complex and dates back to 1948. It was not designed for setting out the boundary between modern care and support and the reformed NHS. It has been subject to much case law and dispute over many years. The clause establishes the boundary between the responsibilities of local authorities and the NHS and includes a regulation-making power to enable clarification in the event of uncertainty. It is not intended to alter the current boundary, but instead to express it in a more transparent way which fits with the new framework.

I shall cover rapidly the rest of the points made, if I may. My noble friend Lady Jolly asked about the timescales for introducing ratings. We are currently considering the Nuffield review; we will respond in due course with our plans for implementation. We want to proceed quickly, but it is important that the CQC has the time to develop ratings properly in consultation with the wider health and care system. The CQC will begin the discussion on ratings with the publication of a consultation document in June.

The noble Lord, Lord Patel, emphasised that the domains of effectiveness, patient experience and safety should form an important part of the CQC’s ratings of hospitals. In accordance with the Nuffield Trust’s recommendations, it will be for the CQC, working with key stakeholders, to design and develop the rating system. However, the ratings are likely to include information on safety, effectiveness and user experience, as well as some measures of the quality of governance.

The noble Baronesses, Lady Wheeler and Lady Masham, asked why the duty of candour was missing from the Bill. We will introduce a statutory duty of candour on health and care providers to inform people if they believe that treatment or care has caused death or serious injury and to provide an explanation. That will be introduced in secondary legislation as a requirement for registration with the CQC.

The noble Lord, Lord Sutherland, asked about the role of the chief inspector. The Chief Inspector of Hospitals will oversee CQC inspections, assessment and ratings of providers, identifying both good and poor performance. Ratings will be part of the information used to establish a single version of the truth. The chief inspector will be a CQC post, which does not need to be established in statute.

The noble Lord also asked why the CQC is the right body to oversee market failure. The CQC is the independent regulator of care and support providers in England. It already has significant experience of the care and support sector and longstanding relationships with all registered providers, on which it can build to assess financial sustainability. In our view, the CQC is the body best placed to take on that important role.

The noble Lord, Lord Warner, asked why the NTDA is not included in Clauses 76 and 77. Where the TDA considers that it is in the interests of the health service, it can already advise the Secretary of State to place an NHS trust which it considers to be a clinically and/or financially unsustainable into special administration. An equivalent provision for the CQC to trigger similar action in respect of NHS trusts will be made through directions to the TDA; it does not require primary legislation.

I was struck by the fact the noble Baroness, Lady Wheeler, asked me why the Bill was a partial response to Francis. The short answer to her question is that we can do a lot without primary legislation, but we will be producing a further response in the autumn which will include action resulting from the range of reviews currently under way—for example, on complaints, safety, bureaucratic burdens and training and support for healthcare assistants.

I turn briefly to Health Education England. My noble friend Lord Willis asked how it will ensure sufficient workforce supply. I have a lengthy answer, which I hope that he will allow me to entrust to paper and which I shall copy to all noble Lords. I will write similarly in answer to the noble Baroness, Lady Emerton, on the role of the Centre for Workforce Intelligence and the action being taken by Health Education England to support the development of care assistants and to ensure that there is a sufficient number of nurses and the right ratio of nurses to healthcare assistants.

The noble Lord, Lord Turnberg, asked how Health Education England could ensure continuous improvement in the quality of education and training. Again, I have a good answer for him. In short, I can say that as commissioners with responsibility for the investment of around £5 billion, Health Education England and the LETBs will have considerable influence over the education that is commissioned from education institutions and the training that is delivered by employers through clinical placement and training programmes. They will work together with providers to deliver high-quality clinical and public health placements. I can assure the noble Lord that Health Education England must seek advice widely. The Bill requires that the body obtains the necessary advice needed to carry out its functions, which includes professional regulators and organisations involved in the provision of education and training—royal colleges and universities, for example.

The noble Lord, Lord Rix, asked me what Health Education England will do in terms of improving education and training for people who care for those with learning disabilities. The answer is that it will work with employers, commissioners, education providers and professional bodies so that education and training evolves better to support people in that category.

My noble friend Lord Willis and the noble Lord, Lord Patel, asked why local education and training boards do not have a duty to promote research. Health Education England has the primary duty to promote research. As committees of Health Education England the LETBs will support the national body in delivering this duty through their workforce planning and education and training functions. Health Education England will work with the National Institute for Health Research to ensure appropriate investment in education and training to develop clinical academic careers.

I will respond to the noble Baroness, Lady Emerton, on her question of representatives of the professions on the board of the HRA, and that there should be more investment in multi-professional research and not just clinical research. In my letter, I shall also cover transparency of research, which was rightly raised by the noble Lord, Lord Turnberg, and others.

To my noble friend Lord Willis, I can say on his question about the HRA’s responsibility for co-ordinating and standardising regulatory practice that that is precisely what is envisaged for the HRA. That is why the clauses give the HRA a unique freestanding duty to do just that, relating to the regulation of health and social care research, in addition to the duty to co-operate with other regulatory bodies. I am happy to expand on that when I write to him, along with the question posed by the noble Lord, Lord Wigley, about the HRA’s duty to co-operate with the devolved Administrations.

The noble Baroness, Lady Pitkeathley, observed that this Bill does not provide all the answers to the challenges facing us in meeting the needs of those adults who require social care. I would never claim that it does. However, I have discerned that she and other noble Lords regard the Bill as a landmark measure, representing an essential and major advance in the law relating to care and support. Later stages of our debates will provide an opportunity to consider the detailed issues that noble Lords have raised today and the Government’s mind is open to making further improvements to clauses. I look forward to those debates, and to engaging with noble Lords outside this Chamber to clarify and discuss the Bill’s provisions. Meanwhile, I repeat my thanks to all noble Lords who have spoken today in a debate that has been fully worthy of the vital and pressing issues now before us. I commend the Bill to the House.

Bill read a second time and committed to a Committee of the Whole House.