Health: Prescription Drugs
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The Earl of Sandwich
To ask Her Majesty’s Government what changes have been made in the training of junior doctors and nurses in the long-term effects of prescription drugs and in the availability of services to those suffering from addiction to and withdrawal from such drugs.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, recent changes to key documents governing the training of doctors have strengthened the requirements for their training in the long-term effects of prescribed drugs. The training of student nurses, due to the introduction of new educational standards, has been strengthened. Services to treat dependants, including for addiction to medicines, are commissioned locally. Information on changes to the availability of services locally to those suffering from addiction to and withdrawal from prescribed medicines is not collected centrally.
The Earl of Sandwich
My Lords, prescribed medicines can be every bit as dangerous as hard drugs, and the length of withdrawal can be much longer—up to three or four years, as I know from personal experience. Their victims lead a half-life and are out of the range of the NHS, with only the voluntary services to help them. Despite what the Minister has just said, which is encouraging, does he agree that the training being given to the younger generation of doctors and psychiatrists, and even the older ones, is still inappropriate and inadequate? What can the Government do to strengthen this training and to reinforce what the voluntary sector is already doing?
Earl Howe
My Lords, I am sure that the noble Earl will be encouraged to know that a lot of work is going on in this area. The Centre for Pharmacy Postgraduate Education, the Royal College of General Practitioners, Public Health England and others are developing information and educational materials and training on addiction to medicines for GPs and other healthcare professionals. In fact, the Royal College of General Practitioners published a consensus statement in January in which a wide range of professional organisations signed up to tackling this serious issue. I know that the Board of Science of the British Medical Association has also discussed it. I hope that the noble Earl will be encouraged that there is genuine activity in this area.
Lord Walton of Detchant
My Lords, many years ago when I was chairman of the General Medical Council’s education committee before I became its president, I received in the course of two months 32 letters each demanding that the special interest groups that wrote to me should have their conditions and concerns included in the undergraduate medical curriculum. Does the Minister accept that the range of medical knowledge is now so vast that basic medical education over five or six years does no more than simply enable graduates in medicine to benefit from postgraduate or vocational training having acquired skills and knowledge in principle which will help them to do that? Can he assure us that this extremely important matter raised by my noble friend now figures in postgraduate training of doctors, and not least in the mandatory vocational training programme of three years which must be undertaken by all intending general practitioners?
Earl Howe
I do, of course, agree with the noble Lord. I am sure that we have to be realistic about the extent to which every GP can be fully informed about this area. I can only say that it has risen in prominence in recent years, not least thanks to the efforts of the noble Earl. There is growing concern that this particular cohort of patients has been poorly served in the past and that is why the extent to which these drugs are being prescribed has diminished significantly over recent years.
Baroness Corston
My Lords, will the Minister confirm that the Committee on Safety of Medicines and the Royal College of Psychiatrists said many years ago that benzodiazepines are unsuitable for long-term use and should be prescribed for periods of two to four weeks only? And will he revisit a Written Answer he gave me recently saying that there was no connection between benzodiazepine addiction and suicide, when there is 30 years of eminent research to show that that is indeed the case? I declare an interest as the patron of Battle Against Tranquillisers, the foremost charity campaigning in this area, whose mission statement is:
“To lessen the harm caused by benzodiazepine and z drug tranquilizers and sleeping pills”.
Earl Howe
My Lords, of course I will revisit that Answer, and I will come back to the noble Baroness if I find cause to correct what I have said. However, I agree with her that the risks associated with long-term use of tranquillisers have been well recognised for many years. There are several authoritative sources for guidance for prescribers on this issue. I believe that that guidance is having an effect because, as I said, the prescribing rate has considerably diminished of late. There is no shortage of guidance out there. There is the national formulary, which already describes the importance of gradual withdrawal from benzodiazepines, and there is a wide variety of other impartial and trustworthy information resources to support prescribing.
Baroness Jolly
My Lords, GP training is important but for a user the crucial thing is the availability of the services. Will my noble friend tell the House whether services for those addicted to prescription drugs are readily available within each CCG area and where one might find details of such services?
Earl Howe
My noble friend will be encouraged to know that Public Health England has published a commissioning guide for the NHS and local authorities which sets out its expectation that support should be available in every area for people with a dependency on prescription or over-the-counter medicines. Local authorities are now, as she is aware, responsible for commissioning services to support people to recover from dependence in line with local need. Most of the support available for people who are addicted to prescription drugs is with their GP and not in services treating those addicted to illegal drugs, but there is a range of services available.
Baroness Finlay of Llandaff
To better understand the size of the problem, will the Government consider adding a box to the yellow card, which has been successful in reporting adverse drug reactions, to state that the doctor suspects that this person may have dependence on the drug? That would provide ongoing epidemiological monitoring.
Lord Hunt of Kings Heath
My Lords, the noble Earl will be aware that in the past few years nurses have been given much more authority, once they have been properly trained and authorised, to prescribe medicines. Can he confirm that the measures he has talked about will apply to nurse prescribers as well as to doctors?
Health: Anorexia and Bulimia Nervosa
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Baroness Howells of St Davids
To ask Her Majesty’s Government whether they are taking steps to ensure that those suffering from mental health disorders such as anorexia and bulimia nervosa are receiving the most appropriate care; and what provisions exist for urgent cases, particularly those of 17 to 18 year-olds.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, early intervention is essential for those with eating disorders. We have been clear that GPs are expected to use guidance produced by the National Institute for Health and Care Excellence—NICE—when choosing the most appropriate treatments, from physical and psychological treatments to medicines. The NICE guidance is due for review in January 2014.
Baroness Howells of St Davids
I thank the Minister for his Answer. Does he recognise that talking therapies are more effective for treating eating disorders, yet to date there is no legal right to receive talking therapies, as there is for drugs? Recent figures outline that more people than previously are waiting longer than the targeted access time of 28 days to receive those therapies, especially those under 18. In fact, the figures show that those under 18 are sometimes referred to mental hospitals rather than being given such therapy at the time. I respect the fact that the Government have committed to make measurable progress by March 2015 to parity of esteem, and that they cannot make any commitments before that. However, I am concerned that there appears to be no monitoring of this situation. The fact that this is urgent does not seem to be taken on board and many young people under 18 are suffering.
Earl Howe
My Lords, the mental health of children and young people is a major priority for the Government. Half of those with lifetime mental illness first experience symptoms by the age of 14 and three-quarters before their mid-20s. That is precisely why we are investing a large sum of money—£54 million—over the four-year period 2011-15 in the Children and Young People’s Improving Access to Psychological Therapies programme. We know, as the noble Baroness rightly emphasises, that those talking therapies can make the most difference, particularly if early intervention is achieved.
Baroness Gardner of Parkes
My Lords, is it not so that very often parents do not realise what is happening to their child? As for cancer or any other condition, early diagnosis is the secret. What can be done to speed that up? When I was chairman of a hospital, we had a whole ward full of people with this problem, but their condition had been recognised too late and therefore treatment was extremely difficult.
Earl Howe
My noble friend is absolutely right. However, it is encouraging to see that in recent years a range of information and support has become available. The Royal College of Psychiatrists has published a fact sheet on eating disorders, which is aimed not just at the profession but particularly at parents, teachers and young people themselves. It is called Mental Health and Growing Up. The fact sheet discusses the causes of eating disorders, how to recognise them and gives advice on how to cope with a child who has an eating disorder.
The Countess of Mar
My Lords, I am sure that the noble Earl accepts that some young girls have an eating disorder that is not anorexia or bulimia—they may have CFS/ME or reactions to HPV vaccines. Very often, they are incarcerated in mental hospitals when they should receive a different form of treatment. I have spoken to the noble Earl about this but perhaps he could say what progress is being made in ensuring that such young people are not mistreated?
Earl Howe
My Lords, I am sure that this is an area that NICE will need to look at when it refreshes its guidance to the clinical community. The noble Countess is absolutely right to raise the issue. CFS/ME can often be misdiagnosed; it can be mistaken for other conditions without proper differential diagnosis having taken place. We know that there is more work to be done in this area. However, the range of programmes now available to GPs, some of which I have referred to, can be helpful in this area.
Lord Hunt of Kings Heath
My Lords, I refer noble Lords to my health interests in the register. Perhaps I can take the noble Earl back to my noble friend’s question. She mentioned “parity of esteem”, which of course the House legislated for in the 2012 health and social care legislation. Could he tell the House how the Government intend to ensure parity of esteem, particularly ensuring that mental health services are given their fair share of resources in the health service? How do the Government intend to take that forward?
Earl Howe
My Lords, I do not wish to duck the fact that this is a very difficult area to define. We all know that we want to achieve parity of esteem. It depends on ensuring not only that mental health services are given their fair share of the budget but that the right treatments are delivered to the right people, and that everyone in the country has access to appropriate treatments. We are currently firming up with NHS England what the right metrics are in order to judge whether they have met that aim. I will write to the noble Lord with the latest news on that front.
Baroness Tyler of Enfield
My Lords, I am sure that the Minister is aware of the growing trend for eating disorder clinics and hospitals to treat much younger children and, indeed, boys with eating disorders. Given this, what additional steps does the Minister think need to be taken to ensure that everyone involved—children’s services, primary schools and others—are spotting these signs, particularly in boys, where stigma is often attached to acknowledging these things, to ensure that effective treatment is quickly available?
Earl Howe
My noble friend is absolutely right. The figures that I have before me show that by far the largest number of cases occurs in the age group 10 to 17. We are working on raising awareness of mental health problems, including eating disorders, and on providing support in schools. Particularly, we have provided £3 million of funding over two years to the BOND Consortium, which is led by YoungMinds. The aim of that is to build capacity in the voluntary sector to support the access that schools have to local services. We are also producing an e-portal tool for children’s and young people’s mental health, which we hope will be delivered next year.
National Health Service (Licensing and Pricing) Regulations 2013
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
The Health and Social Care Act 2012 gave Monitor a new role in regulating provision of NHS services and an overarching duty to protect and promote the interests of patients by promoting NHS provision that is economic, efficient and effective. These regulations provide key details that enable Monitor to carry out its new functions of licensing providers of NHS services and regulating the prices payable by commissioners for NHS services, in order to protect and promote patients’ interests.
The licence is a key tool by which Monitor will regulate providers of healthcare services for the NHS. Monitor has now taken on its new licensing powers in relation to foundation trusts and we expect this to extend to other providers of NHS services from April 2014.
A provider’s licence is made up of licence conditions that set out the requirements providers must meet if they wish to provide NHS services. In future, all providers of NHS services must hold a licence unless they are exempt under separate regulations, which were laid before the House on 4 July.
Monitor published its first set of standard licence conditions in February this year, after approval by the Secretary of State for Health. They include standard conditions such as requiring licensees to provide information to Monitor, which will apply to all licence holders, or to particular types of licence holder, such as conditions applying to providers whose services are designated as a commissioner-requested service. There are also special conditions that will apply to an individual provider, such as conditions for NHS foundation trusts. The Act sets out a process that Monitor must follow in order to either modify a standard licence condition or include a new standard licence condition that applies to all licences, or licences of a particular description.
These regulations allow the Secretary of State to determine the extent to which licence holders should be able to influence Monitor on any changes to the standard licence conditions, to ensure a balance between allowing real concerns to be addressed and not imposing unnecessary delays to the licence modification process. Monitor intends to engage potentially affected licence holders on the scope and scale of any changes to the standard licence conditions before reaching the statutory process, much as it did when engaging on the first set of standard licence conditions.
The statutory process then ensures that there will be proper engagement with affected licence holders and other relevant bodies about any change to the standard licence conditions, and includes a statutory check on Monitor’s ability to change the standard licence conditions. This check comes in the form of an ability for licence holders who would be affected to object to the change.
The regulations set the two objection thresholds at 20% of licence holders or 20% of market share of NHS provision. If either threshold is met, Monitor will be unable to make the change. However, Monitor may refer the issue to the Competition Commission. Monitor could make the changes only if the Competition Commission judged that the changes were in the public interest.
I turn to the second aspect of these regulations. Monitor has powers to take action where a person—which may be a licence holder, an exempt provider, NHS England or a clinical commissioning group—has not complied with a request for information documents, records or other documents that it considers necessary for Monitor to carry out its regulatory functions. Monitor also has powers to take action where a provider is in breach of the requirement to hold a licence or a condition of the licence.
The Act sets out Monitor’s powers to impose three different types of discretionary requirements, and I remind the Committee of them as a refresher. The first is a variable monetary penalty of such amount as Monitor may determine, up to 10% of the organisation’s turnover in England. The second is a compliance requirement, or, in other words, action to stop the breach in question or to ensure that it does not happen again—for example, a requirement that a provider ceases plans to dispose of an asset needed for the provision of a specified service. The third is a restoration requirement, an action to revert to the position before the breach occurred. For example, Monitor could require that a provider reopen a service that it had closed in breach of a licence condition.
Monitor’s guidance sets out how it will determine the use of its enforcement powers, including fines, and these regulations set the definition of turnover that Monitor will use when determining the level of fines. Simply put, providers’ turnover is defined as their turnover from NHS income. The turnover of clinical commissioning groups and NHS England is defined in terms of administrative spend; total spend would be vastly disproportionate.
I turn to the final aspect of the regulations. The Government want to ensure that the health system delivers better health, better care and better value for money. Better value for money and more accurate pricing will be a key part in delivering enhanced services to patients and in equipping the NHS to improve standards. The new system will drive improvement through providing mechanisms to ensure that prices better reflect costs of supply, incentivise better data recording and collection and make available better incentives and stronger compliance mechanisms. Monitor will have the specific duty of promoting healthcare services that represent value for money and maintain or improve quality. Monitor will achieve this by working with NHS England to regulate prices and set rules for determining prices for local pricing and flexibilities.
Lord Hunt of Kings Heath
My Lords, I was just going to refer the Minister to his remarks about the Competition Commission, because it is relevant to the regulation. There is great confusion in the health service about the commission’s role. The Minister will know that there have been interventions in Dorset and Bristol on what seem to be entirely sensible proposals. In Dorset it was the merger of two small acute trusts, while in Bristol it was the “divvying up”, I suppose the phrase is, of services between two trusts in order to allow for more patients to be treated and all the benefits that you get from that, with one trust focusing on some services and the other focusing on others. In anyone’s terms, those are both examples of the kind of configuration of services that is entirely sensible and that the Government in other guises are supporting.
It is quite clear that the OFT has been trying to get into the health service for some years. I will not get into Section 75 now but the OFT now feels that it can get into the health service, although it is very difficult to see what the point of that would be. The OFT is independent, I understand that, but Ministers have been silent about this. There is utter confusion in the health service and, I believe, among the regulators about how to run these two issues—on the one hand, the Competition Commission and OFT approach, and on the other the need for us to be aggressive in terms of the reconfiguration, and in many cases the centralisation, of services. This matter needs to be teased out.
The regulations ought to be considered in relation to more general policy on pricing as part of the national tariff. The Minister will know that in October last year, when the House of Commons Health Committee had its annual accountability hearing with Monitor, David Bennett, the leader of Monitor, talked about perverse incentives with regard to the tariff. He said that he was not sure that they were fundamental to the pricing system but he agreed that the way it is working can create perverse incentives. One example he used was that if we want to move activity out of hospitals and into a community setting, one thing we have to think about is that there some real transition costs which will have to be paid one way or another. The question is: is the tariff being adjusted to allow for that?
The Health Select Committee published its subsequent report in March of this year and concluded:
“The setting of the tariff is of great significance to the NHS because of its implications … for short term cash flows in the system, and for longer term incentives for”,
service changes. It recommended that,
“Monitor and the NHS Commissioning Board … attach a high priority to this process … because NHS parties need to know the likely tariff in 2014–15 as soon as possible, but also because the long term framework of the tariff will have an immediate effect on service design and the integration of service provision”.
I would be interested to know whether it is the noble Earl’s view that progress is in fact being made, so that the regulations and the tariff to which they relate are much more sensitive to the need for change and reconfiguration in the health service. We must reorganise our services to get higher quality, and the work that Bruce Keogh is doing is surely driving us towards this. However, it sometimes seems as though some of our regulatory apparatus is now at risk of getting in the way of what, on anyone’s evidence base, would be a sensible move. I would be interested if the noble Earl is able to respond to any of those points.
Earl Howe
My Lords, I am grateful to both noble Lords who have spoken. First, I hope that I can reassure the noble Baroness, Lady Finlay, on the question she posed about the cross-border aspects of patient flows and the tariffs that apply. The tariff will apply only to services commissioned by commissioners in England: that is to say, CCGs and NHS England. Any provider who provides healthcare services for the purposes of the NHS which are covered by the proposed tariff will be able to object to Monitor’s proposed methodology, so I do not see that patients in Wales or on the border need to be anxious about this.
The noble Lord, Lord Hunt, asked a series of questions. First, he questioned the wisdom of allowing Monitor to fine providers. It is worth saying that the discretionary requirements which Monitor can impose, as laid down in these regulations, are based on those used for other regulatory offences. In fact, they are based on Part 3 of the Regulatory Enforcement and Sanctions Act 2008. That menu of options has been picked up and put into the 2012 Act.
As regards fines, we need to be clear—and it is certainly my understanding—that Monitor regards fines as a last resort. It will need to consider each case carefully and has a responsibility to ensure that its regulatory actions are reasonable, while deterring poor conduct in the future. It must also consider whether its other powers would be more appropriate. I understand the point that the noble Lord has raised but it is unlikely that we will see Monitor exercising this power with any frequency. We must bear in mind that 10% of turnover is of course a maximum figure.
The noble Lord asked about the thresholds as laid down in the regulations. The 20% threshold relating to licensing is based on a similar process which was in place for modifying licences in the energy sector. We considered that the situation here in the health service was comparable, and it is a threshold that commanded general acceptance.
Earl Howe
I take the noble Lord’s point about uncertainty and confusion that I know exists in certain parts of the health service as to what all this means. I can tell him that officials in the department have had some very productive discussions with both the OFT and the Competition Commission to ensure that their approach need not set unnecessary hares running as regards apprehensions that a purist competition-based approach will be taken by these bodies. I am satisfied that that will not happen. My advice is that the Competition Commission, in particular, has welcomed the input of departmental officials in terms of the factors that need to be brought into play when making a judgment on what is in the best interests of the health service and patients.
At the same time I am aware that a number of useful events and conversations took place within the health service itself when we clarified with providers the considerations that the OFT and the Competition Commission will look at in proposed mergers. We are ensuring that when proposals are made the benefits of mergers are clearly defined in terms that will resonate with the competition authorities. The noble Lord is right that we are in new territory in many senses, but I am optimistic that the system will work in the way that it should. It is certainly about looking at competition aspects but, more pertinently, looking at the criteria that I mentioned earlier, such as the public interest in the case of licence modifications, the test of appropriateness in pricing methodology, and in the case of mergers, the interests of patients in the health service. The OFT and the Competition Commission must take into account the benefits of a proposed reconfiguration if they consider it under the Enterprise Act 2002. I remind noble Lords that that is the governing Act, so in theory at least, we have been in this situation for more than 10 years. In doing so the competition authorities must consider whether those benefits would outweigh any substantial lessening of competition that they find.
The noble Lord asked about the tariff, and in particular, primary care. We agree that payment mechanisms need to be aligned to drive better outcomes and better value for patients. They also need to be responsive and flexible, for example to enable services to be provided in an integrated way. Monitor and NHS England will work together to move the tariff in this direction. They are best placed to do that given their different roles.
The noble Lord asked me what would happen if the tariff proved to be inadequate. We expect the tariff in future more closely to relate to the costs of providing particular services. If the price payable for a service would make it uneconomic for a provider to provide a service, Sections 124 and 125 of the 2012 Act provide for a process for local modifications of the price payable.
My advice is that NHS England and Monitor are working very well together in this regard. Guiding principles have been defined and six shared principles for pricing have been agreed: that the pricing mechanism should enable and promote improvements in care for patients and taxpayers; that it should enable efficient providers to earn appropriate reimbursement for their services; that it should have regard to sustain the NHS offer in the long run; that it should not preclude the delivery of the Secretary of State’s mandate for NHS England; that it should have regard to the principles of better regulation; and that it should support movement towards a fairer playing field for providers.
I hope that I have answered most if not all the questions, but I undertake to write to noble Lords if I have failed to do that.
Baroness Finlay of Llandaff
I seek a small point of clarification. I take the example of a Welsh provider that is providing services for Welsh patients and that is also licensed to provide for patients coming across from England. In the event of them being deemed not to meet the conditions and therefore a fine potentially being levied at 10%, would that be only 10% of the contract issued on behalf of the English patients? Two very different healthcare systems will be operating.
I realise that this is complex, but the two healthcare systems are becoming more divergent yet the population on the border has to access both sides, I am concerned that these are some of the things that need to be clarified. It is a detail, I know.
Care Bill [HL]
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Baroness Wheeler
My Lords, the Joint Committee on the Bill acknowledged that it had been widely welcomed, but asserted that this did not mean that it could not be improved—there are gaps and risks and unintended consequences. The failure of the Bill adequately to underline the importance of housing not just to well-being but to integrated care, to prevention and to being included in the provision of advice and information on quality of care and assessment is what these amendments seek to address. The interplay between housing and well-being—the standard of someone’s living circumstances and their health condition, the appropriateness of their house or flat and the likelihood of their being able to remain in it and care for themselves—is long established. However, as noble Lords have shown, it is overlooked in key clauses of the Bill.
Our Amendment 87ZC takes forward the vision of specialist houses fully integrated into the health and social care system which was so comprehensively set out by stakeholders from across the housing sector in their evidence to the Select Committee. The quality of that evidence was commented on by the noble Baroness, Lady Jolly. There are numerous examples of inspiring best practice where housing is an integral part of care and support and service delivery. The Bill needs to provide the momentum for good practice to become embedded across all local authorities and health providers.
The evidence to the Select Committee from organisations across the housing sector cites inspiring examples of where housing, health and social care provision and support join up to provide integrated person-centred care. However, alongside this, there is huge frustration that progress across the country has been so slow and patchy. This is especially so when what stakeholders refer to as low-level interventions, which really make a difference, are often the services earliest to be cut back and dispensed with. The Anchor Trust, for example, described the determination to keep its service-level manager on site at one of its sheltered housing schemes because it made all the difference. The noble Lord, Lord Martin, made this point, too. Anchor said that, in its view, once the manager left, the next steps for elderly and frail people were usually into residential care. This was one of the many examples given of the consequences of not having housing-related support regarded as a key social determinant of health. I look forward to the Minister’s explanation as to why the Government have not ensured that this is fully reflected in the Bill.
Earlier, we heard the case from the noble Lord, Lord Best, and my noble friend Lady Wilkins for Amendment 81, supported forcefully by the noble Lord, Lord Rix, on the importance of including the promotion of housing provision in the duties of local authorities under Clause 3 to provide integrated services, and of ensuring that there are similar duties placed on the health service. Our amendment to Clause 6 complements this by reinforcing integrated joined-up working with registered housing providers, including housing associations and registered social landlords, and recognising these as key, relevant partners under the Bill.
The need to recognise housing as a preventive service cannot be overestimated or overemphasised. Schemes such as Midland Heart’s reablement service for the elderly or frail combine social care and housing association support to enable people to be discharged from hospital back to their homes quickly and help independence to be regained. They delay or prevent the need for more intensive care, reduce the likelihood of repeated hospital stays and can prevent avoidable accidents. Commissioners need to be encouraged to consider specialist housing, home-from-hospital services, housekeeping-related support and adaptations when designing preventive services. Housing is a crucial preventive service and Amendment 80 is important for ensuring that this is recognised in the Bill.
Amendment 88 is also important for ensuring that needs assessments include an assessment of housing options, as is Amendment 86, which underlines the importance of ensuring that local authorities provide information and advice for adults and carers on available housing options and the choice of providers available in the authority’s area. While in Amendment 87 we fully recognise the need for more specialist housing to be built to meet the needs of care and support, we would be cautious at the present time of putting this extra burden on local government when it does not have the resources or the means to deliver. It is the responsibility of national government to provide the £10 billion extra investment in infrastructure that the International Monetary Fund has called for to get the economy moving and make shovel-ready projects such as housing happen.
I am grateful to the National Housing Federation for its excellent briefing, and I refer to an example of integrated care and support it gives that was provided by one of its members, the housing association Look Ahead, for a psychiatric patient. It shows what can be achieved. Following a six-month stay in hospital, it had initially been intended that he should move to a residential care placement, but instead he was referred to Look Ahead’s rehabilitation service. The support that he received helped him with basic life skills, diet management and managing his condition. After 18 months, he had successfully moved to his own flat, had been able to reduce his psychiatric medication and had started a nursing diploma. This service, taking him from hospital to independence in his own flat in 18 months, was provided by successful joint working between the housing association, the local authority and the NHS trust, with an estimated saving of nearly £250,000 across the three services.
We heard, too, at our latest stakeholder group meeting yesterday about a successful jointly procured and delivered reablement centre in Liverpool that is funded by the local authority and the clinical commissioning group in respect of hospital discharge. The scheme provides two to three weeks of intensive occupational therapy and other key services, which doubled from 40% to 80% the percentage of patients who did not require a continuing care package after this initial support. However, we understand that in some parts of the country CCGs are expressing reluctance to enter into joint funding schemes with local authorities in case the health funding element is leaked into other council services, given their budget situations—literally, I suppose, into filling potholes or such like. Can the Minister tell us what steps are being taken to reassure CCGs about this potential barrier to providing integrated services?
As part of its oral evidence, Jake Eliot from the NHF said:
“Too often, the integration that occurs happens because service users, carers, providers and commissioners are working skilfully in spite of the system rather than because of it”.
This is something that the Bill can change effectively. I hope that the Minister takes these words to heart and accepts the amendment. It would ensure that the Bill recognises the importance of housing. It is important not just for well-being but for prevention, for the provision of advice and information in the assessment process and for ensuring that the overall quality of care is fully recognised.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in tabling these amendments, the noble Lord, Lord Best, brings to the attention of the Committee the important role that housing plays in both care and support, and as a determinant of well-being. I have listened with care to the powerful contributions in support of them. Having done so, I begin with an observation that I hope is incontrovertible, which is that simply having a roof over your head will have a profound impact on your well-being. Having access to suitable housing for those with care and support needs plays a vital role in promoting not only their well-being, but their independence. The noble Lord, Lord Best, brought this point home very well. Properly taking into account the suitability of someone’s living accommodation could, for example, help to prevent a frail older person from falling and thus suffering the pain and trauma of broken bones and an unnecessary stay in hospital, the need for a greater level of care and support following discharge, and the costs of this to the public purse. It is vital that the system actively works to promote independence rather than waiting for people to reach a crisis point.
To reflect the importance of housing as a determinant of well-being, we have explicitly included the “suitability of living accommodation” in Clause 1(2), which sets out a list of things to which well-being relates and that the local authority is required to promote in performing its care and support functions. Furthermore,
“accommodation in a care home or in premises of some other type”,
is set out in the high-level list of examples of how to meet needs in Clause 8. Together, this means that the Bill ensures that housing is an integral part of care and support, where it is not general housing as excluded by Clause 23.
Baroness Gale
My Lords, I will speak to Amendments 92ZZEA and 92ZZEB. Clause 22 is titled:
“Exception for provision of health services”.
Subsection (1) is crucial, as it sets out the legal test for when NHS continuing care or registered nursing care should be provided and when the means-tested social care system may lawfully provide for nursing care.
Recently, I have been listening to people give evidence to the APPG on Parkinson’s, which I chair and which has been conducting an inquiry into NHS continuing care. Listening to the witnesses, it has become very clear that there are often lots of problems with the health service and social care services arguing over funding. People are having difficulty accessing continuing care under the NHS and have to get over lots of barriers. It is quite heartbreaking to hear the problems that people are having.
The wording of Clause 22 still carries a potential risk for those who self-fund their care. There are various provisions in the clause that allow local authorities to arrange for health services that should be provided by the NHS. Once councils start delivering healthcare, when they traditionally used to deliver means-tested and chargeable social care, there is a risk that someone—somewhere in the system—will mistakenly conclude that the council can charge for those services. There is a need to ensure that self-funders are not exposed if they are found to be eligible for NHS continuing care, or registered nursing care, and the package of delivery is with the local authority. These matters were raised by the Joint Committee scrutinising this Bill but have not yet been addressed.
In legal terms, local authorities are prohibited from providing anything authorised or required to be provided under the NHS Acts. This means that social services cannot provide care home accommodation if a power or a duty to provide the accommodation exists under any of the NHS Acts. Clause 22 has narrowed this down to just “required”, for example by omitting the “power” or authorisation provision. That leaves local authorities able to provide accommodation that the NHS has a power to provide. I believe that disputes and confusion have occurred between councils and the NHS over continuing care, and this seems to be a recipe for more. The Bill should be amended to prohibit local authorities providing a service or facility that is authorised or required to be provided under the NHS Act 2006.
My amendment would mean that local authorities would be prohibited from providing health services that are authorised or required to be provided under NHS Acts. My aim is to make it clear who can deliver what, so as to avoid self-funders being at risk, however small that risk might be, of having to pay for care that they should be getting free.
Clause 22(4)(a) also states that a local authority may, despite the prohibitions, arrange for care home accommodation with nursing care if it has consent to do so from the clinical commissioning group. This may also put self-funders at risk of being charged for services that should be free.
These amendments would introduce an explicit clause that sets out that, where a local authority provides services on behalf of a clinical commissioning group, the authority may not recover the cost from the individual whose needs are being met. I trust I have set out clearly why these amendments are needed and I hope that the Minister will agree with me.
Earl Howe
My Lords, it is vital that care and support, health and other services are joined up, as this offers the potential to make measurable improvements in individuals’ outcomes and experiences of care and support. Clause 3 places a duty on local authorities to carry out their care and support functions with the aim of integrating services with those provided by the NHS or other health-related services such as housing. Amendment 81C, tabled by the noble Baroness, Lady Wheeler, raises the issue of co-operation duties on the NHS; I have no issue with that sentiment. Clause 3 is intended to reflect the similar integration duties placed on NHS England by Section 13N, and on clinical commissioning groups by Section 14Z1 of the National Health Service Act 2006, in the context of this Bill.
Clause 6 imposes a general duty to co-operate between the local authority and other relevant authorities that have functions relevant to care and support. Clause 7 supplements this by creating a specific duty to co-operate in individual cases.
Clause 22 sets out the limits on what a local authority may provide by way of healthcare and so, in effect, sets the boundary between the responsibilities of local authorities for the provision of care and support, and those of the health service for the provision of healthcare. Our intention is to replicate the effect of the current prohibitions on what a local authority may provide by way of healthcare, which are imposed under Sections 21 and 29 of the National Assistance Act 1948 and Section 49 of the Health and Social Care Act 2001. This is a matter eloquently raised by the noble Baroness, Lady Gale, in tabling Amendments 92ZZEA and 92ZZEB.
The word “authorised” in Section 21 of the 1948 Act has resulted in much confusion and case law. The intention behind Clause 22 is therefore to simplify the language and to make the boundary clearer without moving it. Make no mistake: where nursing care is being funded by the health service, it will continue to be unlawful for a local authority to recover the cost of this from the individual. It is the relevant clinical commissioning group that would be responsible for this cost.
On Amendment 82A, I wholeheartedly agree with my noble friend Lady Barker that no one should be given medical treatment or be medically assessed against their wishes where they have capacity to make such a decision. I hope that my noble friend will be reassured that the existing legal position and clinical practice is clear on that point.
Amendments 87ZZA and 81B were, again, spoken to by the noble Baroness, Lady Wheeler. The prominence of health and wellbeing boards will be strengthened through their role in signing off the joint plans that are required as part of the £3.8 billion pooled fund between local authorities and the NHS to support joined-up and integrated working. The need for local commissioners to engage with their health and wellbeing boards is made clear through their composition, which includes the director of adult social services, the director of children’s services, the director of public health and a representative of each relevant clinical commissioning group. The duty to co-operate already applies to these health and wellbeing board members.
Lord Beecham
That is absolutely true. Neither is the provision of information and advice. However, it is not necessarily the role of a professionally qualified social worker or a professionally qualified health visitor or other person. I agree—it is a point that the noble Baroness, Lady Barker, and I both made—that both sides, health and social work, must collaborate on this. It is perhaps the wording of the amendment, rather than the intention, that might be looked at.
There is a question about how best to proceed with the publicity that should follow the enactment of this legislation. The Joint Committee advised that the Government should work with all interested providers to launch a campaign to raise awareness of and support for the change. I hope that the noble Earl will confirm that that is the Government’s intention and bring us up to date on where the Government stands.
In the context of such a radical change, it might be desirable for there to be some pilots on the ground about this issue of information and advice, working in collaboration with the Local Government Association, the NHS Confederation and other major national partners, to look at how these matters can best be explained. There could also be, at a fairly early stage, some examination of good practice. I am not suggesting that the whole scheme be piloted but that in a few areas, after a relatively short period, there might be a process of peer review and an examination of how it is working on the ground. Given that local authorities retain their scrutiny role for health and social care, it would be worth while developing with the Centre for Public Scrutiny, the LGA and relevant health service bodies, a way for the new system to be subjected to useful scrutiny at local level, and for lessons learnt to be disseminated across the country.
There are questions about the advocacy role. There is clearly a case for advocacy being included. One notes that there is a glancing reference in Clause 8, which is the reason for the stand part debate. It looks a little odd situated between Clause 4 and Clauses 18 and 20, as it does not seem to relate specifically to either. It has been mischievously suggested that there might have been references to advocacy in other parts of the Bill at an earlier stage that were removed and this was left behind. Can the noble Earl indicate the Government’s intention in referring to advocacy in that particular clause? We are not intending to move that the clause should not remain in the Bill; this is purely a probe.
We see most of these amendments as contributing to a refinement of the Bill’s proposals and we welcome that. However, it is necessary to reiterate the need for caution about the role of local authorities, particularly in the context of the financial situation that they are facing, which will get worse under a very tight regime. The Government are making provision for this, but we must be careful that the sum is not divvied up across a range of things without seeing the whole picture. If we are to give priority to this issue of information and advice, it would be helpful if the relevant departments, together with the Local Government Association, could look at the real cost of this and ensure that it is identified and included within the total package. It is easy to add desirable things against a budget. We do not know the extent to which these matters have been costed, for example, in the sum that the Government have allocated. We know that the demand is constantly rising, partly as a result of demographic change, and that the costs are also inexorably rising. This will be a cost. It is a justifiable cost, but it needs to be identified, provided for and kept under review.
Having said that, we are very much in sympathy with the thrust of these amendments and we look forward to the Minister’s reply and to working with others of your Lordships’ House in ensuring that the Bill is capable of delivering what it sets out to deliver and that all relevant players are engaged and financed adequately, so that we can afford the best possible level of care to those—of any age and with any condition —who need it.
Earl Howe
My Lords, I am very grateful to noble Lords for tabling these amendments, which highlight the importance of access to good information and advice, including independent financial advice and independent advocacy, for those who have care and support needs or are planning how to meet future care and support needs.
First, I will address Amendment 82B, in the name of the noble Baroness, Lady Meacher, Amendment 86E, in the name of my noble friend Lord Sharkey, and Amendment 86F, in the name of the noble Lord, Lord Lipsey. Clause 4 introduces a general duty to make a universal information and advice service available to everyone in the local community. I say to my noble friend Lord Sharkey in particular that we are clear that the information and advice service must be accessible to all, whether they fund their own care or get some care and support paid for by the local authority, and in order to fulfil its duty the local authority will need to facilitate access. The noble Baroness, Lady Meacher, raised the issue of early information and advice about Alzheimer’s in particular; this will be one of the vital areas that the services should cover.
The clause deals broadly with what the information and advice service must cover. Subsection (2) sets out the essential requirements for the service but— intentionally—this is not a definitive list. With regard to Amendments 86B and 86H, subject to specific qualifications, it will be for local authorities to determine the precise scope and manner of the information and advice that they offer. We expect many authorities to offer access to independent sources of information and advice, working together locally with the voluntary, not-for-profit and private sectors. We set out our expectations and additional funding for local authorities, which rises to £50 million a year by 2017-18, in the Caring for Our Future White Paper.
I would say to my noble friend Lady Browning that some authorities have also used qualified social care staff as the first point of contact and have found that this can be effective, efficient and timely, helping people to the care and support that will help them most. Others have provided a first point of access to information through more general services, which connect information and advice on a wider range of local authority responsibilities as well as local NHS provision.
I emphasise that statutory guidance will cover how information and advice can be provided in an accessible way and be proportionate to the needs of those for whom it is provided. My noble friend Lord Sharkey expressed doubts about the phrase “seek to” and suggested that it was rather too weak. Statutory guidance will set out the clear expectations of what the local authority’s service should cover or what it should seek to do in order to ensure that the information and advice is sufficient.
My noble friend Lady Browning asked about the number of social workers. More than 1.6 million people are employed in the social care sector, including 200,000 social workers. We do not set out any national targets but we recognise the need to improve skills, capacity and retention. We are working with stakeholders, including the National Skills Academy for Social Care and Skills for Care, to produce new national minimum training standards, which will further raise standards and encourage new people to enter the sector. My noble friend referred to my letter of 27 June. I confirm that this referred to Health Education England. Health Education England’s remit does not extend to social care; it covers health and public health.
Amendments 83ZA and 86A, in the name of the noble Baroness, Lady Gale, cover information and advice on health-related areas and information to people with specific medical conditions. As for many services, there will be a need for the local authorities to work with NHS organisations and more widely to provide focused information and advice to those who would benefit from it. There are already good examples of how information and advice services from a range of organisations can work together with the health and well-being of the individual at heart. Many use the national information provided by NHS Choices as a base. A lot of local authorities are providing information and advice directly to those who may have an entitlement to NHS continuing care. In addition, regulations under the Bill will specify the circumstances in which the local authority must refer the adult for an assessment for NHS continuing care. We will of course work with interested organisations to include such examples in statutory guidance.
Turning to the amendments addressing access to regulated financial advice, the noble Baroness, Lady Greengross, and the noble Lord, Lord Lipsey, make some excellent points about the importance of appropriate financial advice for those who have or are planning for care and support needs. This kind of advice may be particularly relevant to people who are funding their own care and may include a financial adviser who is regulated by the Financial Conduct Authority, but there is no need for the Bill to set this out specifically. There are other kinds of advice that may be relevant to such people and, as I have mentioned, we think it is important to maintain the general terms of Clause 4.
I take on board the concern about the use of the term “independent financial advice”—that this may cause some confusion with the term’s general meaning within the financial industry and the Financial Services and Markets Act 2000. We are happy to consider this aspect in more detail to ensure that no confusion exists. However, we do not believe that taking independent regulated advice should be compulsory. Whether a person takes advantage of independent advice is a matter of personal choice. This is particularly important because some financial advice may be subject to a charge.
There will be individual circumstances in which it will be appropriate to recommend independent advice from a regulated financial adviser, such as when people are planning to meet future care needs or when people go into residential care and are weighing up financial options such as selling the home. The fact that an organisation or individual is regulated is in itself no guarantee that the person has knowledge or experience of wider care and support issues; for example, housing or other care-related options. All this makes the adult’s choice of an adviser a vital aspect. The local authority should advise about the importance of independent regulated advice and signpost the adult to offer a choice of where they can obtain the best and most relevant advice. Again, we intend to cover such issues in statutory guidance.
We will also shortly be consulting on the design and technical implementation of the funding reforms, including deferred payments. This will include how the new duties to signpost independent financial advice will work. The noble Lord, Lord Beecham, asked about an awareness campaign about the funding reforms themselves. We are scheduled to discuss amendments on that very issue in a later group and I hope that the noble Lord will be content for me to cover the issue at that point.
Care Bill [HL]
Earl Howe Excerpts(10 years, 10 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, in tabling these amendments, the noble Lords, Lord Hunt of Kings Heath and Lord Beecham, and the noble Baronesses, Lady Greengross and Lady Emerton, bring to the attention of the Committee the important role that local authorities have to play in fostering a market that offers people genuine choice between a range of high-quality care and support services.
To support choice and control for individuals, and to improve quality of care, it is critical that a range of types of care and support is available locally, and that the market in services is able to grow and adapt over time to meet people’s needs.
The Care Bill marks the first time that local authorities’ responsibilities to promote the market in local care and support services has been captured in law. This recognises the importance of ensuring the availability of a variety of high-quality services to meet the needs and preferences of all local people, not just those whose care is arranged by the local authority.
The duty is about ensuring that the market meets the needs of local people with a choice of quality services; it is not simply about promoting a market for its own sake. This focus on quality should be understood in a broad sense. High-quality services will be fit for purpose and appropriate to an individual’s needs. Consequently, the important issue raised by Amendment 86J, of ensuring that local authorities shape markets that offer people a choice between appropriate services, is already covered by the clause: propriety is an important component of quality. I say to the noble Baroness, Lady Greengross, that Clause 5 requires local authorities to shape diverse markets in care and support services. I do so in the light of her concern that low-paying local authority contracts might preclude smaller, voluntary sector organisations from playing a part in the market. The provision will include ensuring that people are able to choose from a range of providers, including small and micro providers.
In fulfilling the duty, it is vital that local authorities engage with adults using services, their carers and providers, as Amendment 86K emphasises. The Bill therefore requires local authorities to consider how providers can meet current and future demand for services, and the importance of fostering innovation and improvement in their local area. Consequently, I reassure noble Lords that it would not be possible to fulfil the duty as it stands without engaging providers, adults who are using care and support services, and carers.
A number of the amendments relate to one of the most important ways in which local authorities can shape local markets: their commissioning decisions. Local authorities are required by Clause 5 to consider the importance of ensuring sustainability. This requires a strategic perspective on the strengths and demands placed on care and support providers now and in the future. It means that local authorities must consider how their actions may impact on the stability of their local market. They should not act in a way which might risk the sustainability of the market. Looking especially at Amendment 86L, local authorities that set unreasonable or undeliverable prices which undercut the financial sustainability of the provider market would therefore not be fulfilling this duty. However, it is important to emphasise that the normal and effective operation of any market includes some providers entering and exiting the market. The Government do not wish to prevent exit, or require local authorities to prevent exit. It would not, therefore, be appropriate for local authorities to promote the sustainability of individual providers rather than the market in general. For that reason, I cannot support the amendments proposed by the noble Baroness, Lady Emerton, although, of course, I sympathise with her concerns.
The noble Baroness, Lady Greengross, expressed the worry that low-paying local authority contracts might lead to the subsidy of providers by self-funders. The introduction of the cap on care costs will mean that a person who chooses to meet their own needs will be able to compare what they might pay to meet their needs with what the local authority pays. If a person wants to, they will be able to ask the local authority to arrange to meet their eligible care needs so that what they pay to the local authority to meet their needs would be the same as the figure that counts towards the cap. I hope that is helpful.
Lord Campbell-Savours
Does that mean that a self-funder in a home would therefore know what the local authority rate was going to be? That is what I understand the noble Lord to have just said. The information would flow through, would it not?
Lord Campbell-Savours
I am sorry to press the noble Earl. As I understand it, in many homes, self-funders are completely unaware of what the local authorities pay.
Lord Hunt of Kings Heath
We are almost anticipating a later debate when it comes to the Dilnot cap. This is an important issue. It is well-known, is it not, that self-funders essentially subsidise those people funded by local authorities. We know that some homes simply would not be viable if they existed only on local authority rates. In a transparent era, will self-funders put up with that? The cap relates only to local authority rates, so self-funders, in many cases, will have to pay much more than £72,000 before they can look to the local authority for support. If they now know that in addition to having to pay well above the £72,000 they have actually been subsidising people who have been supported by local authorities, I think it is going to lead to some severe problems.
I do not expect the noble Earl to be able to respond in detail, and perhaps this is in anticipation of the debate that we will have in our next session, but I am not sure whether the issue of fairness has been factored in to an understanding of how this is going to work in practice.
Earl Howe
Local authorities and individuals can pay different prices for care. That can be because individuals have consciously chosen premium facilities or because the local authority has negotiated a lower price in exchange for buying care for a larger number of people, which can often happen as well. As is the case now, local authorities and providers will continue to negotiate arrangements and fees for providing care and support. This process should ensure that contracts reflect the market price for providing care. Local authorities that fail to negotiate properly with providers and do not have regard to the actual cost risk legal challenges to the care fees that they set. However, in response to the noble Lord, Lord Campbell-Savours, I would say that in future the independent personal budget will set out the cost to the local authority. That is the transparency point that I was trying to get at earlier.
Lord Campbell-Savours
I am very sorry but the point is being missed and I think that my noble friend on the Front Bench tried to qualify it. Up to £75,000, the self-funder is paying the full whack. As I understand it, what is being said is that in the same home the local authority rate either will be or will not be available to the self-funder who is paying that full rate. All I want to know is: if they are paying under the £75,000 cap, will they know what the local authority rate is? That is what I am trying to find out.
Baroness Greengross
My Lords, I have mentioned to the noble Earl another aspect of this which I think needs to be taken into account. Not only will this funding by some people of other people—or the “secret tax”, as I call it—become better known but there will be a strong incentive for self-funders to dispose of their assets so that the local authority pays the local authority rate for them, even if they pay in more on top of that. Therefore, I think that the Government need to take into account the huge extra cost on local authorities which we have not thought about so far. If self-funders were to go to a financial adviser and ask for advice, I imagine that many financial advisers would say, “Dispose of some of your assets and at least the local authority will pay that rate for you”.
Earl Howe
But for somebody with assets who is looking to be taken care of in a residential home the incentive to dispose of their personal assets is surely going to be a great deal less than it is at the moment. I would have thought that that incentive was much greater now than it will be in the future, when we hope that there will be financial products on the market to enable people to insure up to the level of the cap. Therefore, I am not sure that I completely understand the force of the point that the noble Baroness is making. Obviously there will be some incentive for people to dispose of their assets but I suggest that it will be less than she has stated.
To move on to the noble Baroness’s Amendment 86M, there will be a dispute between a local authority and a provider as to the prices proposed or other matters. Occasionally, disputes may become intractable. Therefore, I completely understand why the noble Baroness proposes through her amendment to, in effect, require a new independent adjudicator to arbitrate in any unresolvable disputes. However, it is our view that any disputes arising as part of a contractual negotiation must be resolved through that process. Appointing or establishing a new independent adjudicator would be likely to add unnecessary cost and bureaucracy to the process of commissioning. We also believe that it will be likely to increase disputes by providing a means of challenge which would soon become a standard process.
Earl Howe
My Lords, I thank all those who have contributed to an informed and very interesting debate. The amendments mostly focus on the assessment process, but some also refer to Clause 13 on the eligibility criteria which we will consider later.
The noble Baroness, Lady Wheeler, is quite right that assessments will remain an integral part of the reformed care and support system. However, rather than acting primarily as a gateway to the adult receiving care and support, the future system will place more emphasis on supporting people to identify their needs; understand the options available to them; plan for meeting care and support needs, and reduce or delay needs where that is possible.
The amendments tabled by the noble Lord, Lord Low, Amendments 87H and 88PB, rightly point out that intermediate care services, such as reablement, can play a vital role in helping people regain their independence and in preventing avoidable re-admissions. Under this Bill, local authorities would be expected to consider how the provision of reablement and other types of care and support could contribute to the achievement of an individual’s desired outcomes as part of the assessment process. Clause 13(2)(b) makes it clear that, in determining eligibility, local authorities must consider if the person would benefit from preventive services—whether or not they have eligible needs. This would include reablement services.
Amendments 88PA and 88PC, tabled by the noble Lord, Lord Low, look to build on the measures in Clause 13(2) about prevention. Amendment 88PC raises the issue of individual entitlements to preventive services, facilities and resources. I hope he would agree that Clause 2 is an important step forward in itself, capturing prevention in primary legislation for the first time. It will require local authorities to provide or arrange prevention services and actively to consider the steps that they should take. The Bill makes clear that prevention is a core part of care and support provision, not an optional extra. This duty is only one part of a broader approach throughout the Bill to preventing, delaying and reducing needs.
One of the aims of the pooled budget, to which the noble Lord, Lord Low, referred, is that local authorities and CCGs should spend it on preventive services. However, individual entitlements should be built around people with ongoing needs for care and support—as they are now. We do not think it is necessary, or would make sense, for there also to be individually enforceable rights to preventive services which would be too broad, and therefore carry a very significant cost burden for local authorities. I took note of the comments of the noble Lord, Lord Low, on that point but, despite these, our view is that any enforceable right in this area would almost unavoidably lead to very high budgetary pressures.
I turn now to Amendments 87J, 88D, 92ZZF and 92ZZL tabled by the noble Baroness, Lady Wheeler. We heard during consultation that assessment processes should look at what an individual wants to achieve and what they can do, not just at their “deficits” or what they cannot do. Assessments should help the person to identify their needs, strengths, goals and aspirations, and consider what type of proportionate intervention might support them. The purpose of Clause 9(4)(d) is not to suggest that such matters should replace more formal types of care and support. The clear purpose of the duty is to assess an adult’s need for care and support. However, it recognises that in order to make the connections to the variety of support available in the community, the local authority should consider how these matters, along with more formal care and support provision, could be of benefit in achieving the adult’s outcomes.
Amendment 88A, to which the noble Baroness, Lady Wilkins, spoke so powerfully, raises the question of employment, education and training, and in doing so repeats Clause 10(6). This re-enacts specific existing provision for carers in relation to such issues, which the Law Commission recommended should remain. We recognise that these areas are of equal importance to adults receiving care and support. However, it is not necessary to recreate this provision as local authorities must already consider during the assessment process the adult’s aspirations in relation to work, education, training or recreation when considering the outcomes they wish to achieve.
On Amendment 88B, I agree with the principle of joining up assessments when it is sensible to do so. The provisions in the Care Bill are compatible with those in the Children and Families Bill, and both Bills allow for joint assessment. I am satisfied that the Care Bill includes the legal framework to enable a co-ordinated approach. My noble friend Lady Browning asked how the Children and Families Bill will fit with this Bill in relation to care planning, and particularly in relation to those with autism. The Children and Families Bill will improve co-operation between all the services that support children with special educational needs and their families. This will require local authorities to involve children, young people and parents in reviewing and developing care for those with special educational needs. Local authorities will also need to publish information about what relevant support can be offered locally. The Care Bill and the special educational needs provisions in the Children and Families Bill require that there is co-operation within and between local authorities to ensure that the necessary people co-operate, that the right information and advice are available, and that assessments can be carried out jointly. We are in discussion with the Department for Education about the links between both Bills.
The noble Baroness, Lady Emerton, proposes in her two amendments that assessments must involve health professionals. In our view, this would not be proportionate because not everyone would have health needs or need to involve a health practitioner. The Bill already allows the individual to decide if they wish to involve a health professional, and Clause 12 includes a power to allow authorities to carry out a joint assessment with other bodies such as the NHS.
My noble friend Lady Browning and the noble Baroness, Lady Wheeler, made important points about the appropriate training and skills of assessors. Stakeholders have told us of the importance of having appropriately trained assessors. We have therefore extended the powers in Clause 12 and I can reassure both noble Lords that we will make regulations to require local authorities to ensure that assessors are properly trained.
My noble friend Lady Browning asked why we have not specified that a qualified social worker should carry out assessments on people with complex needs. The social care workforce, as she well knows, is a mixture of qualified social workers and care managers who have been trained to carry out tasks such as assessments. It is, we believe, for local authorities to determine the mix of their workforces. Local authorities should also make a professional judgment on who has the appropriate skills and training to carry out assessments, and I really do not think it would be appropriate to do this from the centre.
The noble Baroness, Lady Meacher, raises an important point through Amendments 88SA and 88SB about the eligibility criteria for adults with care and support needs helping to prevent young carers from taking on inappropriate or excessive caring responsibilities that can impact adversely on their lives. The draft regulations make clear that an adult’s needs for care and support will be eligible if, because of mental or physical impairment or illness, they are unable to carry out fully any caring responsibilities for a child, or need support to maintain family relationships. Our policy intention is to encourage local authorities to take a whole-family approach, both in assessing and supporting an adult needing care and support, meaning that an individual adult is not seen in isolation from their family circumstances. That would include having to identify the child.
The noble Baroness made the point that better support for young carers will save money for the taxpayer. We agree that better supporting young carers will improve both their well-being and that of the person they care for and that it is also likely to benefit the public purse. That is why we are working with the Department for Education to ensure that a whole-family approach is taken.
Amendment 92ZZCZA follows the same principle, but seeks to add to the duty to meet eligible needs. As I have set out, we see the appropriate way of dealing with the issue of avoiding inappropriate young caring roles to be through the eligibility criteria. We would not wish to create a new stand-alone duty in this regard, which may have a distorting effect on the duty in Clause 18, but rather to ensure that such matters are reflected in the determination of eligible needs. However, as I indicated in debate last week, we need to ensure that the developmental and educational needs of young people are appropriately considered in the context of children’s legislation and services. We will work with stakeholders, including the National Young Carers Coalition, to ensure that, for their part, adult care and support services make appropriate provision in supporting an adult’s needs for care and support to prevent inappropriate or excessive caring by a child. However, we also need to keep in view what should be provided through children’s services and that is what the Minister for Children and Families has committed to do.
The noble Baroness, Lady Wheeler, raised an important point about the impact of the funding reforms. We recognise that people will want to have their care costs counting towards the cap as soon as possible. If this Bill is enacted, people cannot begin accruing costs towards the cap until 1 April 2016. That does not mean that preparation cannot be made locally before that time. We believe that it is appropriate for local authorities to begin assessing people ahead of 1 April 2016. To ensure that local authorities can take advantage of this opportunity, we have provided £335 million to fund the implementation of our reforms. This should enable local authorities to begin assessing people’s needs for care and support around six months before April 2016, if they choose to do so.
I hope that I have reassured the Committee that we are putting in place the support to allow local authorities to manage the implementation of our reforms. We have had a very good debate on assessment and eligibility. I hope that I have reassured all noble Lords who have spoken that the Bill already addresses the concerns that have been raised and that the noble Baroness, Lady Meacher, will feel able to withdraw the amendment. I am sorry—it was the noble Lord, Lord Low.
Lord Low of Dalston
Yes, I was going to say that I think it probably falls to me to consider whether I withdraw the amendment. Before I do so I just want to thank the noble Earl for his full and careful response, and also all those who have spoken in a debate that has ranged quite widely. I have found the noble Earl’s response to the points that I raised very helpful and will consider whether I continue to feel that the Bill needs strengthening in the area of assessment and eligibility in the light of his comments. I listened carefully to what he had to say and feel it will be very helpful in considering how to deal with these issues during later stages of the Bill.
Public Health England Advisory Board Membership
Earl Howe Excerpts(10 years, 10 months ago)
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Baroness Hayter of Kentish Town
To ask Her Majesty’s Government what steps they are taking to ensure that women are represented on the Advisory Board of Public Health England.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
In April 2013, we appointed four non-executive members to Public Health England’s advisory board. They each bring to this role a great range of experience. We will shortly advertise for further candidates to enhance the expertise available to Public Health England. We aim to ensure that, as far as possible, the advisory board provides an appropriate gender balance and representation from ethnic minority and disability backgrounds.
Baroness Hayter of Kentish Town
My Lords, I hope the House knows that in addition to the other two who sit on this board, this an all-white, all-male board. I am delighted that the Minister has admitted this in the sense that they are going to re-advertise. However, can he explain why No. 10 vetoed the highly respected and experienced woman who was recommended by the independent appointments panel? Could it possibly be because she sits on the Labour Benches in your Lordships’ House?
Earl Howe
My Lords, absolutely not. The noble Baroness to whom the noble Baroness refers is, in everybody’s eyes, a highly qualified person. It would be inappropriate in any case for me to comment on individual candidates, successful or unsuccessful. However, I can confirm, and I emphasise this strongly, that the recruitment campaign was managed in a way that completely complied with the principles of the Commissioner for Public Appointments’ code of practice. It was open and transparent, and appointments were made on merit against published criteria for the role.
Baroness Jolly
My Lords, will my noble friend explain what action is being taken to grow tomorrow’s female and minority leaders in health?
Earl Howe
My Lords, across the field of health it is difficult for me to give a generic answer, but the NHS Leadership Academy, which is now starting its work, will ensure that women with promise for leadership will be encouraged to come forward in a variety of roles, not just clinical but managerial. I hope that we will see the fruits of that work over the coming months.
Baroness Masham of Ilton
My Lords, does the Minister agree that Public Health England is responsible for campaigns for vaccinations, and that as vaccinations deal mostly with children and young people, mothers are involved, so it is essential to have women on the advisory board?
Baroness Gould of Potternewton
My Lords, may I follow up on the question asked by my noble friend on the Front Bench? I have two specific points. First, if the Government have a diversity policy, why was such an appointment not made in the first place? Secondly, when are the adverts that we understand will extend the board going to go out? Are they going to look specifically for more women and more ethnic minority members?
Earl Howe
The advertisements will go out, I understand, in September, with a view to making the appointments by the end of the year. As regards the gender balance, the noble Baroness may like to know that within Public Health England itself there are almost twice as many women and men across the workforce, and in senior roles there are more women than men. I hope noble Lords will understand that Public Health England itself has no gender bias. The key thing is that appointments are made in accordance with the published criteria on merit. It is our aspiration to have gender balance, but the criteria must be related to those issues.
Baroness Scotland of Asthal
My Lords, the Minister is dedicated to equality and understands very well the issues relating to female health, particularly as a result of the World Health Organisation report last month, which indicated that the greatest cause of morbidity in women and girls, in one case in three, is domestic violence. Can he therefore explain why the Government chose to have a board that has no women on it? That board cannot then reflect the reality of the health needs of our nation.
Earl Howe
We are very mindful of that, but I come back to the point that these appointments were made on merit in accordance with the published criteria. That is not to say that the unsuccessful candidates lacked merit, but we did not operate a policy of positive discrimination and I do not think that anyone would wish us to do that. Having said that, we are mindful in the department of the need to have gender balance whenever we can in public appointments. Our record is not bad; we are in the region of 44% of appointment rates for women appointed to public positions, which is quite high up in the departmental league table.
Baroness Gardner of Parkes
My Lords, does the Minister recall a famous speech of Baroness Thatcher’s, when she was Mrs Thatcher, when she said that the experience that women gain in life generally is not to be underestimated? It is all very well to have everyone with all the experience and qualifications in the world, but does he not think it is also important to have some women who could bring basic common sense to the board?
Baroness McIntosh of Hudnall
In view of the answer that the Minister gave to my noble friend a few moments ago about not operating a positive discrimination policy, is it possible or even likely that the next round of advertisements will also result in the appointment only of men?
Earl Howe
I simply cannot tell because we do not know which candidates have come forward. It may be that no women come forward. I hope that that is not the case. We make a point of advertising our appointments on the website of Women on Boards UK Ltd—the noble Baroness may be aware of it—which is an open UK-wide organisation for women seeking to leverage their professional skills, if I can put it that way, on to leadership roles. We will see what happens, but I assure the noble Baroness that while there will not be positive discrimination, there certainly will not be negative discrimination either.
Baroness Deech
Does the noble Earl agree that very well qualified women are held back from getting appointments by the lack of affordable childcare and that this is especially crucial in medicine? Does he agree that report after report has recommended that medically qualified women be given more flexible working arrangements, and more time and help, to serve on boards such as this, and that those reports have by and large not been implemented?
Care Bill [HL]
Earl Howe Excerpts(10 years, 10 months ago)
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Lord Low of Dalston
I apologise to the Members of the Committee, who will understand my difficulty in that a considerable number of amendments to which I put my name have been grouped together. Five amendments in this group had my name and I had a little bit to say about all of them which I hope the Committee will have found useful. It is not my wish to try the patience of the Committee in any way so I will wind up my remarks immediately.
I echo the point made by the noble Lord, Lord Touhig, that greater concentration on prevention could actually save resources. In summary, prevention—or early intervention—matters: it works. The Bill needs to bring the Government’s White Paper vision of a genuinely preventive care system to life, but doing so relies on local authorities assessing how needs can be reduced or prevented from getting worse.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, it is always good when there is an outbreak of consensus across—
Earl Howe
My Lords, I apologise to my noble friend for intervening before she had a chance to speak. As the Committee will have gathered, I was observing that it is always good when there is an outbreak of consensus across the Chamber, and I think this is a case in point. It is critical that care and support work actively to promote people’s well-being and independence, rather than just waiting for people to reach crisis point. We want a system that promotes independence and reduces dependency as well as supporting those who already need care and support.
Preventing and delaying needs from arising, or reducing them where they exist, is a central part of local authorities’ modern responsibilities for care and support. Adopting preventive approaches can reduce needs in the longer term, saving public money and improving outcomes. There has never before been a clear legal duty that reflects this priority and establishes prevention as part of the core local authority responsibility. Clause 2 fills that gap, requiring local authorities to provide or arrange services to prevent, delay or reduce needs for care and support and carer’s support. This will create a legal basis for a wide range of preventive services that can help people maintain their independence for longer. The noble Lord, Lord Low, mentioned some good examples but they might also include exercise classes, which can help people maintain and increase their mobility, befriending services and hobby clubs, which can reduce loneliness and social isolation, and installing grab rails in a frail person’s home, which can prevent falls, broken bones and unnecessary stays in hospital. However, those are not the only examples. We want local authorities to be truly innovative in the services offered in their area, which is why we have not been prescriptive in the way that local authorities carry out the duties conferred by the clause. I agree with the noble Lord that these things can bring direct financial savings, and I quoted some good examples, I hope, in speaking on an earlier group of amendments.
Amendments 79A and 79K make the point that prevention should be an overarching principle of a local authority’s care and support functions, and that this should be framed in the context of well-being. This is surely right. To that end, Clause 1 sets out that in exercising care and support functions, local authorities must promote an individual’s well-being. This includes, among other things, having regard to preventing, delaying and reducing needs, as expressly stated in Clause 1(3)(c).
The noble Lord, Lord Rix, makes clear in tabling Amendment 79D the need for local authorities to be proactive in preventing, delaying and reducing needs for care and support, but also in safeguarding adults with needs for care and support from abuse or neglect. As he mentioned, Clause 41 does just that by requiring local authorities to ensure that inquiries are made when an adult with needs for care and support is at risk of abuse or neglect. Clause 42 and Schedule 2 create the legal framework for local authorities to establish safeguarding adult boards, which must devise, publish and implement annual strategic plans for adult safeguarding in their area. There will of course be the opportunity to discuss safeguarding in greater detail at a later date.
Amendment 80C, proposed by the noble Lord, Lord Low, raises the issue of prevention as part of the joint strategic needs assessment and joint health and well-being strategy under the Local Government and Public Involvement in Health Act 2007. I listened to him with care and hope that I can reassure him. The existing legislation in relation to these joint assessments and strategies is clear that where any needs can be met by the local authority exercising its functions under the prevention duty in Clause 2, these would be included as part of the joint assessments and strategies.
In Amendments 78C, 79C and 79G, the noble Baroness, Lady Greengross, highlights the importance of preventing, delaying and reducing health needs as well as needs for care and support. Again, I find myself in complete agreement with her and, as I said, I believe that the Bill achieves this laudable aim. This is where the importance of integration and co-operation can clearly be seen, a matter also raised by the noble Lord, Lord Hunt, in Amendment 79B. Clause 3 requires local authorities to promote the integration of care and support with health and health-related provision, including where this would contribute to preventing, delaying and reducing needs.
Clauses 6 and 7 require local authorities and their relevant partners to co-operate in the exercise of their care and support and carer’s support functions. Such co-operation is to be performed for the purposes of, among other things, promoting an individual’s well-being, which in turn includes having regard to the importance of prevention through Clause 1(3). Accordingly, there is a clear duty on local authorities and their relevant partners to co-operate with one another in preventing, delaying and reducing needs for care and support and carer’s support.
These duties, coupled with the return of public health responsibilities to local authorities as a result of the 2012 Act and the new prevention duty, present a unique opportunity for aligning prevention services across health and care and support. That is why local authorities will be required to ensure the co-operation of their director of public health, where relevant to care and support functions.
I turn briefly to Amendments 87F and 87G, tabled by the noble Lord, Lord Low, and the noble Baroness, Lady Greengross. The Government believe that the Care Bill allows for the assessment process fully to take account of prevention. As the well-being principle requires the local authority to have regard to the importance of preventing, reducing or delaying needs for care and support, it must also consider this when conducting an assessment.
Amendment 80A highlights that, to be able to prevent delay and reduce needs for care and support and thus promote independence and well-being, we need to improve the quality and diversity of preventive services, facilities and resources. To achieve this, Clause 5(7) makes explicit provision for local authorities to promote the diversity of services, resources and facilities which can prevent delay or reduce needs for care and support. As the noble Baroness also points out with Amendment 80B, commissioning decisions, including for preventive services, should be made on the best evidence available. In the case of preventive interventions, we know through engagement with the care and support sector that this is not yet as strong as we would like. The Government have committed to developing a library of evidence on prevention. That will enable commissioners to make decisions knowing what is proven to work and what is not. However, to be able to build this evidence base and to find the solutions to the care and support needs of the 21st century, we need to allow room for innovation in developing and testing new models of preventive interventions. Without breaking the mould of traditional care packages, pioneering solutions such as shared lives schemes, which offer an alternative model to home care or residential care using community networks, would not have been able to flourish.
The noble Baroness, Lady Greengross, observed that local authorities need more than a year to plan in terms of the budget cycle. Local authorities already have multiyear financial settlements and that gives them scope to plan services in the longer term The noble Lord, Lord Touhig, returned us to the important subject of autism. He remarked that adults with autism rely on low-level preventive services and he felt that the Bill does not do enough in this area. The reforms to care and support set out in the Bill will benefit people with disabilities, including people with autism. The provisions around prevention, personal budgets and transition between children and adult services are just some examples of new laws which will benefit many people with autism.
As local areas gain a better understanding of autism needs locally and develop autism commissioning plans, we expect them to look more at the cost benefits of more low-level and preventive services, such as befriending services or social skills training. Preventive services can be provided to prevent, delay or reduce needs for care and support, regardless of the level of need involved. I hope that I have reassured noble Lords that prevention is suitably reflected within the Bill and that the noble Baroness, Lady Greengross, will feel able to withdraw the amendment.
Baroness Greengross
My Lords, I was very encouraged by the words of the Minister, but I am still rather worried. It was great to hear the points made by the noble Lord, Lord Touhig, who is so knowledgeable about autism. I am also very grateful to the noble Lord, Lord Hunt, for his comments, and to the noble Lord, Lord Low, who made some very apposite points about prevention. If I were a director of adult social services and had very limited funds, I would have to concentrate on the people in the greatest need, and it would be likely that prevention would slip to a lower level of my attention. This is the danger of preventive services not getting the attention that they need. I have yet to be totally convinced that prevention will prevail in the way that the noble Earl suggested. I hope that he is right.
We need a longer timeframe. It is difficult for local authorities to budget in that way, but it is essential if we are to focus on preventive services in the long run. I hope that, as we go through the remaining parts of the Bill, we can be clearer about how to ensure that prevention is at the top of our list. That will apply to eligibility criteria, which we will look at later. In the mean time, I thank all noble Lords who supported what I said and my colleagues for their support. I beg leave to withdraw the amendment.
Baroness Gale
My Lords, Amendment 88H seeks to amend Clause 12. The clause provides an excellent framework for assessments to be carried out by local authorities. However, the clause should be tightened to ensure that the framework is fully and properly implemented.
People with Parkinson’s and long-term conditions have problems in accessing NHS continuing healthcare. The APPG on Parkinson’s, which I chair, is holding an inquiry into NHS continuing care. We have been hearing about the difficulties people experience in finding out about NHS continuing care and the further difficulties in getting an assessment. Even when people are assessed, the assessment can be fraught with problems such as assessors not really understanding the condition and even assessments happening without people knowing about them.
Clause 12(1)(g) states that the regulations may,
“specify circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare”.
The Care and Support Alliance believes we must ensure that local authorities and health services work together and make people aware of NHS continuing care and that people are referred on to continuing care assessments when there is a health need.
The importance of this cannot be understated. Social care is means tested and healthcare is free, so whether someone is funded by the NHS or through means-tested social care systems has significant cost implications for that individual. The Care Bill provides a perfect opportunity for councils to ensure that people who may well be eligible for free NHS continuing care are rightly signposted to, and assessed for, it.
Clause 12 offers guidance about what may be in the regulations relating to assessing social care needs and assessments for carers under Clauses 9 and 10. It states that regulations “may” make provision on the circumstances in which the local authority must refer the adult for continuing care. This does not go far enough and the word “may” should be amended to “must”. If there is not a clear mandate placed within these regulations, the vital issue of signposting for services and systems such as continuing care could be overlooked in the drafting of these important regulations.
The regulations must make provision for the circumstances where local authorities may refer the adult on to NHS continuing healthcare. There is a lack of knowledge about who is eligible and the funding that people are potentially entitled to, so we should have certainty that these regulations will stipulate these circumstances. This should lead to a greater awareness of NHS continuing healthcare and greater access.
These attributes could ensure that all assessments are carried out in a way that supports the individual, take into account their needs and the needs of their families and carers, ensure that the appropriate professionals and experts are involved in the assessments and that people are referred on to NHS continuing healthcare as appropriate. I know that “may” and “must” are very small words, but I hope that the Minister will take note and agree to the amendment.
Earl Howe
My Lords, the Care Bill marks a historic step forward in improving the rights of adult carers. Although successive Governments have recognised the contribution carers make and have supported Private Member’s Bills about carers, this is the first time that the Government have included specific provision for carers’ rights to social care in their legislative programme. These provisions have been warmly welcomed.
Amendments 88E and 88F, tabled by the noble Baroness, Lady Pitkeathley, bring to the attention of the Committee the important role that the NHS can play in helping those with caring responsibilities look after their own health, identify themselves as carers and access information and advice.
Clinical commissioning groups already work with local authorities through health and well-being boards to understand and plan for identifying and supporting carers. Many clinical commissioning groups already have, or are developing, joint carer strategies. Importantly, the pooled health and care budget for 2015-16 announced last week as part of the spending round will help health and care and support to work together in supporting carers.
I quite agree that it is, of course, crucial that steps are taken to help individuals with caring responsibilities to identify themselves as carers. The Department of Health has provided over £1.5 million to the Royal College of GPs, nursing and carers’ voluntary organisations over recent years to develop training and resources to help those working in primary and community healthcare to support people with caring responsibilities. We will consider further bids to extend this work programme, including extending support to nurses working on hospital wards and outpatient departments.
I listened with care to the noble Baroness, Lady Royall, in this context and I would say that carers of people with cancer will benefit from steps which NHS England and the Department of Health are taking, some of which I have already referred to. I would also say that the current initiatives have unleashed an enormous amount of enthusiasm among frontline staff, and both nurse and GP carer champions and voluntary sector carers’ ambassadors have been recruited. They are increasing understanding about supporting carers locally at both strategic and practice levels.
In terms of identifying carers and helping them to access support, it is also critical to align assessments undertaken by other bodies, including NHS continuing healthcare assessments undertaken by clinical commissioning groups. If a carer is identified in the course of an NHS continuing healthcare assessment, the national framework for NHS continuing healthcare and NHS-funded nursing care makes clear that the clinical commissioning group should inform them about their entitlement to have their needs as a carer assessed and, where appropriate, either advise the carer to contact the local authority or, with the carer’s permission, refer them to the local authority for an assessment.
The provisions in the Care Bill provide a lower threshold for a carer’s assessment than exists now. A situation where the person whom the carer supports is being assessed for NHS continuing healthcare is highly likely to be regarded by a local authority as one where it appears the carer may have a need for support. A carer’s assessment would then be triggered. Clause 10(5) already requires a carer’s assessment to include an assessment of whether the carer is able and willing, and is likely to continue to be able, to provide care for the person needing care. Moreover, regulations under Clause 12 may make provisions for joint assessments. We will consider such particular circumstances further as we develop these regulations.
I turn now to Amendments 78F, 79E, 79H and 88C relating to disabled children. I would not wish to underestimate the challenges that families can face in supporting these young people. Policy on supporting children and families of course lies with the Department for Education. The Minister for Children and Families’ view 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. The Department for Education’s investment in parent carers’ forums and short breaks provision for disabled children in recent years have helped to shape family support.
In addition, the special educational needs reforms in the Children and Families Bill, which received its Second Reading in this House yesterday, are intended to give parents much more choice and control about the support they and their children receive. My noble friend Lord Nash confirmed yesterday, at Second Reading, that the Department for Education would consider how legislation for young carers might be changed. I simply ask noble Lords to be a little more patient in waiting for those proposals.
Before turning to the effect of Amendments 79F, 79J, 79M, 88H and 88K, tabled by the noble Lord, Lord Hunt, and members of the Opposition Front Bench, I would like to confirm, as I hope my words just now have, that both the Minister for Care and Support and the Minister for Children and Families are clear about the need to protect young carers from excessive and inappropriate caring by using “whole family” approaches.
Young carers should be regarded first and foremost as children and they should be assessed and supported in the context of children’s legislation. The Minister for Children and Families has confirmed that his department will look at what it can do to remove any legal barriers preventing young carers and their families from receiving the support they need under children’s legislation. We will also work to ensure that children’s legislation works with adult legislation to support the whole family in a meaningful way.
These amendments would extend the requirements on a local authority to prevent and reduce the needs of children caring for either an adult or a child. The local authority would also be required, when identifying carers in the area with needs for support, to include young carers aged under 18. One of the key principles when considering young carers is to address first what is needed to support adults in the family with care and support needs, and then see what remaining needs for support a young carer in the family has.
I hope I can reassure noble Lords that, first, through the provisions in Clause 2 to establish prevention as a core duty of local authorities, and secondly, through the provisions in Clause 12 to make regulations about a “whole family” approach to assessment of adults, we are ensuring that adult care and support makes the appropriate contribution to supporting children and young people with caring responsibilities as well.
Of course, provision of preventive services for adults would be of benefit to other family members, including children, by preventing or delaying either an adult’s needs for care and support or an adult carer’s needs for support. As it stands, without this amendment, I believe that the provisions of Clause 2 will help children and young people significantly.
Amendment 88H looks to require the Secretary of State to make regulations in all the areas listed in Clause 12(1). I reassure the noble Lord, Lord Hunt, that this is our intention, as these are essential in ensuring that the assessment is carried out in an appropriate and proportionate way. In relation to the noble Lord’s Amendment 88K, I confirm that we intend in regulations to make clear that a local authority should have regard to the needs of children in the family, and indeed we would wish to encompass other significant family relationships as well.
As I have set out, robust arrangements are in hand to ensure that carers are identified and supported by the NHS and local authorities, and that both parent carers of disabled children and young carers are adequately and appropriately supported under children’s legislation. The Department of Health and the Department for Education will continue to work closely together to ensure that children’s and adult legislation join up in respect of supporting adults with parenting responsibilities, and in the period of transition from children’s to adult services. I hope that those remarks will be sufficient to enable the noble Baroness to withdraw her amendment.
Baroness Pitkeathley
My Lords, I am grateful to all noble Lords who have spoken and for the recognition that all noble Lords have shown of the problems of carers, as well as the commitment to giving carers the support that they so much need. It is recognition of the fact that, however good a health and care system we put in place, the vast bulk of care will continue to be provided by our families and friends.
I know that the Minister shares this understanding and commitment and I acknowledge the attention given to carers in this Care Bill. In the history of the carers’ movement, with which I have been associated for nearly 30 years, it is truly the most significant development that we have seen.
The hour is late and I think that many more people would have wished to speak on this had we been debating it at a different time of day. I hear what the Minister says about young carers and parent carers. We need to monitor very carefully the progress of the Children and Families Bill to see how that Bill pans out and particularly how the two bits of legislation join up, as the Minister put it. In the mean time, reserving the right to come back to these issues on Report, I beg leave to withdraw the amendment.
Care Bill [HL]
Earl Howe Excerpts(10 years, 10 months ago)
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Baroness Eaton
I endorse what the noble Baroness, Lady Howarth, has just said because I am firmly of the belief that it will take time to find all the appropriate people for the move which the CQC has clearly said it would make, from generic to specialist inspectors. I am sure that this will make a huge difference to the outcomes of inspections. I, too, think that we should give this organisation time. From what I have seen, it has the drive and the initiative to make sure that things improve enormously.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, this has been a very useful debate and in addressing this group of amendments, it might be helpful if I began by setting out why we believe this clause is necessary.
At the moment, there is no straightforward way for members of the public to get a clear view of performance in hospitals and care homes, nor is there a measure to help drive up performance, so we believe that a new system is needed to give patients and the public a fair, balanced and easy to understand assessment of the quality of care provided. Clear ratings on performance will help to incentivise providers to improve their services, as they will be able to see how well they are doing. One of the central principles behind this clause is that it will enable the CQC to develop the new performance assessment system—informed by the views of stakeholders, of course, but nevertheless independent of government. In its report into ratings, the Nuffield Trust said:
“While there is a legitimate role for … government … to influence priorities, the process should largely be sector-led including the public and users”.
I am rather pleased that we did not debate this group of amendments on the previous Committee day because the CQC has, in the mean time, published a consultation on changes to the way in which it regulates, inspects and monitors care. I draw that to the attention in particular of the noble Lord, Lord Campbell-Savours, whose points I will address in a moment. This consultation, A New Start, sets out the commission’s initial thinking on the timetable for implementing ratings. The consultation document also sets out some detailed thoughts on how the CQC will rate NHS acute hospitals. I take the point made by the noble Lord, Lord Sutherland: this rating process will have to have some fundamental differences from that followed by Ofsted. However, the ratings will be based primarily on inspection judgments. They will be informed by a series of indicators, using data already available and the findings of other bodies such as those from accreditation schemes, clinical peer review and the judgments of other regulators. The CQC will be consulting on this model more fully later this year.
Noble Lords have raised concerns about the ability of a rating system to reflect the complexity of NHS acute hospitals. I assure the Committee that both the CQC and the Government are fully alive to this risk. The CQC is committed to producing ratings at a level which recognises the complexity of NHS services and is useful to people who use them, as well as those who commission NHS care. It is therefore proposing to provide ratings for certain individual services, such as emergency and maternity services, as well as for each hospital.
A rating will also be provided against each of the CQC’s key questions. They are: is the service safe? Is it effective? Is it caring? Is it responsive to people’s needs, and is it well led? This will mean that where the evidence is available, a trust would have five ratings at three different levels—for the individual service level, for the hospital site and for the whole trust. I am sure that noble Lords will agree that this is an ambitious aim, and one that seeks to reflect the complexity of the organisations that provide care.
The Government will draw up regulations that will enable the CQC to develop the programme of performance assessment in the manner outlined in A New Start. The consultation is the first small, but important, step in the process of developing a robust system of performance assessment of providers of health and adult social care. The first ratings of acute hospitals will appear at the end of this year: I will come on to the timetable in a moment. This will be another significant step in developing a ratings system, but it will not be the end of the journey. The Government are clear that the development of ratings will be a process of continuous evolution.
Amendments, 74, 75, 76ZA, 76ZZA and 76ZAA set out areas that the CQC must or could consider as part of its performance assessment of providers. These amendments would mean that the CQC would be required to include or consider the specific issues raised as part of its methodology. The Government share the view of noble Lords on the importance of the issues they have raised through these amendments. I am sure we can all agree that they are useful ideas. However, I hope that they will equally accept the importance of the central principle that we believe should be adhered to: that the CQC should be given freedom to develop its own methodology for the new performance assessments. The clause is deliberately designed to be flexible in that sense. I therefore hope that noble Lords will be content to withdraw their amendments, in the knowledge that the CQC is ready and willing to listen to all good ideas as it puts its final plans together.
The noble Lord, Lord Hunt, has also tabled Amendment 76ZB, which would require the CQC to undertake a pilot of its new performance assessment system and require the evaluation report to be approved by Parliament. The Government agree that the CQC’s new performance assessment methodology should be subject to evaluation. This is why, in our response to the Francis inquiry, Patients First and Foremost, the Government made the commitment that:
“The Department of Health will commission an independent evaluation of the operation of the new ratings system, and this will inform future adaptations”.
The amendment would give Parliament a power of veto over the methodology which the CQC develops for performance assessment. This is not desirable as it would constrain the freedom of the CQC to act on the findings of its consultation with stakeholders. I therefore hope that noble Lords will be content not to move that amendment.
Amendment 74A would require the CQC to undertake performance assessments of commissioners of healthcare services, specifically clinical commissioning groups and NHS England. The wording of Clause 80 could enable the CQC to undertake reviews of local authority commissioning of adult social care services. The absence of a similar requirement for healthcare commissioning therefore requires an explanation. The requirement for the CQC to review healthcare commissioning was removed by the Health and Social Care Act 2012 on 1 April 2013 when primary care trusts were abolished. This is because the function of supporting the development of the commissioning system for healthcare in England has become the responsibility of NHS England. NHS England’s role is to determine how the performance of healthcare commissioners, including clinical commissioning groups, is assessed and managed. There is therefore no need for the CQC to carry out a virtually identical role. I trust that the noble Baroness will be content to withdraw her amendment, but I would like to address the particular points raised.
Lord Hunt of Kings Heath
I do not quite see the logic of that, because in a sense NHS England has a vested interest in ensuring that all is well with the CCGs. It is not an independent body in the way that the CQC would be.
The other question is about NHS England itself. It is a massive commissioner of specialist services. If a local authority is to be assessed, I still do not see why NHS England ought not to be subject to some kind of independent assessment. It could have a huge impact on where specialist services are going to be provided in future. We know that Ministers are no longer prepared to answer questions about lots of things that NHS England does, so there seems now to be a gap in the architecture.
Earl Howe
Ministers most certainly are willing and able to answer questions about what NHS England is doing, and will continue to do so. Parliament, of course, will be entitled to keep NHS England’s performance in the spotlight; that architecture was built into the 2012 Act very deliberately. I do not accept the noble Lord’s point about clinical commissioning groups, because it is for NHS England to assure itself that the commissioning system for healthcare in England is working properly. There will be a high degree of transparency in that regard. The performance management role of NHS England will be right there, and I think that the proof of that will emerge over the coming months.
Perhaps I could cover the individual points raised by noble Lords. The first point was raised by the noble Lord, Lord Hunt, and echoed by the noble Lord, Lord Campbell-Savours, about how we expect the CQC culture to change in a relatively short time. I say to both noble Lords that I firmly believe that the CQC is already very much a changed organisation. It has a new leadership team in which I have full confidence. It has a new board—which, incidentally, the noble Lord, Lord Hunt, may be interested to know will include Kay Sheldon—and I think it has a new attitude to openness and transparency, as its handling of the Grant Thornton report demonstrates.
On 16 July, the CQC’s chief inspector of hospitals, Professor Sir Mike Richards, will start in post, so that is very soon. By September the CQC will be publishing a list of hospitals that it has the greatest concerns about, and it will be using its new surveillance system to develop this list. The CQC is committed to learning from the past and pressing ahead rapidly to improve for the future. I agree with the noble Baroness, Lady Howarth, that the CQC needs stability.
Lord Campbell-Savours
On the question of the surveillance system that the Minister just referred to, what about the proposal that keeps coming up all the time of two unannounced visits per year for every care home within the United Kingdom? Why can that at least not be set down by the Government as a requirement, irrespective of all the other recommendations and decisions that the CQC comes to over its new so-called surveillance system?
Earl Howe
It is not for Ministers to do that. I say that with great respect to the noble Lord. In saying that, however, I also highlight the ability of the CQC to flex its inspection frequency in accordance with information received. The noble Lord will know that organisations such as local Healthwatch, and indeed local authorities themselves, are able to alert the necessary authorities through Healthwatch England, which, as noble Lords know, is an integral part of the CQC, to any problems that may be flagged up. The CQC will be consulting in future on its proposals for care home inspections, and I do not doubt that a difference of view will emerge about the frequency of those inspections. I am the first to say how important it is that the inspections take place, and I totally take the point that those assessments should not be allowed to drift in any way. However, for better or worse we have an independent body known as the CQC, which should be allowed to act accordingly. The noble Lord, Lord Campbell-Savours, took us back to the 2008 Act. I would say to him that, in agreeing with the noble Baroness, Lady Howarth, Robert Francis was clear in his report that the system should not be significantly reorganised.
Lord Sutherland of Houndwood
Perhaps I may ask for clarification on one further point relating to complaints. Amendment 76ZZA does not propose that the CQC should handle complaints, which was the gist of the Minister’s response. Rather, it proposes that there should be a clear and transparent method of handling complaints within each trust and relevant area. The role of the CQC is to open up that window, very much in line with the Francis report, so that we can know that complaints will be handled at the appropriate level and in the appropriate way.
Earl Howe
I completely understand the noble Lord’s point. He will remember that in the registration requirements for providers of health or social care, the existence of a complaints system is one factor on which the CQC will need to satisfy itself. On the quality of the complaints-handling system within that provider, my answer is that it is a powerful point and an important area, but in the end it is one on which we should let the CQC decide as it develops its methodology. I do not in any way dismiss the noble Lord’s suggestion, but it is one for the CQC to take forward.
Baroness Pitkeathley
My Lords, this has been a wide-ranging and well informed debate. It has focused on anxieties about the role and competence of the CQC. The anxieties seem to focus on questions about whether the job of the CQC is doable at all, doable in the very short timescale, or doable with current resources. Suggestions about how to address the anxieties and concerns have included piloting new structures, but there has been much support for the CQC being given time to improve its strategy and performance—although with strong reservations from my noble friend Lord Campbell-Savours. I am grateful for the support for my amendments on integration, and sorry that the Minister was unable to accept them. Given the concern and strength of feeling about the CQC, I am sure that we shall return to this matter on Report. For the present, I beg leave to withdraw the amendment.
Lord Beecham
My noble friend is right to draw attention, as many of your Lordships already have, to the need to integrate the provision and to avoid the sort of cost-shunting that can arise if organisations are kept separate. That is the point of the pooled budget: you look not just at the straightforward provision of care by one or other partner, or both partners, but at what will perhaps reduce the need for care in other ways. As I say, other local services such as leisure and adequate housing, in conjunction with the public health agenda, may very well reduce the demand for particularly expensive forms of care, as I am sure we all agree.
Of course, local government’s track record is not uniform, but it is right to say that local government has proved over the years to be the most efficient part of the public sector. There has been a huge improvement programme in local government, recognised by the shortly to be lamented Audit Commission, and others, over the years. The LGA in particular has sought, through a whole series of policies, including the very extensive and successful use of peer review, to engender new approaches and more cost-effective ways of dealing with a range of problems, including those in the social care arena.
I was about to conclude by drawing attention to another figure, which has just emerged today. It is a rather startling figure: £9.8 billion of uncollected VAT—10% of the total take—according to today’s Guardian. That dwarfs the amount that the Government are putting into the new arrangements. Just as local government needs, together with its partners, to engender the utmost efficiency in the mechanisms that it develops to provide services and make them cost-effective, as my noble friend suggests, so on the revenue-raising side central government has a massive obligation to ensure that it collects the taxes—instead of cutting the resources going into HMRC, which is responsible for collecting VAT, by a further 5% in the spending review.
We do not consider the cost of £3.8 billion and the welcome money that the Government are going to provide to be the last word in these matters. There will have to be a continuing process of establishing programmes that are effective and cost-effective. Looking at the totality, there is scope within the system to prioritise this area, providing that the Government take the right decisions—across the piece, not merely on the narrow front of health and social care but considering the implications for other services and functions of government—and collect the money that they are due anyway and which would relieve the huge pressure on these services and others.
I have a good deal of sympathy with the concerns expressed by the noble Lord, Lord Best, but I share the view of the noble Lord, Lord Sutherland, that it would not be right to hold things up. We must get on, but in doing so we must be realistic about the challenges that will be posed to those responsible for delivering these services. I look forward to hearing the Minister’s response to the various questions that have been raised in the debate.
Earl Howe
My Lords, I do agree with the spirit of this amendment. It is critical that care and support generally, and these reforms in particular, are fully funded. Without adequate funding, they will not deliver the benefits we all want to see. However, let me reassure noble Lords that we already have full procedures in place to ensure that there is proper funding for social care.
The first and very basic point is that the Government set spending plans for all areas of public expenditure at once during a spending review. This ensures that decisions can be taken about the future funding requirements of government as a whole, rather than assessing each part piecemeal. The noble Lord, Lord Sutherland, spoke about the review of priorities being a task of government. I agree, and that is exactly what spending rounds are designed to do.
Secondly, we have the new burdens doctrine in place, which requires that,
“all new burdens on local authorities must be properly assessed and fully funded”.
That ensures that all new funding pressures, including those that result from this Bill, are fully funded. I can tell the noble Lord, Lord Best, that our commitments are in line with the new burdens doctrine, the costs have been identified in the impact assessment, and the funding in the spending round will support local authorities to deliver on current and future commitments through to 2015-16. To answer the noble Lord, Lord Campbell-Savours, yes, the work has been done.
It is only right that the Government take spending decisions for all areas of public expenditure at once. This ensures that future spending plans are drawn up which are coherent and consistent across all public services. This is exactly the purpose of a spending round, the latest of which concluded last week, as noble Lords know, and set spending plans for 2015-16. Fundamentally, this settlement delivers the funding required to ensure that service levels in the care and support system can be protected and are able to deliver on all the commitments in this Bill.
However, with additional pressure on the system, we must ensure that the Government, the NHS, local government and care and support services are all working together to offer the best possible services for patients while also addressing the growing demand on the system that the noble Lord, Lord Best, rightly referred to. That is why we have announced in this year’s settlement a £3.8 billion pooled health and care budget to ensure that everyone gets a properly joined-up service, so that they get the care and support they need from whoever is best placed to deliver it, whether that is the NHS or the local authority.
In 2014-15, the NHS will transfer £1.1 billion to support social care with a health benefit. The pooled fund will include £2 billion more through the NHS in 2015-16. But this money will be given only on the basis that services are commissioned jointly and seamlessly between the local NHS and local councils. I hope that that helps to answer the question posed by the noble Lord, Lord Beecham.
Lord Campbell-Savours
Before the noble Earl moves on, perhaps he can answer this question. Is he saying that the statistics that were used in the report by the Committee on Public Service and Demographic Change were known to the department and were all taken into account, and that the calculations the department made were based on those statistics, which were well sourced, when the budget for these areas was decided upon by the Government?
Earl Howe
The statistics that the Government relied upon were official statistics and, I think, were exactly the same as the statistics used by the report to which the noble Lord referred. Of course, that report takes us forward 10 and 20 years. I am not pretending that the spending round has done that—it never does and I think it is safe to say that it never will. But we did look forward in a rigorous way to the pressures on the system in 2015-16 and based our assessment on the statistics that are officially issued.
As all plans will be jointly agreed by the NHS and local authorities in the pooling arrangements that I referred to, that in itself will provide a strong guarantee that the money is spent in a way that delivers on the priorities of health as well as of care and support. Not only will this fund help to deliver joined-up services, it provides the necessary funding for all the commitments and duties set out in this Bill, and the growth in demand from an ageing population and growing number of disabled people—I say in particular to the noble Lord, Lord Rix, and the noble Baroness, Lady Campbell. In particular, funding worth £335 million has been set aside for the introduction of the cap on care costs and the extension of deferred payment agreements.
Lord Beecham
My question was not about the purpose of the pooling, which I think we all share. My question was rather more detailed. If part of the funding is to be based on outcomes, how and when is that to be judged? If the outcomes are not achieved, how will the money be reclaimed? All this is something of a mystery as matters stand.
Earl Howe
The details of the payment-by-results system will be worked through. We are working with our partners in the sector including the LGA and NHS England to ensure that the system is designed with a view to incentivising integration. Further details of those arrangements are in course and we will announce them as soon as we can.
The kind of things that we will be looking for are, for example, the results that we have seen in places such as Cheshire West and Chester. The pilots, the whole place community budgets, showed that savings from integration could be substantial if implemented effectively. A business case needs to be presented. In that context, the pilot suggested that, once proposals are fully implemented, the net savings that could be achieved over five years are considerable.
Cheshire West and Chester has made savings of £26 million, with £3.8 million for Greater Manchester, £190 million for the Triborough authorities and £90 million for Essex. These savings are being identified. It gives us confidence to say that there is real potential to save money across the country, as shown by the pilots and other reviews, such as the Audit Commission review. Oxfordshire recently announced that it was nearly doubling the amount of money in its pooled budget for older people. That is a significant move.
I agreed with much of what the noble Baroness, Lady Wall, said. Savings are eminently possible without detracting from quality, by slowing and preventing the development of care needs or the onset of health conditions, or the loss of independence. We hope and believe that preventive care can increase the quality of life for individuals. A proactive stance by local authorities will deliver that. At the same time, preventive care will provide longer-term financial savings to the public purse. For the first time, Clause 2 creates a clear legal duty on local authorities to ensure the provision of preventive services.
I come to the point raised by the noble Lord, Lord Campbell-Savours, about the Dilnot package. I do not view the Dilnot package in the same way that he does. I do not see funding reform as being about protecting people’s inheritances. It is about providing hard-working people with peace of mind about how much they will pay for their care. Deferred payments will ensure that people will not have to sell their homes in their lifetime to pay for care. That will prevent distressing sales of houses and provide everyone with breathing space to make decisions and choices about what happens to their home. In the long term, the scheme is broadly cost-neutral to government, because the deferred payments will be repaid. Everyone will benefit from these reforms, but they will particularly help people with modest wealth who are most at risk in the current system of losing their entire home and savings.
Delivering on these transformational changes to health and care is the only way to secure the long-term sustainability of services, both for the NHS and local authorities. I would be firmly against delaying this —I think we would be heavily criticised if we did. The noble Lord, Lord Bichard, referred to the burgeoning weight of regulation during the past 60 years and one cannot argue with the statistics that he produced. This Bill serves to consolidate more than 60 years of legislation; it will repeal provisions from more than a dozen Acts of Parliament. Reducing the complexity of the statute and rationalising burdens on local authorities are our key aims in this context. I hope that, for the reasons that I have outlined, the noble Lord, Lord Best, will feel sufficiently reassured to be able to withdraw his amendment.
Lord Best
My Lords, I am deeply grateful to all noble Lords who have spoken: to the noble Lord, Lord Bichard, for pointing out that we cannot keep loading responsibilities on local authorities and others without willing the means to pay for those things; to the noble Baroness, Lady Howarth, who said that we cannot go on like this; and to the noble Lord, Lord Rix, who explained the position from the Mencap perspective—it could have been that of many other charities which are facing very tough times because local authorities cannot keep up the level of support that they used to have. The noble Lord, Lord Campbell-Savours, produced more impressive statistics, not least in relation to the people with long-term conditions and dementia who are living in the community and need to fund their care needs. The noble Baroness, Lady Campbell, brought us the users’ voice, pointing out that funding cuts have already meant people losing some of the control and choice which had been increasingly expected with use of direct payments and so on.
The noble Lord, Lord Sutherland, pointed out that the culprit is not local government or central government but demography, and that we need to make some choices as a result of those demographic pressures. However, in his view, one of those priorities is clear: it is that we should go ahead with this Bill. The noble Lord, Lord Beecham, also felt that it would be unwise for us to delay things, even though he accepted that cuts mean that social services in Newcastle have returned to the position that they faced in 1973 in terms of the resources available. He pointed that it is local government that has shown itself best able to be more efficient in these difficult times. We need to remember that. The noble Baroness, Lady Wall, pointed out that local authorities should try to make savings wherever they can, and the noble Lord, Lord Beecham, was right that statistics show that local government is doing just that.
I think that it is fair to say that the noble Lord, Lord Bentham, felt that it was necessary to find additional resources, but he thought that those could be found from the underspend in the NHS or the uncollected VAT or some other source. However, he did not want the amendment to delay the good things that the measures bring with them. The noble Earl, Lord Howe, agreed that we need fully to fund the measures—did I say Bentham?
Baroness Greengross
My Lords, I support Amendment 78ZA. Six years of serving on the Equality and Human Rights Commission taught me that if we embedded dignity and respect into the training of staff we would avoid many of the tragedies we have read about. This applies, right across the board, to staff in health, social care and housing. It is essential that we take dignity and respect as very serious elements of the training of all staff who come into contact with frail and vulnerable people.
Earl Howe
My Lords, the well-being principle in Clause 1 was devised on the basis of the Law Commission’s report on adult social care which this part implements. The report recommended that the new statute should set out a single, overarching principle that adult care and support must promote or contribute to the well-being of the individual. Not least in the light of our debate at Second Reading, I can therefore understand the noble Lords’ intention in tabling Amendments 78 and 79. It is to ensure that any functions that the Secretary of State exercises under this part take into consideration how such provisions will impact upon people’s well-being. I can give the Committee what I hope will be a welcome reassurance on that issue and, in the process, a rather better and fuller answer than I gave at Second Reading.
It is already the case that the Secretary of State must have regard to the general duty of local authorities to promote an individual’s well-being when making guidance or issuing regulations. This is because, when making regulations or issuing guidance, the Secretary of State must consider how local authorities can fulfil their statutory obligations. He cannot ignore those obligations and I believe this addresses the central concern of the noble Lord, Lord Hunt, and others who have spoken to the amendment. The question is whether the Bill should go further. The Government do not believe that it is appropriate to apply the well-being principle directly to the Secretary of State. The well-being principle is intended to apply at a very real, individual level. It has been designed to frame the relationship that exists between the local authority and the individual adult, in effect setting out how it is expected the local authority will behave when making a decision, or doing anything else, in relation to a person needing care and support or to a carer. The Secretary of State does not act at this individual level, and I am still reluctant to make any amendment which might be seen to detract from this important legal reform.
Having said that, I have listened with care to the strength of feeling in this debate, not least to the point made by the noble Baroness, Lady Pitkeathley, about the Secretary of State’s duty to have regard to the NHS constitution and whether there was something comparable that we could devise in this context. That is an interesting comparison and, while I am not yet convinced that it is fully comparable, I am happy to take the points that have been made away with me and give this matter further thought before the next stage of the Bill.
Amendment 78A seeks to bring in to the well-being principle the idea of spiritual well-being and I listened with care to my noble friend Lady Barker who spoke to this amendment. The Government believe that the clause, as it is already drafted, takes such a factor into consideration. Clause 1(2) sets out that well-being means an individual’s well-being in relation to emotional well-being. The Government believe that emotional well-being incorporates the concept of spiritual well-being.
I turn to Amendment 78B, which proposes that local authorities must take into consideration an individual’s beliefs, values and past practices. While we share my noble friend’s intention in this regard, we believe that the clause as it stands already incorporates the idea that people’s beliefs and values should be taken into account when a local authority has regard to an individual’s views, wishes and feelings.
The second part of the amendment would be to ensure that “past practices” were also taken in account. I reassure my noble friend that we will be setting out in guidance the importance of taking into consideration, when planning a person’s care, their views and feelings as well as considering any practices in the past that have been important to that individual.
The noble Lord, Lord Bichard, highlights the importance of dignity in care in his Amendment 78ZA, and he spoke about that concept very powerfully. I am pleased to say that the Government agree that this is important, which is why we amended the Bill to make an explicit reference to dignity into the well-being principle, following pre-legislative scrutiny. With respect to the noble Lord, I cannot agree with him that the word has somehow been lost; it is right there on the page.
I turn to Amendments 78E, 87K and 88J, tabled by my noble friend Lord Black of Brentwood. These amendments focus on the very important topic of pets. The Government have considered this issue carefully since the amendment was tabled, and we believe that the Care Bill already allows for the consideration of pets. First, Clause 1, the well-being clause, provides that local authorities, when exercising any function under Part 1 of the Bill, have a duty to promote the well-being of an individual. Well-being is composed of many aspects, including emotional well-being. A pet might be so important to an individual that their emotional well-being would depend in some way on their pet. If that is the case, a local authority will have to take it into consideration.
Furthermore, Clause 1(3)(b) sets out that in exercising any function under Part 1 of the Care Bill a local authority must have regard to an individual’s “views, wishes, and feelings”. This could include how an individual feels about a pet, and their wishes for the pet. Clause 9, which covers the assessment of needs for care and support, also allows scope for pets to be taken into consideration in the assessment process. As Clause 9(4)(a) sets out, a needs assessment must take into consideration a person’s well-being. This could certainly include an individual’s pet, from which they derive a lot of emotional well-being.
I turn to Amendments 78D and 88L. The Government believe that it is more important than ever that care and support services operate in tandem with health services. The Government have committed to breaking down barriers between health, care and support, as well as encouraging co-operation, integration and joined-up working between local partners. The Government believe that the Care Bill already allows for such co-operation to occur, and I shall explain how. First, Clause 1(2)(a) makes it clear that the well-being principle incorporates physical and mental health. Local authorities must therefore already consider a person’s health when exercising any functions under Part 1. Secondly, Clause 3 details how local authorities must exercise their functions under Part 1 with a view to ensuring the integration of care and support with health provision, where they consider that this would promote the well-being of an individual.
Regulations on assessments for care and support are also relevant. As Clause 12(1)(f) sets out, regulations may set out when a local authority must consult someone with expertise before undertaking an assessment. Regulations may also set out conditions around co-operation with the NHS, by specifying the circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare.
The noble Lord, Lord Hunt, expressed the view that the eligibility regulations do not sufficiently promote integration. I note the point that he made and look forward to debating this in perhaps fuller measure when we come to discuss eligibility. However, I ought to point out that the draft regulations published last week are subject to consultation, and I am sure that the discussion will explore the points that he made.
My noble friend Lady Tyler said that the regulations do not mention dignity specifically. I think that they have to be read in context. The well-being principle, including the reference to dignity, applies to the assessment of the adult’s needs and to the local authority’s determination of whether those needs are eligible.
To return to my noble friend Lord Black’s amendment on companion animals, we are clear that there should not be any limitations on the uses of direct payments, which was an issue that he raised, as long as they are used to meet needs for which they are paid and not in a way that is unlawful. The key is that direct payments are used to improve people’s outcomes.
I understand the intentions of noble Lords in tabling these amendments but I hope that they feel reassured that they are not necessary, although I will take back the specific issue that I referred to earlier. In the light of that, I hope that the noble Lord, Lord Hunt of Kings Heath, will feel able to withdraw the amendment.
Baroness Masham of Ilton
Before the Minister sits down, I would just like to ask him: does he not really want to get things right? When there were problems at Mid Staffordshire, people were desperately thirsty, drinking out of flower vases, and were lying in their own refuse in their beds. Surely dignity must be written in all over the Bill.
Earl Howe
I agree that dignity is a very important concept, which is why we expressly amended the Bill to include that word right at the beginning. Clause 1, which defines the well-being principle, is the foundation for everything that follows. While one could pepper the Bill with references to the word “dignity”, I am not sure that that would add very much in practice.
Lord Hunt of Kings Heath
My Lords, I am grateful to the Minister for that response. I hope that he will reflect a little on the amendment from the noble Lord, Lord Bichard, and the noble Baroness, Lady Tyler. I understand what he is saying about the words in the Bill; I think that noble Lords just wanted to find a way of giving that greater focus. That will be well worth giving further consideration to. With regard to the amendment from the noble Baroness, Lady Barker, I am grateful for the reassurance that the Minister has given.
On Amendments 78 and 79, the Minister has essentially said that he still sticks to the general principle that the well-being clause applies to local authorities and individuals. The point here, though, and the reason why I am glad he is taking it away, is a point raised by a number of noble Lords: this legislation, which is a wholesale recasting in the light of the Law Commission’s work, is likely to endure for many years to come. That is why it is so important that the link between the Secretary of State’s duties, and those of local authorities, and the Secretary of State’s powers regarding guidance and regulations are brought together. I hope that the Minister will find a way of getting this into the Bill.
The noble Baroness, Lady Campbell, was very eloquent when she talked about what happens if health and social care do not provide an integrated service. She gave an example of a very distressing case of someone who could be out of hospital and back into work. This was down to a failure of two public bodies to sort things out. I know that the Minister says that in fact the legislation is okay; the problem is that these public bodies will continue to fail people who fall between two stools. These bodies do not seem to have an understanding that it is imperative for them to look after the interests of those individuals. I hope that the noble Baroness might return to this at a later stage.
The noble Lord, Lord Black, made some wholly persuasive arguments. My noble friend Lady Wheeler reminded me that Canine Partnerships is another organisation that is very much involved in pet companions for people with stroke, epilepsy and other illnesses. I myself have come across organisations in Birmingham in connection with the health service that do a fantastic job. All I would say is that if the noble Lord put this to a vote, the Opposition would be right behind him, so let us see. I beg leave to withdraw the amendment.
Health: Diabetes
Earl Howe Excerpts(10 years, 10 months ago)
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Lord Harrison
To ask Her Majesty’s Government what assessment they have made of the quality of healthcare available to diabetics with eye problems.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, we have set clear objectives for the NHS and Public Health England to improve the care and quality of life for people with diabetes. The public health outcomes framework includes an indicator on preventable sight loss, which will track three of the commonest causes of preventable sight loss, including diabetic retinopathy, to drive improvements in quality.
Lord Harrison
My Lords, given the decline in the regular and important annual check-up for diabetics, does the Minister acknowledge that the retinopathy screening for diabetics introduced by the previous Government is being undermined and underresourced? On cataract operations, will the Minister explain why, among our European Union colleagues, we are the most demanding regarding the threshold required to have such operations? Given the importance of cataract operations, especially for older people in retaining their vision, will the Minister meet me and other colleagues to discuss these matters and allied subjects?
Earl Howe
I would be happy to meet the noble Lord. I am aware that the whole area of the cataract threshold and, perhaps more importantly, the interpretation of that threshold, is one that NHS England is now actively looking at to ensure greater consistency around the country.
I do not agree with the noble Lord’s interpretation of the screening figures. The UK countries, I believe, lead the world in the area of diabetes eye screening. This is the first time that a population-based screening programme has been introduced on such a large scale. The latest figures show that up to March 2013, 99% of people with diabetes who were eligible for screening were offered it in the previous 12 months.
Baroness Finlay of Llandaff
My Lords, given the importance of prevention, have the Government been monitoring the progress of access to insulin pumps for children with diabetes, in order to prevent eye problems later in life, given that they have better control with insulin pumps?
Earl Howe
My Lords, that tends to be a matter for provider trusts, working in conjunction with clinical commissioning groups. I am aware that there is concern about the variability of access to insulin pumps. Of course, they are not a universal remedy for every diabetic patient, but where they are appropriate they should be commissioned. If I can give the noble Baroness the latest information on that, once I have consulted NHS England, I would be happy to do so.
Baroness Jolly
My Lords, the House has heard that eye screening is critical for those with diabetes. As the national screening programmes are now commissioned by NHS England on behalf of Public Health England, and while diagnostic and treatment services are commissioned by clinical commissioning groups, will my noble friend tell the House what challenges these arrangements pose to the patient when trying to assess quality?
Earl Howe
The key thing here is for NHS England, Public Health England and local commissioners to work closely together, which is indeed what they are doing, so that the patient experiences a seamless service. Essentially, the new commissioning arrangements for national screening programmes enable effective commissioning and oversight of the whole screening pathway, alongside integrating those with the diagnostic and treatment services. To ensure a quality service, local programmes are assured by NHS screening programmes’ quality assurance teams and services are measured against 19 standards.
Lord Low of Dalston
My Lords, I declare my interest as vice-president of RNIB. The Minister will be aware that NICE has recently approved the use of Lucentis as a treatment for those suffering from diabetic macular oedema. We are hearing reports from various parts of the country of queues building up of people requiring treatment for diabetic macular oedema. Will the Minister undertake to do his best to ensure that the necessary resources are put in place to relieve these backlogs and enable people to benefit from this new treatment that has now become available?
Earl Howe
My Lords, I am aware of the issue that the noble Lord raises. He will know that NHS commissioners are statutorily required to fund clinically appropriate drugs and treatments which have been recommended by NICE. The Centre for Workforce Intelligence has been commissioned to review the ophthalmology medical workforce after discussions were held between the royal college and Health Education England earlier this year. That review is due to report in the summer and the results of it should, I hope, point the way to a resolution of the issue that the noble Lord has raised.
Lord Collins of Highbury
My Lords, as a type 2 diabetic, I benefit from annual retinal check-ups at UCH; it is an excellent service. However, despite there being a national screening programme, there is a large variation in take-up, which in some areas is as low as 65%. What steps are the Government taking to ensure a higher and more consistent take-up?
Earl Howe
In the end, accepting the offer of screening is a matter for each individual. There are some people who, for personal reasons, will choose not to take up the offer. However, as part of the process of continuous improvement, we would expect the gap between the number of people offered and the number of people receiving screening to reduce, and for there to be greater consistency in numbers offered and received across local screening programmes.
NHS: Association of Medical Research Charities Report
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Baroness Wheeler
I, too, congratulate my noble friend Lord Turnberg on securing this debate, especially his timing following hot on the heels of our scrutiny of the Health Research Authority under the Care Bill. My noble friend is a much respected and tireless champion for research and innovation, leading to improved quality care for patients, and we in our party rely strongly on his expertise and support.
My noble friend and other noble Lords from across the House between them ensure that the importance of research and innovation to the NHS is kept to the fore, by this debate and, for example, in recent debates by the noble Lord, Lord Kakkar, on the impact of the EU healthcare in the UK and the concern over the UK losing its global allocation of clinical trials, and in the powerful debate earlier this year of the noble Lord, Lord Saatchi, on medical innovation, which reinforced the need to deal with the regulatory burden, to which noble Lords have referred, and to speed up the availability of innovative treatments.
Like other noble Lords, we welcome the progress on speeding up research approvals made by the HRA through the single portal of entry and single application procedure and bringing together the various research ethics committees. However, the point about the need for progress in getting the local R&D committees of NHS trusts singing from the same hymn sheet is well made and I look forward to the Minister updating us on the action that the Government are taking.
Like other noble Lords, I congratulate the AMRC on its excellent report and the accompanying survey of healthcare professionals’ views on the importance of research to the NHS and to staff working for it. Under the Care Bill, the need for Health Education England to ensure that research and innovation are incorporated into education and training for healthcare staff was a major theme, echoing the Joint Select Committee on the Bill on this issue. All NHS staff need to be able to make use of research throughout their careers and should be equipped with the tools to understand and support research and to assess and use evidence to inform their decisions when caring for patients or supporting clinical staff.
As noble Lords have pointed out, the association’s survey showed the challenges to be faced. The good news was that staff overwhelmingly recognised the value and importance of research, but the barriers to taking part in research, identified by the majority of staff surveyed, including doctors and nurses, was deeply worrying. It is clear that these barriers of lack of time, problems over funding and support and the difficulties of navigating regulation have to be overcome, particularly the need to develop stronger support among GPs to become personally involved in research. After all, they are such an important gateway to spreading the message to get patients interested and involved in research. As my noble friend put it, there is still much to do at the coal face. This is where the ARMC report is so valuable. It offers an authoritative but very practical vision of how the goal of having every clinician a researcher and every willing patient a research participant can be progressed and achieved, as well as how the leadership and support that the NHS staff need can be developed and built into a service-wide research culture.
The case studies in the report are particularly informative, providing examples of excellence and best practice in cancer, arthritis and other key research areas of patient consultation and involvement, and of building staff support and confidence about participating and using research findings so that they can show their patients the benefits of them taking part.
In the context of this debate it is important also to reflect on the progress being made on the UK life sciences and the innovation, health and wealth strategies, the central aim of which is for innovation to become the NHS’s core business. No one reading these reports and the recent one-year reviews can be in any doubt of the dramatic pace and scale of change in the medical and life sciences, such as the breakthrough in genomic medicine, which is changing fundamentally the way disease is diagnosed, prevented and treated, and the progress on regenerative medicine, which are all breathtaking to a lay person such as myself.
There are important developments on the service side, too, as part of the high impact innovation programme, such as in wheelchair design. Can the Minister update the House on progress on implementing the strategies? I could not find any details on the website about further review reports or of the Government’s response to the MHP Communications review of the strategies, which charted good progress but also some continuing problems, including implementation of NICE technology appraisals by NHS trusts and the poor level of awareness of the IHW strategy; only 30% had discussed the strategy at board level. How are these issues being addressed?
Finally, on the association’s vision, I would reinforce the need to keep our foot on the pedal to ensure that we continue to be a world leader in clinical research. We must ensure that CCGs in the absence of SHAs and PCTs continue the focus on research and do not allow it to diminish. The AMRC vision highlights the need for leadership and guidance to CCGs to promote research; to encourage NHS managers so that they understand the value of research and actively support it through their management decisions and processes; and to ensure that all parts of NHS support research, including primary care and all non-NHS providers. I look forward to the Minister’s response updating the House on the Government’s actions to ensure that real progress is made on all these fronts.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Lord, Lord Turnberg, for having tabled this debate. He has spoken with both authority and passion about Our Vision for Research in the NHS, the report by the Association of Medical Research Charities. The Government welcome the report; it is a challenging and insightful contribution to the debate on optimising the research potential of the NHS.
It is now more than seven years since the National Institute for Health Research was established in April 2006. The NIHR has a wide-ranging role that is central to our debate today. It provides the framework through which the Department of Health can position, maintain and manage the research, research staff and research infrastructure of the NHS in England as a national research facility. Indeed, together, NIHR people, facilities and systems represent the most integrated clinical research system in the world—driving research from bench to bedside for the benefit of patients and supporting economic growth.
My noble friend Lady Sharp referred to the importance of clinical trials, and of course, that is centre stage for the NIHR. As a result of the NIHR, large numbers of patients have the opportunity to take part in research. In the past financial year, more than 630,000 participants were recruited to trials and studies hosted by the NIHR Clinical Research Network Portfolio, and more than 99% of NHS trusts were involved in the recruitment. During the whole of 2013-14, the NIHR is promoting the fact that, “It’s okay to ask” about clinical research. We want everybody to get involved—patients, medical professionals and the public to support the campaign.
In March 2013, the Government published the revised NHS constitution, which contains a pledge to inform patients of research studies in which they may be eligible to participate. The pledge aims to give people better access to the potential benefits of participating in research studies, including clinical trials. We have already improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I just say to the noble Lord, Lord Aberdare, who spoke very powerfully about pancreatic cancer and the need to enlist more patients into trials for that condition, that the launch of the gateway was promoted through leaflets and other printed materials, including postcards and posters, and the gateway is also being actively promoted by INVOLVE, which is the NIHR-funded patients and public involvement body. In the course of just one month, May of this year, there were 11,570 visitors to the gateway website. Although not all of them will be related to pancreatic cancer, I hope that that gives an indication of the powerful influence that we hope the gateway will have in alerting patients to relevant studies.
Crucial to all this activity is the need to both protect and promote the interests of patients and the public in health research. That is why we established the Health Research Authority in 2011, and provisions in the Care Bill will give it added stability and independence. To my noble friend Lady Sharp I would say that the HRA has a programme of work to enable the implementation of a unified approval process and to support the authority in promoting consistent and proportionate standards for compliance and inspection. The programme includes a feasibility study with a number of pilots to test the effect of rationalising and combining elements of NHS study-wide review with elements of the research ethics committee review into a single HRA assessment. The findings are expected to identify and show how to release the potential to improve both study set-up times and the quality and consistency of ethical review.
The noble Lord, Lord Kakkar, very helpfully acknowledged that enactment of the Health and Social Care Act is a milestone for research in the NHS. It recognises the need to promote research and the use of research evidence and created unprecedented powers and duties at all levels to meet that need. The Government’s mandate to the NHS Commissioning Board—now NHS England—sets an objective to ensure that the new commissioning system promotes and supports participation by NHS organisations and patients in research funded by both non-commercial and commercial organisations, most importantly to improve patient outcomes, but also to contribute to economic growth.
The noble Lord, Lord Kakkar, specifically asked how CCGs will be held to account. The mandate asks for demonstration of progress against the five domains and all the outcomes indicators in the NHS outcomes framework. The framework document emphasises that vital to the quality and delivery of these outcomes will be continued research and the use of research evidence in the design and delivery of services at a local level.
NHS England welcomes the vision for research set out by the AMRC and shares its aspirations to empower patients to take part in research; to engage clinicians and other NHS staff; and to implement research findings to lead to better outcomes for patients and the public. Although NHS England is a new organisation, the NHS—as I do not need to tell the noble Lord, Lord Turnberg—has a strong existing culture of research, although we want to strengthen that culture. There is a wide wealth of research activity already taking place and considerable expertise within organisations. However, NHS England recognises there is further work to do to ensure that all NHS commissioning staff embrace a research culture, which was the theme of my noble friend Lord Saatchi’s excellent contribution, that they have access to research evidence and use it to inform commissioning decisions. It has recently recruited a team to lead the research agenda and develop and implement its research strategy. It is anticipated that a draft strategy will be in place by autumn this year, when extensive consultation with key stakeholders and partners, including patients, will be undertaken.
The noble Lord, Lord Turnberg, and my noble friend Lady Sharp rightly referred to the vital role of clinical commissioning groups within the new system. Through their formal declaration of compliance, all these groups have confirmed that they understand and will comply with their statutory responsibilities regarding promoting research. They have also confirmed that they are committed to following the policy of ensuring the NHS meets the treatment costs for patients taking part in research funded by government and research charity partner organisations. Alongside NHS England, Health Education England has responsibility for promoting high quality education and training that is responsive to the changing needs of patients and local communities. It will work with stakeholders to influence training curricula as appropriate.
HEE will work to build a workforce that is research-literate, with the skills and confidence required to diffuse the latest ideas and innovations. HEE will establish mechanisms to ensure that ongoing engagement takes place with a wide range of partners. This will include building relationships with academic health science networks and academic health science centres to align education with research and innovation. The noble Lord, Lord Turnberg, referred to the role of LETBs, which are responsible for commissioning education and training and securing quality and value from education and training providers. Indeed, they will need to ensure that the education and training that they commission is in line with national objectives, which include building a flexible workforce that is receptive to research and innovation. HEE and the LETBs are working with the NIHR to ensure appropriate investment in education and training, to develop clinical academic careers and to increase the number of staff accessing academic careers programmes across all clinical and public health professions.
I say to the noble Lord, Lord Rea, that the NIHR supports a wide range of programmes for research training and career development. The purpose of these is, self-evidently, to create the next generation of researchers focused on people-based research. The programmes provide support for the academic training paths of all healthcare professionals and other key disciplines involved in health and social care research, including, importantly, general practice. The NIHR is actively building research in general practice—for example, through its School for Primary Care Research. Through its integrated academic training programme, the NIHR has already taken a lead in reversing the decline in clinical academic careers.
The noble Lord, Lord Turnberg, spoke about investing in research, and of course I very much identify with the need to do that. As part of the commitments announced by the Government yesterday to invest in Britain’s future, the department will provide £150 million of capital investment in 2015-16 to fund health research infrastructure in the areas of dementia, genomics and imaging.
As regards clinical excellence awards and the consultant contract, discussions are ongoing between the UK government health departments, NHS employers and the BMA about changes to the consultant contract. The aim is to agree a heads of terms next month and to move to detailed negotiations. I will write to the noble Lord with further details about that.
My noble friend Lord Selborne spoke very powerfully about data from the NHS. One million people have some form of contact with the NHS every 36 hours. That produces, as he rightly said, a staggering amount of data, which can be used to drive forward research into new treatments. The NHS is in a unique position in that sense. We can draw on linked datasets on a scale unprecedented elsewhere in the world. Provided that we ensure confidentiality and privacy for individual patients, the opportunities for research and innovation are vast. In April last year, we established the Clinical Practice Research Datalink, which enables access to anonymised patient records to support the development of novel treatments. I can reassure the noble Lord, Lord Turnberg, that the CPRD is working with the NIHR primary care research network to recruit more GP practices to contribute their data to the CPRD’s data assets.
The clock is moving against me, so noble Lords will have to forgive me if I do not cover all their questions today but I undertake to write to those noble Lords whose points I have not covered—and there are many. I hope that the noble Lord, Lord Turnberg, in particular, has gained a sense of the importance that the Government attach to promoting research in the NHS, and a sense that we need, and have, a whole-system approach to this agenda, which is so vital for the future health and prosperity of our nation.