Care Bill [HL]
Earl Howe Excerpts(10 years, 7 months ago)
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Baroness Tyler of Enfield (LD)
My Lords, I rise briefly to speak to government Amendment 2 on dignity and respect. I know that it was implicit in the well-being clause in the earlier versions of the Bill that we looked at, but I am very pleased that the need to ensure that all people are treated with dignity and respect has been brought out so explicitly. These are words that the man and woman in the street really understand; they get to the heart of some of the concerns about the type of social care that has sometimes been provided, which has fallen well below those standards, and caused some of the scare stories that we have heard so much about recently.
The noble Lord, Lord Bichard, and I raised this issue in Committee, but as he is unavoidably unable to be in his place today, I thank the noble Earl, Lord Howe, on behalf of both of us, for listening and for bringing this amendment forward.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I am grateful to all noble Lords who have spoken and for the opportunity to discuss once again this important new well-being principle set out in Clause 1. The amendments in this group cover three important issues. The first of these relates to the application of the duty to promote well-being to the Secretary of State. In Committee we debated the link between the role of the Secretary of State and the duty of local authorities to promote the well-being of individuals. There was clear strength of feeling in the Committee that the Bill should make explicit reference to the Secretary of State having regard to the duty on the local authority to consider the well-being of the individual. An amendment in this regard is not essential because the local authority well-being duty is in any event a relevant factor for the Secretary of State to take into account when issuing guidance or regulations. However, I do recognise the strength of feeling and I am happy to clarify the position.
In response to the concerns, I have tabled Amendment 138, which explicitly requires the Secretary of State to have regard to the local authority well-being duty when issuing regulations and guidance. This achieves, I hope, the same ends as intended by the amendments tabled by the noble Lords, Lord Hunt and Lord Warner, and I trust that they will support the government amendment.
The second issue relates to the focus on dignity, to which my noble friend has just referred. In Committee, noble Lords expressed concern that personal dignity was not adequately reflected in the well-being principle, in spite of the change that the Government made to this effect following consultation on the draft care and support Bill. Let there be no doubt that the Government place the utmost importance on dignity and respect in care. These factors must be central to the well-being principle. In order to ensure that dignity is given due prominence in primary legislation, I am pleased to have been able to table Amendments 2 and 3, which give greater emphasis to personal dignity and respect as components of well-being.
The third issue in this group relates to another constituent part of individual well-being: spiritual well-being. My noble friend Lady Barker’s Amendment 4 would include an explicit reference to spiritual well-being in Clause 1(2). We debated a similar amendment in Committee. I said then, and I emphasise now, that the Government recognise the importance of spiritual well-being as a concept and understand the particular significance that it can have for some people, especially at the end of their life. We would absolutely not want an approach that excluded spiritual well-being from consideration where that was clearly of consequence to the individual concerned.
However, it is important to understand that that is not the approach which the Bill sets out. The factors included in Clause 1(2) contain high-level matters which should be interpreted broadly to fit the individual case. Spiritual well-being should be considered where it is relevant to the person’s overall well-being. Moreover, spiritual well-being is likely to be closely related to other matters, such as emotional well-being, which are listed in the clause.
In addition, local authorities must also consider the person’s views, wishes and feelings, as set out in Clause 1(3)(b). This provides a further clear direction to local authorities to have regard to personal matters, which could well include beliefs or other views that would promote an individual’s spiritual well-being. Although it is not explicitly mentioned, spiritual well-being is nevertheless accounted for.
I hope that I have reassured in particular my noble friends Lord Hamilton, Lord Deben and Lord Cormack, and indeed the noble and right reverend Lord, Lord Harries of Pentregarth—
Lord Hamilton of Epsom
Will my noble friend explain why the NHS has actually changed its policy on this? In 2002, new Department of Health guidance on NHS chaplaincy said that all NHS trusts should make provision for the spiritual needs of all patients and staff from all faith communities. It strikes me that the NHS is now rowing back on a previous commitment.
Earl Howe
First, we are not dealing with the NHS; we are dealing with local authorities and adult social care. Secondly, the NHS has not rowed back on this. We have debated hospital chaplains on many occasions and I have made very clear the Government’s view that hospital chaplains perform an important role in the spiritual context. So on the NHS front, I want to reassure my noble friend that here we are dealing with local authorities and adult social care. I was trying to explain that the way in which this Bill is framed is perhaps different from how my noble friend has construed it.
Lord Deben
If it does not make any difference to add this to the Bill, why cannot the Government accept that many people would feel much reassured by its addition?
I have been in my noble friend’s position—and he knows with how much respect I view him—and I cannot remember an occasion when I have said, “This does not make any difference” that it did not quite mean that. What worries me here is that it does not quite mean that. I should be much happier if he would please look again at this, because it is a matter which does concern people. If it makes no difference, surely we can do these things in order that people should not be concerned? Their not being concerned would make a difference.
Lord Warner
I am trying to help the Minister. If he does agree to provide the assurances sought by noble Lords to look again, could he see whether if he moved in the direction they suggest, he would be discriminating against humanists?
Earl Howe
I can do no other than to look at this again, but I want to reassure my noble friends that their concerns are groundless because of the way that this clause has deliberately been framed. It is framed in terms of high-level principles. It is not designed to exclude any form of well-being whatever. It is designed to look at the person holistically and to ensure that no aspect of well-being is overlooked. I shall of course have a fresh look at this question, but I ask my noble friends, and the noble and right reverend Lord, Lord Harries of Pentregarth, to understand that this clause has been framed in a particular way quite deliberately, not to exclude any form of well-being but to encapsulate all forms of well-being.
In other words, the provisions allow consideration of this and indeed many other matters where relevant. I hope that with these assurances the noble Lord will feel able to withdraw his amendment, and indeed to support the amendments which I have tabled.
Lord Hunt of Kings Heath
The noble Baroness, Lady Barker, will respond to the point in relation to Amendment 4. Part of the confusion arises because the Department of Health seems to equate spiritual well-being with emotional well-being. I do not think that that would be generally held to be appropriate. Whether you have a faith or none, it does seem to me that by classifying spiritual belief within emotional well-being, the department has fallen into a pit of its own digging. I hope the noble Earl will indeed go back, and I assume that means this could be debated at Third Reading. Clearly noble Lords would wish to come back to it.
Whether this is for the noble Baroness, Lady Barker, or for the noble Earl, taking up the point raised by my noble friend Lord Warner, the chairman of the All-Party Humanist Group, my assumption would be that the duty on a local authority in relation to spiritual well-being would apply only when a person had a belief. Whether one defines humanism as spiritual I do not know—we are getting into deep waters here. I assume it is not intended that a person of no religion be required to be treated by the health service or local government as having a spiritual need.
We welcome Amendments 2, 3 and 138, and I beg leave to withdraw Amendment 1.
“( ) personal dignity (including treatment of the individual with respect);”
Lord Mackay of Clashfern
My Lords, I particularly support the amendment of the noble Baroness, Lady Pitkeathley. It is obviously important that the situation regarding children who are carers is properly focused. As your Lordships know, I am a vice-president of the Carers Trust and have an interest from that point of view. I have difficulty understanding exactly the scope of the clauses here, because the clause dealing with well-being talks about the “individual”. I assume that this includes the disabled child as well as the carer, and that the same is true even when the child is not disabled. If one has a carer, the child will be an “individual”, I assume. The adult definition comes in the next clause, Clause 2. Clause 1 refers to an “individual”, so I assume that children are included in that clause and therefore that the local authority, in performing its functions, has an obligation to have regard to the well-being of children.
Earl Howe
My Lords, as my noble friend Lady Tyler said, Amendments 7, 10 and 34 in this group about young carers provide an opportunity within our debates to welcome the Written Ministerial Statement yesterday from my right honourable friend the Secretary of State for Education about the Government’s proposed amendments to the Children and Families Bill on the assessment of young carers. They give effect to the Government’s stated intentions to consolidate and simplify legislation relating to young carers’ assessments, making rights and duties clearer to both young people and practitioners. In the Government’s view, these provisions sit most appropriately within children’s legislation.
The right to an assessment of needs would be extended to all young carers under the age of 18, regardless of who they care for, what type of care they provide or how often they provide it. Local authorities would have to carry out an assessment of a young carer’s needs for support on request or on the appearance of need. The amendments also enable local authorities to align the assessment of a young carer with an assessment of an adult that they care for.
I believe that the government amendment will achieve the desired effect of my noble friend Lady Tyler’s amendment to Clause 10 by putting a young carer’s entitlement to an assessment on a similar footing to the provisions in the Care Bill for an adult carer’s assessment. I have also tabled an amendment to Clause 12 of the Care Bill, which we will debate shortly, that makes it clear that a local authority may combine an adult assessment with a child’s assessment, including a young carer’s assessment, provided all parties agree. The government amendment to the Children and Families Bill will also achieve the desired effect of Amendment 10 by requiring local authorities to take steps to identify the extent to which there are young carers within their area who have needs for support.
Amendment 7 would extend to young carers provisions in Clause 2 that require a local authority to provide services, facilities and resources to prevent or reduce needs for support among adult carers. Prevention is an important matter to highlight, but the Bill already makes sufficient provision on this issue, as it requires local authorities to have regard to overall family circumstances when fulfilling their duties under the Bill.
Clause 1 requires local authorities to promote an individual’s well-being in exercising all their Part 1 functions, including those in Clause 2. Domestic, family and personal relationships are specifically included, and such relationships could encompass parenting responsibilities, the adequate functioning of the family and the household and the impact of providing care and support on other members of the family. We do not think that it would be appropriate to refer to preventing the needs of young carers specifically. One means of preventing their needs will be, of course, to meet or delay the needs of those whom they care for, and this is clearly covered by the existing provision. There may be other means, which could include the provision of services directly to the young carer. However, such routes would not be appropriate for adult care and support to take, and we do not believe that a duty should sit within adult legislation.
We will make it clear in statutory guidance that all these provisions should take into consideration family relationships and circumstances, and I am happy to make a commitment that such guidance will refer specifically to the importance of preventing children undertaking inappropriate or excessive caring responsibilities. In addition, in drafting regulations about an adult’s assessment under the regulation-making powers in Clause 12, we will make it clear that a whole-family approach should be adopted, where appropriate. An adult’s assessment should then take into account the functioning of the family and the household, and the impact of providing care and support on other members of the family, including children.
I turn to the position of those with parental responsibilities for disabled children, which is an important issue. However, we do not consider it appropriate to include provisions within the Care Bill about the assessment of parent carers of disabled children, as proposed in Amendments 6, 8, 9 and 35 from the noble Baroness, Lady Pitkeathley. In the Government’s view, the main provision for assessing and supporting those caring for disabled children should be in children’s legislation, so that the family’s need for support can be looked at holistically. In most cases, the best way of supporting a parent carer of a disabled child and other members of the family is by the provision of support directly to the child concerned. It would not be appropriate for adult care and support to be undertaking an assessment of those needs, when adult support is not best placed to meet them. The view of the Minister for Children and Families is that there is already sufficient provision under Section 17 of the Children Act 1989 to provide for the assessment and support of children in need, including disabled children and their parents.
I turn to Amendments 46 and 58 from the noble Baroness, Lady Pitkeathley, about charging carers for support. We remain of the view that local authorities should retain the power that they have now to charge carers for support provided directly to them. Many local authorities do not impose charges on carers because they, of course, recognise the valuable contribution that carers make to society. However, some may choose to impose a nominal fee to cover a proportion of the costs of providing a particular form of support for carers—for example, a relaxation class or gym membership—and we do not think it appropriate to remove that discretion and flexibility. Indeed, removing the ability to charge even a small amount could result in the withdrawal of such services altogether.
The noble Baroness argued that the cost of caring should not count towards the care account within the cap arrangement. Local authority assessments take the support provided by carers into account in determining the care package. We are clear that the care package should count towards the cap, because that should ensure that all people receive the support that they need. We have heard from the care and support sector that the cap will provide carers, as well as care users, with the financial support to help them decide on the right care for them to help provide, and to reassure them that their families will not face catastrophic care costs.
I have some concern about the noble Baroness’s Amendment 48, which proposes that the provision of intimate services to a person needing care cannot be provided to meet a carer’s need for support. This would create a legal barrier that could significantly hinder the provision of a much-needed type of support to carers. Let me provide one example. It may be appropriate to meet a carer’s needs by providing a service direct to the person cared for. If some type of replacement care is provided to allow the carer to take a break from caring, it may look like home care delivered to the adult needing care, even though it is provided to meet a carer’s needs. The amendment would seriously limit the ability of local authorities to make such arrangements because it would provide that the care workers could carry out some activities, but not others of an “intimate nature”. That could leave a situation where the care worker was able to sit with an adult needing care but not take them to the toilet. That is likely to lead only to confusion, I suggest. We accept that clarity is needed about when a type of support should be considered to be provided directly to the carer, and when to the adult needing care. We will produce guidance on this matter, but we cannot support an amendment that sets such an inflexible rule in primary legislation.
I also reassure noble Lords that the Bill is already very clear that carers should not be charged for any form of support that is provided directly to the person needing care. Clause 14(3) makes it absolutely clear that local authorities cannot charge carers for services provided to the person being cared for. This would include services of an intimate nature.
I hope that I have reassured noble Lords that, together, the Care Bill and the Children and Families Bill provide a clear legislative framework to support local authorities to consider the needs of young carers and protect them from excessive or inappropriate caring roles. On the important issue of assessing those with parental responsibility for disabled children, we remain of the view that they are best supported through the provisions of the Children Act 1989. However, I have noted the concerns raised about those who care for disabled children having the same entitlement to a carer’s assessment as young carers and adults caring for adults will have through the respective provisions of the Children and Families Bill and the Care Bill. Department of Health officials will explore further, with officials at the Department for Education, the issues raised by the noble Baroness. I know that my noble friend Lord Nash is always willing to listen to the concerns of noble Lords on these and other matters.
I hope that I have also reassured noble Lords that the Bill is already very clear that carers should not be charged for support provided directly to the person needing care. However, I am conscious that I have not directly answered an issue raised by the noble Baroness, Lady Wheeler, about the need for identification of carers to ensure that there is no unmet need. It is important to support people to identify themselves as carers so that they can access information, advice and support in their caring role. My department is funding the Royal College of General Practitioners to raise awareness among health professionals. Health and well-being boards should also be identifying the numbers of carers in their local population through joint strategic needs assessments.
My noble and learned friend Lord Mackay asked whether children were already covered in the scope of Clause 1. They are covered in terms of the functions set out in Part 1 of the Care Bill. The local authority must have regard to the well-being principle in discharging any function under Part 1 that relates to children. They would be “individuals” in the case of the exercise of that function—for example, in the provisions relating to the assessment of children in anticipation of their transition to adulthood. I hope that that is helpful.
I have taken a little while to reply to these amendments, but I hope that I have been sufficiently illuminating to encourage noble Lords not to press them.
Lord Warner
My Lords, I am sorry that I missed the beginning of this debate but I was with the noble Baroness, Lady Masham, listening to Sir Bruce Keogh explaining how the mess around paediatric surgery was going to be sorted out.
I lend my support to Amendments 11 and 15. I remind the House that many years ago, in the good old days, housing and health were together in the same ministry; there was a united ministry covering both health and housing. We have lost something by that separation. I think that the NHS needs to be given a push on integration, so I very much like the amendment of my noble friend. Too often the NHS forgets that it could help itself by working more closely with other interests, and it would be a timely reminder in this piece of legislation to get that message across. As the noble Lord, Lord Best, has said, we have missed many opportunities over a long period of time, to bring housing into the party as the population has aged. All it has done is increase the burden on adult social care and the NHS. It would be a missed opportunity if we did not rectify some of that now.
Earl Howe
My Lords, I very much agree with noble Lords that housing, along with health, and care and support, should be considered as the three legs of the stool. In relation to housing we are clear about two things: first, many types of housing can be provided as a means of meeting or preventing care and support needs—for example, extra care housing. That is why accommodation is listed as a way of meeting needs in Clause 8.
Secondly, housing is a wider determinant of health; simply having a roof over your head can have an enormous impact on your health and well-being. To reflect this, the “suitability of living accommodation” is listed as part of well-being in Clause 1(2). I hope that those two points in particular will serve to reassure the noble Baroness, Lady Masham.
Amendment 12 clarifies that housing is a “health-related” service, and that both local authorities and the NHS are required to promote integration between care and support, health and housing. This makes the importance of housing explicit not only in the integration duty in this Bill but in the comparable duties on the NHS in the 2006 Act. I hope noble Lords will welcome that.
In Committee, noble Lords also expressed the view that we needed to clarify that local authorities are required to co-operate with providers of services, including providers of housing services. Amendment 28, again in my name, does just this. The non-exhaustive list of the types of “other persons” we expect local authorities to co-operate with would now include certain providers of health, care and support, and housing services. However, we cannot add these bodies as “relevant partners”, as public law is limited in the extent to which it can place duties on such private bodies.
Baroness Barker
When would it be safe to anticipate the statutory guidance which he mentioned?
Baroness Masham of Ilton
Would Amendment 28 be more acceptable if “may consider” were replaced by “shall consider”? There is a big difference between “may” and “shall.”
Lord Hunt of Kings Heath
My Lords, it is good to know that after due consideration the noble Earl is satisfied with his own amendment. On the housing amendments, the noble Lord, Lord Best, will make up his own mind, but it struck me that he is relying on the difference between the local authority as the local housing authority and the local authority as the care authority. He is of course right to say that in county shire areas in some places it is a different function. However, there remains a concern, given that in relation to care and support we are talking about difficult circumstances, often with vulnerable people, over whether the appropriate advice and support will be given. No doubt the noble Lord, Lord Best, will reflect on that.
On my Amendment 11, on integration, the noble Earl relies on existing duties of co-operation on the NHS, and Clauses 3 and 6. Where I fundamentally disagree with him is on the impact of the 2012 Act. The noble Earl may not be aware of just how difficult it now is for the NHS to put a cohesive plan and programme together in every locality, because the current incentives do not encourage that integration. I know that he warns us against putting what he thinks is a superfluous clause in the Bill—but this Care Bill is vitally important. It revises social care legislation and adds the foundations of the implementation of the Dilnot commission. It would be very helpful if there were an explicit duty of co-operation on the National Health Service, because we will not bring about integrated care without the full support of the National Health Service. On due reflection, I would like to test the opinion of the House.
“( ) For the purposes of this section, the provision of housing is health-related provision.
( ) In section 13N of the National Health Service Act 2006 (duty of NHS Commissioning Board to promote integration), at the end insert—
“(5) For the purposes of this section, the provision of housing accommodation is a health-related service.”
( ) In section 14Z1 of that Act (duty of clinical commissioning groups to promote integration), at the end insert—
“(4) For the purposes of this section, the provision of housing accommodation is a health-related service.””
Baroness Meacher
My Lords, perhaps as a point of information in response to the noble Lord, Lord Warner, I should clarify that my amendment does not suggest that qualified social workers should provide financial advice, for example. The important point about the role of these qualified social workers is that they are used to co-ordinating services for people and would be well aware of the need for financial and all sorts of other advice. Therefore, in relation to people with very complex needs, they are in a good position to make sure that all the bits of the jigsaw are actually provided. That was the objective behind the amendment.
Earl Howe
My Lords, let there be no doubt at all that in the Government’s view high quality, accessible information is vital if we are to realise the aims set out in this Bill. We heard some excellent arguments in Committee about financial advice, advocacy, accessibility and signposting to other sources of information and advice. I hope that the amendments we are tabling today, and the commitments that we can give about our work with the sector on statutory guidance, will persuade noble Lords that we have listened to what we heard in Committee and have acted accordingly.
The noble Baroness, Lady Greengross, has tabled two amendments, Amendments 13 and 18, which state that local authorities should facilitate access to information and advice and that they should be accessible to those who would benefit. Amendment 21, tabled by the noble Baroness, Lady Meacher, proposes regulation-making powers which specify when social workers should provide information in complex cases. Following consultation, we made clear that information and advice must be accessible to those who have a need for them in relation to care and support. It says exactly that in Clause 4(4). Local authorities will have to meet the information needs of all groups, including those who often find it most difficult to access information, such as those with sensory impairments, people from BME backgrounds, people who are socially isolated or who have complex conditions. We are absolutely clear about that.
“Accessible and proportionate”—the words that we use in the Bill—also mean ensuring that information and advice are available in the right format, in the right places and at the right time. A vital aspect of this is making them available face to face and one to one, by phone, through leaflets and posters as well as online. When appropriate and most effective, that advice should be given directly by a qualified social worker. There will be other occasions when information and advice are best and most appropriately provided by others. We are working with all interested parties on what this means in practice and on translating this into the statutory guidance.
Amendment 18, tabled by the noble Baroness, Lady Greengross, seeks to ensure that information should be accessible and proportionate to those who would benefit. We consider this amendment to be unnecessary. The duty to provide information and advice applies to a local authority’s whole population—including those who would benefit from that. Each local authority will need to tailor the service to its population’s needs. I can confirm to the noble Baroness that the detail about how to do this will be covered in statutory guidance, and we are working with stakeholders, including carers and user groups, to make sure that we get this right.
The Government have also listened carefully to concerns expressed about the provision of information and advice on financial matters. We have in response tabled Amendments 16 and 17, which seek to make clearer the active role that local authorities have. Amendment 16 requires local authorities to have regard to the importance of identifying individuals who would be likely to benefit from financial advice. This encourages a more active role for local authorities to consider whether people would benefit from financial advice. Amendment 17 means that local authorities must seek to ensure that adults understand how to access information and advice on the range of financial options available to them.
There are various options for people who could benefit from financial advice relating to care and support, both regulated and non-regulated. Our amendments highlight the importance of ensuring that people understand how to access the variety of advice available independently from local authorities. They mean that local authorities must seek to ensure that adults understand how to access the different financial advice available to them, thereby supporting people to make informed choices.
A particular point that I want to bring out here is that the Government do not believe it would be appropriate to require local authorities to make direct referrals. For the most part, local authorities do not possess the necessary expertise, and there is a risk that a referral leading to poor advice could bring a significant burden of accountability on to the local authority. We will work closely with stakeholders as we produce the statutory guidance to understand how different types of financial advice, including regulated financial advice, might be of benefit for people in different situations, as well as the active role of local authorities within this.
Amendments 14 and 19 seek to simplify and clarify Clause 4 and to respond to specific concerns raised in discussion in Committee. Amendment 14 simply re-words Clause 4(2)(d) in a more concise and understandable way. This makes the clear and unambiguous statement that the information and advice service must cover how a person can access independent financial advice on matters relevant to the meeting of needs for care and support. Amendment 19 responds to concerns raised about the potential confusion, particularly in the financial services industry, over the term “independent financial advice”. The amendment clarifies that the term means financial advice independent of the local authority.
( ) have regard to the importance of identifying adults in the authority’s area who would be likely to benefit from financial advice on matters relevant to the meeting of needs for care and support,( ) ”
“( ) “Independent financial advice” means financial advice provided by a person who is independent of the local authority in question.”
Lord Lipsey
My Lords, perhaps I may start with a procedural point. We have had these matters under discussion for quite some time, and the first three Peers named on the amendment—myself, the noble Lord, Lord Sharkey, and the noble Baroness, Lady Greengross—had a most useful meeting with the Minister and Norman Lamb from another place on 12 September. There was complete agreement at that meeting that, if it was at all possible, we wanted to go forward on the basis of consensus on the matters of advice and information, and I am sure that that is right. However, I think it fair to say that we are not quite there yet.
The Minister very kindly agreed to share with us his notes for his speech in reply to the debate this evening in advance so that we could consider them, because many things that he might want to say are very relevant to whether we have a picture for advice that really does the job—sorry to mix the analogies. The Minister fulfilled his kind promise, but only at 2.41 pm this afternoon, and I have not had a chance to digest his words, nor to discuss them with my colleagues, whose names are on the amendment. He also suggested that we should have further talks if they would be helpful, particularly, he said, between Report stage days. Clearly we are not considering finished business here. All I am asking is that there should be agreement from him and from the House that if either he or we think that an amendment at Third Reading is appropriate and necessary—it may well not be—he will not resist it on the grounds that we have thoroughly debated it. This is open territory and we are trying to find a way forward. In that way we can avoid any Divisions this evening. I would be grateful if the Minister would agree.
Lord Lipsey
That is marvellous. That makes it much easier.
As I said, I think we are making headway, but I do not think we are necessarily there. There are three elements to this amendment: the information campaign, which the noble Lord, Lord Sharkey, will concentrate on in his remarks; special groups and housing, which the noble Baroness, Lady Greengross, will address; and I will concentrate on the issue of advice.
Why do I spend so much time banging on about advice? This is an incredibly complicated area. The financial products are very complicated, and many people do not have a natural understanding of them. We all sort of know what a pension is. How many people, even in this House, know what a point-of-use care plan policy is? Who would be able to evaluate whether it was good value for money or bad? There is a large gap in the degree to which people know and understand the kind of products that can be involved here and the issues that can arise.
There is not a lot of this advice about, by the way. Some 53% of councils did not even refer people in care homes for independent financial advice. Only 7,000 of the 53,000 self-funders in care homes have had appropriate financial advice. A point-of-use policy can ensure that they can go on paying for their care however long they happen to stay in the home. Their whole lives are at stake, yet hardly more than 10% have received the financial advice they need.
This is costly not just to the individual but to the councils. Nearly one-fifth of self-funders end up falling back on the state to pay. It costs councils £435 million a year, which is a substantial sum. Much of this could be avoided if people got appropriate financial advice. I do not think that this is not common ground with the Government, but it is, I think, a reason why the Government need to make absolutely sure that they get it right in what they do.
The need for financial advice has greatly increased as a result of the Dilnot scheme. The scheme has no stronger supporter than me, except possibly the Minister. I think it is a very good outcome to a very long and protracted debate. Nevertheless, it does make a lot of things more complicated. I will give an example that I gave in an earlier debate. You can apply for help under the means test and find that you are worse off if you get it because, although you get a little help under the means test, you lose attendance allowance if you get any means-tested support at all. I was amazed when I found that out, and I study this every day. How many people would know that unless they had the right kind of financial advice? That could come from citizens advice bureaux if their computer systems were up to it, but you really want an independent adviser to help you in the round. I do not think that is very controversial.
Earl Howe
My Lords, I begin by thanking the noble Lord, Lord Lipsey, my noble friend Lord Sharkey, the noble Lord, Lord Hunt, and the noble Baroness, Lady Greengross, for the amendment, which covers a number of distinct issues relating to information, advice and awareness of the reforms to care and support funding. I am grateful to them all for meeting me over the summer to discuss these issues so constructively.
A number of speakers, including the noble Lords, Lord Hunt and Lord Warner, stated that public awareness of these matters, particularly on the potential cost of care, is woefully low and that this needs to be addressed. My noble friend Lord Deben made some telling points in that connection. The Government agree that if we are to realise in the fullest sense the benefits of these reforms, it is critical that people are made aware of them and what the reforms mean for them. There is absolutely no dispute on that point. I explained in Committee that Clause 4 requires local authorities to provide information and advice on care and support, and that this must be accessible to their whole population. This will need to include information on the capped costs system.
However, we accept that local awareness-raising alone might not be sufficient. Furthermore, we accept that the department has an important role to play at the national level. For an awareness campaign to be successful it needs to be delivered in partnership—national and local government working alongside the wider care sector. We do not believe that a specific duty in the Bill would achieve this and we do not think that it is necessary. It is not necessary, for one thing, because we are already building a partnership without legislation. We have embarked upon a joint programme with local government to implement the reforms, and I can assure my noble friend Lord Sharkey, and the noble Lord, Lord Warner, in particular, that awareness-raising will be a part of this. We are engaging with the voluntary sector, care providers and the financial services industry to make sure that we all play our part in communicating these reforms effectively. It is a joint effort and a joint responsibility.
To answer my noble friend Lord Sharkey, the public awareness campaign will be timed to coincide with the coming into force of the key elements—that is, April 2015 for most; April 2016 for the capped costs system. I can assure him, too, that the Government do not intend to shy away from the need to raise public awareness.
Turning to the second limb of the amendment, the Government are not convinced that it is proportionate to require the Secretary of State to conduct a poll and publish a subsequent annual report on awareness of the capped costs system. However, we do agree with the need to monitor the effectiveness of the reforms and the Government have committed to conduct post-legislative scrutiny of all new legislation. Moreover, recognising the need to improve data on public understanding of care and support, we have also taken steps to develop and include new survey questions for the annual Health Survey for England. The new questions will be used to monitor and track public awareness over time. If questions are included, fieldwork will be conducted throughout 2014, and the report will be published at the end of 2015. These data would provide us with a baseline against which we can evaluate changes in public awareness. The survey is conducted annually, so there is scope to include the questions in subsequent years. Additionally, there are already questions in the English Longitudinal Study of Ageing— ELSA—which capture public awareness of care and support and expectations of how it is funded. Some data are already available and the next set will be available at the start of 2016. Together, these steps will inform the ongoing implementation and policy development process that will take place in the years to come. I hope that is helpful to my noble friend and provides him with some reassurance.
We are currently consulting about the design and implementation of the funding reforms. Through this we are seeking views about how best to raise awareness of these reforms nationally and locally. We will consider the responses carefully before deciding on the way forward. I can assure the House that this will include a role for the department nationally.
The next part of Amendment 20 would introduce a regulation-making power to specify circumstances where local authorities must, and where they may, make referrals to financial advisers regulated by the Financial Conduct Authority. Given that quite a bit of the ground covered in this amendment was discussed at length earlier in the debate, and relates to a number of government amendments which have been accepted by the House, I hope that noble Lords will forgive me if I do not rehearse all the arguments they have already heard.
The noble Lord, Lord Lipsey, emphasised the importance of people understanding the various products that are available. We agree that, in some instances where someone is considering a financial product such as a care annuity, financial advice should be regulated through the Financial Conduct Authority. However, there are many sources of valuable financial advice that do not need to be regulated and can be provided free of charge—such as advice on managing money from the citizens advice bureaux or from the Money Advice Service. In addition, the fact that financial advice is regulated does not mean that it is appropriate for care and support purposes. Very few regulated financial advisers currently have a qualification or expert knowledge of care and support, though we hope that this sector will develop over the coming months and years. In this context, the term “independent financial advice” covers both regulated and non-regulated advice.
The noble Lord, Lord Lipsey, also asked about the regulation of advisers in this particular field and what we are doing about this. The regulation of financial advisers comes within the remit of the Financial Conduct Authority. We have opened up discussions with the authority and with the Association of British Insurers on the regulation of financial products and advice.
From the comments of the noble Lord, I took it that he accepted that it would be inappropriate to require local authorities to make direct referrals where, for the most part, they do not possess the necessary expertise to judge between advisers. Requiring them to do so would present a significant burden and could result in a local authority making an unnecessary or inappropriate referral. There is the further risk that a referral leading to poor advice could be seen as the fault of the local authority, a point he acknowledged, bringing yet more of a burden of responsibility in increased disputes, and even legal challenge. We believe that the decision to take up financial advice, of whatever form, and the choice of adviser, should belong to the individual and not to the local authority.
In respect of the third limb of the amendment, about housing, this is very similar to Amendment 15 tabled by the noble Lord, Lord Best, which we have already discussed. If the noble Lord has any further concerns, I should of course be happy to speak to him separately.
With regard to the provision of information and advice to people with specific health conditions, this is primarily the responsibility of the NHS. For example, there is a wealth of tailored health and social care information on the NHS Choices website that is public-focused and available to local authorities to use however they see fit. Health and housing are, of course, vital for people using care and support. Clause 3 puts local authorities under a duty to promote the integration of care and support with health and health-related services. The House has accepted Amendment 12 to clarify that this incorporates housing, which includes joining up the provision of information and advice. We will address this in detail through statutory guidance.
I hope that this persuades at least some noble Lords that these issues are all being considered very seriously by the Government, as we work with local authorities and others to implement the reforms. On that basis, I hope that they feel able to withdraw their amendments.
Lord Lipsey
My Lords, I thank the Minister for that reply and for the positive things that he said from which we can draw encouragement. I was particularly pleased to hear him talk about the national role of the department in information provision and confirm that there will be campaigns around landmarks in the Dilnot report to carry that forward. Equally, there are some things on which, if I may say so, he still is not quite there. Nobody advocates direct referrals—nobody. I accept his argument—everybody does—that you cannot just send people to say, “You have to go and see so and so”, or, “So and so is your man”. The other extreme is to say that you do nothing. You provide, for example, a list of suitably qualified advisers within the local authority area; you tell people how to get hold of them. We should not set up straw men, whom nobody is advocating, in order to fend off suggestions that need to be acted upon.
Some things the Minister said would be valuable to follow up in writing. I am sure that the noble Lord, Lord Sharkey, will agree with me that it would be fascinating to see the monitoring suggestions as a substitute for the poll that he suggested, because if they work, that is fine and we will not press it, but if they seem to fall short, that would be different. I think that there will be room to ask the Minister for further discussions with the movers of this amendment so that we can narrow even further the ground before us. I do not pretend to be fully satisfied as I stand here tonight. I gave my reasons earlier why I do not think that the Government’s amendments to the Bill complete the picture, but we are making progress, as we all want to, and we are having a good dialogue. With the Minister’s help, I want to carry that forward before Third Reading, at which stage we will see whether an amendment is needed. With that, I beg leave to withdraw the amendment.
Care Bill [HL]
Earl Howe Excerpts(10 years, 7 months ago)
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Lord Low of Dalston (CB)
My Lords, perhaps I might be permitted a word before the end of the debate. I supported these amendments in Committee and am happy to do so again this evening, though I take the points that have been made about being too prescriptive about time limits in Amendment 25. I think the essential point is that the Bill introduces a number of important new duties and responsibilities designed to enshrine the right values at the heart of our care system—for example, the primacy of the well-being of the individual. However, these values are only as good as the services that are put in place to give effect to them. It is not enough simply to put empty principles into legislation. The Bill needs to contain concrete requirements that will help to guarantee quality in the services that are delivered.
The Government’s amendment requiring local authorities to have regard to the well-being principle when commissioning services is welcome, but I do not feel that it is clear or specific enough to underwrite even the very modest guarantee of quality sought by the amendments of the noble Baroness, Lady Meacher. It provides no assurance that the practice of commissioning very short personal care visits will stop. It also fails to commit the Government to producing regulations that set out in greater detail what should count as quality commissioning. From those points of view, I still feel that the amendments of the noble Baroness are in every way to be preferred.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by thanking noble Lords for the excellent debates that we have had on these topics in Committee and again this evening. As the report by Leonard Cheshire Disability highlighted earlier this week, we need to move away from overly prescriptive commissioning, which focuses on price and time slots, to consider how local authorities can deliver better outcomes and quality care. I therefore fully agree with the principles behind the amendments that noble Lords have tabled with regard to poor local authority commissioning practices. Of course, noble Lords will be aware that Clause 5 requires local authorities to promote a market in high-quality services and specifically requires authorities to consider this duty when arranging services to meet people’s needs. This would make it very difficult for local authorities to commission services in 15-minute slots where doing so undermines the quality of those services.
Clause 5 also requires local authorities, in fulfilling this duty, to have regard to the need to ensure there are sufficient services available to meet people’s needs. With regard to Amendment 26, it is important to recognise that local authorities can achieve this only through working with providers in their area. We therefore do not believe that it would be appropriate to require local authorities to ensure sufficiency of services independently. This could lead to local authorities finding themselves forced into providing services where a market had not developed otherwise. Therefore, I cannot support the amendment tabled by the noble Baroness. She asked me to clarify what “having regard to something” means. Where that duty is present, it is not something that local authorities are able to ignore. In other words, if they have to have regard to a particular thing, that is not something they can disregard. Rather, the clause as drafted is intended to recognise, as I have said, that sufficiency of services can be achieved by local authorities only when working with providers and not by local authorities alone.
It was clear in Committee that, in the view of many in this House, the Bill as it stands does not go far enough in relation to poor local authority commissioning practices. We have reconsidered our position and developed our own amendment, Amendment 27, in the light of the concerns raised. This amendment would require local authorities, when commissioning services, to consider the effect of their commissioning decisions on the well-being of the people using those services. Our approach has some significant differences from and, I would argue, three clear advantages over, the approach suggested in Amendments 22 and 25, which seek to prohibit specific commissioning practices and in particular to require homecare visits to last at least 30 minutes. The first advantage is that our approach sends a clear message on the face of the Bill that commissioning services without properly considering the impact on individuals’ well-being is unacceptable. We believe, in the light of the arguments expressed in Committee, that it is important that we are able to send this message on the face of the Bill.
Secondly, our approach also explicitly prevents local authorities making decisions about how they commission services without giving due regard to the impact on individuals’ well-being. This goes a long way towards achieving the objective we all share of tackling poor commissioning practices while maintaining local authorities’ ability to decide the most appropriate approach to commissioning services for the people in their area, and acknowledging that the underlying issues here are cultural and cannot be tackled by legislation alone.
Thirdly, our approach has a singular focus on the outcome that we all want to achieve of promoting individuals’ well-being. Consequently, our approach is holistic of all poor commissioning practices and future-proofed against new practices that could emerge without risking the creation of perverse incentives through taking an overly prescriptive approach. Moreover, our approach is also holistic of commissioning for all types of care and support, not merely focused on one area: that is, not just on personal care.
In contrast, there are three reasons why I cannot support the approach set out in the amendments of the noble Baroness, Lady Meacher. First, it is important to recognise that local authority commissioners do not act in ways that undermine well-being because they want to, but rather because they do not recognise the effects of their decisions or feel unable to commission in other ways. As the president of the Association of Directors of Adult Social Services has argued, we should be careful of assuming that,
“simply by abolishing 15-minute slots a magic wand will have been waved, and improvements automatically achieved”.
It is important to recognise the limitations of legislation in tackling this issue. We have heard during this debate some appalling examples of people having to choose between being fed and being cleaned as a result of homecare visits being commissioned for too short a time. Local authorities that commission such services are palpably failing in their duty to meet people’s needs. That they still commission such services demonstrates the fact that the underlying problems here are cultural and cannot simply be legislated away. Banning specific poor practices will only lead to other poor practices emerging. Instead, I strongly believe that we need to work with authorities to enhance commissioners’ understanding of the effects of their commissioning decisions on individuals’ well-being and of how they can commission more effectively.
Lord Hunt of Kings Heath
My Lords, I agree with the noble Earl that the commissioning policies of some local authorities are called into question. However, are there some issues here regarding the resources they have available? Is the overall reduction in local authority expenditure not also responsible for some of these policies?
Earl Howe
My Lords, we certainly know that the reduction in resources has had some effect. However, it is interesting that the feedback from local authority chief executives and directors of adult social services suggests clearly that the detrimental effect on the provision of adult social care is not as dramatic as one might suppose from the drop in local authority budgets. This is partly because of the funding provided by my department to local authorities to make up some of the gap. I would not wish to say that there has been zero effect. We think, from the feedback, that the volume of services has diminished by about 5%. This is 5% too much, in most people’s eyes, but may not be as significant as some have feared.
My second point is that central prescription risks prohibiting practices that may, in some circumstances, be consistent with high-quality care. For example, 15-minute homecare visits could well be appropriate in some situations, for instance for helping people to take medication, which is not a process that takes very long at all. Further, using legislation to ban specific processes may result in perverse incentives arising, without addressing the actual problem. A number of noble Lords made that point.
Thirdly, legislating for a specific period of time for which homecare visits must last risks reinforcing one of the key problems here: inappropriate use of time and task commissioning. Instead, we need to move away from overly prescriptive commissioning practices which focus on—
Baroness Meacher
My Lords, I apologise for intervening, but I want to make clear that there is absolutely no prescription: there is flexibility. It is simply saying that you cannot do a personal care visit of less than 30 minutes.
Earl Howe
I do understand that and apologise if I implied anything different. I was seeking to make the point that once you specify a period of time in a Bill it starts to look prescriptive, even if that is not the intent or the effect.
As I was saying, we need to move away from overly prescriptive commissioning practices that focus on price and time-slots, to consider how local authorities can deliver better outcomes and quality care. None the less, there is more that we can and will do to tackle poor commissioning practices. There is a role for regulation. We are therefore proposing an amendment that will make it clear that the CQC may, with approval from both Secretaries of State of DH and DCLG, undertake a special review of local authority commissioning of adult social services in cases of systematic failure. Subsequent to any such review, CQC could issue an improvement notice in the event of a non-substantial failing and recommend special measures to the Secretary of State in the event of substantial failings.
We also intend to issue statutory guidance specifically on local authority commissioning. This will be a valuable opportunity to influence local practice. In particular, we will include in this guidance clear examples of high-quality and poor-quality commissioning practices to support local authorities to develop and improve their own approach.
As well as tabling Amendment 27, we have also, in response to points raised in Committee, tabled Amendment 24, which will require local authorities to consider through their commissioning decisions the importance of fostering a workforce able to deliver high-quality services when shaping local markets. This amendment is, of course, not just about local authority commissioning practices but more widely about how the local authority can work with the market in its area, including with providers from which it does not commission services, to foster a high-quality workforce. This reflects our strong belief that the characteristics of the workforce, including opportunities for learning and skills development, have a direct relationship with the quality of the care that individuals receive. Improving the capability of the workforce through continued skills development and appropriate working conditions is therefore a key component of market shaping.
I therefore fully agree with the intention behind Amendment 151, but I note that the CQC already has powers to take into account standards of employment as part of its inspection of providers. A separate duty on the CQC to undertake periodic assessments of employment standards would duplicate what the commission is already able to do and compel it to undertake assessments of a very specific nature. For that reason, I cannot support Amendment 151, tabled by the noble Lord, Lord Hunt. It is vital that we give the commission the time and freedom to develop its own performance-assessment methodology. In the fullness of time, this may mean that ratings consider employment standards, but this should be a matter for CQC to determine after considering the views of key stakeholders.
Lord Hunt of Kings Heath
I am grateful to the noble Earl for giving way and I imagine that we can debate this more fully when we come to his amendments around CQC independence. However, there is surely a distinction to be drawn between the way that the commission does its work and the overall strategic framework in which it does it. I should have thought that it would be appropriate for Parliament to lay down that it would be right for the CQC to focus on standards in the care sector. Does the noble Earl agree that you can draw a distinction between the framework that is set out in legislation and the way in which the CQC does its work—and I very much support the idea of its independence?
Lord Warner
Can I be clear about something arising from what the noble Earl said? I am struggling with whether the CQC can look at these employment practices only as it plods its way around the country, one authority at a time, or whether, if it starts to pick up something—either from looking at one or two authorities or from public reactions—it can commission a generic review or study of commissioning practices across the country. I am not clear what the noble Earl is saying about this—whether the commission has to work its way through authority after authority, or whether it can make a generic review of particular practices.
Earl Howe
My Lords, I was distinguishing between providers and commissioners. The CQC can do thematic reviews under, I believe, Section 48 of the Act, but we are talking there about providers. As regards commissioners, we are proposing in a later amendment to give the CQC powers to conduct special reviews where concerns have been raised about a particular local authority or NHS commissioner; there would not be periodic, regular reviews. However, the CQC will be looking at every provider over a period of time. The amendment from the noble Lord, Lord Hunt, specifically addresses the ability of the CQC to examine providers. I was saying earlier that it already has the necessary powers to do detailed work in whatever area it chooses.
I return to the issue of local authority commissioning practices. As I argued, the underlying causes of poor commissioning are cultural, and we need to work with local authorities to tackle these issues. We are therefore undertaking a number of non-legislative activities, including the development in co-operation with ADASS of a set of commissioning standards. These standards will enable individual authorities to gauge their own effectiveness, and will support the LGA and ADASS to drive sector-led improvement.
In addition, we are working with the Towards Excellence in Adult Social Care initiative to support local authorities to seek continuous improvement in their adult social care functions, and in the outcomes achieved. This programme brings together local, regional and national stakeholders, and is focused on providing peer support and interventions by local government to share learning, find new ways of engaging local people, and use knowledge of what works, data and innovation to drive improvement in the quality of services.
I hope that these arguments, and the amendments we have tabled, are sufficient to demonstrate to the House that we understand and agree with the strength of feeling around these issues. For the reasons I have set out, I cannot support the amendments tabled by noble Lords, but I hope that the arguments I have made today will be sufficient for those noble Lords to feel able not to press their amendments. I do not yet know what the noble Baroness, Lady Meacher, intends to do with her amendment, but it may be helpful for noble Lords to know that the Government do not consider that a decision on Amendment 25 is consequential on Amendment 22.
Baroness Meacher
My Lords, I thank the noble Earl for his thoughtful response and also all noble Lords who contributed to this debate. It has been very considered, and the points raised have been very important. These visits can require three hours of work, or one and a half hours—all sorts of different lengths of time. Whatever is decided ultimately must enable those visits needing that length of time to be undertaken in that way. I welcome the amendment of the noble Lord, Lord Hunt, and I am sure that the CQC has an enormously important role to play in this. I wonder whether the Minister would think it appropriate to require a thematic review of this issue to be undertaken by the CQC, bearing in mind the level of concern across the country about what is happening at the moment, which clearly is not acceptable in terms of these very short visits for personal care.
The noble Earl mentioned the 5% reduction in the budget for adult social care. It sounds small, but we all know that the adult social care budget has always been incredibly low—way below what it should be. Priority has never been given to this area of work, so a 5% reduction is pretty serious. There is a lot to be done. The noble Earl referred to guidance, regulations, and so on. I personally would welcome an opportunity to have a discussion with him about how, in the guidance and regulations, it might be possible to ensure that adequate priority is given to this area of work. This is really what we are talking about here.
My amendments are aimed at stimulating the debate. They are also an effort to draw out some commitments from the noble Earl, and to some degree I think we have achieved that objective. I do not know whether the Minister would be willing to have a conversation about what might be included in the guidance and regulations.
Baroness Meacher
With that assurance, I am happy to withdraw the amendment.
“( ) the importance of fostering a workforce whose members are able to ensure the delivery of high quality services (because, for example, they have relevant skills and appropriate working conditions).”
“( ) In arranging for the provision by persons other than it of services for meeting care and support needs, a local authority must have regard to the importance of promoting the well-being of adults in its area with needs for care and support and the well-being of carers in its area.”
“( ) The following are examples of persons with whom a local authority may consider it appropriate to co-operate for the purposes of subsection (2)—
(a) a person who provides services to meet adults’ needs for care and support, services to meet carers’ needs for support or services, facilities or resources of the kind referred to in section 2(1);(b) a person who provides primary medical services, primary dental services, primary ophthalmic services, pharmaceutical services or local pharmaceutical services under the National Health Service Act 2006;(c) a person in whom a hospital in England is vested which is not a health service hospital as defined by that Act;(d) a private registered provider of social housing.”
Baroness Finlay of Llandaff
My Lords, I shall be brief since the hour is getting late. This amendment makes a very important point, though it may be better in guidance. One of the problems is that the pinch point is always A&E, and getting patients out is really difficult. At the moment, there is tokenism in planning discharge. It needs to be much more embedded in trying to predict people’s needs and having things in place. Until discharge planning really is part of looking ahead at the aims for the patient we are still going to have backlogs, because we are still going to be waiting for somebody to come in and do something.
Earl Howe
My Lords, I should like to thank the noble Baroness, Lady Greengross, for tabling Amendments 29 and 125, on what is undoubtedly an extremely important issue, not just for the system but, most importantly, for the patients themselves. When someone is discharged from an acute care setting, care and support must be joined up to prevent unnecessary delays and readmissions that can be distressing to patients and their families and carers. The noble Lord, Lord Hunt, was absolutely right on increasing pressure on acute trusts, not least in A&E.
There is a mixture of reasons why this is occurring: the weight of patient demand; the acuity of patients who present at A&E, more of whom have to be admitted; workforce issues in some A&E departments; hospital discharge practices that may not be as efficient as they should be; an absence of follow-on care in certain locations or, indeed, adult social care services; and delays in installing home adaptations. One cannot generalise about this problem. One can say only that in many areas it is very real.
I will just correct the noble Lord on one issue: the £250 million that we have allocated to ease the pressures on A&E. Those moneys went to 53 NHS trusts before the end of September. They went to trusts that were most at risk of breaching the A&E standards. They were not chosen by Ministers or the Government. The process was led by NHS England and Monitor, so it was done on a structured and objective basis.
Lord Hunt of Kings Heath
The point is that the chief executive of each of those trusts had to sign, if you like, for the money, but they did not get all the money. Most of the money went to clinical commissioning groups. Some of them are still meeting to discuss how to spend it, which is the worry.
Earl Howe
At least we have given them more notice this year than they have had in previous years. Quite often, winter pressure money has been released into the system only around Christmas. We have consciously tried to do it several months earlier. While I acknowledge the truth of what the noble Lord said in certain areas of the country, I hope and believe that by the time the pressure becomes significant, those crucial decisions will have been made.
Baroness Masham of Ilton
As the Minister has brought this matter up, I shall ask about the hospitals that got the money. York and Leeds got extra money, but Hull did not. Hull is one of the most deprived and difficult areas in the country. Will he look into it and let me know?
Earl Howe
I will happily look into it, because I do not have with me the complete list of trusts and the factors that lay behind the decision that was taken by NHS England. I will certainly write to the noble Baroness about that.
Delivering joined-up, person-centred and co-ordinated care in a way that stops patients falling through the gaps in the system is of key importance to improving their outcomes and experiences. I believe it is incontrovertible that local authorities and relevant partners must co-operate in order to ensure safe and timely transfers of care. Indeed, the Bill already requires that. Clause 6 requires that local authorities and relevant partners co-operate with one another where this is relevant to care and support. Subsection (5) of the clause sets out some key examples of when this duty should be used. There can be no question that this duty would apply also to ensuring safe and timely discharges, and we do not see the need to add further detail to such broadly worded provisions. New guidance on discharge planning and on how local authorities should perform co-operation duties under Clauses 6 and 7 will be issued following the passage of the Bill.
Further, Schedule 3 to the Bill sets out a process around ensuring the safe and timely discharge of acute hospital patients. This not only requires the local authority, following notification from the responsible NHS body, to assess a patient who it appears may have a need for care and support before they are discharged but requires the authority to have the necessary care and support package in place before discharge takes place. The duties to co-operate apply to that process as well. In fact, to come back to the point that the noble Lord, Lord Warner, raised about guidance, the current discharge guidance, Ready to Go, makes it clear that discharge planning should start before or on a patient’s admission to hospital. We know that that does not always happen, but it is best practice, and has been best practice for some considerable time.
Amendment 125 would allow the Government to specify what the authority and its partners must have regard to when performing that assessment. Surely this is right. I reassure the noble Baroness that, as the assessment required to be carried out by this schedule is the same as the one in Clause 9, we already have this power in Clause 12(1)(b) of the Bill, which allows for regulations to,
“specify other matters to which the local authority must have regard in carrying out the assessment”,
and in Clause 12(6) which allows for an assessment to be carried out jointly.
I hope that I have reassured the noble Baroness that the Bill already requires local authorities and “relevant partners” to co-operate in the safe and timely discharge of patients and contains sufficient provisions to make such regulations and to issue guidance on this matter. With those reassurances, I hope the noble Baroness will be able to withdraw her amendment.
“( ) the Minister of the Crown exercising functions in relation to social security, employment and training, so far as those functions are exercisable in relation to England;”
NHS: Out-of-Hours Services
Earl Howe Excerpts(10 years, 9 months ago)
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Lord Hunt of Kings Heath
My Lords, I beg leave to ask a Question of which I have given private notice. In doing so, I refer noble Lords to my health interests in the register.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, NHS England has closely monitored performance for all 111 providers, including NHS Direct, and reports weekly on performance to the Secretary of State for Health. NHS England will recommission NHS Direct’s 111 contracts and transfer staff who currently provide them to alternative providers. Patients should be reassured that they will continue to receive a safe and high-quality service when they call 111.
Lord Hunt of Kings Heath
My Lords, It is on this Government’s watch that a service staffed by unqualified call handlers has put patients at risk. When will Ministers take responsibility, and why did the noble Lord reject a plea from Dr Buckman, then chair of the BMA GP Committee, for the rollout of 111 to be slowed down because of risk to patient safety? Will the Government now agree to the release of all official advice given to Ministers on the service’s introduction?
Earl Howe
My Lords, the NHS 111 service is not unsafe—it is a safe service. In the vast majority of the country it has been provided very well for patients. We were confident that the service could be provided well, and so it has proved. The isolated cases where the service has fallen short are highly regrettable, but there is no issue about the quality of NHS Direct’s provision of NHS 111. I am afraid the issue there is that it got its sums wrong and cannot provide the service economically.
Lord Laming
The noble Earl will recall that in his response last week on the pressure on accident and emergency services, he referred to the change that had taken place in the GP contract that relieved them of the opportunity of being on call. Are the Government going to renegotiate the GP contract? If not, is there a possibility of placing a primary care service in every accident and emergency unit in the country?
Earl Howe
My Lords, we are straying a little from the Question before us, but I understand the relevance of the noble Lord’s point to the urgent care pathway generally. We are obviously looking very carefully at the GP contract. I cannot tell him at the moment how far negotiations have reached, because we are only at the start of the process. However, his point about primary care services in A&E departments is well made, and many A&E departments do indeed provide that to ensure safe triage of patients on arrival.
Baroness Gould of Potternewton
My Lords, during the process to establish this contract, concerns were raised by many GPs and others which, we are told, were ignored. Can there be a guarantee that this time there will be absolute full concentration and discussion with the relevant bodies, with the GPs and others, who want to be assured that the new contract, whenever it comes, is going to be valid and will work? How are we going to explain this process to the public, who are going to feel very uncertain about the future of 111?
Earl Howe
My Lords, I can give the noble Baroness that reassurance, because we want local commissioners and doctors involved in the process to be confident in the service that they are commissioning. We did not ignore the warnings from Dr Buckman and others in the BMA. Indeed, on the strength of that we allowed a six-month extension to those providers who felt they needed it to ensure that they were confident in providing a good service. Only two providers took us up on that, which seemed to indicate that our confidence in the service was not misplaced.
Baroness Jolly
My Lords, this is an issue around commissioning. As we have heard, CCGs can now commission NHS 111. Can my noble friend tell the House what support CCGs are likely to receive in commissioning these new services, and from whom?
Lord Reid of Cardowan
My Lords, may I gently advise the Minister against complacency? Many of these changes in the NHS will take time to show whether they are beneficial or otherwise. Anecdotally, the successor of NHS Direct—111—appears to be in turmoil, both practically and commercially. The deterioration in accident and emergency services is getting exponentially greater; trolley waits are back, and predicted potentially to reach crisis point. Sir Bruce Keogh’s report, if read carefully, identifies as underpinning many of the problems in the major hospitals a chronic shortage of skills and finance. Can I please ask the Minister not to accept this with any degree of complacency and to introduce some scheme of forensic appraisal of 111 and some of the other issues which are arising from what looks increasingly like a costly and disastrous reorganisation of the NHS?
Earl Howe
The last thing I would ever wish to be is complacent, and I certainly am not. Whenever problems and concerns arise, we take them extremely seriously. I do not think anyone takes issue with the concept of 111. Unfortunately, however, we have seen problems arising in a few isolated cases. I emphasise that the vast majority of the country is receiving a good service. Incidentally, there is no evidence that attendances at A&E have been affected by the rollout of 111; in fact, attendances have not increased since 111 was introduced—the figures have actually gone down.
Baroness Hayman
I wonder whether the noble Earl could help me, because I am genuinely puzzled about the current status of NHS Direct, its funding and governance, who makes decisions about contracts and whether they are viable or not. NHS Direct was set up as a national service, paid for and provided by the NHS. What exactly is it now?
Earl Howe
The NHS is a provider, in certain parts of the country, of the 111 service, and other services more generally. But there is a very distinct difference between NHS Direct’s old service and the 111 service being provided now, in that 111 is a much more comprehensive service. That was an area of agreement between the Government and the noble Baroness’s own party before the last election. I sense that I have not answered the noble Baroness’s question; perhaps she would like to ask it again.
Baroness Hayman
Since I can quibble about my own party as I am now a Cross-Bencher, I take this opportunity to say that I am not puzzled about the 111 service—but who is NHS Direct now? Who is responsible for its governance, its funding and decisions about whether it goes for contracts?
Lord Willis of Knaresborough
My Lords, may I try to redress the balance? There is a real sense that very significant numbers of people calling the 111 service get a good service. On 9 June, I had reason to call 111 because I was having a heart attack. The response from 111 was excellent, in York. At the same time not only did the service call the paramedics but it had me in hospital within 25 minutes to an absolutely superb accident and emergency service. If York can do that in such an efficient and superb way, why cannot we guarantee that service throughout the country?
Earl Howe
I am sure that I speak for all of us in saying how pleased I am that the service worked so well in the noble Lord’s case. The answer to his broader question is that the service is working well in the vast bulk of the country. Unfortunately, in two particular areas we have seen problems, which are being gripped, and I am confident that NHS England has taken these issues forward with the seriousness that they deserve. I am assured that, even in the areas where problems have arisen, the service is good.
Baroness Masham of Ilton
Would it not have been simpler to build on NHS Direct, which would have saved confusion?
Earl Howe
The difficulty there was that we were more ambitious than simply wanting a revamped advice service. This is a service that puts a patient directly in touch with a doctor if they need one, a nurse if they need a nurse, or an ambulance if they need an ambulance, without the need for call-back. It is also free of charge, which the old NHS Direct was not.
Care Bill [HL]
Earl Howe Excerpts(10 years, 9 months ago)
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Lord Hunt of Kings Heath
My Lords, this has been a very interesting debate. I open on today’s Committee by declaring interests as president-elect of GS1, chair of a foundation trust and a consultant trainer with Cumberlege Connections.
There is no doubt that the backdrop to our discussion is one of the availability of resources. As every day goes by in Committee, we have discovered new responsibilities being placed upon local authorities: the provision of information and advice; the assessment of adults’ and carers’ needs for support and the provision of that support; the implementation of the national eligibility criteria; the Dilnot proposals; and the assessment of self-funders.
I am sure that my noble friend Lord Lipsey is right. We have said a number of times, without really getting a response yet from the noble Earl, that the moment that self-funders become aware that they are essentially subsidising the people funded by local authorities, there will be an end to that. I am absolutely convinced that self-funders will express the view that they ain’t going to put up with it. I wonder whether the Government have thought through the implications of that. I doubt that they have, but those implications will have to be thought through. People will not find it acceptable to be paying above the local authority rate, then taking longer to get to the £72,000 cap, and then finding that the local authority will fund them only at its rate, with potential consequences for where they can be provided with care. It will possibly not be in the care home to which they have already been paying for their own resources. There is real concern about the financial implications of the Bill, which noble Lords all generally welcome, and the fact that the gap between the expectation and the reality could be very wide indeed.
We are of course confronted by the very difficult funding pressures that are on local authorities at the moment. Noble Lords have spoken eloquently about that. My noble friend Lady Bakewell pointed to the differential funding as a result of the Government’s change in formula as far as local authorities are concerned. That is why the Labour Party has called for £1.2 billion of NHS underspend to be transferred to social care over the next two years. However, that is just the start. We are going to see major demographic challenges, which will affect the NHS as much as social care. That is why my noble friend’s amendment has so much ingenuity in suggesting that the Office for Budget Responsibility be asked to complete a review of funding of adult social care by the end of 2014.
This has to be linked to NHS funding as well. I was very interested in a piece in the Independent this morning, emanating from Sir Bruce Keogh. It pointed out that for the NHS since 1948, the amount of money that has been made available has gone up by an average of about 4.5% a year. Now, he says, we are looking at no increase at all. I am not sure that the bodies for which the noble Earl’s department is responsible have woken up to that. For instance, NICE continues to produce guidance which, if implemented, would cost more money. The reports coming from royal colleges and the Keogh review of the 14 trusts talk a lot about staffing deficiencies, but the whole thrust still coming from these reports is to increase expenditure. There is genuine concern that we are talking up the expectation on health and social care knowing that at the moment we cannot see our way to finding where the resources are going to be. Without making this too much of a political debate, I thought that Mr Lansley’s comments in the run-up to the previous election in relation to the so-called death tax were very unfortunate in trying to get a dispassionate debate about how we are to find our way to funding health and social care in future.
This is a very interesting debate. My noble friend has done us a great service in allowing us to discuss this in depth. I hope there may be some sympathy from the Minister for the amendment.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in some ways this is a reprise of an earlier debate we had in Committee, but none the less it has been valuable. I am grateful to all noble Lords who have contributed. I begin by saying to the noble Lord, Lord Warner, that I am in total agreement that care and support funding is vital. It is essential for the success of the reforms we have been discussing that these services are fully funded. I start by assuring the noble Lord on one key point, which is that the costs of these reforms have been clearly set out in the Bill’s impact assessment, as was our duty.
I listened with care to the case put by the noble Lord that the Office for Budget Responsibility should conduct a review of care and support funding. I do not believe that such a review would be necessary or desirable. As noble Lords will be aware, the Government recently announced the conclusion of the spending round for 2015-16. It is only right that decisions on care and support funding are taken by the Government at the same time as spending plans are set for all areas of government. It is the job of the Government to decide on priorities and what is affordable. Any further review by the OBR would clearly cut across that process.
There is also an issue about the OBR’s autonomy. The OBR performs its duties independently with complete discretion to determine the content of its publications and its programme of research and analysis. It would not be in keeping with the OBR’s duties or its independence to have the Secretary of State commission a report in the way the noble Lord, Lord Warner, suggests. The main duty of the Office for Budget Responsibility is to examine and report on the sustainability of public finances, including a statutory obligation to publish an annual fiscal sustainability report. The most recent of these was published this month and already includes long-term projections of care and support spending, taking account of the cap on care costs and the extension of the means test. A further report, such as the one proposed by this amendment, would risk duplication and repetition.
It will perhaps be helpful if I confirm that the projections set out in this OBR report are broadly in line with the department’s own, and it is on the basis of this analysis that I am in a position to say that the spending round settlement delivers the funding required for the care and support system. We have identified the financial burdens facing care and support, including those arising from this Bill and demographic pressure, and we are putting enough money in to maintain service levels. This will ensure that care and support can be protected and will allow us to deliver on the reforms set out here.
However, we need to do more than simply put more money into care and support. We also need to improve the way that health and care is delivered, and in particular how these services work together. That is why the settlement includes a £3.8 billion pooled health and care budget—the noble Lord, Lord Warner, referred to this—which will be given only on the basis that services are commissioned jointly and seamlessly between the local NHS and local councils.
This is, in many ways, a historic moment. What we intend to do represents a genuinely new departure. It will help to ensure everyone gets a properly joined-up service, with people getting the care they need from whoever is best placed to deliver it—whether that is the NHS or the local authority. Chris Ham from the King’s Fund has welcomed this, calling it,
“a much more ambitious approach to delivering integrated care and a real opportunity to improve the co-ordination of services for patients and service-users”.
We will ask local areas to work collaboratively together in drawing up plans for the use of this money, ensuring that the priorities of both the NHS and care and support are addressed. All plans will include a commitment to protect care and support, ensuring that this money goes where it is needed.
The settlement also provides the funding for the commitments and duties set out in this Bill, and factors in the growth in demand from an ageing population and a growing number of disabled people. With additional pressure on the system, we must ensure that the NHS and care and support services are working together to offer the best possible services for patients, while also addressing the growing demand on the system, which noble Lords have rightly referred to.
The creation of pooled budgets will help to achieve the more efficient use of resources in the system as a whole, driving down costs by tackling expensive pressure points in the system, like A&E, by improving preventive services, reducing unplanned hospital admissions and by allowing people to stay in their homes and live independently for longer. It is intended that £1 billion of the pooled fund will be linked to outcomes achieved, ensuring that local areas are incentivised and rewarded for achieving better outcomes, including those that could reduce financial pressure on the system.
Noble Lords have rightly referred to the pressure on local authority budgets. Of course, we recognise that the last spending round provided local government with a challenging settlement. That is why we took the decision to provide extra funding to help local authorities maintain access to services; that includes £1.1 billion in 2014-15. In fact, spending has been roughly flat over the period since 2010-11. The latest survey shows that councils are expecting a small increase in expenditure next year. The survey also shows that the vast majority of the savings that have been made have been efficiencies. Councils have largely been able to protect services. They should now, however, be looking at how they can transform care by innovating and exploring new ways of working. Many local authorities are achieving much greater integration between health and care services and thereby improving the care for those they look after.
The latest ADASS budget survey shows that only 5% of directors of adult social services believe that quality has suffered as a result of the savings they have made. Five per cent is regrettable but it is a lot less than some of the figures that we see printed in the media.
In 2012-13, bed days lost because of delays attributable to social care were nearly 50,000 fewer than in the previous year. One of the other criticisms one hears is that quality is getting worse in social care and that that is having an impact on the NHS. But if we are going to continue to make these sorts of improvements, we need radically to rethink how we deliver health and social care and move to a more integrated system.
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.
Lord Warner
My Lords, this has been a helpful debate and I am grateful to all noble Lords who have spoken in it—overwhelmingly, I should add, in support of my amendment. I take great confidence from that.
The noble Earl has made not a bad job of answering my four questions about the £3.8 billion. I am feeling generous and so will give him a B minus for his attempts. At least he has come clean that only half the money is new money, which is a helpful clarification, and that only half of the £1 billion of the rest will be paid up front, while the rest is dependent. Therefore, to some extent my point has been made that that £3.8 billion looks a little less glossy than when it was announced in terms of what new money people will get in 2015-16. I notice that the noble Earl did not answer my question about the base budget, which took up much of my speech. The bottom line in all this is that the base budget is very deficient. The local authorities which will take on these new roles are starting, essentially, from a deficit position.
The noble Earl is always one of the most plausible Ministers and has done a good job of explaining efficiencies and productivity. However, the people who gave evidence to the Joint Select Committee just do not believe that this has all been achieved through efficiencies. They are seeing cuts in services and tougher eligibility criteria. The interesting mini-debate we had about the difference in payments for publicly funded people in care homes and self-funders illustrates that local authorities have been cutting the rate for the job for those who they pay for. We will see more of that. Until we face up to this base budget issue, we will have a problem.
I do not doubt that the Government have done a pretty reasonable job of costing the new provisions in the Bill. However, it will be introduced on the basis that the underlying base budget is too low. No one has yet answered my question with very much confidence about the fact that we are talking about a base budget deficit, which is in the Dilnot report, and which in broad terms has risen two and a half times since this Government came to office. That is the nub of this issue.
The noble Earl also glided over with his usual elegance the issue of why the Government are so preoccupied with this rather strange way of giving money to local government. First you see the Department for Communities and Local Government take money away and then local authorities have to cut other services if they want to prop up social care. Then Health Ministers, almost in desperation and worried about the implications for the NHS of what is happening to social care, long before they were betting the farm on integrated care, are—perfectly understandably—starting to slide money across to prop up social care. That is what is going on. If I were a director of social services these days, I would find it rather difficult to plan my service response to a kind of resource allocation system based on that kind of approach. That is a real problem for central government, which is expecting local authorities to plan well for these new changes. It is a pretty messy way of giving money to people at the local level.
I will read very carefully what the noble Earl has said in this debate. I am not convinced that we do not need an impartial review. If it is not the OBR I will think of somebody else. I might try a few on the noble Earl during the Recess—the Institute for Fiscal Studies comes to mind. We need a hard look by somebody who is not party pris. If my own party wins the 2015 election, it will need that hard look as well. I will think about it further, but in the mean time, I beg leave to withdraw my amendment.
Lord Hunt of Kings Heath
My Lords, subject to later comments about funding and the issues raised by my noble friend Lord Beecham, I have a great deal of sympathy with my noble friend Lord Dubs in wanting to have some kind of transparent appeal decision. It is clear from our debates on the Bill that local authorities will be called upon to make decisions which will have a fundamental impact on people living in their local authority area—eligibility, care plans, personal budgets, support for carers, self-funders baseline assessment and many more. We know that this will be hard for many people and their families to navigate. At the moment, it appears that the Government are relying either on local authorities themselves to develop their own mechanism, which might not enjoy public confidence, or on referrals to the Local Government Ombudsman. As my noble friend Lord Dubs says, that would be on the basis of maladministration rather than, perhaps, on the facts of the case.
Judicial review is hardly an option for many people. The reduction in legal aid will have an impact on the ability of places such as law centres to take JR cases forward on behalf of clients. I am the patron of Birmingham Law Centre, which has had to close its doors. In the last few years, the law centre was able to undertake a number of JR cases but it is no longer there to do that. The availability of a simple, low-cost appeal system would command some support.
When I was DWP Minister, I attended a day at the Birmingham tribunal centre looking at how cases were conducted. I was impressed at the ability of the three-person panels to allow the complainant to put their case across in a fairly informal setting with decisions made pretty rapidly. We know that these tribunal systems have been used more frequently with the introduction of the new arrangements. They command some public confidence. While I do not want to add to the financial burden on the system as a whole, I wonder whether it would be cost effective, as my noble friend Lord Warner says, for there to be a simple, fast, low-cost system. This will give people some confidence that, where they felt that the local authority had not made a reasonable decision, there would be allowance for it to be reconsidered. I am sure that this is a matter for discussion between Committee and Report and perhaps the noble Earl would be prepared to meet with my noble friend to discuss this further.
Earl Howe
My Lords, I am pleased that this important issue has been raised. I hope that I can provide the noble Lord, Lord Dubs, with at least a measure of reassurance relating to his concerns. As he has explained, the purpose of Amendment 104ZE is to include in the Bill provision for adults to make an appeal to the First-tier Tribunal if they disagree with the local authority about its decisions relating to matters such as eligibility, financial assessments, care and support plans and other obligations under this Bill. Often the individuals who access the care system are some of the most vulnerable in our society and it can seem daunting to challenge the decision of the local authority. I entirely agree that it is important that such people have the opportunity to make their voice heard if they feel that the local authority has reached the wrong decision in their case and that their argument is given the fullest consideration before a transparent, fair outcome is reached. The changes which the Bill would bring about will result in many more people being brought into contact with their local authority. This is why it is appropriate that we are now reviewing the current arrangements regarding complaints.
The current complaints arrangements for adult care and support were reformed in 2009 and are set out in regulations. The regulations require the local authority to have a publicised arrangement for the consideration and timely handling of complaints. Local authorities have flexibility in developing their own procedure for dealing with complaints. Each local authority will have a different process, and we appreciate that local variation may result in varying user experiences.
If a complainant is not satisfied with the response from the local authority, they are then able to refer the case to the Local Government Ombudsman, as has been mentioned. The Local Government Ombudsman is independent of the local authority. It can investigate complaints about whether the decision-making process has been conducted appropriately and can make a recommendation to the local authority.
Earl Howe
Certainly, I anticipate that the results of the review will be available before the Bill has concluded its passage through Parliament. I stand to be corrected on that but I think I am right. In any case, changes to the way in which complaints are handled can be made through regulations under existing legislation, so I think that provides the necessary flexibility.
Lord Hunt of Kings Heath
Would the noble Earl find it helpful if, on Report, we introduced an order-making power in the primary legislation that is specifically built around the Bill?
Earl Howe
That might prove helpful but I will take advice on it. We do not want to duplicate powers that already exist in legislation. However, if we decide that changes are needed, we need to make sure that they can be expedited properly. I am advised that the consultation will close in October this year and that the review of complaints arrangements, of which the consultation is a part, will conclude in the winter. Therefore, if changes need to be made to the Bill, they will need to be made in another place.
The noble Lord, Lord Dubs, said that in our response to the Joint Committee it is vital to consider redress. Of course, the principle of that is not in dispute. Our review of complaints arrangements is in line with our response to the Joint Committee’s recommendation, as I hope he acknowledges. In answer to the noble Lord, Lord Warner, I agree with him that there are likely to be teething problems as this system is established. That is precisely why we felt the need to review the current system. We will aim to ensure that any new mechanisms are in place before implementing the new system, as I have already indicated.
With that, I hope that I have provided at least some reassurance to noble Lords opposite that we take this issue seriously. We understand the concerns that have prompted this amendment and will certainly give further consideration to the noble Lord’s idea of a tribunal system in the light of the outcome of the consultation. I hope therefore that for the time being he will feel content to withdraw his amendment.
Lord Dubs
I am grateful to the Minister and I am interested in what he has to say. First, I thank my noble friends who have contributed to the debate and for the useful suggestions that they made, some of which, however, have been overtaken by what the Minister has said. My noble friend Lord Hunt talked about a simple, low-cost appeals system. That is very much in line with what the Minister said. The only issue is what chance we have to discuss further the outcome of the review and the Government’s further proposals.
I think the Minister said that either it will be possible in the Commons to consider any proposals the Government put forward as a result of their review; alternatively, it may be done by order, in which case we would all have a chance to look at it. In any case, that takes us quite a lot further. I am grateful to the Minister for what he has said and I beg leave to withdraw the amendment.
“(6A) An SAB’s objective under section 42(2) does not include helping and protecting adults who are detained in prison or residing in approved premises; but an SAB may nonetheless provide advice or assistance to any person for the purpose of helping and protecting such adults in its area in cases of the kind described in section 41(1) (adults with needs for care and support who are at risk of abuse or neglect).”
Earl Howe
My Lords, I thank the noble Lord, Lord Warner, for tabling these amendments which bring us to an important and sensitive set of issues. The Government have great sympathy with these concerns and I hope that I can reassure the Committee on them.
Amendment 105P would give the Secretary of State a power to introduce regulations for two specific but related issues—a right for NHS patients to die in the place that they regard as their home and an exemption from local authority charges for care and support for adults who are in the final six months of their lives. The Department of Health’s End of Life Care Strategy provides a blueprint for improving quality and choice in palliative and end-of-life care, and NHS England, which is now responsible for end-of-life care, is pressing on with its implementation, including aspects relating to the pathway to which the noble Baroness, Lady Emerton, referred.
We made a commitment in Liberating the NHS: Greater Choice and Control to move towards a national choice offer to support people’s preferences about how to have a good death. This is not an easy task and it cannot be done overnight. For example, commissioners need to be sure that the right services are available in the community to support people to be looked after at home. A lot of work is needed to make choice in end-of-life care a reality. We shall take all the evidence into account and review progress this year to see how close we are to being able to introduce a national offer on the choice to die at home. The noble Lord, Lord Warner, rightly pointed out that there are variations across the country as regards people’s ability to die in the place of their usual residence. I take that point completely. However, if we are to solve that disparity, it is important that we do not act prematurely. If an area is not ready to roll out a better system for palliative and end-of-life care, it will serve no one’s purposes, so we must take the necessary time to do this.
On the issue of palliative care funding, as the noble Lord is aware, in the Care and Support White Paper, published in July 2012, we stated:
“We think there is much merit in providing free health and social care in a fully integrated service at the end of life”.
This followed the report of the independent Palliative Care Funding Review in July 2011, after which the Government set up seven adult and one children’s palliative care funding pilots. The pilots are running for two years, with the aim of having a new funding system in place by 2015, a year sooner than the review proposed. From April 2013, we gave responsibility for this work to NHS England. We need to analyse the evidence from the pilots thoroughly before the details of the new funding system are finalised. Any changes to social care palliative care funding could be made by secondary legislation under Clause 14(1) in due course and will not require an amendment to the Bill.
My noble friend Lady Jolly referred to the cost savings in hospital admissions at the end of life and suggested that this might cover the cost of nursing care at home. This is a point made cogently by Marie Curie. The issue we need to bear in mind here is the readiness of the service to cope with sudden changes in services that an amendment would entail, so we still think that it is better to gather the evidence, as the pilots are now doing, and allow services to be properly planned for.
I turn to Amendment 105PA. The Bill allows local authorities to treat a person’s care and support needs as urgent, as set out in Clause 19(3). We believe that in end-of-life cases a person’s needs would be highly likely to be considered “urgent” and therefore should be fast-tracked so that needs are met as quickly as possible. We do not believe that the Bill should set out a list of urgent situations where a local authority can meet an adult’s needs without having yet carried out a needs or financial assessment, or made an eligibility determination. The problem is, as we have debated on many occasions in the past, that such a list could never be exhaustive and might suggest that only certain situations could be treated as urgent. Local authorities must have the flexibility to determine themselves which situations they consider to be urgent, depending on the facts of each individual case. The wording of Clause 19(3),
“which appear to it to be urgent”,
enables this. However, I can say that we intend to refer to end-of-life cases specifically in statutory guidance.
I can readily identify with the questions asked by the noble Baroness, Lady Pitkeathley, about carers and the need to support them after the death of the person they have been caring for and to make sure that they are informed about the stages at the end of life, the additional pressures that may be placed on them and the need to plan. The duty on a local authority to provide information and advice in Clause 4 very definitely includes information and advice relating to support for carers, including in these circumstances.
The noble Baroness, Lady Wheeler, asked about end-of-life care for BME groups in particular and the need to address the low use of palliative care services among those groups. She asked how we are addressing that. I shall write to the noble Baroness on that point, as I do not have information in front of me on whether the pilots are collecting those data specifically. However, I agree that it is a material issue. The noble Baroness also asked whether the palliative care funding pilots had been impacted by the transition to the new NHS system and whether we would meet the timescales. I can reassure her that the work of the pilots is on track.
I hope I have demonstrated that the Government are committed to offering patients the support to facilitate their dying at a place that they regard as their home, when the system is able to meet this commitment and where this is the person’s wish. I hope that the noble Lord, Lord Warner, will be sufficiently encouraged to withdraw his amendment.
Lord Warner
I am grateful to all noble Lords, across the Benches, who spoke in support of this amendment. I will, of course, consider carefully the noble Earl’s points in his constructive response. I will discuss them with my co-signatories and the voluntary sector. However, I want the noble Earl also to ponder something. The idea of giving people a right to die where they choose is one of the major social right breakthroughs. It is on a par with some of the other things that Parliament has spoken on and passed legislation about. In my view, it is more than about waiting for the bureaucracies to give their blessing that there is a state of readiness for this change to take place. This is an issue where the political parties and Parliament should show their willingness to press on as a top priority. I will certainly consider what the noble Earl has said, but I hope he will consider what I have said. We did not have everything ready when Parliament decided to ban smoking in public places and the workplace. It thought it was the right thing to do and it did it. This issue of people’s right to choose where to die is in the category where Parliament should say, “It is the right thing to do and we are going to get Governments to do it”.
I may be wrong. The Government may bring forward these changes in good order. But I take a different view from the noble Earl about the issue of local variation. They need to put a marker in legislation to make jolly sure that those parts of the country actually deliver the goods on a similar timescale to everybody else. I do not think that we could rely on strong messages from NHS England necessarily to deliver that. In the meantime, I will consider carefully and I beg leave to withdraw my amendment.
Lord Hunt of Kings Heath
My Lords, very briefly, I support my noble friend. In a sense, we have already had two debates on the employment practices of providers that are contracted by the local authority. The first was on Clause 5, regarding the local authority’s market-making role. We have also discussed under Clause 80 whether the Government, through regulations, will ensure that the CQC’s oversight of local authorities’ commissioning will be treated as a major priority.
The challenge for us on Report will be to deal with this issue by bringing it all together. There is no doubt that there is real concern about the employment practices of a number of companies that work in the adult social care sector and the lack of monitoring by local authorities in their commissioning. One way or another, the Bill will be very much enhanced if we can get to grips with this problem of poor employment practice. I have no doubt whatever that the general use of zero-hours contracts and the fact that those workers who are often low-paid have to pay the cost of travel themselves and are not paid for the time they take to travel from client to client leads inevitably to an impact on the quality of care, however worthy those people are. We will have a great opportunity on Report to do something about it and we will do so.
Earl Howe
My Lords, these are indeed serious issues and I am grateful to the noble Lord, Lord Warner, for raising them. Those who work directly providing care and support play a vital role in helping and supporting vulnerable people. Organisations that provide care must do all that they can to make sure that their workforce provides compassionate care and that people are treated with dignity, consistent with well-being principles.
Although the majority of care and support provided is good, I am aware that in some cases the practice of both providers and commissioners of care risks a negative impact on the well-being of those cared for. For example, the recent report of the Low Pay Commission has warned of lack of compliance with the national minimum wage, such as by not paying for travelling time between appointments. I am also aware that some local authorities’ contracts with care providers may lead to inappropriate practices, such as very short visits.
I agree entirely with the noble Lord’s intent to see a move away from such practices, which can undermine well-being, independence and dignity, as well as disempower those responsible for providing care and support. The question is how to do that. I believe that addressing these issues requires a broad range of approaches, some of which are already included in the Bill, but I am doubtful that further legislation is appropriate.
The terms and conditions of care and support workers, including pay, are set by employers within the existing requirements of employment legislation, with the same enforcement through HM Revenue and Customs, penalties and sanctions as in other sectors. All providers must, of course, pay at least the national minimum wage. This is law, and failure to meet the requirement is never acceptable. However, the law need not be repeated in the Bill or, indeed, in separate regulations that effectively duplicate those that we already have.
Where care and support is funded by the state, it is allocated through local authorities, which must ensure that the providers they commission from offer good value for money and a high-quality service. Clause 5 establishes a new duty on local authorities to promote a sustainable, diverse and high-quality market for care and support in their area, and is clear that an authority’s own commissioning practices must be in line with this duty. The Department of Health is working with the Association of Directors of Adult Social Services, the Think Local, Act Personal partnership and local authorities to embed this duty and improve commissioning generally.
We are providing firm leadership in this area. The Minister of State for Care Services, my colleague Norman Lamb, recently announced a home care challenge, whereby we will work with the sector to generate new ideas around improving quality in home care services and local authority commissioning. The department is also offering support to local authorities to develop their market-shaping capacity, and encourage high-quality provision and an understanding of market capacity and capabilities.
I am sure that the noble Lord, Lord Warner, will appreciate, without my needing to say this, that wages and associated employment practices are not the only determinant of service quality and a range of factors affect care workers having the right attitude, values and skills. The Department of Health is working on a number of initiatives with partners to develop a code of conduct and a recommended minimum training standard. Further work includes supporting workforce training through a workforce development fund and working with Skills for Care and the National Skills Academy for Social Care to improve the capability and skills of care workers. For the first time, this will now include support and training for personal assistants as well as people working for more formal providers. The department is also working with Skills for Care to develop a sector compact to promote culture change and skills development in the sector.
More broadly, through registration and monitoring, the Care Quality Commission enforces standards in this sector. The CQC requires that employers ensure that staff are well managed and have the opportunity to develop and improve their skills. Once services are registered, the CQC continues to monitor and inspect them against essential standards.
Lord Hunt of Kings Heath
I have never really been able to tempt the noble Earl to comment on the priority to be given by the CQC to the role of the providers and the responsibilities of local authorities in commissioning services. Can I tempt him to say more? Clause 80 clearly states:
“The Commission must, in respect of such English local authorities as may be prescribed … conduct reviews of the provision of such adult social services provided or commissioned by the authorities”.
Would the Government be willing to say to the CQC, “We will prescribe regulations that make it clear that this will indeed be a priority”? I have long felt that the way to deal with this is through the CQC’s own monitoring of how local authorities commission those services. It would be a way through if the Government were prepared to say that. The more I listen to our debates, the more I begin to think that this ought to be, of all the things that the CQC does, its number one priority.
Lord Warner
Supplementary to that, my simple view of the world is that if the situation is so bad, the CQC ought to be able to deregister someone who persistently engages in these kinds of employment practices. Do the Government share that view?
Earl Howe
My Lords, I am the first to agree that these are very important issues. I cannot do justice to explaining where we are with them at the moment and I ask both noble Lords for their indulgence. I will write to both of them and provide more information on this subject.
I was referring to the role of the CQC, which has the power to act in response to any concerns and to take enforcement action where services are failing people. Failure to comply with the requirements is an offence and, under the Health and Social Care Act 2008, CQC has a wide range of enforcement powers that it can use if the provider is not compliant. These range from issuing a warning notice and fines through to cancelling a provider’s registration. The new Chief Inspector of Adult Social Care will be in post from October and will provide additional focus on quality issues in care and support.
I repeat my reassurance to the noble Lord, Lord Warner, that the Government fully agree with the intention behind the amendment—that employment standards and workforce issues are fundamental to quality care—but I hope I have demonstrated that there is a wide range of activity bearing down on poor practice and that the variety of existing law and other non-statutory approaches mean that further legislation is not required. I hope the noble Lord will feel reassured enough to withdraw the amendment on that basis.
Lord Warner
I am grateful to the noble Earl for his reassurances. However, like my noble friend Lord Hunt, I am still uneasy about the extent to which there is, if I may put it this way, a clunking fist that could be used to stop such practices in their tracks, possibly by the regulator.
It would be helpful if before Report we could meet, perhaps with David Behan or someone from the CQC, to satisfy ourselves that, possibly by using guidance and advice from the department to the CQC, enough priority will be given to this issue and systems will be put in place to take action swiftly when concerns are raised. However, in light of the possibility of further discussions, I beg leave to withdraw the amendment.
“(ca) regulations under section 22(2)(b) (services or facilities which a local authority may not provide or arrange);”
“( ) sections (Section 47: cross-border cases), (Temporary duty on local authority in Wales), (Temporary duty on Health and Social Care trust in Northern Ireland) and 49 (provider failure: temporary duty in relation to cross-border cases);”
Health and Social Care Act 2012 (Consequential Amendments) (No. 2) Order 2013
Earl Howe Excerpts(10 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we had many debates in this House on the Health and Social Care Act 2012 during its passage as a Bill last Session. In this Session we have also debated some significant items of secondary legislation that put in place key elements of the new system, including the regulations that we have just debated.
This draft order, however, is very different from those instruments. It is short, and it raises no new issues of substance. Since it seeks to amend primary legislation, it is right and proper that it is subject to affirmative resolution but it is made under a narrow power to make provision in consequence of the Act. I cannot claim that the amendments it makes are of significant interest. They are minor adjustments, generally needed as a direct consequence of the Health and Social Care Act 2012, which I shall now refer to as the 2012 Act. They help to keep the statute book up-to-date and coherent, but they involve no new policies. Consistently with this, neither the Joint Committee on Statutory Instruments nor the Secondary Legislation Scrutiny Committee has seen a need to draw special attention to the draft order.
Before I explain what the draft order does, it may be helpful to start with a very brief reminder of the relevant provisions of the 2012 Act. That Act made a number of changes to the architecture of the National Health Service in England. Before the 2012 Act came into force on 1 April this year, the functions of commissioning and providing health services were conferred by legislation on the Secretary of State and were delegated by him to bodies such as primary care trusts. The Act, however, now gives the function of commissioning health services direct to the NHS Commissioning Board—also known as NHS England—and to clinical commissioning groups; while primary care trusts have been abolished. The Secretary of State continues to be under a duty to promote a comprehensive health service. He has ministerial accountability to Parliament for the health service. He is under new duties to keep under review the effective exercise of functions by the national-level bodies, such as the NHS Commissioning Board, and to report annually on the performance of the health service. That is the framework established by the 2012 Act.
I turn now to the individual amendments made by the draft order. The first amendment is to the Disabled Persons (Services, Consultation and Representation) Act 1986. The 1986 Act creates a requirement to assess the needs of people who are discharged from hospital after at least six months’ inpatient treatment for mental disorder. Section 7 of the Act sets out the services to which such an assessment must relate. Schedule 5 to the 2012 Act amended Section 7 of the 1986 Act to reflect, for example, the abolition of primary care trusts and the fact that it is clinical commissioning groups which now have to carry out the assessments in England.
However, that schedule did not update the reference to the services to which the assessment should relate. These are currently described as services that the Secretary of State is under a duty to provide under the NHS Act 2006. The order removes that reference, and updates it to take account of the changes in responsibility for commissioning and providing health services in England that were made by the 2012 Act. In making that change, we are able also to refer correctly to the bodies that provide services for the purposes of the Scottish and Welsh health services, and to the Acts under which they do so.
The second amendment made by the draft order is to the Community Care (Delayed Discharges etc.) Act 2003. That Act puts in place arrangements to ensure the safe and timely discharge of patients from hospital. Under the 2003 Act, the responsible NHS body is required in certain cases to issue an assessment or discharge notice, and the relevant local authority is required to assess the patient and put in place a support package by the named day. Schedule 5 to the 2012 Act made some amendments to the 2003 Act, but not those required to ensure that the arrangements continue to apply to NHS patients in independent hospitals. The draft order therefore makes the necessary amendments by adding NHS England and clinical commissioning groups to the definition of “NHS body” in Section 1 of the Act. This puts those bodies under a duty to issue the relevant notices in relation to patients discharged from independent hospitals commissioned by them.
Lastly, the draft order amends Section 256 of the National Health Service Act 2006. That section deals with the powers of certain NHS bodies to make payments towards expenditure on community services. Schedule 4 to the 2012 Act replaced the references to primary care trusts in the main body of Section 256 with references to the NHS Commissioning Board and to clinical commissioning groups, but unfortunately it did not amend the reference to primary care trusts in the cross-heading to the section. The draft order corrects that oversight.
In conclusion, I hope that I have demonstrated that the draft order contains changes that are consequential on the Act. It makes some minor but necessary changes to keep the statute book coherent and up to date. I commend the draft order to the House. I beg to move.
National Health Service (Licence Exemptions, etc.) Regulations 2013
Earl Howe Excerpts(10 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the regulations that we are now considering, which were laid before this House on 4 July, exempt some types of providers of NHS services from the requirement to hold a licence from Monitor. Providers who will not be required to hold a licence are as follows: NHS trusts; providers which are not required to register with the Care Quality Commission; small providers of NHS-funded healthcare services whose annual turnover from the provision of NHS services is less than £10 million; providers of primary medical and dental services; and providers of NHS continuing healthcare and NHS-funded nursing care.
The Health and Social Care Act 2012 gave Monitor a new role in regulating providers of NHS services, and the licence is a key tool for Monitor in carrying out its new functions. The Act strengthens sector regulation by building and improving on Monitor’s previous role as the regulator of foundation trusts and makes sector regulation more comprehensive by extending Monitor’s role to all providers of NHS services. While the 2012 Act allows licensing to apply to all providers of NHS services, these regulations provide for exemptions to this requirement for certain types of provider where the licence would not give additional protection for patients or would impose an unfair burden on providers.
Regulation 2 defines a licence holder as the legal entity responsible for delivering NHS services to patients, the body receiving NHS funding and providing care directly to patients. This approach mirrors that for CQC registration. Regulation 2 also ensures that, where a provider has subcontracted elements of a service, the subcontractor is considered a separate entity and thus in need of a licence.
Regulation 3 confirms that no exemptions apply to foundation trusts. This is consistent with the position under the 2012 Act that all foundation trusts must hold a licence.
Regulation 4 provides that NHS trusts will not be required to hold a licence. This is because directions from the Secretary of State require the NHS Trust Development Authority to set and enforce requirements on NHS trusts similar to those set by Monitor's licence. The NHS Trust Development Authority must seek and consider advice from Monitor in setting these conditions to ensure that the requirements for NHS trusts will provide similar protection for patients’ interests compared with those set by Monitor through the licence.
Under Monitor’s licensing regime, a commissioner may request that a service be subject to additional regulation to ensure patients’ continued access to that service. Any provider of such commissioner-requested services will not be eligible for an exemption under the regulations even if the provider otherwise qualifies for an exemption. Where commissioners have designated a service as a commissioner-requested service, Monitor must be able to intervene in order to secure continuity of that service. I should highlight to the House that this particular override would not apply to NHS trusts because the NHS Trust Development Authority will be able to undertake similar interventions on an NHS trust which becomes unsustainable. Regulation 9 provides for this.
Regulation 5 provides for an exemption from the requirement to hold a licence for providers of primary medical or primary dental services under contractual arrangements made under Parts 4 and 5 of the National Health Service Act 2006 with NHS England. NHS England will ensure that such providers comply with requirements that will ensure equivalent protections for patients.
Lord Hunt of Kings Heath
My Lords, I am sure that the whole House is indebted to the noble Earl for his lengthy explanation of the order before us. I just want to ask him three or four questions.
I noticed in the Explanatory Memorandum that there is an intention to review how licences are working and that it is to take place during the next Parliament. I must say that I thought it was rather presumptuous of officials to assume that this will be done. Of course, it is for me to point out that Governments cannot bind their successors to action to be taken, so I look forward to a Bill that will perhaps do away with some of the requirements that will be necessary.
The noble Earl will not be surprised if I ask him a question about the NHS Trust Development Authority. Reference was made in his remarks and in the Explanatory Memorandum to the relationship of the NHS TDA to the other regulatory bodies. Can he update the House on how long he now thinks that the NHS TDA is likely to be in existence? Of course, this relates back to the question we debated in the Bill, which is: what is his expectation in relation to non-foundation trusts and the pipeline, if you like, towards foundation trust application? Can he also give an indication of which services are likely to be designated as commissioner-requested services?
Paragraph 7.15 of the Explanatory Memorandum says that Regulation 7,
“exempts any provider that is not required to register with the CQC from the requirement to hold a licence from Monitor … This exemption would cover, for example, providers of ophthalmic services”.
Can the Minister tell us the rationale for why ophthalmic services are excluded? Is it to do with the fact that they are regulated in a different way?
The Explanatory Memorandum, at paragraph 7.16, says that NHS England is,
“well placed to enforce standards in relation to primary medical and dental services”.
As there has been a considerable amount of debate in the last few months about the quality of primary medical services and out-of-hours performance, can the Minister say anything about how NHS England will go about its business in ensuring standards in primary medical services? There are questions about whether it has the capacity to do that, and any reassurance on this subject would be welcome.
Finally, on exemptions, as I understand it, CCGs, when commissioning services from GP practices, are not exempted by Regulation 5. However, if the practice is large and goes over the £10 million threshold under Regulation 8, it may be covered, whereas if its turnover is below £10 million it is exempt under Regulation 8. The Minister will know that when we debated the Bill that became the Health and Social Care Act 2012 we had a great deal of debate about conflicts of interest. I have never been satisfied that that problem has been resolved satisfactorily. If, under these arrangements, CCGs are commissioning services from GP practices—remember that those practices are members of the CCG, so there is always a potential conflict of interest—I would have been more reassured if there had not been an exemption for practices with a turnover of less than £10 million. I would have thought that most traditional GP practices would fall below that threshold.
I understand the rationale for not wanting to catch small businesses under the regime, but does the Minister accept that when CCGs are commissioning services essentially from themselves—in the sense that GP practices make up the CCG—greater safeguards should be built into the regulations?
Other than that, these regulations are unexceptionable. I should, of course, remind the House of my interests in health, as president-elect of GS1, chair of a foundation trust and a consultant and trainer with Cumberlege Connections.
Earl Howe
I am grateful to the noble Lord for his questions, some of which I shall write to him about. He first asked me about the review of licensing exemptions that the department plans to carry out in 2016-17. He is, of course, right to say that no Government can commit their successor, of whatever colour, and it will be open to a successor Government, if they are of his party, to revise that aspiration. However, we think it right that after such an interval, the department should look to see whether the exemptions are continuing to prove appropriate, and if they are not it should propose amendments. I do not think that is a very controversial aim.
On the working life of the NHS Trust Development Authority, it will not have escaped the noble Lord’s notice that the original lifespan that we marked out for the TDA will now be exceeded. We have quite consciously, and rightly, determined that the process for approving foundation trusts should be extended, bearing in mind the outcome of the Francis review and the need for trusts, some of which by their very nature will prove more difficult to bring to foundation status, to focus on those aspects of the Francis report which need to be addressed if they are to be worthy of foundation trust status. Therefore, the length of life of the NHS TDA will undoubtedly extend into 2015. I cannot be more specific than that at this stage. It is a special health authority established by order. We will review that order in the normal course of things in three years’ time to assess whether there is a need for the authority. That is mentioned in the Explanatory Memorandum to the establishment order.
The noble Lord asked me why ophthalmic services are exempt. It is because they are not subject to registration by the CQC. We will of course keep those exemptions under review, as I have said. If evidence emerges to suggest that we should extend the licensing or make further exemptions, we will do so. When I spoke to the ophthalmic sector, it said that it did not see the need for a licence from Monitor, and we have taken account of its views.
The noble Lord asked me for some examples of commissioner-requested services. It is difficult for me to do that because they will be services which commissioners deem are in need of additional regulation to protect patients’ interests. Monitor has published guidance for commissioners to help them determine the considerations around commissioner-requested services. It will very much depend on the needs of the local population and what services are considered to be indispensable in a particular area.
The noble Lord asked me why GPs and dentists are exempt. As he knows, providers of primary medical services and primary dental services under contract to NHS England will be exempt from the requirement to hold a licence. As NHS England holds the contract with providers of those services, it is clearly well placed to place requirements on those providers that are similar to some of those in the licence. An agreement between Monitor and NHS England will underpin the arrangements. Monitor and NHS England are currently working on that. GPs and dentists sometimes provide other types of services under contracts with commissioners other than NHS England, such as minor surgery clinics or diagnostic testing services. They will be subject to licensing in respect of these services but at the same time be eligible for the de minimis threshold exemption. In addition, all providers of designated commissioner-requested services will require a licence, even if they would otherwise qualify for an exemption. It is therefore conceivable that a service provided by a GP practice might be considered a commissioner-requested service, but that is a speculative assumption on my part.
The noble Lord referred to conflicts of interest when such services are commissioned from GP practices by clinical commissioning groups. As I am sure he knows, there are clear rules around conflicts of interest. While GP practices are, by definition, members of a clinical commissioning group, the commissioning process must be done as much at arm’s length from an individual GP practice as possible. If someone in the clinical commissioning group has a direct personal or professional interest in the decision being taken, he or she must follow the rules surrounding that conflict.
The noble Lord asked me how NHS England is going to maintain standards in primary medical services. I have largely covered that point. NHS England will monitor the quality of care being delivered under the contract via the local area teams. Clinical commissioning groups are themselves engaged on peer-review exercises of their member practices which will, in turn, inform NHS England’s assessments.
I think I have answered all the noble Lord’s questions, but if I have not I will follow up in writing.
NHS: Accident and Emergency Services
Earl Howe Excerpts(10 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government recognise the severity of this issue and acknowledge that there was a dip in performance. We are taking robust action to address these issues and the 95% standard on four-hour A&E waiting times has now been met for the 12 consecutive weeks ending 14 July. The Government and NHS England are now looking at how we address the long-term issues facing A&E and the wider NHS.
Lord Hunt of Kings Heath
My Lords, the crisis in A&E happened on this Government’s watch as a result of the disastrous structural changes that they embarked on, the drastic cuts in social services and the disastrous launch of the 111 service. The noble Earl has talked about robust action being taken, but he will be aware that yesterday the Health Select Committee made it clear that local urgent care boards are simply not getting to grips with the problem. We are therefore heading for another very difficult winter, with many services at breaking point. Will Ministers take responsibility? Why, when the noble Earl talks about robust action, is the Government’s emergency care review only to be implemented next spring, six months too late?
Earl Howe
My Lords, I do not share the noble Lord’s analysis of the problem. A&E departments are currently meeting targets, but the long-term pressures have been building up for many, many years. Over the past decade, emergency admissions have risen by 35% and an extra 1 million patients have attended A&E compared to three years ago. This is not anything recent. The Government’s reforms will, if anything, help to ease the pressure because doctors now have the freedom to provide the health services their patients really need. The action we are taking in the immediate term is to encourage doctors and all the key players in the health system to get together in urgent care boards to make sure that next winter we see a much easier picture.
Lord Trefgarne
My Lords, is it not the case that the problems now being faced by many A&E departments are the result of changes to GP contracts introduced by noble Lords opposite many years ago?
Earl Howe
My Lords, there are many factors at play here. There is no doubt that the GP contract severed the legal responsibility that individual GPs had to look after their patients out of hours. It would be idle for me to stand here and say that that has had no effect on A&E attendances. Patients are confused now about whom to contact out of hours and many turn up at A&E when perhaps they should not have done so.
Lord Kakkar
My Lords, I declare my interest as professor of surgery at University College London and chair of quality for University College London Partners. What progress has been made in the commissioning of integrated care services across hospitals and the community for frail, elderly patients with multiple co-morbidities, who frequently have to attend A&E for the lack of such services?
Earl Howe
Not for the first time, the noble Lord hits on an extremely important aspect of the problem that we are facing. It is the frail elderly who often turn up at A&E with a crisis in their health when that crisis could have been averted. That is why Sir Bruce Keogh has been tasked to look across the piece at the whole system to see how we can ensure that the frail elderly in particular are served better by the health service, not least to prevent the exacerbation of long-term conditions.
Lord Dubs
The Minister has suggested that the problems of A&E are going to get worse in future. How will the Government’s attempt to tackle those problems be helped by the closure of A&E departments in many parts of the country? In particular, how will they be helped in west London with the impending closure of A&E departments at Hammersmith and Charing Cross hospitals?
Earl Howe
As the noble Lord will be aware, the latter issue is currently being scrutinised by the Independent Reconfiguration Panel, so it would be wrong of me to comment on that. On the question of reconfigurations generally, we are clear that this is a matter for local decisions by doctors, nurses and all those with a stake in the system. It is not for Ministers to issue edicts from the top. We are clear that any reconfiguration of A&E services has to take into account the capacity of the system to absorb any closures of A&E and the capacity of community services to step in where that is appropriate.
Baroness Jolly
My Lords, there is emerging evidence that younger people are using A&E as their first point of contact with the health service rather than their GP or out-of-hours services. Are there any plans to run local campaigns to remind people that accident and emergency units are just that? They are for accidents and emergencies and not coughs and colds.
Lord Richard
My Lords, the Minister said that the Government are taking robust action. What robust action?
Earl Howe
We have been taking action in several areas. We released additional money to ensure that immediate pressures were relieved in the health service in the spring and, as I have said, that was successful. We are encouraging, and have ensured, the setting up of urgent care wards, which amount to the kind of discussions across the system in local areas that are needed to ensure that there are no blockages in that system. More fundamentally, we have tasked Sir Bruce Keogh to undertake the work that I referred to earlier, looking at the root causes of why there have been these pressures on A&E. There is no single answer to that question.
Baroness Finlay of Llandaff
My Lords, I declare my interests, including that my daughter is an A&E consultant in London. Are the Government planning specifically to put in some additional resources to support A&E departments now, given that the consultants need more infrastructure support, including people at a much lower grade—clerical staff, care assistants and alcohol support workers—to cope with the peaks that occur of those who have come in having abused alcohol, who take staff away from the other very sick patients, who are often in resus and whom they are also trying to look after at the same time?
Earl Howe
The answer to the noble Baroness’s question is yes. We are looking very carefully at workforce issues and the mix of skills needed in those A&E departments that have been struggling. I refer not simply to A&E consultants but also specialists in their field—perhaps alcohol is a good example—who can deflect the pressure away from staff looking after acutely ill patients.
Baroness McIntosh of Hudnall
My Lords, building on the question from the noble Baroness, Lady Finlay, is there evidence that current difficulties in the administration of A&E departments are discouraging young doctors from regarding emergency medicine as an attractive specialism? Are the Government doing anything to encourage them to look at emergency medicine more favourably and to ensure that, if they do so, there will be jobs for them in the departments?
Earl Howe
That is very much in the focus of Health Education England, which oversees workforce issues in the health service. There has been a shortage of A&E consultants for some time and Health Education England is looking at that area very carefully. A&E is a discipline that has not traditionally proved attractive to trainee doctors for a number of reasons. It is very stressful and the remuneration is perhaps less than in other areas of medicine. That needs to be addressed and is very much an area of scrutiny.
Baroness Masham of Ilton
My Lords, following on from that, is the Minister aware that half as many again emergency doctors are needed? What is he going to do about recruiting?
Cigarette Packaging
Earl Howe Excerpts(10 years, 9 months ago)
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Baroness Thornton
To ask Her Majesty’s Government what action is being taken to ensure that they implement their obligations under Article 5.3 of the World Health Organisation Framework Convention on Tobacco Control when consulting on cigarette packaging.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, the Government take very seriously their obligations as a party to the World Health Organisation’s Framework Convention on Tobacco Control. This treaty places obligations on parties to protect public health policy from the vested interests of the tobacco industry. Our tobacco control plan has a chapter dedicated to how we are going about protecting tobacco control from vested interests. Our approach is consistent with guidelines that have been agreed to assist parties to implement Article 5.3 of the treaty.
Baroness Thornton
I thank the Minister for that Answer but, for the information of the House, the guidelines for the implementation of Article 5.3 state that parties to the convention,
“should require rules for the disclosure or registration of the tobacco industry entities, affiliated organizations and individuals acting on their behalf, including lobbyists”.
The guidelines specify that that covers meetings, receptions and all conversations which should be a matter of public record. Will the Minister ask his right honourable colleague the Secretary of State for Health to write forthwith to all his colleagues across government, reminding them what HMG’s long-standing commitments to the World Health Organisation’s convention are and how they should be enacted? Can he assure the House that Article 5.3 has been complied with in every particular in the past year while leading up to the disappointing announcement that plain packaging has been delayed?
Earl Howe
I can give the noble Baroness that assurance. She will know from her time in government how seriously the Department of Health takes its obligations in this area, not least around transparency but also minimising the extent to which officials meet representatives of the tobacco industry. I am sure that my colleagues in other departments need no reminding of their obligations as well. We do of course interact with the tobacco industry, as the framework agreement allows, but we encourage those representations to be in writing and minimise face-to-face contact.
Lord Foulkes of Cumnock
My Lords, has the Minister seen reports that Downing Street said yesterday that Lynton Crosby advises on strategy, not on policy. What is the difference in relation to tobacco legislation?
Earl Howe
I am sure that we could get into an interesting conceptual discussion about the difference between strategy and policy. The key point is that Mr Crosby has been very clear in his public statement. He has said:
“At no time have I had any conversation or discussion with or lobbied the prime minister, or indeed the health secretary or the health minister, on plain packaging or tobacco issues”.
That is very clear.
Baroness Finlay of Llandaff
What assessment do the Government intend to make in the coming year of the appeal of current packaging, given that some of the slimline packaging is particularly attractive and enticing to young women and that some of the chunky packaging is particularly enticing to the macho side of young men?
Baroness Jolly
My Lords, what better adviser is there for the Department of Health or indeed the Prime Minister than Cancer Research UK, whose only interest is preventing children starting to smoke? When did my noble friend’s department last speak to that organisation about tobacco packaging?
Earl Howe
My Lords, I cannot tell my noble friend about the dates on which the department spoke to Cancer Research UK; I can tell her that we have very regular dealings with Cancer Research UK. CRUK made a submission to the consultation on the plain packaging of tobacco. I can feed back to my noble friend with specific details.
Baroness Symons of Vernham Dean
My Lords, given that the Government clearly wanted to make the distinction between strategy and policy, would the Minister have another shot at answering the question raised by my noble friend Lord Foulkes? If he is unable to do so, perhaps he could consult with his colleagues who made such a distinction and write to my noble friend to explain why that distinction was made and what it meant.
Lord Elystan-Morgan
My Lords, the issue is not whether or not he spoke to the Prime Minister but whether he, or any other corporate interest in which he is involved, sought any contact with government or any agency of government in relation to this matter.
Earl Howe
My Lords, I am aware that officials in my department—not Ministers, I emphasise—had face-to-face meetings with certain tobacco companies in the context of the consultation on plain packaging. That was done to clarify certain aspects of their written submissions and is as far as it went. I am not aware of which companies those were, but if I can enlighten the noble Lord I will write to him.
Lord Avebury
My Lords, does my noble friend agree that it is harmful to public health in the United Kingdom for Mr Crosby to have any dealings whatever with government departments while exercising a malign influence in the background, and that he should be got rid of and sent back to Australia?
Antibiotic-Resistant Bacterial Infections
Earl Howe Excerpts(10 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I shall begin by saying how grateful I am to the noble Lord, Lord Crisp, for securing this important debate, and indeed to all speakers for their thoughtful contributions. The Government recognise that few public health issues are of greater importance than antimicrobial resistance. The scale of the threat was set out this March in Volume 2 of the Annual Report of the Chief Medical Officer on Infection and the Rise of Antimicrobial Resistance. Her call to action highlights the key issues that we need to tackle. These include, for example, good infection prevention and control measures to help prevent infections rather than a reliance on antibiotics, plus good techniques for diagnosing and deploying the right treatment. Equally important is ensuring that patients and animal keepers fully understand the importance of the treatment regimens prescribed, coupled with stronger surveillance measures to identify quickly new threats or changing patterns in resistance, and working to develop a sustainable supply of new antimicrobials.
Noble Lords will know that antimicrobial resistance refers to the ability of certain bacteria to survive after exposure to an antimicrobial that normally would be expected to kill them or inhibit their growth. Antimicrobial resistance affects us all, but some groups in society are particularly susceptible to infections and will feel the impact of antimicrobial resistance more than others. These groups include children, older people, and those with weakened immune systems such as cancer patients undergoing treatment, transplant patients and HIV/AIDS patients. An increase in difficult-to-treat infections will affect everyone as most of us will belong to vulnerable groups at some stage in our lives. Moreover, we know already that mortality is greater with resistant infections.
Antimicrobial resistance has obvious human costs, but it is also costly in terms of healthcare expenditure. It is estimated that antimicrobial resistance costs the European Union approximately €1.5 billion in healthcare expenses and lost productivity each year. This is indicative not only of the scale of the problem but of the fact that antimicrobial resistance requires action at the national and the international level.
At the national level, we will be publishing a comprehensive new cross-government five-year strategy to tackle antimicrobial resistance, which will have three strategic aims. The first is to improve the knowledge and understanding of antimicrobial resistance, through better information, intelligence and supporting data and through developing more effective early warning systems to improve health security. The second key aim is to conserve and steward the effectiveness of existing treatments, through improving infection prevention and control and through development of resources to facilitate the optimal use of antibiotics in both humans and animals. The third aim is to stimulate the development of new antibiotics, diagnostics and novel therapies by promoting innovation and investment in the development of new drugs and by ensuring that new therapeutics reach the market quickly.
A key component of antimicrobial stewardship is infection prevention and control. I would like to take this opportunity to reassure your Lordships that we will maintain a focus on healthcare-associated infections. Existing provisions, such as that requiring all healthcare providers to demonstrate compliance with the code of practice on the prevention and control of infection, will remain in place. The new NHS infrastructure also offers opportunities. For example, antimicrobial resistance has been included in key documents such as the Government’s proposed mandate for the NHS for 2014-15, which is currently subject to public consultation.
The noble Lords, Lord Crisp and Lord Turnberg, and the noble Baroness, Lady Masham, rightly noted the need for improved diagnostics. Public funders of research already invest widely in the development and evaluation of rapid diagnostic tests for infectious agents. In fact, just this month, the NIHR launched a themed call for antimicrobial resistance research and the development of new tests. The research and development of new tests is within the scope of this initiative.
Another example of what the Government are doing is that, from April 2014, the NIHR aims to fund 12 health protection research units for five years. These will be partnerships between universities and Public Health England. A number are expected to cover infectious disease areas and could potentially aim to include research on rapid diagnosis within their research programmes. From 1 September 2013, the Department of Health will provide a total of £4 million over four years to establish four National Institute for Health Research diagnostic evidence co-operatives to catalyse the generation of evidence on the clinical validity, clinical utility, cost-effectiveness and care pathway benefits of in vitro diagnostics. Based in NHS organisations and involving multidisciplinary teams, they will enable collaboration between a range of stakeholders, including providers of NHS pathology services and NHS commissioners. Two of the four DECs have identified diagnostics for infectious diseases as areas of focus.
The Government are well aware that they cannot deliver the action required to tackle antimicrobial resistance on their own. We need a societal shift, where antimicrobial resistance is seen as a priority that everyone can help address. To this end, we will continue to use the annual European Antibiotic Awareness Day to provide online educational materials that the NHS can use for local initiatives. In previous campaigns we reminded people that colds, and most coughs and sore throats, get better without antibiotics. That is because they are caused by viruses and not bacteria, and antibiotics only work on bacteria.
Although the scientific consensus is that use of antimicrobials in human medicine is the main driving force for antimicrobial-resistant human infections, use in the veterinary sector contributes to overall resistance rates. I listened with care and interest to the noble Lord, Lord Trees, on this aspect. We recognise that antibiotics, used responsibly, remain a vital part of the veterinary surgeon’s toolbox, without which animals suffering from a bacterial infection could not be treated effectively. As the noble Lord, Lord Trees, emphasised, the use of antibiotics in veterinary medicine is controlled by veterinary prescription and is equivalent to the arrangements for humans. In this way we are minimising antibiotics being used routinely and encouraging their responsible use. The Government’s position on the use of antibiotics in farming is very clear; we do not support the routine prophylactic use of antibiotics in animal health. I am pleased to say that Defra will be strengthening its guidance to ensure that this point is brought out very clearly. We very much welcome the support of the Royal College of Veterinary Surgeons on these prescribing issues.
Both the noble Lord, Lord Trees, and the noble Lord, Lord Crisp, referred to the vital need for international action. The Government recognise that to achieve many of the objectives of their strategy it is essential that the international community is actively engaged, and I can tell the Committee that the Government have been at the forefront in galvanising action at an international level. For example, this May my right honourable friend the Secretary of State for Health delivered the keynote address at the World Health Assembly, with antimicrobial resistance as a focus. Last month we ensured that antimicrobial resistance was a focal point of the G8 science meeting on 12 June. Furthermore, we held a special event at Chatham House to engage international experts on ways and means to tackle this complex problem. The noble Baroness, Lady Masham, and the noble Countess, Lady Mar, will be reassured to know that incentivising the development of new drugs was covered at this meeting, and I assure the noble Lord, Lord Turnberg, that the UK will continue to progress this issue.
A number of noble Lords, not least the noble Lord, Lord Crisp, referred to the barriers to producing new drugs. The discovery and development of new drugs takes time—up to 10 or even 15 years—and a barrier to developing new antibiotics is, as the noble Lord, Lord Crisp, rightly said, the relatively low private return on investment for antimicrobials relative to making investments in other therapeutic areas. Our work on strengthening international collaboration will be key to new drug development because international agreement to address this issue, as I said, is essential; it is too large an issue to tackle alone. We will build on existing international research collaborations, including public/private partnerships, as well as taking action internationally.
The noble Baroness, Lady Masham, referred to PVL. We agree that the PVL toxin needs to be recognised and treated rapidly. Guidance is available for professionals and is currently being reviewed. However, the available evidence indicates that the prevalence of PVL infections is low in the UK. She also referred to E. coli. E. coli bloodstream infections are increasing year on year. The department’s expert advisory committee asked the HPA—now Public Health England—to undertake enhanced surveillance of E. coli and to have experts advising on prevention strategies. However, many E. coli infections are not associated with healthcare.
Regarding the interim decision by the JCVI on the meningitis B vaccine, I will write to the noble Countess. The JCVI has just published on its website today a call for comments from stakeholders. It will consider those responses before finalising its statement on meningitis B immunisation. The consultation is for six weeks.
The measures contained in our strategy are comprehensive and far-reaching. To ensure that they are brought to fruition, a high-level cross-government steering group will be established to oversee implementation, monitor progress and publish progress reports. The actions that I have outlined set out a broad canvas. We have heard the warnings from the CMO and we are acting on her message. The new UK antimicrobial resistance strategy will set out what needs to be done across a broad front, both nationally and internationally, and, using our combined efforts, we aim to be better placed to confront the spectre of antimicrobial resistance before it is too late.
NHS: Children’s Congenital Heart Services
Earl Howe Excerpts(10 years, 9 months ago)
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Lord Sharkey
To ask Her Majesty’s Government what assessment they have made of the recommendation of the Independent Reconfiguration Panel in its report of 30 April on children’s congenital heart services that NHS England must ensure that any new review process properly involves all stakeholders.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, NHS England is taking forward the new national review of congenital heart services as quickly and effectively as possible, basing its actions on the recommendations of the Independent Reconfiguration Panel. I am advised by NHS England that it will ensure that all stakeholders have a chance to contribute to its review. Any decisions must carry the confidence of the public and be focused on the best outcomes for all patients.
Lord Sharkey
My Lords, the now discredited Safe and Sustainable review proposed closing the Royal Brompton Hospital children’s heart surgery unit, yet over the past three years this unit, along with Newcastle, has been the best performing in the country. Will the Minister reassure me that, before there is another proposal to close this or any other unit, he will publish a detailed model showing exactly what factors will be taken into account in any future proposal and how each factor will be weighted?
Earl Howe
My Lords, the first point to emphasise to my noble friend is that the new review is the responsibility of NHS England. It is not a piece of work that Ministers are in charge of. NHS England’s advice to me is that it is too soon to describe what the exact process will be. However, I can say that NHS England is developing a process that is, in its words, “rigorous, transparent and inclusive”, particularly in the use of evidence and data. As I have said, there will be opportunities for all stakeholders to participate in the review—including, importantly, the current providers of children’s congenital heart services.
Lord Walton of Detchant
My Lords, can the Minister give any estimate of how long this saga is likely to smoulder on? By all national and international comparisons, the unit at the Freeman Hospital in Newcastle upon Tyne has proved to be absolutely outstanding, and awaiting the outcome of this lengthy process is delaying a number of important and significant developments. Can the Minister give us any assurance about how long this will take?
Earl Howe
My Lords, my right honourable friend the Secretary of State wrote to NHS England as soon as the IRP’s report was published to say that it will need to work with all interested parties to ensure that progress on its new review of congenital heart services is made as quickly as possible. NHS England’s aim is that by June 2014 it will have developed, tested and revised a proposition for the review and undertaken work to identify a preferred approach to implementation.
Lord Woolmer of Leeds
My Lords, does the Minister recognise that the south Asian communities of Yorkshire, who felt deeply neglected by the previous review, will be watching with great care to see whether this review takes account of travel times and ensures that those communities most at risk of these issues are not only properly consulted but fully weighed in the balance?
Earl Howe
Yes, my Lords. The point that the noble Lord makes is extremely important. I think that there were a number of people who, for whatever reason when the Safe and Sustainable review was going on, felt left out of the picture. NHS England is clear that that should not happen again and that lessons have to be learnt so that this is a genuinely inclusive process.
Baroness Masham of Ilton
My Lords, does the Minister agree that adult and children’s services for congenital heart disease should be located on the same site to ensure continuity of care? When young people reach the age of 16, they seem to be thrown out of children’s service provision.
Baroness Howarth of Breckland
My Lords, during the previous difficulties and confusion when there was much lobbying and debate, the people who found it most difficult to follow the information and the evidence were parents. Presumably, they are the most important stakeholders, particularly in the case of children’s congenital heart disease. Can the Minister convey to NHS England the importance of finding clear and sometimes simple ways of helping parents at a time when they are stressed, anxious, worried about the geography and not able to understand the outcomes? They do not always have the best information with which to make decisions.
Lord Hunt of Kings Heath
My Lords, I refer the House to my health interests as set out in the register of interests. In the mantra of the market in the health service, which the noble Earl and his party are so wedded to, can he tell me when the Competition Commission can be expected to intervene in this issue, given that under the market mantra the decision to reduce the number of children’s heart centres reduces choice?
Earl Howe
My Lords, before I answer that, perhaps I may be so bold as to offer the noble Lord my congratulations on his silver wedding anniversary. I recognise why he has asked that question. It is too early to prejudge the final outcome of NHS England’s review, and I should stress that there is no preconceived result in its head. What I can say is that NHS England will need to engage with all key stakeholders throughout this review, including around any competition considerations.
Lord Mawhinney
My Lords, if I understood my noble friend correctly, he said that it would take until 2014 to test the process and then the review has to take place. Given the years that have been consumed in the past and that will be consumed in the future, what does my noble friend think all this is doing to the quality of service that is being provided and to the morale of those who are providing it?
Earl Howe
NHS England fully recognises that morale is extremely important and that it is fragile in certain locations. That is why the timescale is actually quite ambitious. Contrary to what my noble friend has said, its aim is to have a preferred approach to implementation ready by next June, which, given the scale of the task, is a major piece of work. It will of course build on the modelling and analysis that has already been done, so it is not going to be a wasted effort. In the mean time, I can reassure the House that children’s heart surgery is being delivered safely in all locations.