Greater Manchester Combined Authority (Public Health Functions) Order 2017

Lord Beecham Excerpts

Tuesday 7th November 2017 Lords Chamber

[Lord Beecham (Lab)]

My Lords, I declare an interest as a member of Newcastle City Council and of its health scrutiny committee. I have served long enough to recall the original reorganisation of local government, combining public health services with social care, in the early 1970s. I congratulate the Government, the Mayor of Manchester and the combined authority on taking the issue forward in the way that the Minister described. Perhaps I should also declare a rather unfortunate interest as I myself am suffering from some oral problems—not, however, as a result of any lack of fluoridation in the north-east. In fact we have a very good record on that; it is one area in which we somewhat lead the way.

My noble friend referred in passing to funding. The public health budget is under great pressure. I hope that the Minister will be arguing the toss with the Chancellor for the forthcoming Budget and the following announcement of the local government finance settlement, which will come no doubt on Christmas Eve or thereabouts. It is crucial that this innovative approach by Manchester, but also the work done by authorities up and down the country under the present system, is adequately funded, and there is a real risk of serious problems arising unless that occurs.

In congratulating Manchester and the Government on this step, however, I ask the Minister what progress he anticipates being made on the rather more difficult area of combining health and social care provision in the way envisaged by the agreement and advocated by the Government across the whole policy field. That will be much more difficult than what is being carried through in Manchester under the terms of the order. The NHS structure is so complicated that it is difficult for local authorities to deal with it adequately now in one local authority area, let alone across a wider area. I cite as an example the difficulties that my authority and the area I represent in the city are having with the clinical commissioning group, which is a big, powerful body, one of several separate powerful bodies within the NHS, and has decided to close a surgery in an area of considerable social need, quite a distance down the hill, as it were, from other surgeries and where there is a growing population on a new housing development in the area.

This suggests that any further development of the combination of health with local services will need a review of how all the partners to that manage to co-operate. It will be very interesting to see what Manchester manages to achieve in that regard. My advice to my colleagues in Newcastle would be, frankly, while exploring options to wait and see what happens in Manchester and how it works out when that stage is reached. I appreciate that we are not at that stage yet, but it is necessary to flag up some of the potential difficulties that might have to be faced if we are to have really effective collaboration across the whole field of health and social care.

[Baroness McIntosh of Pickering (Con)]

My Lords, perhaps I may take this opportunity to question my noble friend on the fluoridation programme. I must declare an interest. I cut my legal teeth as a devil and an apprentice with Simpson & Marwick, and my devil master was the junior advocate in the fluoridation case brought by a pensioner who had dentures—she had none of her own teeth. She objected to the fluoridation programme to be carried out by Strathclyde regional council in the early 1980s. She won her case and Strathclyde regional council did not fluoridate the water supply at the time on the grounds that compelling evidence was led by the petitioner, Mrs McColl, to prove, among other things, that fluoride could be a carcinogen.

Has the Minister taken the time to consider such evidence, and can he assure the House that the level of fluoridation in the public water supply will not be such that any such fears will be raised in the fluoridation programme to be carried out by Greater Manchester council?

National Health Service (Mandate Requirements) Regulations 2017

Lord Beecham Excerpts

Wednesday 6th September 2017 Lords Chamber

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare all my interests as a clinician. I worry that, if we keep on changing the way that we collect data, we have no way of monitoring what is happening. One thing about the figures as they are at the moment is that they are monitoring process. In addition to that, there must also be monitoring of outcomes—both clinical outcomes and outcomes in terms of the patient experience.

I worry that, if we start saying that the demography has changed and we have an elderly population, it makes it sound as if we are blaming people for living well and living longer, which we must not do. Actually, if people remain well, they are not a drain on the NHS at all. One of the most important predictors of poor outcomes is loneliness. If we have a population of people who are kept relatively well and mobile, they look after each other in communities. Good work on compassionate communities is happening around the UK already.

When we look at this question of targets and what the Government are doing, a worrying message is being sent. The Royal College of Emergency Medicine contacted me yesterday because its members are worried that they will not be able to cope with winter pressures. They are going into the winter with absolutely no wiggle room at all. They are at capacity. There has also been a change in the way that people behave. For an urgent appointment, they go through A&E, so the number of emergency department attendances has gone up as well.

In that group are those people who have been waiting for a time and during that time they have deteriorated. As they have deteriorated, something else has happened and they collapse—a bit like a stack of cards. Multiple problems arise and then those become more complex for the NHS. So it is not as if people are stable during their 18-week wait. If they have a disease that is progressing, they may well be deteriorating. Even worse for them, if the diagnosis in the original referral was wrong, they may need a complete review of their diagnosis. So simply talking about treating them is not correct.

My other concern is this: at what point does the clock start ticking? In some clinical commissioning groups, we are seeing groups being set up to look at the so-called appropriateness of the referral on paper. As a clinician, that worries me greatly, because I do not see how one can assess on paper. I know from many years of looking at referrals coming through on paper that they are only a very rough guide. Too often, I might see a referral that does not sound urgent and the patient in front of me should have been seen yesterday. Another one might sound urgent but actually is not. There is a real worry that, if we fiddle around with when the clock starts to tick, some people who really need to be seen urgently will be in a no-man’s zone before they are even properly referred because there have been delays. We hear about delays in access to primary care as well. The delay in being seen by a GP must be added on to any delays in being referred.

We also need to remember that, when we talk about 10 years ago, medicine has changed enormously. There are a large number of procedures now that, if they are done early, can be done in out-patients or as day cases. The days of needing to be admitted are not there, so that is all the more reason why we should be able to get more patients through more quickly if they are seen earlier.

I have a real worry that, as has been expressed very well by the noble Baroness, Lady Thornton, this flies in the face of reassurances that we were given during the passage of the Health and Social Care Bill through this House. Also, this sends a message to the service out there that, actually, we cannot cope. I worry that it will also disincentivise finding ways of treating people more speedily—as day cases and so forth—which could, with a little more investment, help to address the problem.

[Lord Beecham (Lab)]

My Lords, the impact of the cuts which are being debated tonight—and here I congratulate my noble friend on bringing forward his Motion—are not confined to the health service. They also stretch to social services departments and social care. The most rewarding period of my fairly lengthy political life was as the chairman of social services in Newcastle from 1973 to 1977 when we transformed social care in that city. Much of what we did in those days is now being undone as the result of pressures on the social care budget and a lack of adequate funding for the problems which many of us are becoming increasingly familiar with. What are the Government going to do about that impact of the decision, as it would appear to be, not to adhere to the 18-week period? What estimate have they made, if any, of the impact on social services and social care in a climate where local government budgets are extremely hard pressed? The two things are inseparable. It was a Health and Social Care Bill, now an Act, and we need to look at the social care implications of this extended period because, undoubtedly, it will put increasingly impossible pressure on local authority social services departments and other organisations involved in supporting people in the community.

[Viscount Bridgeman (Con)]

My Lords, we have a health service which is endeavouring to meet an ever-present and probably ever-growing demographic challenge. I was interested to hear the remarks of the noble Baroness, Lady Finlay, on the effect of the number of older people accessing the service, but there are many more people growing old and it is surely self-evident that there is bound to be an increase in waiting lists.

Perhaps I may leave your Lordships with two statistics. It is remarkable that last year the NHS carried out 11.6 million operations, some 1.9 million more than in 2009-10, and 61 million out-patients were seen, again 1.9 million more than in 2009-10. The health service is not perfect and there is certainly no room for complacency, but perhaps I may remind noble Lords that the 2016 GP patient survey showed that 84.6% of respondents rated their overall experience as good, while the 2016 British Social Attitudes survey showed a historical high level of satisfaction. This is a service which is endeavouring under very strict budgetary pressures to improve the lot of the nation.

Junior Doctors: Industrial Action

Lord Beecham Excerpts

Monday 25th April 2016 Lords Chamber

[Lord Prior of Brampton]

I can confirm both those points. If the Secretary of State for Health was to fall under a bus tomorrow and somebody was writing his obituary, it is “patient safety” that would be written on his tombstone. That is the one big issue that he has consistently fought for ever since the problems at Mid Staffordshire were uncovered three years ago. Patient safety is his guiding star as Secretary of State for Health. I agree with my noble friend that it is tragic to see thousands of highly committed, highly intelligent and otherwise sensible young people going out on strike.

[Lord Beecham (Lab)]

My Lords, I am sure that there are many in your Lordships’ House, and perhaps people outside it, who rather regret that the noble Lord himself is not Secretary of State for Health as opposed to the present incumbent of the office. He has shown great sensitivity about this issue and, indeed, all others, and is widely respected here. However, is it not unfortunate that the Statement made this afternoon is somewhat disingenuous? It refers, for example, to the high mortality rates for people admitted to hospital at weekends—something which has been disputed in the sense that, to the extent that it exists, it is not necessarily connected to the issue of a seven-day service but rather a function of the emergency situation that many people face which is why they are admitted to hospital at that time.

Is it not equally somewhat disingenuous to refer to the recently announced further investment in the NHS as something that is directed at the issue which is the cause of the dispute? As has already been pointed out, the service has been denied comparable funding to that in previous years and is in a very serious condition up and down the country. I hope that the Minister can persuade the Secretary of State that it would not be a futile exercise, as he has perhaps suggested today, to accept the suggestion made by the group of four people from different backgrounds, including a former Conservative Health Minister who was also a doctor, to have a discussion about trialling the new scheme? As is so often the case in this House in other contexts, decisions appear to have been made without any proper assessment of the potential outcome. In this case, there is a very serious potential outcome both for the service and for patients. Will the Minister speak again to the Secretary of State to reflect the view, which I suspect is fairly widely shared, that the Secretary of State is making a mistake in not acting on the suggestion that has been made?

[Lord Prior of Brampton]

On mortality rates at weekends, the noble Lord is absolutely right that there has been confusion about the difference between the terms “excess mortality” and “avoidable mortality”—the two are clearly very different. However, having said that, I think it is widely recognised that the lack of senior cover and diagnostic support, particularly at weekends, is not at all satisfactory. Certainly Bruce Keogh and others have looked at this—I think that there have been six very detailed studies looking at mortality at weekends. The fact that there is a higher level of mortality than you would expect is ground for providing greater support at weekends. As for the suggestion that there should be a pilot scheme to study the contract, I tried to answer that in my response to his noble friend and I have nothing else to add to that.

NHS: Food Banks

Lord Beecham Excerpts

Thursday 26th November 2015 Lords Chamber

Asked by

[Lord Beecham]

To ask Her Majesty’s Government what assessment they have made of the provision of food banks at, and the distribution of food to people in need by, NHS hospitals.

[The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)]

My Lords, decisions about such schemes are rightly made locally. The Government’s policy approach is that economic growth, productivity and employment offer the best route to give people a better future and reduce poverty. We implemented a long-term economic plan which is working. The employment rate is at a new record high and earnings are growing. We also announced that a new national living wage will be introduced from April 2016 for those aged 25 and above.

[Lord Beecham (Lab)]

My Lords, four weeks ago the Guardian reported that hospitals in Tameside in Greater Manchester and in Birmingham were opening food banks on their premises. In the ward I represent in Newcastle, all six primary schools and the local secondary school run a breakfast club for their pupils. These stark facts are reflective not of lifestyle choices, as some would have it, but of real need. When will the Departments of Health, Education, Work and Pensions and the Treasury come together to develop and implement policies to address the scandal of food poverty in what is still one of the richest countries in the world?

[Lord Prior of Brampton]

My Lords, the people running the schemes in the two hospitals in Birmingham and in Tameside are to be congratulated. I am not sure that there is a similar scheme in Newcastle. I know from experience of homelessness how difficult it is, for example, to discharge patients when they have nowhere to go, with the risk of discharging people onto the street who will then come back into hospital. The work they are doing in those two hospitals is to be applauded. We have a welfare safety net in this country. Tragically, anywhere around the world there will be some people who fall through that net. The fact that there are voluntary groups and charities prepared to help pick those people up is a cause for celebration. It is that combination of a state welfare net with an active civic society which makes this country as good as it is.

Health: Children

Lord Beecham Excerpts

Thursday 10th September 2015 Lords Chamber

[Lord Prior of Brampton]

I am not sure that I can give that question a full answer. I am aware of the early years programme and I think that it is largely up to schools to monitor the development performance of children when they come into reception classes, which they are doing. I have seen the figures that the noble Baroness refers to—the 40% figure of children who have not reached the right development age by the time they come into reception class. It is a serious issue and I will take her words on board.

[Lord Beecham (Lab)]

My Lords, what is the Government’s response to the recent concerns expressed by the Royal College of Nursing about the reduction in the number of school nurses in recent years, and what assurance can the Minister give that the reduction in the public health budget will not lead to a still further reduction in the number of school nurses?

[Lord Prior of Brampton]

I have not seen the figures that the noble Lord refers to on school nurses but I will take that away and look into it.

Local Authorities: Public Health Budget

Lord Beecham Excerpts

Wednesday 15th July 2015 Lords Chamber

Tabled by

[Lord Beecham]

To ask Her Majesty’s Government what is their assessment of the impact of the £200 million reduction in the public health budget on local authorities in the current financial year.

[Baroness Pitkeathley (Lab)]

My Lords, with the leave of the House and at the request of my noble friend Lord Beecham, I beg leave to ask this Question.

Mesothelioma

Lord Beecham Excerpts

Thursday 5th December 2013 Lords Chamber

[Lord Beecham (Lab)]

My Lords, I refer to my interest in the register. Section 48 of the Legal Aid, Sentencing and Punishment of Offenders Act 2012 requires the Government to review the application to mesothelioma claims of the provisions banning conditional fees. The Government have announced that, in the light of a consultation as yet unpublished, they will not treat those cases differently from other claims. They seek to conflate this issue with entirely different provisions in the Mesothelioma Bill.

Is the Minister aware that the Civil Justice Council has been unable to agree whether the current consultation,

“fulfils the conditions set out in Section 48 of LASPO”?

Is this not another example of the Government cravenly caving in to the demands of their friends in the insurance industry and ignoring the strong feelings of this House in support of those suffering from this terrible disease?

[Earl Howe]

I am sure that the noble Lord wants to take advantage of this opportunity to raise that particular issue, but it is a rather different one from the Question posed by the noble Lord, Lord Alton. However, I will take his question away and ensure that a letter is sent to him in response.

Care Bill [HL]

Lord Beecham Excerpts

Monday 29th July 2013 Lords Chamber

[Lord Dubs]

My Lords, it is very clear that this Bill puts upon local authorities enormously complex duties as regards assessing the care needs of disabled people. The way in which local authorities exercise those decisions will have a major impact upon the lives of elderly and disabled people and may well occasionally be unjust or factually inaccurate. This will not be deliberate, but it sometimes happens in the nature of decisions that are so difficult and sensitive. The purpose of my amendment is to give the Government a duty to set up a tribunal system for issues such as individual eligibility, care plans, the level of personal budgets, and cases where individuals believe local authorities have made errors of fact or law in their decisions. Issues such as these can be challenged and put to the test. It is a complex area and I say at the outset that this is a probing amendment. Although it is quite detailed, I appreciate that the issues are difficult and will need further thought. I am anxious to see what the Government’s response is at this stage.

It hardly needs to be said how crucial these decisions are for elderly and disabled people. The system is hard for individuals to navigate. People often feel that they are powerless in the face of such a complex system. Where people lose out, in terms of the assessment made of them, they can in the worst cases feel trapped in their own homes, unable to get to work, unable to get out, depressed, and perhaps even suicidal. The consequences can be very serious indeed. They may be left in a vulnerable position without any ability to achieve redress.

The Government, in response to the Joint Committee, said,

“it is vital that people have an effective way to complain and seek redress that provides real challenge, particularly to the decision-making process.”

That is fair enough, but I cannot see anywhere in the Bill where the Government have actually done that. Perhaps I have missed it. The point of my amendment is to give people precisely that safeguard.

The Government may say there are other ways of doing this, such as going back to the local authority and persuading it that it has made a mistake. That is not very easy to do. One might be able to require the local authorities to have a route by which individuals can formally request reconsideration of care decisions where they believe an error of law or fact has been made. Again, this is not an easy thing to do. One might even go one step further and require local authorities to convene an independent panel to consider social care decisions where there is a dispute between an individual and the local authority. In theory, such options might work; but in practice one would have to be absolutely convinced that every local authority would do it, and do it properly. I am bound to say that although some local authorities might be willing to move in this direction, I am not convinced they all would.

The difficulty is that there are alternatives. One alternative is judicial review. However, we do not want to be standing here and telling elderly and disabled people to go through the costly business of a judicial review in order to get redress for what ought to be a simple procedure. Although my amendment is fairly lengthy, what I have in mind is a process that should be simple. Not all tribunals need to be complicated. Indeed, we know in the scheme of things that some tribunals can work quickly, efficiently and in not too costly a manner. I hope the Government will not say that people can take the option of judicial review and that is okay, because I do not believe it would be. In any case, going for judicial review would be a costly additional burden for local authorities, and I do not think anybody wants that.

Let me repeat—it is inevitable that, on a national scale, some mistakes would be made. You cannot devise a system, with the best will in the world, where mistakes are not made with regard to individual assessments. So let us not have judicial review at one end of the scale and mistakes at the other, for which there is no remedy.

I appreciate that any system of tribunals has some costs attached to it. I do not want to say to the Government, or to my friends in the Labour Party, that we should rush into this blithely, never mind the costs. I am aware that the costs must be of concern, and I do not want to stand here urging that something costly should be set up. But having some proper tribunal system of redress would be a much better way in which to resolve issues than to ask people to approach the local authority, and I do not believe that we would be left with all that many cases, anyway. I am hopeful, and I hope not excessively optimistic, that the tribunal system would be there in place for a few cases that could not be resolved in any other way. An appeal option must be a feature of any decision-making; it is so for many public authorities and should be in this particular instance.

Lastly, I have thought about the question of the Local Government Ombudsman, and I hope that that the answer given by the Minister is not his only answer. After all, the ombudsman is there to deal with maladministration and, although one or two instances might be susceptible to local authority ombudsmen looking at maladministration, I do not believe that that is the answer. It is for different sorts of instances, not for the sort that I am talking about.

What I am putting forward is a simple proposition. I want the Minister to respond in terms of the detail. I have said that I am concerned about the cost, so I hope that the Minister will not simply say that it is too expensive. I hope that he will not say that judicial review is the answer and will appreciate that I am putting something forward quite seriously. I am indebted to Leonard Cheshire Disability for the help that it has given me in some of the details that I have put forward in my remarks.

[Lord Beecham]

My Lords, I have a lot of sympathy with the case that my noble friend has put in establishing the structure that would permit appeals. However, there is one potential problem. I endorse what he says about the undesirability of requiring people ultimately to have recourse to judicial review, which is a lengthy and very expensive process. However, it is likely that people wishing to make an appeal to such a tribunal would need at least legal advice and, possibly, legal aid. I would imagine, as matters stand, that such a procedure would be out of scope of the legal aid system as it has been “reformed”—I put that word between inverted commas. Perhaps the Minister and my noble friend could indicate whether they think that it would be a sensible addition to the terms of the amendment, which would command a good deal of support across your Lordships’ House.

[Lord Warner]

My Lords, I briefly intervene from the perspective of a member of the Joint Select Committee, which proposed that there should be some kind of body. Much of our thinking was focused on the early days of these new arrangements. We thought it highly unlikely that there would not be a lot of disputes in the first few years of what would be a pretty major change to the arrangements. There are two sources of potential dispute—those by people who do not like the results of an assessment made about them, in some form or another, and some of the stuff that comes out of making markets. There is the issue of the rate for the job between local authorities and providers. We could see some of those areas also leading to disputes.

We had it in mind that some mechanism should at least be ready to go into action should this happen. It may be that, in the longer term, things will settle down and there will not be a great problem. However, even if the Minister is not prepared to accept my noble friend’s amendment and make statutory provision, the world would be reassured if the Government at least had a plan B so that we do not end up with judicial review if things do not go well. Rather, we end up with some kind of arbitration system which is low cost, speedy and can deal with some of the inevitable teething problems of a fairly major change to these systems.

Care Bill [HL]

Lord Beecham Excerpts

Tuesday 9th July 2013 Lords Chamber

[Baroness Greengross]

My Lords, I hope that noble Lords will forgive me, but I forgot to speak to one of the amendments that is relevant to this group; that is, Amendment 86C. It is about people with dementia who have had a diagnosis. I know that the noble Earl will share the Prime Minister’s view and those of all of us who have looked at the number of people who receive a diagnosis of dementia. We now want to ensure that many more are diagnosed, and diagnosed early.

However, there are many reports that people diagnosed with dementia and their carers feel terribly abandoned after they have had the diagnosis. The Bill’s emphasis on access to prevention services and information and advice for people, particularly if their needs have not yet reached the threshold of eligibility for social care, is welcome. But there are no specific prompts to ensure that people receive the information they need at the time when it is most useful. The risk is that, although local authorities have set up information and advice services, the information does not reach people at the right time. A post-diagnosis information pack tailored to specific long-term conditions should be given to every individual who is diagnosed with one of those conditions. It would provide access to tailored information about the support that is available to them, and it would enable them to cope with the challenges of living with a long-term condition. The pack would provide information on the likely impacts of dementia and contain core information on national and local services. I think that this would be an important aspect of providing the right information and advice at the right time.

[Lord Beecham]

My Lords, this Bill has the potential to do for social care what Beveridge did for the welfare state and Bevan did for the health service. It is potentially the most significant development in, for example, residential care since the workhouses were replaced by a more civilised form of residential accommodation.

The noble Baroness, Lady Barker, anticipated precisely the point I was going to make, which is that this is not just a matter for local authorities. My principal reservation about these amendments, if I have one, is that it looks as though the entire burden of information and advice is to be placed on local authorities whereas of course, as the noble Baroness rightly said, there are other potential partners who clearly need to be involved. I scribbled on the grid that is helpfully provided by those who support the Front Bench on this side the words “in collaboration with”, and then I thought of a number of potential partners. Of course the health service is one of them, but in addition I would suggest that the Court of Protection needs to be involved. It has a supervisory and supportive responsibility for a particular group of people and, with the development of lasting powers of attorney and so on, their deputies as well. I have to say—I have said it before and I will say it again—that I am not convinced that the Court of Protection is doing a terrific job in this area, but that is another reason why it should be looked at as a potential partner.

There may be other partners. For example, in the case of younger people perhaps with a learning or other disability, there are roles for those involved in further education, the Department for Work and Pensions and the Department for Business, Innovation and Skills. Those bodies might look at their role in terms of what is available by way of education, training and so on. It seems to me that a range of organisations should be involved, certainly as a whole, but more particularly in the provision of information and advice.

On these Benches we support most of the amendments that have been moved and spoken to this afternoon, with the qualification that, where relevant and necessary, a reference to collaboration should be included. For example, in Amendment 82B, the first amendment moved by the noble Baroness, Lady Greengross, one would want to see “in collaboration with” appropriate partners.

We support the amendments, notably moved by my noble friend Lord Lipsey, around the provision of independent financial advice. That seems very important. I have a slight reservation about Amendment 86D, which is about payment of,

“the reasonable costs of a first consultation with an independent financial adviser”,

to be paid for “by the local authority”. If I am ever in need of this kind of advice, I would be able to afford that relatively easily. Given the pressure on budgets, is a universal application of that principle necessary or desirable? That, however, is a detail, that might be looked at later. Given the scale of the potential involvement and the potential conflict of interest referred to by several noble Lords, the independence and proper status of such financial advice are important considerations.

With regard to the amendment in the name of the noble Lord, Lord Sharkey, I will perhaps anticipate the Minister by quibbling over the word “demonstrably”. Frankly, I am not sure that that takes us very far. As the noble Lord admitted, what is demonstrable to some is not necessarily demonstrable to others. I do not think that that part of his amendment is particularly cogent, although I agree with the rest of it.

I have more serious doubt about the amendment of the noble Baroness, Lady Browning. Amendment 86H requires that the information and advice be provided by “social work-qualified staff”. It could be, but I am not sure that it should be a requirement that it should be, given the pressure on the service in dealing with casework as it is. I do not think that the skills of social workers are always consistent with the role of giving information and advice in the sense that is intended by the amendment.

[Baroness Browning]

It is important that qualified social workers are present for the initial assessment. One of the things that might come out of our scrutiny of the existing Mental Capacity Act is the fact that the assessment of capacity requires professionals. Social workers clearly have a part to play in that. Whether the person has capacity, partial capacity or no capacity at all, at that point some advice is given and direction is needed. It seems to me that that is not the role of an amateur.

[Lord Beecham]

That is absolutely true. Neither is the provision of information and advice. However, it is not necessarily the role of a professionally qualified social worker or a professionally qualified health visitor or other person. I agree—it is a point that the noble Baroness, Lady Barker, and I both made—that both sides, health and social work, must collaborate on this. It is perhaps the wording of the amendment, rather than the intention, that might be looked at.

There is a question about how best to proceed with the publicity that should follow the enactment of this legislation. The Joint Committee advised that the Government should work with all interested providers to launch a campaign to raise awareness of and support for the change. I hope that the noble Earl will confirm that that is the Government’s intention and bring us up to date on where the Government stands.

In the context of such a radical change, it might be desirable for there to be some pilots on the ground about this issue of information and advice, working in collaboration with the Local Government Association, the NHS Confederation and other major national partners, to look at how these matters can best be explained. There could also be, at a fairly early stage, some examination of good practice. I am not suggesting that the whole scheme be piloted but that in a few areas, after a relatively short period, there might be a process of peer review and an examination of how it is working on the ground. Given that local authorities retain their scrutiny role for health and social care, it would be worth while developing with the Centre for Public Scrutiny, the LGA and relevant health service bodies, a way for the new system to be subjected to useful scrutiny at local level, and for lessons learnt to be disseminated across the country.

There are questions about the advocacy role. There is clearly a case for advocacy being included. One notes that there is a glancing reference in Clause 8, which is the reason for the stand part debate. It looks a little odd situated between Clause 4 and Clauses 18 and 20, as it does not seem to relate specifically to either. It has been mischievously suggested that there might have been references to advocacy in other parts of the Bill at an earlier stage that were removed and this was left behind. Can the noble Earl indicate the Government’s intention in referring to advocacy in that particular clause? We are not intending to move that the clause should not remain in the Bill; this is purely a probe.

We see most of these amendments as contributing to a refinement of the Bill’s proposals and we welcome that. However, it is necessary to reiterate the need for caution about the role of local authorities, particularly in the context of the financial situation that they are facing, which will get worse under a very tight regime. The Government are making provision for this, but we must be careful that the sum is not divvied up across a range of things without seeing the whole picture. If we are to give priority to this issue of information and advice, it would be helpful if the relevant departments, together with the Local Government Association, could look at the real cost of this and ensure that it is identified and included within the total package. It is easy to add desirable things against a budget. We do not know the extent to which these matters have been costed, for example, in the sum that the Government have allocated. We know that the demand is constantly rising, partly as a result of demographic change, and that the costs are also inexorably rising. This will be a cost. It is a justifiable cost, but it needs to be identified, provided for and kept under review.

Having said that, we are very much in sympathy with the thrust of these amendments and we look forward to the Minister’s reply and to working with others of your Lordships’ House in ensuring that the Bill is capable of delivering what it sets out to deliver and that all relevant players are engaged and financed adequately, so that we can afford the best possible level of care to those—of any age and with any condition —who need it.

[Earl Howe]

My Lords, I am very grateful to noble Lords for tabling these amendments, which highlight the importance of access to good information and advice, including independent financial advice and independent advocacy, for those who have care and support needs or are planning how to meet future care and support needs.

First, I will address Amendment 82B, in the name of the noble Baroness, Lady Meacher, Amendment 86E, in the name of my noble friend Lord Sharkey, and Amendment 86F, in the name of the noble Lord, Lord Lipsey. Clause 4 introduces a general duty to make a universal information and advice service available to everyone in the local community. I say to my noble friend Lord Sharkey in particular that we are clear that the information and advice service must be accessible to all, whether they fund their own care or get some care and support paid for by the local authority, and in order to fulfil its duty the local authority will need to facilitate access. The noble Baroness, Lady Meacher, raised the issue of early information and advice about Alzheimer’s in particular; this will be one of the vital areas that the services should cover.

The clause deals broadly with what the information and advice service must cover. Subsection (2) sets out the essential requirements for the service but— intentionally—this is not a definitive list. With regard to Amendments 86B and 86H, subject to specific qualifications, it will be for local authorities to determine the precise scope and manner of the information and advice that they offer. We expect many authorities to offer access to independent sources of information and advice, working together locally with the voluntary, not-for-profit and private sectors. We set out our expectations and additional funding for local authorities, which rises to £50 million a year by 2017-18, in the Caring for Our Future White Paper.

I would say to my noble friend Lady Browning that some authorities have also used qualified social care staff as the first point of contact and have found that this can be effective, efficient and timely, helping people to the care and support that will help them most. Others have provided a first point of access to information through more general services, which connect information and advice on a wider range of local authority responsibilities as well as local NHS provision.

I emphasise that statutory guidance will cover how information and advice can be provided in an accessible way and be proportionate to the needs of those for whom it is provided. My noble friend Lord Sharkey expressed doubts about the phrase “seek to” and suggested that it was rather too weak. Statutory guidance will set out the clear expectations of what the local authority’s service should cover or what it should seek to do in order to ensure that the information and advice is sufficient.

My noble friend Lady Browning asked about the number of social workers. More than 1.6 million people are employed in the social care sector, including 200,000 social workers. We do not set out any national targets but we recognise the need to improve skills, capacity and retention. We are working with stakeholders, including the National Skills Academy for Social Care and Skills for Care, to produce new national minimum training standards, which will further raise standards and encourage new people to enter the sector. My noble friend referred to my letter of 27 June. I confirm that this referred to Health Education England. Health Education England’s remit does not extend to social care; it covers health and public health.

Amendments 83ZA and 86A, in the name of the noble Baroness, Lady Gale, cover information and advice on health-related areas and information to people with specific medical conditions. As for many services, there will be a need for the local authorities to work with NHS organisations and more widely to provide focused information and advice to those who would benefit from it. There are already good examples of how information and advice services from a range of organisations can work together with the health and well-being of the individual at heart. Many use the national information provided by NHS Choices as a base. A lot of local authorities are providing information and advice directly to those who may have an entitlement to NHS continuing care. In addition, regulations under the Bill will specify the circumstances in which the local authority must refer the adult for an assessment for NHS continuing care. We will of course work with interested organisations to include such examples in statutory guidance.

Turning to the amendments addressing access to regulated financial advice, the noble Baroness, Lady Greengross, and the noble Lord, Lord Lipsey, make some excellent points about the importance of appropriate financial advice for those who have or are planning for care and support needs. This kind of advice may be particularly relevant to people who are funding their own care and may include a financial adviser who is regulated by the Financial Conduct Authority, but there is no need for the Bill to set this out specifically. There are other kinds of advice that may be relevant to such people and, as I have mentioned, we think it is important to maintain the general terms of Clause 4.

I take on board the concern about the use of the term “independent financial advice”—that this may cause some confusion with the term’s general meaning within the financial industry and the Financial Services and Markets Act 2000. We are happy to consider this aspect in more detail to ensure that no confusion exists. However, we do not believe that taking independent regulated advice should be compulsory. Whether a person takes advantage of independent advice is a matter of personal choice. This is particularly important because some financial advice may be subject to a charge.

There will be individual circumstances in which it will be appropriate to recommend independent advice from a regulated financial adviser, such as when people are planning to meet future care needs or when people go into residential care and are weighing up financial options such as selling the home. The fact that an organisation or individual is regulated is in itself no guarantee that the person has knowledge or experience of wider care and support issues; for example, housing or other care-related options. All this makes the adult’s choice of an adviser a vital aspect. The local authority should advise about the importance of independent regulated advice and signpost the adult to offer a choice of where they can obtain the best and most relevant advice. Again, we intend to cover such issues in statutory guidance.

We will also shortly be consulting on the design and technical implementation of the funding reforms, including deferred payments. This will include how the new duties to signpost independent financial advice will work. The noble Lord, Lord Beecham, asked about an awareness campaign about the funding reforms themselves. We are scheduled to discuss amendments on that very issue in a later group and I hope that the noble Lord will be content for me to cover the issue at that point.

Care Bill [HL]

Lord Beecham Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Lord Sutherland of Houndwood]

My Lords, the noble Lord, Lord Best, is right in his analysis. He is pointing towards a financial problem that we all know is there and will continue to be there, not least in the current situation, for a number of years to come. The noble Lord, Lord Rix, is right about the consequences of this within the community. I declare an interest as president of Alzheimer’s Scotland and I know that the same applies to its sister body in the rest of the UK. There is a shortage of cash, which means that services are being provided more cheaply or, of greater relevance, are not being provided and are being squeezed. That is the analysis.

I do not think I can vote for the amendment as it stands. What is driving this difficulty is not the profligacy of this Government, previous Governments or local authorities—we can all tighten our belts and are doing so—but the reality of changing demography. My favourite statistic is that since the start of this Committee stage our statistical life expectancy has increased by 27 minutes. We cannot cash that in individually, but that is the reality. That is the driver of the difficult position we are in.

Ministers are often between a rock and hard place, and none more so than now. However, in the light of these facts, the Government have not reviewed the priorities of public expenditure across the board—I hope the Minister will persuade them to do that—and how many things can we afford to do with the population that we have. That means looking at priorities across departments. I do not just mean health and social care. It is inevitable that we will have to do this. The sooner the Government—the previous Government were not good at this—are prepared to say that we must undertake a review of priorities in view of the changing nature of our society, the sooner we will begin to move forward. In the mean time, I am in favour of keeping pressure on the Government by introducing a Bill of this kind because there is no doubt that that will sharpen the appetite of the voters for how change should be devised in the future.

[Lord Beecham]

My Lords, I declare an interest as a vice-president of the Local Government Association and as a member of Newcastle City Council.

Forty years ago, as the newly-appointed chairman of the social services committee in Newcastle, I had to come to terms with the impact of Sir Keith Joseph’s reorganisation of the health service which came into force that year. Among much else, that involved the transfer of responsibility for public health from local government, where it had largely resided for over a century, to the NHS, taking with it paramedical services such as chiropody and bath attendants. The area health authority, as it turned out, was so limited in its resources that, for a period, we as a council felt it necessary to fund the continued provision of those services by the health authority. At the same time, we hugely increased social care provision, doubled the home help service and trebled the number of meals on wheels. I am sad to say that now those services are roughly back to where they were in 1973 as a result of the pressure on the authority’s budget. Now, in a step on which the Government are to be congratulated in principle, public health largely returns to its local government home and the concept of a holistic approach to social care, involving both local government and the NHS, is enshrined in the Bill.

It is unfortunate that the previous Secretary of State, in his shadow capacity, walked out of cross-party talks which the Labour Government had initiated to address the issue of care and its cost, and that it has taken three years to produce the proposals that we are debating. However, it is even more unfortunate that during that time not only has demand risen inexorably, but local authority funding has been severely and deliberately reduced by a greater extent than any other area of government expenditure. It is sad, but not untypical, that the Secretary of State for Communities and Local Government should not only have acquiesced in, but actively promoted, this perverse order of priorities with all it has implied for key services, including those that we are debating in this Committee.

As we have heard, the Local Government Association avers that adult social care budgets have been reduced by £2.6 billion, or 20%, over the past three years, with additional dire impacts on other services, such as leisure and housing, which should contribute to health and well-being and which are threatened with virtual extinction as local authority services by the end of the decade. The noble Lord, Lord Best, reminded us of the London Councils report and its estimate that the cost of the reforms—which, I repeat, we welcome in principle—will amount nationally to an average of £1.5 billion a year over the next four years. Apparently, the greater amounts will be spent in the first and last years of those four. London itself will be facing a bill of at least £877 million as a result of implementing the proposals.

Of course, this, in part, reflects the increasing demand from different client groups. We largely talk of the elderly, but there are other significant groups. The noble Lord, Lord Rix, has reminded us about people with learning disabilities, and there are also people with physical disabilities. These two groups are growing as medical advances have enabled them to live longer. The quality of their life, of course, is the subject of much concern and that imposes additional strains on the budget. It is another example of incremental demand that needs to be met. In addition to that, there are people suffering from mental health problems. The increasing demand so far has manifested itself as between something like 10% and 14% in these different categories. It is clear that inflation and demographic trends alone will push up the cost, as the noble Lord, Lord Best, has indicated, by some £421 million by the beginning of the next spending review period.

There is also a serious question about the amount and timing of the funding designed to assist transition to the new regime, given that this welcome increment was announced in the spending review for 2015-16, but work will have to begin before then if we are to make progress at that time. It would be helpful to know, given that part of the rationale for the changes is that a whole-systems approach is likely to be more cost effective, just what savings the Government anticipate will be made and over what timescale by each of the two principal partners—local government and the health service—and in the case of the latter, by which of its several components.

Given the huge problems currently experienced in A&E—in contrast with the position under the previous Government when 98% of patients were seen within four hours—and the emerging problems that we have read about in the past few days in general practice, how confident can we be that the basic funding projected for both partners is adequate, even before taking into account the scale of change envisaged? How do the Government respond to the comment on the spending review of the Foundation Trust Network, which warns of,

“a further major squeeze on NHS front line services as £4 billion is diverted from the NHS budget to social care”

in 2015-16? It points to fact that trusts,

“are, in many cases, struggling to meet the rapidly rising demand created by an ageing population”.

The concept of pooled budgets is welcome, but given the number of parties to the commissioning process, with local authorities joined by clinical commissioning groups commissioning hospital services and NHS England, currently the national Commissioning Board, commissioning general practice and mental health services, how will this pooling work in practice?

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[Baroness Wall of New Barnet]

I know very little about local government other than that I work with it in the health sector, but I wonder whether, with the pressure that is on all of us with the cuts and the absolute need to reduce things, local authorities have looked at every opportunity. All I know is that since our income in an NHS trust has been looked at more carefully, we have had to have a look at the cost improvement programmes that we can deliver. We had never done that before, but we have delivered so many of those, improving costs by £17 million in the last year.

I am not making a criticism as I have no idea at all, and I know that we can all bemoan the fact that we have less money and all the rest of it, but until we know that we have done everything that we can, and got right down to questioning if we could do things differently, then we perhaps need to look at ourselves as well. Forgive me if you have already done that.

Perhaps I might respond to the question that the noble Lord is asking about what it means to integrate social care and local authority stuff. This is why I worry to death about this amendment. If this part of the legislation does not happen, the whole system will be in much worse straits than it is now. We have an issue about our local authority cutting back on some of the places in nursing homes, which means that we do not have the opportunity to put patients who no longer need to be in a hospital in the place where they ought to be to receive care.

At some stage or other, all of us have got to work together and say, “How do we do this?”. For lots of different reasons, not just the bed space, it is much cheaper for an individual to be in a care home bed than in a hospital bed. If we cannot resolve it between ourselves, and we cannot do it on our own as providers, local authorities cannot do it on their own, and neither can the care sector generally, then I wonder if we are ever going to get there. People perhaps need to start to look at how we might achieve this by being a bit tighter in other things.

[Lord Beecham]

My noble friend is right to draw attention, as many of your Lordships already have, to the need to integrate the provision and to avoid the sort of cost-shunting that can arise if organisations are kept separate. That is the point of the pooled budget: you look not just at the straightforward provision of care by one or other partner, or both partners, but at what will perhaps reduce the need for care in other ways. As I say, other local services such as leisure and adequate housing, in conjunction with the public health agenda, may very well reduce the demand for particularly expensive forms of care, as I am sure we all agree.

Of course, local government’s track record is not uniform, but it is right to say that local government has proved over the years to be the most efficient part of the public sector. There has been a huge improvement programme in local government, recognised by the shortly to be lamented Audit Commission, and others, over the years. The LGA in particular has sought, through a whole series of policies, including the very extensive and successful use of peer review, to engender new approaches and more cost-effective ways of dealing with a range of problems, including those in the social care arena.

I was about to conclude by drawing attention to another figure, which has just emerged today. It is a rather startling figure: £9.8 billion of uncollected VAT—10% of the total take—according to today’s Guardian. That dwarfs the amount that the Government are putting into the new arrangements. Just as local government needs, together with its partners, to engender the utmost efficiency in the mechanisms that it develops to provide services and make them cost-effective, as my noble friend suggests, so on the revenue-raising side central government has a massive obligation to ensure that it collects the taxes—instead of cutting the resources going into HMRC, which is responsible for collecting VAT, by a further 5% in the spending review.

We do not consider the cost of £3.8 billion and the welcome money that the Government are going to provide to be the last word in these matters. There will have to be a continuing process of establishing programmes that are effective and cost-effective. Looking at the totality, there is scope within the system to prioritise this area, providing that the Government take the right decisions—across the piece, not merely on the narrow front of health and social care but considering the implications for other services and functions of government—and collect the money that they are due anyway and which would relieve the huge pressure on these services and others.

I have a good deal of sympathy with the concerns expressed by the noble Lord, Lord Best, but I share the view of the noble Lord, Lord Sutherland, that it would not be right to hold things up. We must get on, but in doing so we must be realistic about the challenges that will be posed to those responsible for delivering these services. I look forward to hearing the Minister’s response to the various questions that have been raised in the debate.

[Earl Howe]

My Lords, I do agree with the spirit of this amendment. It is critical that care and support generally, and these reforms in particular, are fully funded. Without adequate funding, they will not deliver the benefits we all want to see. However, let me reassure noble Lords that we already have full procedures in place to ensure that there is proper funding for social care.

The first and very basic point is that the Government set spending plans for all areas of public expenditure at once during a spending review. This ensures that decisions can be taken about the future funding requirements of government as a whole, rather than assessing each part piecemeal. The noble Lord, Lord Sutherland, spoke about the review of priorities being a task of government. I agree, and that is exactly what spending rounds are designed to do.

Secondly, we have the new burdens doctrine in place, which requires that,

“all new burdens on local authorities must be properly assessed and fully funded”.

That ensures that all new funding pressures, including those that result from this Bill, are fully funded. I can tell the noble Lord, Lord Best, that our commitments are in line with the new burdens doctrine, the costs have been identified in the impact assessment, and the funding in the spending round will support local authorities to deliver on current and future commitments through to 2015-16. To answer the noble Lord, Lord Campbell-Savours, yes, the work has been done.

It is only right that the Government take spending decisions for all areas of public expenditure at once. This ensures that future spending plans are drawn up which are coherent and consistent across all public services. This is exactly the purpose of a spending round, the latest of which concluded last week, as noble Lords know, and set spending plans for 2015-16. Fundamentally, this settlement delivers the funding required to ensure that service levels in the care and support system can be protected and are able to deliver on all the commitments in this Bill.

However, with additional pressure on the system, we must ensure that the Government, the NHS, local government and care and support services are all working together to offer the best possible services for patients while also addressing the growing demand on the system that the noble Lord, Lord Best, rightly referred to. That is why we have announced in this year’s settlement a £3.8 billion pooled health and care budget to ensure that everyone gets a properly joined-up service, so that they get the care and support they need from whoever is best placed to deliver it, whether that is the NHS or the local authority.

In 2014-15, the NHS will transfer £1.1 billion to support social care with a health benefit. The pooled fund will include £2 billion more through the NHS in 2015-16. But this money will be given only on the basis that services are commissioned jointly and seamlessly between the local NHS and local councils. I hope that that helps to answer the question posed by the noble Lord, Lord Beecham.

--- Later in debate ---

The noble Lord, Lord Beecham, asked me how the pooled budget arrangements would produce the kind of outcomes that we all want to see. I think the key point here is that this pooled health and social care budget will benefit by its very nature both care and support and the NHS. It will safeguard those funds in the process and it will, as I have outlined, help to save money by keeping people well for longer. It will be given only on the condition that services are commissioned jointly and seamlessly between the local NHS and local councils. I have already explained about having all the plans agreed together, so that we can ensure that the NHS’s priorities are also met and that this money, as it delivers on the priorities that are important to the NHS—I have mentioned a few—will be used effectively.

[Lord Beecham]

My question was not about the purpose of the pooling, which I think we all share. My question was rather more detailed. If part of the funding is to be based on outcomes, how and when is that to be judged? If the outcomes are not achieved, how will the money be reclaimed? All this is something of a mystery as matters stand.

[Earl Howe]

The details of the payment-by-results system will be worked through. We are working with our partners in the sector including the LGA and NHS England to ensure that the system is designed with a view to incentivising integration. Further details of those arrangements are in course and we will announce them as soon as we can.

The kind of things that we will be looking for are, for example, the results that we have seen in places such as Cheshire West and Chester. The pilots, the whole place community budgets, showed that savings from integration could be substantial if implemented effectively. A business case needs to be presented. In that context, the pilot suggested that, once proposals are fully implemented, the net savings that could be achieved over five years are considerable.

Cheshire West and Chester has made savings of £26 million, with £3.8 million for Greater Manchester, £190 million for the Triborough authorities and £90 million for Essex. These savings are being identified. It gives us confidence to say that there is real potential to save money across the country, as shown by the pilots and other reviews, such as the Audit Commission review. Oxfordshire recently announced that it was nearly doubling the amount of money in its pooled budget for older people. That is a significant move.

I agreed with much of what the noble Baroness, Lady Wall, said. Savings are eminently possible without detracting from quality, by slowing and preventing the development of care needs or the onset of health conditions, or the loss of independence. We hope and believe that preventive care can increase the quality of life for individuals. A proactive stance by local authorities will deliver that. At the same time, preventive care will provide longer-term financial savings to the public purse. For the first time, Clause 2 creates a clear legal duty on local authorities to ensure the provision of preventive services.

I come to the point raised by the noble Lord, Lord Campbell-Savours, about the Dilnot package. I do not view the Dilnot package in the same way that he does. I do not see funding reform as being about protecting people’s inheritances. It is about providing hard-working people with peace of mind about how much they will pay for their care. Deferred payments will ensure that people will not have to sell their homes in their lifetime to pay for care. That will prevent distressing sales of houses and provide everyone with breathing space to make decisions and choices about what happens to their home. In the long term, the scheme is broadly cost-neutral to government, because the deferred payments will be repaid. Everyone will benefit from these reforms, but they will particularly help people with modest wealth who are most at risk in the current system of losing their entire home and savings.

Delivering on these transformational changes to health and care is the only way to secure the long-term sustainability of services, both for the NHS and local authorities. I would be firmly against delaying this —I think we would be heavily criticised if we did. The noble Lord, Lord Bichard, referred to the burgeoning weight of regulation during the past 60 years and one cannot argue with the statistics that he produced. This Bill serves to consolidate more than 60 years of legislation; it will repeal provisions from more than a dozen Acts of Parliament. Reducing the complexity of the statute and rationalising burdens on local authorities are our key aims in this context. I hope that, for the reasons that I have outlined, the noble Lord, Lord Best, will feel sufficiently reassured to be able to withdraw his amendment.

--- Later in debate ---

[Lord Best]

Oh, not again! I do apologise. How many times has this happened to the noble Lord?

[Lord Beecham]

My Lords, I hope to be of some utility, but I would not claim to be utilitarian.

[Lord Best]

I deeply apologise, and not for the first time, to the noble Lord, Lord Beecham, one of the most distinguished of the vice-chairs and past chair of the LGA.

The noble Earl, Lord Howe, agreed with everybody that we need fully to fund the new measures and to ensure that the funding for existing care services is there. He expressed to us the belief that the new measures will do just that and they herald a sustainable funding arrangement for the future. He noted that the settlement for local authorities is extremely challenging this time round, but that, in terms of social care, the settlement that we are now pointing towards, with jointly commissioned services, the pooling of the £3.8 billion and NHS and local authorities working together, will in his view prove enough to fund a sustainable care service. Only time will tell whether those calculations prove to be accurate rather than too optimistic. In the hope that the noble Earl’s predictions are correct, and recognising that government really are attempting to make serious change in this Bill to the funding system as well as in so many important ways to the care services, I beg leave to withdraw the amendment.