Care Services: Winterbourne View

Earl Howe Excerpts

Monday 10th December 2012 Lords Chamber

[Earl Howe]

My Lords, I am very grateful to the noble Lord for his constructive comments and I welcome his commitment to a shared agenda for improving care for those with learning disabilities and autism. I agreed with a great deal of what he had to say.

As to his individual questions, he first asked whether I could articulate the number of in-patient places we expect to be reduced during the coming months and years. My answer is that we want to see a rapid reduction in the number of people with learning disabilities, autism and challenging behaviours who are in hospitals or residential care and who are away from their home areas. That is not to say that there is no role for assessment-and-treatment centres, which clearly have a role—but it is limited. It is important to ensure that everyone has a care plan built around their individual needs, rather than to say that there should be some kind of top-down national target for the number of units. We believe that plans should be in place and put into action as soon as possible. All individuals should be receiving personalised care and support in the appropriate setting for them no later than 1 June 2014, and we shall work towards that end. It is very much a case of defining the appropriate care for the individual.

To pick up the noble Lord’s final question about the involvement of carers and the vulnerable adults themselves, yes, they should indeed be involved in the planning of care. It is families, carers and the individuals themselves who know best what they need. It was one of the besetting failings of this terrible saga that families and carers were not listened to, and not only about the whistleblowing to which they wanted to alert the authorities. They also had a very good idea of what type of setting and care their loved ones would best respond to—and they were not listened to on that score, either.

The noble Lord asked about clinical commissioning groups and the extent of their expertise in commissioning appropriate treatment for those with learning disabilities. I agreed with a great deal of what he said. Commissioning expertise for this group of people is, frankly, in short supply, and that is why the department will fund the joint improvement programme being organised jointly by the NHS Commissioning Board and the Local Government Association. They will be tasked with working closely with clinical commissioning groups and their local authority partners over the next two years, to share and implement best practice. There has to be, as the noble Lord said, a cohesive approach. Joint working here is vital because we are looking at determining not only the right setting for an individual but what the right treatment for that person should be. That necessitates a joint approach. I should add that we would set an expectation that there be pooled budgeting arrangements to drive that forward.

The noble Lord asked me who on the Commissioning Board was leading in this area. Sir David Nicholson has made clear his personal commitment to take action on this. Indeed, the board is meeting people with learning disabilities this Thursday, but the lead director on the board is Bill McCarthy.

The noble Lord asked me what the Care Quality Commission intended to do by way of ongoing work. The CQC will continue to carry out unannounced inspections, which will involve people with learning disabilities and their families, as I mentioned when I repeated the Statement. That will be based on risk, and the CQC has made it plain that these particular settings are a priority for it. We expect it to take account of all the recommendations arising from the serious case review, including the views and statements of those who have left establishments of this kind.

The noble Lord asked me about Castlebeck and the liability that it should have for the ongoing costs of patients who were at Winterbourne View and, indeed, the cost of the serious case review. My reaction is that Castlebeck should give serious consideration to that suggestion. However, there are currently no powers to make that happen, and the Government are keen to ensure that in extreme cases such as this there are consequences for providers of care that is of poor quality.

As regards a requirement for companies to be more open about their board structure and corporate structure, this is something that we shall be looking at over the next two or three months, and we will come forward in the spring with our conclusions on how companies and their boards can better be held to account.

[Baroness Hollins]

My Lords, I welcome the report and the detailed actions that are listed in it. Indeed, it fills me with some hope after so many years of commissioning failure. The proposed change support programme is to be led by the NHS Commissioning Board and the Local Government Association. There is something ironic in responsibility for leading this change being vested in those who primarily have been responsible for the current failure. The evidence is that local authority and NHS leadership do not have the skills or knowledge to effect change. Indeed, my former colleague Jim Mansell’s first report on challenging behaviour was published 20 years ago and made similar recommendations to those in today’s report. Can the Minister confirm that the programme board will indeed be expected to engage with those from the learning disability sector, who understand the issues involved in the design and delivery of the support programme? Finally, why does the report make little or no mention of the need to provide access to the same range of mental health treatments that other citizens have access to, including psychological therapies?

[Earl Howe]

The noble Baroness brings us to a set of key points. She said that in her view the NHS and local government simply do not have the capacity to address these issues properly. In many respects we would agree with that, although it would be wrong to make a blanket statement about the whole country because we know that very good pockets of commissioning and provision exist. One of the tasks of the joint improvement team will be to identify those areas of best practice, and to enable those operating in those areas to go out and mentor other areas. Part of the sum of money that we set aside will be devoted to enabling those high-performing areas to backfill the places while they are engaged in that mentoring exercise. Her basic point is well taken. We think there is a job to do here but it is one of those things that the Board and the Local Government Association need to oversee on a national basis.

That is only a short extension from the function of the Commissioning Board in general, which will be to support commissions. We are grateful to the Local Government Association for its overseeing role for local authorities. I fully expect that they will engage with the learning disability sector. I commend to her the concordat, which is accessible on the department’s website, and she will see from that that the 50 organisations that have signed up to it include a number of voluntary organisations in this sector. Jointly, these bodies have committed to a programme of action. It is not just about defining what needs to be done but about how it will be done. It is an impressive set of commitments that those bodies have signed up to.

[Lord Pearson of Rannoch]

My Lords, the Minister spoke about the need for a fundamental change of culture but I heard nothing in the Statement about training, so I hope that he will forgive me if I ask again a question I have been asking for over 20 years about the training of our teachers, social workers and, in this case, care workers. I do so from my background in the 1980s and 1990s on the body that validated all our teacher training courses and from having taken quite a close look at the curriculum then offered by the Central Council for the Education and Training in Social Work. At the former, I was shocked to find that our mission statement was “to permeate the whole curriculum with issues of gender, race and class”.

Since then we have seen Nursing 2000 put the training of nurses away from hospital wards and into the social science departments of the former polytechnics, with results that I predicted at the time. Have the Government looked into the curricula of the training of care workers and of those responsible for this and similar disasters? What training do they get, if indeed they are trained at all? What genuine qualifications do they have before they commence training? Are they proud of what they do, or are they just in it for the money? I hope I am very out of date, but I look forward to the Minister’s reply.

[Earl Howe]

My Lords, the noble Lord is not out of date, because this is a key issue and I am grateful to him for raising it. It is crucial that staff who work with people with challenging behaviour are properly trained in essential skills. Contracts with learning disability and autism hospitals should be dependent on assurances that staff are signed up to the proposed code of conduct that the Department of Health has commissioned from Skills for Health and Skills for Care and that there should be minimum induction and training standards for unregistered health and social care assistants. Those standards should be met. I would say that owners, boards of directors and senior managers of organisations that provide care must take responsibility for ensuring the quality and safety of their services. There are requirements set out in law in that regard, and they include safe recruitment practices, which necessarily involve selecting the people who are suitable for working with people with learning disabilities, autism and challenging behaviour, and appropriate training for staff on how to support people with challenging behaviour.

From April next year, Health Education England, which is the new, national, multi-disciplinary education and training body, will have a duty to ensure that we have an education and training system across the piece but including a system that can supply a skilled and high-quality workforce for this sector.

[Baroness Browning]

My Lords, my noble friend said that families’ concerns were ignored, but would he accept that there is huge push-back across all the public services involved with this group when anyone who is a family member of someone over the age of 18 tries to make representations on their behalf? I experienced that again personally, yet again, only this week. Paragraph 3.9 of the department’s response makes reference to:

“Where an individual lacks capacity and does not have a family to support them, the procedures of the Mental Capacity Act 2005 should be followed”.

I am appalled at the way in which the Mental Capacity Act, an excellent piece of legislation, is virtually ignored by many professionals who not only do not advise people of their rights under the Act but just ignore it. If ever a piece of legislation cried out for post-legislative scrutiny, it is this Act of Parliament. It is a strong, good piece of legislation but it needs to be enforced; we need more people to know about it and to use its powers to protect the vulnerable.

[Earl Howe]

My Lords, my noble friend is absolutely right. Over the coming months the Department of Health will be working with the Care Quality Commission to agree how to improve the understanding of the deprivation of liberty safeguards and to ensure compliance with them. We are very clear that this work is necessary to protect individuals and their human rights. We will report the results of that work by spring 2014. During 2014 the Department of Health will update the Mental Health Act code of practice, and this will also take account of findings from the review.

[Baroness Wall of New Barnet]

My Lords, I also congratulate the Minister on repeating this Statement made earlier in the other place, and I welcome the report itself. I want to refer to a couple of areas and follow up his reassurance about the patient care pathway. The importance of that pathway, I am sure he knows, is not only in having it but ensuring that it is carried out with regular updates, and that the progress being made is taken into account to make sure the pathway is staying in touch. That does not always happen, so having the patient care pathway is only one part of what I hope he would ensure would happen.

The other part, and the Minister may not be surprised at this, is Part 7 where again, as my noble friend Lord Hunt has done, I urge him to think again about another area. With regard to the expectation as far as training goes—while Skills for Health and Skills for Care, as mentioned in the document, are doing a great job—it is absolutely crucial to recognise that just the induction for health care assistants in social care really is not enough. I have pleaded with the Minister on many occasions in the context of hospitals. It is equally if not more important that healthcare assistants have the confidence given to them by being registered and qualified in the way that registration ensures, so that the very difficult and important job that they do—and more of them are doing it than are working in any other area—is suitably recognised. I urge the Minister to take away that request in the context of this report, and to look again at ensuring registration for these particularly important workers.

[Earl Howe]

My Lords, I am grateful to the noble Baroness for what she has said. She is right to point out that the patient pathway is integral to any proper planning process for individuals, and that it should be built around the particular individual’s needs and preferences if possible. This brings us back to the role of an assessment and treatment centre: namely, as its name implies, to assess the needs of a person and to define what their care plan should be over a future period of time. As I mentioned, the care plan is best when it is drawn up with the benefit of advice from the individual, their family and their carers. Therefore, if we want more community care, we need to ensure that there is the capacity in the community to deliver good patient pathways to individuals. We are clear that some areas of the country are ill equipped to do that. Part of the task of the joint improvement programme will be to look at the facilities and resources that are required in local areas to enable commissioners to plan those patient pathways with confidence.

On the issue of the training of care assistants, I take the noble Baroness’s point. I think that it is common ground between us that those who lack a recognised qualification should nevertheless be enabled to upskill themselves and get themselves on a register to prove that they are familiar with and abiding by a code of conduct that has been recognised, with the register itself being duly accredited. Our position is that the system of voluntary registration, almost by definition, will result in an upskilling of the workforce, but it is not the whole story. There is a role for employers to ensure that there is proper supervision of care assistants, and that proper delegation takes place that does not require a person to do more than he or she is skilled to do. There is no single answer here, but I believe that voluntary registration is a good start.

[Baroness Masham of Ilton]

My Lords, following from the question about registration and regulation, is the Minister aware that people such as nurses and care assistants who have been sacked for dishonesty or undertaking dangerous procedures with patients can take a job anywhere as a care assistant? Without regulation, how will he control the matter? It is very dangerous for vulnerable patients because these establishments are so hard-pressed to get staff to work in their centres that they will take almost anyone, without even taking up references.

[Earl Howe]

My Lords, the noble Baroness raises another important point. In this country we have a list that acts as a check on those who have abused or otherwise maltreated adults or children and have been dismissed on that basis, to ensure that the scenario that she has painted in which someone who has committed such an offence is re-employed cannot occur in practice. I am not sure that I recognise the situation that she outlined because the POVA system is designed to ensure that dangerous people are not employed to look after the vulnerable. However, I will gladly drop her a line in writing to set out what we propose in this area.

[Lord Willis of Knaresborough]

My Lords, I echo the comments around the House that this Statement is appropriate. The fact that it has support across the House demonstrates that there is unity in terms of tackling the issue. I spent a significant part of my professional life working with young people with severe behavioural issues. As the head of a school, I, together with my governors, would be held responsible for what happened to those young people—and rightly so. The weakness in the Statement is that it does not go far enough.

The Minister was right to make clear, and I am glad he did, that it was the management and the corporate owners of the home who were principally responsible, yet it was the staff who were prosecuted and jailed. I would like to hear what steps are going to be taken with the CPS to deal with corporate responsibility, and why that is not the priority here. Without it, frankly, a lot of the things that appear in this report will not have the necessary teeth.

I respectfully but fundamentally disagree with the noble Lord, Lord Pearson, on the training of nurses and other health workers. The more that we demand of staff in terms of their education and other opportunities, the better the staff we will ultimately get. However, I agree with him and with the noble Baroness, Lady Masham, that it cannot be right that the most vulnerable people in our society are looked after by people whom we cavalierly say do not require qualifications. How unacceptable is that in the 21st century? A voluntary register of an organisation that is disreputable is utterly and totally meaningless. We need a commitment on this from the Government. I agree that this will be over a period of time; it will not happen tomorrow. However, simply stating, as recommendation 15 does, that by 2013 there will be a voluntary register will not give parents and carers of these very vulnerable adults and young people the support and comfort that they need. I plead with the Minister to make the case in the department for mandatory registration, to ensure that there is appropriate regulation and that nobody works with these young people or adults who does not have appropriate qualifications and training.

[Earl Howe]

My Lords, I am very happy to recognise the excellent work done by my noble friend in the report that he published and submitted to the Royal College of Nursing, which we will debate later this week. He rightly drew attention to the responsibility that lies with leaders of organisations and boards of directors. They should be fully held to account for poor quality or for creating a culture in which neglect or abuse can happen. I completely agree with that. He was right to say that despite convictions for some front-line staff, Winterbourne View has revealed weaknesses in our ability to hold to account those who were higher up. Owners, boards of directors and senior managers must take responsibility for the quality and safety of their services.

We are determined to strengthen the accountability of boards of directors and managers, but we are not yet in a position to say exactly how that should be done. It is not as easy to define a legal route as it might first appear. It is perhaps easier to do so in the area of financial irresponsibility or negligence than it is where value judgments have to be made over the quality of care delivered to a group of individuals. However, I can tell my noble friend that this is one of the priorities that we have set ourselves. I listened with respect to his suggestions on the compulsory registration of care workers. I repeat what I have said in the past: the Government’s mind is not closed to this suggestion.

Department of Health: Budget

Earl Howe Excerpts

Thursday 6th December 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, in asking the Question standing in my name on the Order Paper, I remind the House of my health interests.

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

My Lords, the department underspent against its budget by 1.7% in 2010-11 and by 1.3% in 2011-12, or by 1.5% combined across the two years.

[Lord Hunt of Kings Heath]

My Lords, I think that is about £3 billion; perhaps the noble Earl will confirm that. This Government promised to protect the NHS and to cut the deficit. In fact, they are cutting the NHS and the deficit is rising. How can the department justify handing back so much money to the Treasury when large parts of the NHS are under great financial pressure at the moment?

[Earl Howe]

My Lords, the deficit is not rising. The Government are putting £12.5 billion extra into the NHS over the course of the spending review. The noble Lord, Lord Hunt, will know from his ministerial experience that government departments have an absolute requirement to manage expenditure within the financial controls that are set by Her Majesty’s Treasury and voted on by Parliament. For the Department of Health that means that the net expenditure outturn, which incidentally stems from around 400 organisations, all of whose accounts have to be consolidated, must be contained within the revenue and capital expenditure limits. Given those circumstances, it is sensible to plan for a modest underspend to mitigate against unexpected cost pressures.

[Lord Mawhinney]

My Lords, why does my noble friend believe that he will be able to tell your Lordships’ House that all the PFI hospital projects undertaken under the previous Administration, some of which are in a serious financial mess, will be deemed to be financially sustainable? How many of them are likely to require extra expenditure from his budget to achieve that desired end?

[Earl Howe]

My noble friend raises a very important issue. The analysis that we have done on hospitals financed by private finance initiative has indicated that there are seven trusts that are basically unsustainable as a result of their PFI commitments. The Department of Health has therefore undertaken to support those trusts to enable them to make up the shortfall which is beyond their control. It would be wrong to suggest that PFI was a solution that did not deliver benefits. Clearly it did, but I am afraid that some of the sums that were done initially were sadly wanting.

[Lord Warner]

My Lords, what consideration was given by the Government before they repatriated, as my noble friend said, £3 billion to the Treasury? What consideration was given to using some of that money to buttress social care, which makes great demands on the NHS and which has suffered on average a 7% cut in each of the past two years?

--- Later in debate ---

[Earl Howe]

My Lords, we did, as the noble Lord would expect, look at the anticipated surplus this time last year and we channelled an extra £150 million into social care then in the near-certain knowledge that the department would generate a surplus during the year. However, as he will know, it is an inexact science to predict in December what the outturn will be in April, and one has to be prudent at that stage.

[Lord Alderdice]

My Lords, my noble friend gave a reassuring Answer a week or two ago about the balancing of expenditure and resources between mental health services and physical health services within the NHS. Is it possible for my noble friend’s department to look to the possibility of any surpluses in the future being used to achieve greater parity between mental health services and the rest of the NHS, given the decisions made in your Lordships’ House regarding the Health and Social Care Act 2012 and the mandate for the NHS Commissioning Board that has flown from it?

[Earl Howe]

My noble friend makes an extremely important point. He will know that the Government have made it clear that mental health problems should be treated as seriously as physical health problems. That commitment has now been made explicit in the Health and Social Care Act 2012. As he mentioned, the Government’s mandate to the NHS Commissioning Board explicitly recognises the importance of putting mental health on a par with physical health. It tasks the NHS Commissioning Board with developing a collaborative programme of action to achieve that and it will be held to account accordingly.

[Lord Laming]

My Lords, does the Department of Health and its Ministers monitor the number of people who today are in hospital and whose treatment is being completed, but who are there because alternative arrangements have not been made for them?

[Earl Howe]

Yes, my Lords. As the noble Lord will know, the problem of delayed transfers of care is not new. We have seen a drop in delayed transfers in terms of the number of days but there has been a levelling off in recent years. However, it is up to the NHS and social care services to collaborate to ensure that proper and appropriate community services are available to patients when they are discharged from hospital. That planning process begins the moment the patient enters hospital.

[Baroness Farrington of Ribbleton]

My Lords, the Minister very unusually failed to answer my noble friend Lord Warner’s question as to why the money that has gone back to the Treasury could not have been used to meet the needs of the patients to whom the noble Lord, Lord Laming, referred.

[Earl Howe]

My Lords, I apologise. I addressed part of the noble Lord’s question in relation to the issue around social care. The important point to make about the surplus is that none of the underspend is lost to the NHS. Under Treasury rules, the NHS is allowed to carry forward all underspends to the next year. It is not a case of the NHS having to give up any money and thereby depriving patients of treatment.

[Lord Flight]

My Lords, will the Minister say how much NHS spending has risen in the past 20 years in cash and real terms? I believe that in cash terms it is of the order of about £11 billion to well over £100 billion.

[Earl Howe]

My Lords, I would be happy to write to my noble friend. I do not have the figures for the past 20 years in front of me but I can tell him that, unlike the party opposite which promised to cut NHS expenditure had it been re-elected last time, we are protecting the NHS budget. It is now well over £100 billion. As I said earlier, it will be increased by £12.5 billion over the course of this Parliament.

NHS: Hospital Services

Earl Howe Excerpts

Thursday 6th December 2012 Lords Chamber

[Lord Warner]

To ask Her Majesty’s Government what progress they are making with the reconfiguration of NHS hospital services.

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

My Lords, the Government’s policy is that front-line NHS reconfigurations should be locally led and clinically driven. Changes to services should be led by those who know their patients’ needs best. That is why we are empowering clinical commissioners to design the services that will make the greatest difference to improving healthcare and improving people’s lives.

[Lord Warner]

I am grateful to the Minister for that reply so far as it goes. In the light of yesterday’s Autumn Statement, will the Minister and his colleagues study carefully the recent Nuffield Trust report, which cogently suggested that we are facing a decade of austerity within the NHS with the need to secure 4% efficiency savings on a yearly basis, not just to 2015 but up to 2021-22? Will Health Ministers engage in a serious dialogue with the Academy of Medical Royal Colleges whose new chairman, Professor Terence Stephenson, suggested in July that we had far too many acute centres trying to provide 24/7 services across too wide a range of medical specialities? Will he accept, particularly in the light of the Answer that he gave to the previous Question, that we should be doing more to take money out of acute hospitals that are performing indifferently and putting it into community-based services?

[Earl Howe]

My Lords, I think it is common ground between the noble Lord and the Government that we need to see care delivered more in the community and less in acute settings; that was a policy that his Government espoused. I agree with the noble Lord and with Terence Stephenson that we need to deploy clinical leadership, evidence and insight as a driving force behind service change. Service change is not new; it has happened all the time throughout the NHS’s history. Clinical commissioning groups on the ground will be the driving force for this, but the NHS Commissioning Board will be there in support and the wisdom of the royal colleges will clearly need to be tapped to provide the board with expert clinical advice. Indeed, that is the theme behind the board’s aim to establish clinical networks and senates to help build the clinical evidence for change.

[Lord Walton of Detchant]

My Lords, is the Minister aware that too many patients are still being admitted to hospital solely to undergo investigations and tests that could perfectly well be carried out on an out-patient basis? Is it not therefore time to reconfigure out-patient services so that individuals will be in a position to attend hospital in order to have a clinical consultation and all the relevant tests on a single visit? That would avoid a great number of unnecessary hospital admissions.

[Earl Howe]

My Lords, I agree with the noble Lord. He is right to say that many hospital admissions prove to be unnecessary, wasteful and expensive and we need to ensure that those who do not need to go to hospital can be appropriately looked after in the community. We also need to reduce the level of unplanned, emergency admissions to hospital. There is huge scope to do this. Many trusts are already succeeding in bringing more services into the community, but we need to accelerate the process.

[Baroness Williams of Crosby]

Does my noble friend agree that one thing that emerges very clearly is that real difficulties arise from not having a 24/7 primary care service, which means that figures for weekends and holidays are of course much worse than they are for the normal level of health service provision? Does he agree that it is well worth looking at bringing into the work of CCGs the contribution that can be made by ancillary services to medicine, in order to move towards a 24/7 primary care service?

[Earl Howe]

I agree with my noble friend and that is why work is currently being done under the leadership of Sir Bruce Keogh in the Department of Health to examine the scope for greater 24/7 working. She is right that this is important, not just for the benefit of patients but also to make the NHS more efficient and effective in deploying its staff and assets.

[Lord Campbell-Savours]

If services are carried forward as the noble Earl suggested, how does that influence estimates?

[Earl Howe]

We have reverted to the previous Question, if I am not mistaken. The departmental expenditure limit is set by the Treasury. My own department is in the fortunate position of knowing that it has real-terms increases every year of this Parliament; however, if the department has an underspend that cannot be carried forward, yes, some money has to be returned to the Treasury.

[Lord Hamilton of Epsom]

Does my noble friend accept that if he takes the advice of the noble Lord, Lord Warner, and moves resources from acute services to other services in the NHS, that will lead to the closure of many general hospitals that were built under the previous Government under PFIs, and even more of them will get into financial trouble than there are already?

[Earl Howe]

I do not anticipate that there will be widespread closures of hospitals, and it is important to reassure people about that. The NHS has always had to respond to patients’ changing needs and advances in medical technology. Reconfiguration that ensues from that is about modernising the delivery of care and facilities with a view to improving patient outcomes and developing services, as I have mentioned, in a way that makes them available closer to people’s homes. While we will see changes in service configuration, I trust and hope that we will not see widespread hospital closures, although the possibility of a hospital having to downsize can never be eliminated.

NHS: Hospital Beds

Earl Howe Excerpts

Thursday 6th December 2012 Lords Chamber

[Lord Turnberg]

To ask Her Majesty’s Government what assessment they have made of the analysis of hospital bed availability in the report Dr Foster’s 2012 Hospital Guide.

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

My Lords, Department of Health data show that the average bed occupancy rate for all beds open overnight has remained stable, at between 84% and 87% since 2000. Rather than being a cause of concern, this indicates that hospitals are making efficient use of beds. NHS hospitals need to manage beds effectively in order to cope with peaks in demand. We expect to see higher occupancy rates in winter, when these demands are at their highest.

[Lord Turnberg]

My Lords, in thanking the Minister for his response and his endurance, I believe that we owe a debt of gratitude to Dr Foster for the report, which shows so clearly how severe the stress is that our hospitals are suffering under. With bed occupancies of 95% to 100% for much of the year for many of the hospitals, there are too often no beds available, staff are rushed off their feet, patients are not cared for properly, infection rates rise and mistakes occur. Given that almost one-third of the patients now in hospital do not need to be there and would be better off cared for in the community, and given that the community services cannot provide that care because they are so underfunded, where are we to get the money from? Simply saying that we can close a hospital or two and slide the money across from a cash-strapped NHS before those services are available will just exacerbate the problem. Would it not be better to use those end-of-year surpluses that we have been hearing about instead of returning them to the Treasury?

[Earl Howe]

My Lords, as I mentioned earlier, NHS underspends are not lost to the NHS—they can be carried forward from year to year. But on his central point, I should make it clear that we are struggling to reconcile the Dr Foster bed occupancy figures with those that we have. Dr Foster has stated that bed occupancy is at a dangerous level, at over 90% for 48 weeks of the year. We are looking closely at that analysis and methodology, but we cannot agree with those conclusions at the moment, given that the department monitors the position on a daily basis during the winter and on a quarterly basis at other times. However, I agree with the noble Lord that there are too many people in hospital. We need to ensure that we move more care into the community. I do not see this as insuperable within the current budgetary expenditure limits.

[The Earl of Listowel]

My Lords, I want to ask about community midwifery services and avoiding bed use by that means. Is the Minister aware of the great value to children in terms of outcomes of promoting a good relationship between midwives and parents, increasing the rate of breast-feeding and reducing episiotomies? In his reconfiguration, when he is thinking about not using so many bed spaces, will he recognise the value of local community midwifery services?

[Earl Howe]

Yes, my Lords. That is the precise reason why there are currently 5,000 midwives in training, which is a record number. The noble Earl is absolutely right to identify the midwifery service as key to enabling children to get a healthy start in life and parents to ensure that children get into good eating and exercise habits.

[Baroness Barker]

My Lords, the Dr Foster report identifies those hospitals which have a high level of inappropriate referrals of older people. Will the department do further research in those areas to see whether there is a correlation between out-of-hours GP services, and the work that they do, and a high level of inappropriate referrals of older people to acute hospitals?

[Earl Howe]

My Lords, it is questions of that kind that we expect the clinical commissioning groups to examine because they will become responsible for out-of-hours primary care. Therefore, it is incumbent on them to ensure that that service not only is a good one but does not lead to unwanted consequences in terms of unplanned admissions to hospital.

[Lord Tomlinson]

My Lords, does the Minister accept that his usual clarity has deserted him somewhat today as he has indicated that money which is underspent is returned to the Treasury but on the other hand he has said that it is not lost to the National Health Service? Does he agree that this gives a completely new meaning to double-entry bookkeeping?

[Earl Howe]

I shall be happy to write to the noble Lord to explain why my answers have been absolutely correct and the situation that I have described is nothing new. However, we are in a new situation in the sense that it appears that the supplementary questions can be extended at will over any other Question on the Order Paper, but I am happy to take questions from the noble Lord at any time.

[Baroness Finlay of Llandaff]

Given the report’s figure that 6% of beds are occupied by patients who are readmitted within a week, costing almost £8 million per annum, what guidance is the department giving to clinical commissioning groups to ensure that support is available in the community so that patients discharged from hospital with multiple comorbidities and frailty do not tumble back into the admissions system?

[Earl Howe]

The noble Baroness has identified a very important issue. The causes of emergency readmissions are, of course, several. Some of them are not the fault of the provider but some are. Therefore, we have given an instruction to commissioners to build into the contracts that they have with those providing services that penalties may be applied to the provider should emergency readmissions occur which are the fault of the provider. I would be happy to write to the noble Baroness with further details.

Autism

Earl Howe Excerpts

Wednesday 5th December 2012 Lords Chamber

[Lord Touhig]

To ask Her Majesty’s Government what will be the scope of the review of the national adult autism strategy, due to take place in 2013.

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

My Lords, we are currently considering how to deliver the 2013 review of the adult autism strategy and, in particular, a range of options about how best to secure the views of service users and carers. The review, which will take place from April to October next year, is an opportunity for the Government to take stock and consider where future action is required to realise the vision of fulfilled and rewarding lives for people with autism.

[Lord Touhig]

My Lords, the National Audit Office report on the adult autism strategy said that the health service needed to improve the training of key professionals who make decisions about a person’s eligibility for benefits and services. Can the Minister confirm that the review will ensure that all government departments will implement the strategy in full, so that autistic adults around the country can access the support services that they need?

[Earl Howe]

My Lords, this matter runs across government departments. While central government can set the framework, and while it can work to remove barriers and increase awareness, which is very important, the real work—the delivery of lasting change—is for professionals, providers, voluntary organisations and, indeed, service users working together in collaboration. That effort needs to take place at a local level, which is why there is statutory guidance to prompt that action.

[Lord Wigley]

My Lords, I declare an interest as patron of Autism Wales. Will the Minister confirm that he is aware of the national strategy on autism that was introduced in Wales in 2008, which is being looked at in Scotland as a model to be followed? Of course, Northern Ireland has its Autism Act 2011. Will the Minister undertake to look at the experiences of the Celtic countries in developing the policy for England?

[Earl Howe]

My Lords, I am grateful to the noble Lord and I am quite sure that we in England can learn from what is going on in both Wales and Scotland in this area. However, we can take some encouragement from the National Audit Office memorandum earlier this year, which stated that considerable progress had been made in the two years since the strategy in England was published. Twenty-four of the 56 commitments had been implemented, and action was under way in response to the remainder.

[Baroness Browning]

My Lords, does my noble friend agree that if we are really going to achieve equality for the autistic community, we need to start looking now at the sort of services that they require when they become much older and frailer? It would be a tragedy if we improved services for children and adults but, when they become old and frail and are no longer able to maintain independent living, even with support, they are then segregated from the rest of society.

[Earl Howe]

My noble friend is right, which is why the existing statutory guidance extends not only to local authorities but to the NHS; it is unique in that regard. The strategy is about integrating care across the NHS, social care and all other local authority services, and its focus must be on putting people with autism at the centre of any plans to improve their own lives.

[Lord Maginnis of Drumglass]

My Lords, I declare an interest as I chaired the independent review of autism services in Northern Ireland. Would it be inappropriate if I asked the Minister if he was aware that it does not matter how good one’s intentions are or whether you have an Act of Parliament; if you do not have the geographical structure that enables you to implement the measures that are required for early assessment and diagnosis, there is nothing that will naturally follow? Will he consider consulting the Northern Ireland authorities and those in Wales and Scotland, where possibly we have made more progress?

[Earl Howe]

My Lords, I shall gladly take that idea away with me. The noble Lord is right about the structures for delivery. Local authorities in England are responsible for the delivery of services and support for people with autism, and the NHS is the body that we are relying upon to identify those with autism and diagnose their needs. The two must work together.

[Lord Addington]

My Lords, will the Minister tell us a little more about the problems of being the lead department and trying to relate to other sections of government? How good, for instance, are the links with various stages of education in order to allow not only for people with the most acute forms of autism but for those at the higher-functioning end of the spectrum, such as those with Asperger’s? How is that developing and have we done any work in that field?

[Earl Howe]

Yes, my Lords, the autism strategy is a cross-government strategy and is already having an impact in areas such as employment and education. It includes activity to help adults with autism into work. The mandate to the NHS Commissioning Board particularly mentions those with learning disabilities and autism and their need to receive safe, appropriate and high-quality care. From 2014, when necessary, young people up to the age of 25 with special educational needs, which would include autism, will have an education, health and care plan. I assure my noble friend that work is going on across government in this area.

[Baroness Pitkeathley]

My Lords, last week on Carers Rights Day I spoke to a great many parents who raised the same matter as the noble Baroness, Lady Browning—the transition period for young people with autism. Does the Minister consider that it is a problem that parent carers are not yet referred to in the draft Care and Support Bill, which we are about to start scrutinising? What role does he think local Healthwatch and local well-being boards can have in this regard?

[Earl Howe]

My Lords, local health and well-being boards and local Healthwatch will be instrumental in ensuring the improvement of the quality of services for people with autism. As regards the transition from childhood to adulthood, the Department for Education is working with my own department to make the transition recommendations in the strategy the success that we all want them to be. A project funded by both departments and led by the University of York will report before the end of the year and will inform good practice in service at the point of transition.

Abortion

Earl Howe Excerpts

Tuesday 4th December 2012 Lords Chamber

[Baroness Knight of Collingtree]

To ask Her Majesty’s Government what steps they will take to prevent illegal abortion operations.

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

My Lords, an abortion may take place only on grounds under the Abortion Act 1967, as amended. Allegations of illegal abortions are taken very seriously by the Government and anyone suspected of acting outside the law will be referred to the police for investigation. It is for the Crown Prosecution Service to decide whether to prosecute individuals and for the courts to determine whether there has been a breach of the law on abortion.

[Baroness Knight of Collingtree]

My Lords, is my noble friend aware that Parliament passed the Abortion Act 1967 on very firm assurances that clear medical reasons would have to be agreed by two doctors, who examined the patient before an abortion could take place, and that abortion on demand would not happen? Is he aware that if Parliament had known that abortions would occur because the coming child was a girl when the mother wanted a boy, the Act would not have gone through? Did he note the Government’s Care Quality Commission’s findings that some doctors who have never even seen the patient are signing blank forms and leaving them in a handy place for use by colleagues, while others are aborting girl babies unwanted by the mother for no medical reason at all? What is being done to stop these illegal acts?

[Earl Howe]

My Lords, my noble friend raises some extremely important questions. The House will remember that reports came to light in February of pre-signing of the HSA1 forms—the approval forms that have to be signed by two doctors—and the CQC carried out a serious of unannounced inspections of all abortion providers in the light of that story to uncover any evidence of pre-signing. As a result, 14 NHS trusts were found to be non-compliant and clear evidence of pre-signing was identified. We await the outcome of investigations by the Metropolitan Police on that issue. Of course, as a department, we take it very seriously indeed.

On the issue of sex selection, my noble friend is absolutely right. The Act stipulates specific circumstances in which termination of pregnancy is permitted. Gender selection is not one of those circumstances. It is illegal for a practitioner to carry out an abortion for that reason alone, unless the certifying practitioners consider that an abortion is justified in relation to at least one of the Section 1(1) grounds in the 1967 Act. My noble friend will also be pleased to know that the Chief Medical Officer for England has written to all clinics and hospitals undertaking abortions to remind them of the provisions of the Abortion Act.

[Lord Alton of Liverpool]

My Lords, is the Minister familiar with a report that recently appeared in the Economist, which said that around 100 million abortions have taken place throughout the world on the basis of gender, which it calls “gendercide”? Does he not agree that in a country where routinely, every working day, there are some 600 legal abortions there is a real danger that, culturally, people imagine that it is simply a right to choose to take a life on whatever basis they believe it reasonable to do so? Can he therefore spell out again the illegality of taking the life of a child on the basis of its gender? Can he tell the House what penalties there will be when such actions occur and how long it will be before the police inquiries complete their course?

[Earl Howe]

In answer to the last question I have no firm information about when the police inquiries will complete their course. They have been ongoing for some months. The noble Lord, Lord Alton of Liverpool, is right to raise his concern, but I can again state emphatically that under the law of this country it is illegal to perform an abortion on grounds of sex selection alone. If evidence of such practices comes to light, the penalties are that the doctor or doctors concerned may be referred to the GMC. The Care Quality Commission will be called in and there will be the possibility of police investigation and prosecution resulting. This is not something that any provider of NHS-funded abortions should ever consider doing.

[Lord Steel of Aikwood]

Does my noble friend agree that the real scourge of illegal abortion occurred before the 1967 reforms, when every hospital in the land had patients admitted for septic and incomplete abortion, and up to 50 women a year died as a result of criminal abortion? Does he accept that, in addition to the gender selection question, another worrying feature is the number of women reporting for repeat abortions, who appear to be using abortion as a form of contraception? Does that concern his department?

[Earl Howe]

My Lords, I pay tribute to my noble friend for the role that he played in bringing the 1967 Act to the statute book. We have no particular evidence that repeat abortion is a rising issue. Contraception prevents the establishment of a pregnancy and the number of women visiting contraception clinics has, I am pleased to say, gone up, particularly among the young. We are seeing a fall in the number of abortions in the teenage age group. Unfortunately we are also seeing a rise in abortions in the 20 to 29 age group. While I agree with my noble friend’s initial comments, the focus of the public health effort has to be to bear down on the figures as we see them today and make sure that all women have access to contraceptive advice.

[Baroness Gould of Potternewton]

My Lords, the Minister has answered part of my question, but I shall question him a little further. First, I make the point that of course the law must be maintained at all time. Some of the arguments demonstrate attempts not to keep to the 1967 Act. Is it not therefore important that we stress what it says and maintain in absolute the Act as it stands? Any attempt to water down that Act would return us to the days of backstreet abortions and the deaths that followed them. Does the Minister agree—he mentioned this in his last point—that we should maintain proper, available contraceptive services for all ages? A lot of PCTs are not giving contraceptive services to the over-24s, which is why the abortion rate has gone up in that age group. Does he agree that there should be open access to contraceptive services for all ages and by all methods?

[Earl Howe]

My Lords, I agree with the thrust of the noble Baroness’s two points. In particular, I agree that there should be no departure from the terms of the 1967 Act, which is why the CMO took the trouble to write to all clinics and hospitals, as I mentioned earlier, to remind them of the provisions of the Abortion Act and in so doing to remind them that sex-selective abortions are illegal.

I must correct what I said earlier. I hope I did not give the wrong impression about repeat abortions. My briefing states that in 2011, 36% of women undergoing abortions had had one or more previous abortion. That proportion has in fact risen from 31% since 2001. Twenty-six per cent of abortions to women aged under 25 were repeat abortions, which is quite a high percentage.

Health: HIV

Earl Howe Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Collins of Highbury]

To ask Her Majesty’s Government whether they intend to endorse the standards of care for people living with HIV published by the British HIV Association on 29 November.

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

My Lords, the Department of Health commends the British HIV Association for these important standards, which we welcome. The NHS provides excellent care for people living with HIV. These standards are important in setting out best practice to support continuing high-quality HIV care services for all HIV patients. They will provide a valuable resource and inform the commissioning of comprehensive HIV care services.

[Lord Collins of Highbury]

I thank the Minister for that response. One recommendation made by BHIVA related to self-management. As with many other long-term conditions, this approach can help people with HIV to gain confidence, skills and knowledge to manage their own health, with resulting improvements in the quality of life and independence. In the light of changes in the commissioning process, who will now have responsibility for funding the excellent self-management services currently provided by organisations such as the Terrence Higgins Trust and Positive East?

[Earl Howe]

My Lords, the noble Lord is quite correct. Self-management is one of the BHIVA standards. I agree that self-management and supporting patients to manage their own care, both for HIV and, for that matter, any other long-term condition, are very important for promoting the best treatment outcomes for individuals. A variety of approaches will be needed to support individuals to self-manage their HIV. There are already some innovative programmes, such as the online resource, My HIV, for people living with HIV, delivered by the Terrence Higgins Trust. The key to this is for commissioners of services to work together in future to ensure that self-care is part of the HIV care pathway, and GPs will have a role to play in that.

[Lord Fowler]

My Lords, I declare an interest as patron of the British HIV Association. Is it not the case that we now have 100,000 people living with HIV in this country but that a quarter of them are undiagnosed, so obviously risk spreading the infection further? Does that not mean that we must persuade even more people to come forward for testing? In that respect, will the Government now commit themselves to bringing forward proposals to allow home testing?

--- Later in debate ---

[Earl Howe]

My noble friend is quite right. As he will know, this is National HIV Testing Week. We support the Terrence Higgins Trust and its partners in this important new initiative. The NHS medical director has written to all medical directors about the week and the importance of healthcare professionals being alert to the need to offer HIV testing. As regards self-testing, we agree that the current regulations are not sustainable, which is why we are reviewing our policy on banning the sale of home HIV testing kits. We support repeal but we are required to do a short consultation setting out our reasons. We plan to do that early next year.

[Baroness Masham of Ilton]

My Lords, is the Minister aware that we have some of the best services in the world for HIV/AIDS? Can he give an assurance that, with the changes in the National Health Service now, there will not be a dilution of these services?

[Earl Howe]

My Lords, yes. We believe that the complex needs of people with HIV will be best served by the work being done by the HIV national clinical reference group of the NHS Commissioning Board. The board will commission these services in the future, and that will drive greater consistency and quality throughout the system.

[Lord Hughes of Woodside]

My Lords—

[Baroness Trumpington]

Our turn. I am not sure whether I am in order but I should like to congratulate, through this House, the Minister on his award yesterday as Minister of the Year in the Lords.

[Earl Howe]

I am exceedingly grateful to my noble friend for that and for not asking me a question that I was unable to answer.

[Lord Hughes of Woodside]

My Lords, I am grateful that I gave way. In view of the reports of an alarming increase in the incidence of HIV, is not the old adage that prevention is better than cure even more important? Is this significant rise in HIV incidence caused by less use of condoms, or what?

[Earl Howe]

In fact, the numbers are more or less stable if one compares this year to last. However, the noble Lord is right: we cannot drop our guard in this area. There is a pressing need to reduce undiagnosed HIV. It is estimated that about 23,000 people are undiagnosed and 47% of those newly diagnosed with HIV are diagnosed late—that was the figure for last year. That is why the prevention campaign through local authorities will be so critical in this area.

[Lord Maclennan of Rogart]

My Lords, in view of the extensiveness and particularity of this important report, will the Government contemplate producing a response which deals with the matters particularly focused on? Will they seek to ensure that, due to the increase in non-AIDS comorbidity and the complexity of HIV drug interactions, clear protocols are established between primary and secondary care as there is some patient disquiet, particularly about primary care?

--- Later in debate ---

[Earl Howe]

My Lords, my noble friend is absolutely right that this is a complex condition. As regards a response to the BHIVA report, we are planning to publish an integrated sexual health strategy which will embrace all aspects of sexual health, including HIV. The vast majority of HIV in the UK is sexually transmitted. HIV and sexual health services are closely linked, as he will know, and we believe that it is in that strategy that the appropriate guidelines should be set out.

[Baroness McIntosh of Hudnall]

My Lords, will the noble Earl bear in mind that the stigma around people with HIV is still an extraordinarily important issue? Will he encourage healthcare providers to ensure that as much as possible is done to reduce this disincentive to people to come forward for testing?

[Earl Howe]

The noble Baroness is of course right to say that stigma is an issue, and it is doubtless why many people do not come forward for testing. Through the National HIV Testing Week we are encouraging doctors in all parts of England to consider this matter and to see what role they can play in terms of having the right conversations with patients who are in the most at-risk groups.

Social Care: Apprenticeships

Earl Howe Excerpts

Thursday 29th November 2012 Lords Chamber

[Baroness Wheeler]

To ask Her Majesty’s Government what progress they are making on establishing social care apprenticeships; and how voluntary registration of social care workers will assist apprentices and staff to provide the quality of care required in domiciliary and community settings.

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

My Lords, apprenticeships and voluntary registration for social care workers are part of the vision set out in the care and support White Paper and will contribute to improving quality of care. The latest figures report that more than 60,000 apprenticeships have started in 2011-12. A system of assured voluntary registers will help to support the delivery of quality care by enabling individuals to demonstrate that they meet set standards of education, training and competence.

[Baroness Wheeler]

I thank the Minister for his response and welcome the progress being made. As he knows, apprentices will join the current social care workforce of 1.6 million, more than two-thirds of whom now work in the voluntary, independent and private sectors or are employed directly by service users in their homes. Given the Government’s desire to have only a voluntary register for social care staff, can the Minister explain to the House how consistent quality and dignified care are to be delivered across this fragmented employer base?

--- Later in debate ---

[Earl Howe]

My Lords, I agree that quality in the apprenticeship programme is essential and the Government are committed to the pursuit of quality. The noble Baroness will know that from April next year the role of NICE is to be expanded to embrace social care, and no doubt it will focus on quality standards in that area. The care and support White Paper acknowledges the need to ensure that there are enough skilled people to deliver high-quality care in the future. We believe that expanding apprenticeships in social care will involve a continual driving up of the apprenticeship offer. To ensure high quality, all apprenticeships need to entail a rigorous period of learning and the practice of new skills under approved training providers. That involves a minimum of 12 months for a 16 to 18 year-old; it also applies to adult apprenticeships.

[Lord Martin of Springburn]

My Lords, will these apprenticeships be available to young boys and girls who perhaps do not have academic qualifications when they leave school?

[Earl Howe]

Yes, my Lords. Health and social care is the second largest area of apprenticeships in the country. We think that they provide a route for the young people the noble Lord has described to acquire skills and add to the capacity and capability of the social care workforce. They also provide a rung on the ladder to more senior positions in young people’s career progression.

[Baroness Williams of Crosby]

My noble friend will know that, apart from those who are apprentices, a great many people are currently serving in the area of social care for whom in-service training would be extremely useful. I am talking about older people. Can he tell us whether, in the training discussions held in the NHS and in social care, any plans are being made to try to provide at least some in-service training for people already working in the field?

[Earl Howe]

My Lords, a great deal of work is going on, not least in the field of leadership. As I have mentioned, the National Institute for Clinical Excellence, soon to be the National Institute for Health and Clinical Excellence, will be issuing quality standards in this area. Skills for Care is also working to refine and improve the standards that social workers need to adhere to—and, of course, social workers as opposed to social care apprentices are statutorily regulated.

[Lord Laming]

My Lords, the noble Earl and the House will have been shocked by a number of recent reports about the exploitation of the vulnerability of people who are receiving social care, either in institutions or in their own homes. Can the noble Earl assure the House that the Government will do everything they can to ensure clear managerial accountability for the quality of care that is delivered, and will ask the inspectorates to make sure that they will do what they can to assess the quality in the different parts of social care services?

--- Later in debate ---

[Earl Howe]

The noble Lord makes some centrally important points. The CQC, which is the regulator of national minimum standards in this area, is very clear that the need to safeguard the vulnerable is one of the most important tasks that it has to assure itself about when inspecting providers. The role that employers play is key here and he is right to point out that it is the responsibility of management to ensure not only that those working for them have the right skills but that there is also the right supervision, for apprentices in particular.

[Baroness Farrington of Ribbleton]

My Lords, can the Minister assure the House that a voluntary scheme will not allow those very people who have a culture of not caring or of neglect—we know that happens from time to time in this sector—not to take up the option of voluntary registration? Surely it is most important in this field that we protect people from the very people who may well not take voluntary action.

[Earl Howe]

My Lords, accreditation by the Professional Standards Authority will help to foster high standards, because it will allow practitioners and people who use services to distinguish more easily between registers that meet nationally accredited standards and those that do not, and therefore between those social care workers who are accredited to a high standard and those who are not. In addition, we have commissioned Skills for Health and Skills for Care to develop a code of conduct and recommended induction and minimum training standards for healthcare support workers, as she will know. The key here is to progress to a system that encourages employers to employ those with the right qualifications and for users to be able to see that the employees in an organisation are accredited.

Social Care

Earl Howe Excerpts

Thursday 29th November 2012 Lords Chamber

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

My Lords, I begin by thanking the noble Baroness, Lady Pitkeathley, for calling this debate and for having introduced it so well. As the contributions today have amply illustrated, this is a subject of vital importance.

Care and support will affect most people in England at some point in their lives. More than 80% of people in their 60s now will need care in their old age. The fact that people are now living longer thanks to medical advances is something that we should all celebrate. The Government see care and support as essential to helping people live lives that are full and independent. Our vision is, first, for timely care that is preventive rather than simply catching people at a point of crisis. Secondly, to pick up a theme so well articulated by my noble friends Lady Wheatcroft and Lady Barker, and the noble Baroness, Lady Campbell, we believe that care is best when centred on the person and their family. This means that it is joined up with the other services that they use—health, housing and in the community. We also recognise that good, integrated care is important for the sustainability of the NHS.

Due to the economic situation, this spending review has been challenging for local government. However, we have been clear that social care must be protected. We moved swiftly to allocate an additional £7.2 billion over the spending review period to protect adult care. Since then we have allocated an additional half a billion pounds. We remain firmly of the view that the funding we have provided is enough to allow authorities to maintain access to services and to provide good-quality care. Independent research from the King’s Fund corroborates this. This does depend on authorities providing care and support in a cost-effective way, which is a principle we insist on for all public spending. The funding we provide assumes that authorities improve cost-effectiveness by 3% each year in this spending review period. This is an ambitious programme of efficiency savings, but one that partners in the care sector, including the LGA and ADASS, agreed was achievable.

The opportunity is there to make savings and improve outcomes for users at the same time: through investing in reablement—to pick up the word “investment” used by the noble Baroness, Lady Pitkeathley—so that people regain their independence following a crisis; through developing integrated crisis services to deliver health and social support quickly; through rolling out telecare, which is proven to move support from clinics and institutions into the home; and minimising back-office administration to focus resources on users. The Government have provided sufficient funding but authorities are responsible for how it is used. This is an important principle. Whitehall cannot dictate what is best for communities; nor do councils want it to. However, this means that we cannot guarantee that all authorities will prioritise social care or deliver it in the same way.

Social care has been protected more than other services. Many areas have increased their spending but, unfortunately, this is not the case everywhere. It is true that expenditure has fallen when seen at a national level. However, this is not the story of cuts that some critics have made out, and there is only limited evidence of impact on services or on users. My noble friend Lady Tyler will be interested to know that ADASS has found that three-quarters of the reductions are from increased cost-effectiveness. That is, councils are making savings by doing things better. They are achieving an average of 5% efficiency, which is 2% higher than we expected. There are exciting successes and my noble friend Lady Tyler referred to some. For example, Dorset has invested £1.6 million to help people regain independence at home after a crisis. It expects to save £3 million a year from providing preventive, integrated care. That is exactly the type of initiative that we want to see.

Councils have broadly maintained eligibility for services. A few have raised eligibility levels from “moderate”, but only to join the overwhelming majority of councils that already set eligibility at “substantial”. No council has raised eligibility higher than this. We have seen a reduction in the number of people receiving state-funded residential and domiciliary care, but this reflects a return on preventive policies such as those mentioned by the noble Baronesses, Lady Wilkins and Lady Greengross, that are helping people stay independent and in their own home.

The noble Baroness, Lady Pitkeathley, referred to integration of services. This theme was taken up by the noble Baroness, Lady Campbell, the noble Lord, Lord Turnberg, and others. When money is tight for local government, as it is for the NHS and the public sector, the most important way that health and social care services can meet this challenge is through better co-operation and more integrated working. I stress this to the right reverend Prelate the Bishop of Liverpool. It is why the SR settlement includes annual transfers from the NHS to be spent within social care. This year the NHS has provided £622 million in funding for social care.

Local authorities must agree with their PCT how the money will be used. From 2013-14, the conversation will take place through health and well-being boards and will involve the CCG, public health and social care. This is a real opportunity for integrated care. The evidence to date is that, precisely as we had hoped, local areas are investing the NHS contribution in reablement services, and are working in partnership with hospitals. There are some excellent examples of this. Some were cited by the noble Lord, Lord Turnberg. I was in Calderdale last week. Calderdale CCG has taken a joint approach with the local authority and other partners to introduce an integrated intermediate-tier service, informed by a consultation with patients, carers and the public. The single point of access was launched about a year ago. Services are delivered by Calderdale Council’s gateway to care. Patients and carers now need to make only one call to get access to a range of support and reablement services.

It is no coincidence that we have placed such emphasis on integration in the mandate to the NHS Commissioning Board and in the NHS outcomes framework. The department is doing a great deal of work in this area with the board, Monitor and the Local Government Association. We will publish a framework next year.

My noble friend Lady Barker asked what the Government would do by way of an economic evaluation of integrated care. We constantly evaluate new initiatives to get the best possible evidence to inform our policies. In addition, we are engaging with academics and partners from across the sector. For example, a number of local authorities are currently piloting a community budgets approach to integration. We are working with, and offering support to, local authorities to evaluate their pilots, and we will continue to look at emerging evidence.

Looking ahead, we are increasing NHS funding for care services over the next two years. By 2014-15 the NHS will provide £900 million in support for local care services. This increase in joint working will benefit health and care, and patients and the public. We have also invested in housing. I completely agreed with the noble Baronesses, Lady Donaghy and Lady Wilkins, that where the elderly choose to live is of real importance to their independence and well-being. In October, the Government announced an extra £300 million of capital funding to encourage providers to develop new accommodation for older people and disabled adults.

The noble Baroness, Lady Greengross, was absolutely right, as she so often is, that this will support people to stay independent for longer by allowing them to receive care in their own home and by reducing the need for them to go into care homes and hospitals. We have announced a national eligibility threshold that from 2015 will ensure consistent access to care and will end the postcode lottery. The measures in the care and support White Paper and accompanying draft Bill will ensure that prevention, personalisation and integration will become the standard. I will refer to those again in a second.

The right reverend Prelate the Bishop of Liverpool urged the Government to review the local authority funding settlement. We will of course review funding in the next spending review period. When we look at the current situation, it is not in fact accurate to say—as was implied by one or two noble Lords—that cuts to central government grants have hit poorer councils hardest. This year’s formula grant reductions are generally smaller for the most deprived areas and larger for the less deprived ones. The data that we have seen do not show that the most deprived areas have seen the greatest reductions in social care spend. The 10 councils with the greatest increases in spending on social care include Knowsley and Rochdale, which are two of the most deprived local authority areas in the country.

The noble Baroness, Lady Pitkeathley, referred to increases in charges. Of course, she knows that charging decisions for community-based services are the responsibility of local authorities, in line with guidance produced by the department. We have no evidence of widespread increases in what authorities charge for services. However, as a general point, I recognise that this has been an extremely challenging settlement for local government. A number of councils are cutting services or tightening eligibility, as I mentioned. Those councils will have to justify their decisions to the communities that they serve. While any change is regrettable, only six local authorities have tightened eligibility criteria this year, compared to 15 last year. Of these, none has tightened beyond the broad average position of “substantial”.

A recent report by Demos and Scope, Coping with the Cuts, suggested that there was no direct correlation between the budget reductions faced by adult social care services and the impact on local people. This demonstrates that if local authorities make appropriate efficiency savings and develop innovative solutions, they can maintain and improve people’s outcomes and access to the services that they need.

A number of noble Lords, including the noble Lord, Lord Warner, in his extremely thoughtful and constructive speech, the noble Baronesses, Lady Wheeler and Lady Pitkeathley, the noble Lord, Lord Sutherland, and my noble friends Lord Shipley and Lady Tyler, referred to the need to address funding reform and to the Dilnot report. We have stated that we agree with the principles of the Dilnot recommendations. However, I hope that I may be forgiven for repeating that funding reform is complex. In the current economic climate, it is right for us to wait until the spending review, when we can consider funding reform alongside other spending priorities. The noble Lord, Lord Lipsey, was right to make that point.

This will give us time to engage with stakeholders on these difficult issues, which we are already doing, to ensure that we have the right information before making a decision, not least on points of detail that affect the cost and practicalities of implementing a cap. This matter is definitely not on the back burner. Solving social care funding remains one of the key priorities of our time. In response to a number of noble Lords, I will say that since the Dilnot report was published the Government have been very clear about the value that they place on political consensus, and about their commitment to cross-party dialogue in pursuit of that objective. Our offer to the Opposition remains on the table. It is of course up to them to decide when and how to work with us on this.

A number of noble Lords, including the noble Lords, Lord MacKenzie and Lord Sutherland, and my noble friends Lady Barker and Lord Shipley referred to the problem of delayed transfers out of hospital. I will say as a general point that no one should have to stay in hospital longer than is necessary. The NHS must work collaboratively and innovatively with local authorities to help improve discharge, reduce delays and improve outcomes for patients. Older people often need particular support after a spell in hospital. That is why we have made available the £300 million in the current year to develop local reablement services and help people settle back into their homes and recover their strength and independence.

My noble friend Lord Shipley rightly mentioned pooled budgets. As I mentioned, in 2012-13 PCTs will also receive a total of £622 million to invest in social care services. That is in addition to funding for reablement services. In the year up to September 2012 the number of patients with delayed transfers was 5% lower than in the previous year. Delays because of social care issues fell by 12% over the same period.

My noble friend Lady Gardner and the noble Lord, Lord MacKenzie, spoke very powerfully about the tendency for care visits to last for about 15 minutes. While local authorities are responsible for the commissioning of services, not the Government, both the Government and ADASS are fully in agreement that 15-minute visits for personal care are absolutely unacceptable. We will bring an end to commissioning practices that undermine people’s dignity and choice, including commissioning care by the minute. We will work with commissioners, care providers, people who use services, carers and the Think Local, Act Personal partnership to end these practices.

My noble friend Lady Gardner also, rightly, pointed out the need for good regulation by the CQC to ensure quality. The CQC can and will take action where it finds residential services that are not meeting essential standards, and this action ranges from requiring improvement plans to restrictions on, or even the closure of, care and nursing homes in extreme cases.

The noble Lord, Lord Turnberg, spoke powerfully about the quality of care, as did the noble Baroness, Lady Campbell, about the importance of dignity and respect. The care and support White Paper sets out our plans. A national minimum eligibility threshold will make access to care more consistent. People will have clear, practical information and advice on the care system and new ways to report poor care. People will have easy access to information to help them narrow down their search for quality care providers. The new quality profiles will bring much needed transparency to the quality of care people can expect from a care provider. More care workers will be trained, including an ambition to double the number of care apprenticeships by 2017—a subject we debated earlier today. Dignity and respect will be at the heart of a new code of conduct and national minimum training standards.

The noble Baroness, Lady Campbell, spoke about the JCHR and human rights. She raised some extremely important issues and I listened with care to what she said. I hope that she will allow me to write to her to update her as to where we are on that subject.

The noble Baroness, Lady Greengross, spoke about the need to encourage preventive services in particular and I quite agree with all that she said on that subject. As part of the shift to a more preventive approach to care and support, the draft care and support Bill includes a duty on local authorities to commission and provide preventive services. Preventing needs from arising, or reducing them where they exist, is a critical part of local authorities’ responsibilities for care and support.

My noble friend Lady Wheatcroft referred to the centrally important phenomenon of social isolation and loneliness among the elderly. I agree that communities should ensure that people are not alone or isolated. Social isolation is a measure that will be covered in the social care outcomes framework. I will write to her with more information about that.

The noble Baroness, Lady Wilkins, spoke about housing and her wish to meet the Minister for Housing, and about the disabled facilities grant. The draft care and support Bill will set out new duties to be placed on local authorities to ensure that adult social care and housing departments work together. This will support adaptations and ensure that services are joined up better with people’s care and support. I hear her concerns about the disabled facilities grant and grants for housing. I will discuss them with my housing colleagues and respond to her in writing.

My noble friend Lady Scott and the noble Baroness, Lady Wheeler, highlighted the importance of voluntary organisations and volunteers in helping to care for our ageing population, including in the field of mental health. Of course, the Government agree that volunteers and charities play a crucial role, which we must support. I will respond with a note containing more detail on this, including how voluntary organisations may contract with health and well-being boards.

My noble friend Lady Barker and the noble Baroness, Lady Wheeler, spoke about personalisation; in particular, personal budgets, which are only part of the personalisation agenda. Again, the draft care and support Bill places personal budgets in law as the default option for adults and carers alike. People will be provided with a clear allocation of resources so that they can control as much of their care and support as they wish. This will ensure that all people in need of care and support benefit from the choice and control that personal budgets can bring, not least those suffering from mental health conditions.

We have supported social care in this spending review and have made additional funding available. We have provided funding in forms that support integrated and preventive care, extra resources from the NHS and extra resources for housing. There is variation in how well councils are coping with tighter funding. However, many councils are rising to the challenge; they are prioritising care, increasing efficiency and maintaining outcomes for their users. It is clear that this is where councils should be focusing and where we expect services to be by 2015.

NHS: Diabetic Services

Earl Howe Excerpts

Thursday 29th November 2012 Lords Chamber

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

My Lords, I thank noble Lords and, in particular, the noble Lord, Lord Harrison, for an extremely interesting and knowledgeable debate. Given the range of comments and issues raised, if I do not cover all the substantive issues, I hope that noble Lords will allow me to write to them.

I do not need to repeat all the statistics. It is abundantly clear that diabetes is a major current and future challenge for this country. It has to be a priority for the National Health Service. Diabetes is a priority for the Government and, as a long-term condition, it has been prioritised in the mandate for the NHS Commissioning Board. It is also a key marker of improvements in the NHS. Diabetes affects every system in the body. There should be no hiding place for this condition, but as the noble Viscount, Lord Falkland, reminded us, it frequently remains hidden from the patient who does not realise he or she has it, and from healthcare services that treat the complications of diabetes without managing their cause.

This year, the National Audit Office reviewed the management of adult diabetes services in the NHS. This highlighted the progress that has been made over the past 10 years, but also the significant challenges that we face over the next 10 years. As a number of noble Lords have pointed out, there is unwarranted variation in diabetes care. The management of people with diabetes has not been optimised. There is no excuse for poor diabetes care. No one with diabetes should lose their leg or their vision if this could have been prevented. We know what needs to be done and we have to ensure we meet this challenge head on.

A Public Accounts Committee hearing followed the publication of the NAO report, and the PAC has recently published its report. The Government are currently considering the PAC’s recommendations and will prepare a Treasury minute in response, which will be published in the new year. The noble Lords, Lord Harrison and Lord Kakkar, stressed the importance of integration of the patient pathway. The NHS has clear statements of good-quality care, with the publication of the NICE quality standards and a range of NICE clinical guidelines. These were informed by the national service framework for diabetes published in 2001, which sets out the key areas of development required for diabetes services in the NHS. The NICE quality standards require integrated care. They will be used by the NHS Commissioning Board as a basis for describing what good-quality care looks like.

The Quality and Outcomes Framework—QOF—introduced in 2003-04 has incentivised primary care to perform the nine care processes for people with diabetes, even though the percentage of people diagnosed with diabetes has more than doubled since 2004. NICE has been asked to review the quality and outcomes framework and we await its response and findings. We have a wealth of information and data on the provision of services and where we need to improve. The national diabetes audit started in 2004 and is now the world’s largest published clinical audit. There has been a year-on-year improvement in a number of areas. The audit shows that 54% of people with diabetes receive all nine care processes; 76% of people with diabetes had eight of the nine, which equates to 1.4 million people. However, I agree with the noble Lord, Lord Kakkar, that much more needs to be done. We need to ensure that everyone with diabetes for whom it is appropriate receives these essential care processes annually. We aim to achieve nine processes for as many people with diabetes as possible. However, each person needs individual care and it may not be clinically appropriate to do the tests in everyone. Some patients decline blood tests or other procedures. Nevertheless, I take the noble Lord’s point that the variation in the number of people with type 2 diabetes receiving all nine care processes is completely unacceptable.

A lot of work is being undertaken to drive up improvements in care and outcomes for people with diabetes, and I must now commend the work of Diabetes UK in driving change and raising awareness of issues for people with diabetes. I part company, very respectfully, with my honourable friend Dr Lee in another place on this issue. We know what needs to be done. We have the data and the guidelines to support this, and we must ensure that in the future structure clinicians and commissioners come together to commission services that meet the needs of people with this condition.

I went to Huddersfield last week to visit a general practice which is doing just that. The Grange Group practice, which provides a one-stop clinic for people with diabetes, impressed me a lot. It has developed an integrated and multidisciplinary team approach to the management of people with diabetes. It is a great example of a CCG taking the lead on improving the management of diabetes. It is not a one-off: there are examples of this up and down the country and it should become the norm.

The prime objective of the NHS Commissioning Board will be driving improvement in the quality of NHS services and we will hold it to account for this through the NHS mandate. Following the reforms to the NHS, the NHS Commissioning Board will use accredited evidence, such as NICE quality standards for diabetes, to guide local commissioners to improve outcomes for people with the condition. Commissioners can use the Atlas of Variation to identify the areas in their community that need improving and there is a wealth of clinical guidance and commissioning support for diabetes services. All this means that people with diabetes can expect to see a better service, with improved outcomes, and an end to unwarranted variation.

In addition, through the NHS outcomes framework we will be able to track the overall progress of the NHS in delivering improved health and outcomes. For people with long-term conditions such as diabetes, this will be measured by whether patients are in good health and are able to live active, fulfilling lives. Diabetes is relevant to all five domains in the outcomes framework, so it is important that when work programmes are developed they consider diabetes and how optimising care can help to deliver improvements.

We face substantial challenges in the next five to 10 years due to the changing age and ethnicity structure of the population, increased numbers of people with multi-morbidities and the challenges allied with obesity and activity. In 2020, it is estimated that 8.5% of people over 16 years of age will have diabetes—that is 3.8 million people in England. While type 1 diabetes is not currently preventable—I will say more about that in a moment—we must ensure that those with this form of the disease have access to appropriate services and have the knowledge and support to self-manage their condition.

We are fully committed to the prevention of type 2 diabetes. All our work on promoting an active lifestyle and tackling obesity will support this aim. The NHS Health Check programme has real potential to prevent many cases of type 2 diabetes and to identify thousands earlier. The Government have an ambitious programme to improve public health through strengthening local action, supporting self-esteem and behavioural changes, promoting healthy choices and changing the environment to support healthier lives. The Change for Life national campaign is raising awareness around eating healthily and increasing activity. The National Child Measurement Programme is giving people the information they need to make informed decisions about their child’s risk of becoming overweight.

We launched a new national ambition in January this year for a year-on-year increase in the number of adults doing 150 minutes of exercise a week. The public health outcomes framework was published in early 2012 and has key indicators for Public Health England, including diet, excess weight and physical activity.

The NHS Health Check programme, which I mentioned a moment ago, is a universal and systematic programme for everyone between the ages of 40 and 74. It assesses people’s risk of heart disease, stroke, kidney disease and diabetes, and it then supports people to reduce or manage that risk through individually tailored advice. I can reassure the noble Lord, Lord Collins, that the NHS Health Check programme is a key performance measure in the NHS operating framework this year, and take-up of the NHS health checks by the eligible population is another indicator in the public health outcomes framework. Local authorities will be mandated to offer risk assessments to their eligible populations from April next year—and I stress the word “mandated”.

The noble Lord, Lord Collins, referred to the NHS reforms and what these will mean for diabetes commissioning and care. He particularly stressed the importance of clinical leadership in the NHS Commissioning Board. I agree that clinical leadership has been key in driving improvements in care in recent years. Diabetes is a very high priority for the domain directors of the NHS Commissioning Board, both from the perspective of reducing premature mortality and improving the quality of life.

The noble Lord, Lord Kakkar, was right to remind us of the costs of diabetes care. These costs are hard to pin down—he is correct—because people with diabetes can be found in every part of the NHS. The thing to remember is that the greatest cost of diabetes is to the person with diabetes himself or herself in terms of the distress, disability and premature death that can ensue.

The noble Lord, Lord Harrison, spoke about the risk of short-termism and he was concerned that annual checks might be cut and replaced with online advice. He rightly asked about those people who are computer-averse. Annual checks are required by NICE and the Quality and Outcomes Framework and they must be face to face. Online advice does not replace them and, when it occurs, it is an additional option for patients who might find it helpful.

A number of noble Lords, including the noble Lords, Lord Harrison, Lord Kakkar and Lord Collins, referred to the importance of self-management, and I agree with what they said on this subject. The department is working to promote self-management in the care of diabetes through patient education and support from appropriately trained service providers, including the DAFNE and DESMOND programmes. The NHS reforms present an opportunity for stronger and closer partnership working between GPs and specialists, ensuring that the right care is commissioned and that it is focused on the needs of each individual patient and carer.

The noble Lord, Lord Brooke of Alverthorpe, brought us to the subject of alcohol, and particularly calorie counts in labelling. People with diabetes most certainly should have access to dietary advice, and that should include advice on alcoholic drinks. It is a subject that he raises regularly and he is right to do so. Around a quarter of adult men and a fifth of women report drinking at levels that are above the NHS guidelines, and in fact some 2.2 million people have said that they drink more than twice the amount set in the guidelines. That puts them at most risk of illness and death from alcohol. The noble Viscount, Lord Falkland, talked about safe driving with diabetes. I welcome the reminder he gave us that people with diabetes should follow DVLA guidance, and that includes the need for blood glucose testing if the driver is on insulin.

The noble Lord, Lord Harrison, spoke about transitional care, and particularly about children with diabetes in schools, an issue also referred to by the noble Lord, Lord Brooke. There has been long-standing work between the national clinical directors for diabetes and children and young people on improving diabetes care in children and those in the younger age groups. There is now a best practice tariff for children’s diabetes care. NHS Diabetes has been supporting work with young people on transitional care and there are regional paediatric diabetes networks. My noble friend Lord Roberts of Llandudno rightly drew attention to the late diagnosis of diabetes and diabetic ketoacidosis. I agree that it is important that all parents, teachers and healthcare professionals should be aware of the symptoms of diabetes, and I particularly welcome the “Four Ts” campaign from Diabetes UK. He referred to hypoglycaemia and the awareness of diabetes and its consequences. Again, I agree how important it is that children, young people and their families are taught how to avoid unduly low blood glucose levels. Friends, schoolmates and especially teachers should learn about this. An example is the work being done in Essex by the local authority with schools and parents as well as children.

The noble Baroness, Lady Masham, referred to specialist nurses. The Government consider that diabetes specialist nurses are an essential part of the diabetes specialist team. They have a valuable part to play in supporting people with diabetes. It is local healthcare organisations, with their knowledge of the healthcare needs of their populations, that are best placed to determine the workforce required to deliver safe patient care within their available resources, but the reforms once again present an opportunity for stronger, closer partnership working between the new primary care commissioners and secondary care specialists so that evidence-based, multidisciplinary care is focused on the needs of the individual patient. Once again, I saw this for myself last week when I visited Yorkshire. The noble Baroness also drew attention to high-fructose corn syrup, which is used as a food additive. I will write to her on that very important subject, on which a lot of work has been done.

A number of noble Lords, including the noble Baronesses, Lady Masham and Lady Thornton, focused on the very grave issue of amputation of limbs among those with diabetes. The National Diabetes Audit and the Atlas of Variation have both shown that there are unacceptable levels of variation in the care received by people with diabetes, and the noble Lord, Lord Kakkar, gave eminently sensible and important advice. It is important that clinicians review data relevant to their practice and make improvements to the care that they provide to reduce variation. We have plenty of examples of excellent patient-centred services that have improved outcomes and provided value for money. NICE guidance was published in January 2004. The guidelines include recommendations for primary and secondary care settings.

The incidence of amputation among people with diabetes has been declining over time, but the absolute number of diabetes-related amputations is rising as the prevalence of type 2 diabetes increases, and I agree fully with the noble Baroness, Lady Thornton, that the numbers need to come down. Diabetic foot disease accounts for more hospital bed days than all other diabetes complications put together. In the UK, 100 people a week lose a lower limb because of complications from diabetes. One in 20 people with diabetes will develop a foot ulcer in one year, and up to 70% of people die within five years of having an amputation. That shows how important an issue this is, but once again there is evidence that rapid access to multidisciplinary foot care teams can lead to faster healing, fewer amputations and improved survival. Savings to the NHS can substantially exceed the cost of the team. The noble Baroness spoke extremely powerfully on this subject. We join her in supporting the Putting Feet First campaign by Diabetes UK and NHS Diabetes and good patient education. The ambitions for the NHS are set out in the NHS outcomes framework and of course include improving the quality of life. Good care costs less for everyone.

The noble and learned Lord, Lord Morris, and the noble Lord, Lord Collins, spoke about type 1 diabetes. I agree that it is important to provide high standards of care for the 250,000 with type 1 diabetes, and that it would be helpful to improve the costing data around that. The noble and learned Lord, Lord Morris, was right to mention insulin pumps in this context. NICE recommend pump therapy as an option for adults and children over the age of 12 with type 1 diabetes if multiple daily insulin therapy has failed. In May this year, NHS Diabetes launched an insulin pump network to ensure an effective two-way sharing of the most up-to-date guidance, tools, best practice and resources. An insulin pump audit, the first to be undertaken nationally, is currently under way, and provisional unpublished data suggest that 11,985 adults and 4,447 children are currently on insulin pump therapy. Some 8% of people with type 1 diabetes now have insulin pumps. That is an increase, but we still need to go further to achieve the 12% to 15% advised by NICE.

As regards research, the department is currently supporting more than 60 studies into type 1 diabetes through the diabetes clinical research network. The Juvenile Diabetes Research Foundation has spent £1 billion on research around the world into treatments and prevention of the condition. I also acknowledge the major contribution of Diabetes UK to type 1 diabetes research.

Time prevents my replying to the points made about in-patient care, HIV/AIDS and diabetes, and the points made very powerfully about ethnic minorities. The noble Lord, Lord Harrison, asked me about the European Union and sharing ideas. I will write on those topics but will just say that progress has been made. It has been good progress, but we are not there yet. It is encouraging to see that many of the building blocks for making real progress are there and that, in the new NHS structure, there will be renewed awareness and mandated responsibility to improve care and services for all those at risk of this devastating condition.