Care Homes: Hospital Discharges
Lord Dubs Excerpts(7 years, 1 month ago)
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Lord Hunt of Kings Heath (Lab)
My Lords, on behalf of my noble friend Lord Dubs, and with his permission, I beg leave to ask the Question standing in his name on the Order Paper.
Hospital Beds: Availability
Lord Dubs Excerpts(7 years, 9 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)
My Lords, the most recently published figures—for the last Thursday of December 2016—reported that 6,191 people who were occupying hospital beds were ready to return home or transfer to another form of care.
Lord Dubs (Lab)
My Lords, I thank the Minister for that reply. I am extremely puzzled because the official NHS figures I have been looking at suggest that, in November, there were 200,000 people blocking beds. What is more significant, all the experts say that the actual number of bed-blockers is three times the size of the official figure. Bed-blocking means that people are not given the best possible care and beds are blocked for others who could be admitted. Surely we have to solve this problem quickly.
Lord O'Shaughnessy
My Lords, the figures that the noble Lord is referring to are across the whole month. He may be aware that new figures have been published today, which show that an increasing proportion of delayed transfers is due to the availability of social care packages. He will also know that this reflects the changing nature of the patient demographic, which is becoming older and frailer. I agree with him that this needs addressing urgently, which is why the Government took action in the Autumn Statement to increase social care funding. We need to address the wide variation in the rate of delayed discharge from local authority to local authority. As the Prime Minister has said, in the long run we need a more sustainable solution.
Health: Mental Health
Lord Dubs Excerpts(10 years ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
Access and waiting times for people with mental health problems are a priority for this Government. We are committed to ensuring that access to services and waiting times are on a par with physical health. That is why we have put in place the first national waiting times standards in mental health.
Lord Dubs (Lab)
My Lords, will the Minister confirm that according to the widely respected Health Service Journal in April this year there were some 3,640 fewer nurses and some 213 fewer doctors working in mental health than two years ago? Surely it is unrealistic—not to say verging on the dishonest—to talk about the Government putting in place controls on access and waiting times when there is no prospect of achieving them.
Earl Howe
If the noble Lord looks across the piece at the workforce statistics he will perhaps be more reassured than he is at the moment. The £400 million that we are putting into talking therapies, for example, will result in a workforce of 6,000 practitioners trained to deliver IAPT. Health Education England has increased the number of mental health nursing training places by 1.5%. In delivering a multidisciplinary workforce, the aim is to have skills that are transferable between different care settings. NICE will be publishing its authoritative guideline on safe staffing. We have already mandated NHS organisations to publish ward-level nursing with midwifery care staffing levels so that there is an incentive for them to make sure that they have their staffing levels right.
NHS: Hospital Waiting Times
Lord Dubs Excerpts(10 years, 4 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, hospital waiting times are low and stable, but there are pressures from a growing and ageing population, and some patients are not receiving their treatment as soon as we would like. NHS England, the NHS Trust Development Authority and Monitor are working with the most challenged providers and commissioners. Operational resilience guidance, published in June, will help the system prepare for winter and improve waiting times sustainably for emergency and elective care.
Lord Dubs (Lab)
My Lords, that is a very impressive Answer. The Prime Minister said some time ago that the test will be to get NHS waiting times down. Judged by that test, will the Minister comment on this morning’s statistics from NHS England which showed that over the past year the number of patients waiting six months or longer for treatment has gone up by 20%? Does that not show that the Prime Minister has failed his own test?
Earl Howe
My Lords, I do not believe that that is a fair comment. In the past four years, since the Government came to office, we have substantially reduced the numbers of patients waiting longer than 18, 26 and 52 weeks to start treatment. Those numbers are lower than at any time under the previous Government. However, we need to address the build-up in patients waiting and, as a result, we are directing extra support and money for hospitals to do more than 100,000 additional operations over the next few months to meet the extra demand.
Health: Multiple Sclerosis Nurses
Lord Dubs Excerpts(10 years, 8 months ago)
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The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
It is the responsibility of commissioners and local providers to ensure that services have the staff they need to deliver high-quality care for people with multiple sclerosis. Listening to and learning from patients to improve care is a top priority for the Government. We are committed to putting patients at the centre of services. Commissioners are under a legal duty to involve patients and the public in the commissioning of services.
Lord Dubs (Lab)
My Lords, that is a bit disappointing. Does the Minister agree that MS nurses provide an invaluable service for patients as regards treatment, advice and access to services? Does he further agree that MS nurses can save costs elsewhere in the health service because they can reduce the pressure on GPs and on hospital admissions? Would it not be sensible for the Minister to say positively, “We need to ensure that every patient with MS should have an MS nurse to provide help and support”?
Earl Howe
My Lords, I agree with the noble Lord, Lord Dubs; there is no doubt that MS specialist nurses provide support that is extremely valuable for MS patients and their carers. They help to manage relapses and give advice, they act as a gateway into counselling and physiotherapy, and they help to minimise hospital admissions and reduce the need for consultant appointments. I do not disagree with the noble Lord at all. However, it is worth reminding ourselves that NICE guidelines on multiple sclerosis set out that after diagnosis, patients should be,
“put in touch with … a skilled nurse or other support worker”.
We expect those who work in the NHS to take account of NICE guidance.
NHS: Accident and Emergency Units
Lord Dubs Excerpts(10 years, 12 months ago)
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Lord Dubs (Lab)
My Lords, I congratulate my noble friend Lady McDonagh on having initiated a debate that enables us to draw attention to the serious crisis in A&E, which is evidenced by people waiting long hours on trolleys or in ambulances, the consequence of social care cuts, the fact that walk-in centres are being reduced and that NHS Direct has been closed down, all of which aggravate the problem.
I will focus my remarks on north-west London, which has been hit harder than most parts of the country. It is going to lose four of its nine A&E services and two of its major hospitals; for example, at Charing Cross Hospital 500 acute beds are going to disappear and will be replaced by up to 50 rehab beds. It means that the service at Charing Cross will be manned by GPs. There will not be a proper A&E service. There will not be a blue-light service at Charing Cross Hospital and people will have to travel much further. We are losing an excellent hospital for the sake of these cuts.
Above all, it means that the intensive care unit at Charing Cross will be closed; the stroke clinic, which I understand is probably the best in the UK, will go; and there will be no emergency surgery. It means that all the current beds and most of the site will go, mostly likely to be sold for development, and we shall lose an excellent hospital. It means that Charing Cross will become a second-tier site and there will be a knock-on effect at Hammersmith Hospital, which is also going to be hit very hard.
Services in north-west London will be decimated and patients will have to travel much further to go to A&E. In the heavy traffic in London, that is not a small thing. It is not a matter of an extra two or three minutes; it could be an extra long period before an emergency can be dealt with. What we will have locally is some very limited services indeed and we shall lose some of the skills and expertise that we have had.
At Charing Cross there will be GP cover; they will be able to treat simple fractures and will have some beds on site that can admit patients, mainly the frail elderly, for short periods of rehab or assessment. But there will be no emergency service at Charing Cross and nearby Hammersmith will have only an urgent care centre, which will not guarantee to walk-in patients that they will be seen by a GP, and there will certainly be no blue-light service.
We are losing a lot of our services in north-west London and I fear that the standards of the National Health Service will deteriorate. It is not necessary to do this and I very much regret that it is happening.
Care Bill [HL]
Lord Dubs Excerpts(11 years, 1 month ago)
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Baroness Meacher (CB)
My Lords, Amendment 41 is a probing amendment, so I will speak briefly. Before I say anything else, I applaud the Minister for the raft of amendments in this group. I was particularly pleased to see the amendments in relation to young carers, although this is not relevant to Amendment 41. However, government Amendments 32, 33, 36 to 38 and—perhaps in particular—39 and 40 are, of course, relevant to this amendment. My Amendment 41 requires that regulations that make further provision for carrying out a needs or carers’ assessment will specify the circumstances in which a person’s social care needs are to be regarded as complex—the amendments do not refer to that term, so I would like a further clarification of that—and that having defined “complex needs”, social workers should always be involved in the assessment of cases meeting that criterion. That is the proposal of the College of Social Work. I should say that the involvement of a professional social worker does not mean the exclusion of all others. Clearly, if a professional social worker is dealing with a deafblind person, he would need to involve a specialist in that particular group of disabilities.
The college makes the first point that a good assessor sets out to create a complete picture of a person’s situation, strengths, capabilities and aspirations. Social workers are trained and recruited on the basis that they have the necessary cognitive and emotional depth to undertake those assessments. The second point is that people with complex needs generally have an awful lot of different services to which they need to relate if all their complex needs are to be met. The role of the care co-ordinator therefore becomes vital in those situations; care co-ordinators tend to be professional social workers.
As the noble Earl knows, the Law Commission argued that where a person has complex or multiple needs, a proportionate assessment would require an in-depth and comprehensive exploration of those needs. It is difficult to imagine that somebody other than a professional social worker would be equipped to do that. The types of situation which would be treated as complex cases include: where a person is subject to legislation or national guidance; where a person is or may be subject to abuse; where there is conflict between a person and a member of their family or their carer; and where there is a need to support the applications of individuals or their families for continuing healthcare funding.
Government Amendments 32, 33, 39 and 40 could pave the way for regulations which would meet the concerns addressed in Amendment 41. The noble Earl will know that our particular concern is for clients with learning difficulties, mental health problems and, in particular, dementia—people whose needs will be quite complex and difficult to assess. You need people who have been trained in that sort of work. Can the Minister say, with respect to these vulnerable groups, whether regulations will clarify their need for a professional social work assessment, albeit involving others as well? If regulations will not deal directly with the assessment of people with complex needs, and in particular with those who have all those mental health problems, can the Minister explain what provision he plans to make in order to ensure that the needs of these particularly vulnerable people will be properly assessed and addressed?
Lord Dubs (Lab)
My Lords, I welcome how far the Minister has moved from Committee to today. I hope that noble Lords will not think it churlish of me to say that perhaps he might be persuaded to move a little further. I will speak first to Amendment 60, which seeks to oblige a local authority to provide advice and information about what can be done in the event of an emergency, or if needs change. I am specifically talking about what I think we have referred to before as people with fluctuating conditions and needs. We know that there are many millions of people in the country who have fluctuating conditions such as multiple sclerosis, rheumatoid arthritis, HIV, Crohn’s, colitis, epilepsy and Parkinson’s disease, and there may be many others. Therefore, we are talking about a significant number of people who will be affected by the provisions of this Bill.
Not long ago I was talking to a woman in a wheelchair who had MS. She was very lively, bubbly and sparky, and she said to me: “You know, I’m not always like this. Some days I go down and I can’t even get out of bed, so don’t judge my condition by the way you see me today”. I took that very much to heart, and it is clearly the sort of situation that this amendment is about. As the Bill is currently drafted under Clause 25, it would not really make provision for such situations.
This amendment is actually operationally simple. It would help to ease the pressure placed on formal and informal carers, and would give them more certainty. Not only will it ensure that individuals get the timely care that they need when they need it but, equally importantly, it has the potential to prevent costly and unnecessary hospital admissions. If this amendment is not in place, there is always the possibility that with a downward fluctuation in condition, the person without the support will then have to be hospitalised. That in itself is costly and is utterly undesirable from the point of view of the person who could be helped in the home if this amendment were to be passed.
Local authorities are surely in a position to provide better tailored care, to promote confidence and control and allow people to prepare for such rises and falls in their care needs. The current drafting does not allow for it. A snapshot was taken by the NRAS—the National Rheumatoid Arthritis Society—which indicated that currently more than 30% of respondents with rheumatoid arthritis have been admitted to emergency care as a result of a flare-up in the disease in the past year. This is something which I trust could be prevented if we changed the way in which this clause was to operate. A survey of 1,000 people with MS revealed that 95% of respondents felt that better services during a relapse or a sudden deterioration of their condition would help them to maintain their independence. More than 80% said that they want to be able to plan their care and support in advance of that care being required. This amendment would help people whose conditions might suddenly worsen and, as I said earlier, would potentially prevent unnecessary and costly hospital admissions.
I turn to Amendment 61. As the wording of the Bill in Clause 27 states, local authorities have the power to generally review care plans. However, they are not required to specify when they anticipate that these reviews will take place. This amendment seeks to put some certainty into the process. There should be an agreed date between the adult and the local authority upon which a review of the care and support plan would be offered. I envisage a discussion between the local authority and the person concerned about the best way in which their care needs can be met.
An anticipated review date, agreed between the local authority and the adults, would provide stability and certainty to those being cared for. It is not a large change but it would be beneficial for the people concerned. I do not want to spell out with examples where people have said what a difference it would make if they had this element of certainty. I would like this amendment to be passed, which will give the adult the confidence that their care would continue as agreed until the specified date or until the adult themselves chooses to request a review in line with Clause 27(1)(b).
Lord Mackay of Clashfern (Con)
My Lords, I generally support these government amendments, and thank the Minister for introducing them. There is just one small point I want to mention, which has been raised in my mind by the observations made by the noble Baroness, Lady Pitkeathley, in relation to Amendment 33.
I had understood paragraph (b) of Amendment 33 to carry the implication that if something was found that would benefit the person in question as a result of examination of what is in (b), the needs assessment would include that. However, I just wonder whether the last part creates the possibility that if the benefit can be received from something in the community, outside the provisions that the local authorities have made, that would be excluded; in other words, it would tend to reduce the needs assessment. I had rather thought that the proper construction of this phrase would mean that that also should be taken into account as included in the needs assessment, and that, where it was available, the cost of it should be included in the needs assessment. Perhaps my noble friend will be able to clarify that point for me.
Care Bill [HL]
Lord Dubs Excerpts(11 years, 3 months ago)
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“Access to appeals for care decisions
(1) In this section “the Tribunal” means the first tier Tribunal.
(2) Where a local authority—
(a) makes a decision under section 13(1) that some or all of an adults needs meet the eligibility criteria, or none of their needs meet the eligibility criteria,(b) exercises its power to charge for meeting needs under section 14,(c) completes a financial assessment under section 17, (d) makes a determination under section 18 or 19 that it must or may provide services to meet the adults care and support needs, (e) makes a determination under section 20 that it must or may provide services to meet a carers needs for support,(f) has prepared or reviewed a care and support plan, or a care plan under section 25 or 27,(g) has prepared a personal budget under section 26 or 28, or a care account under section 29,(h) the outcome of an inquiry under section 41,an application may be made to the tribunal within the relevant period.(3) The relevant period shall be prescribed by the Secretary of State in regulations.
(4) An application may be made by the relevant service user or carer who is the subject of the relevant decision listed in subsection (2).
(5) An application may be made by any other person with leave of the Tribunal.
(6) The powers of the Tribunal are to—
(a) dismiss the appeal,(b) allow the appeal and quash the decision appealed against, and(c) remit the case to the local authority to dispose of in accordance with the directions of the Tribunal.(7) The Tribunal shall have powers to order costs as it see fit.
(8) The Secretary of State must make regulations concerning the process and procedures of the Tribunal.
(9) In making regulations under subsection (8), the Secretary of State must seek to ensure adequate service user and carer representation on the Tribunal.”
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.
Earl Howe
Certainly, I anticipate that the results of the review will be available before the Bill has concluded its passage through Parliament. I stand to be corrected on that but I think I am right. In any case, changes to the way in which complaints are handled can be made through regulations under existing legislation, so I think that provides the necessary flexibility.
Earl Howe
That might prove helpful but I will take advice on it. We do not want to duplicate powers that already exist in legislation. However, if we decide that changes are needed, we need to make sure that they can be expedited properly. I am advised that the consultation will close in October this year and that the review of complaints arrangements, of which the consultation is a part, will conclude in the winter. Therefore, if changes need to be made to the Bill, they will need to be made in another place.
The noble Lord, Lord Dubs, said that in our response to the Joint Committee it is vital to consider redress. Of course, the principle of that is not in dispute. Our review of complaints arrangements is in line with our response to the Joint Committee’s recommendation, as I hope he acknowledges. In answer to the noble Lord, Lord Warner, I agree with him that there are likely to be teething problems as this system is established. That is precisely why we felt the need to review the current system. We will aim to ensure that any new mechanisms are in place before implementing the new system, as I have already indicated.
With that, I hope that I have provided at least some reassurance to noble Lords opposite that we take this issue seriously. We understand the concerns that have prompted this amendment and will certainly give further consideration to the noble Lord’s idea of a tribunal system in the light of the outcome of the consultation. I hope therefore that for the time being he will feel content to withdraw his amendment.
Lord Dubs
I am grateful to the Minister and I am interested in what he has to say. First, I thank my noble friends who have contributed to the debate and for the useful suggestions that they made, some of which, however, have been overtaken by what the Minister has said. My noble friend Lord Hunt talked about a simple, low-cost appeals system. That is very much in line with what the Minister said. The only issue is what chance we have to discuss further the outcome of the review and the Government’s further proposals.
I think the Minister said that either it will be possible in the Commons to consider any proposals the Government put forward as a result of their review; alternatively, it may be done by order, in which case we would all have a chance to look at it. In any case, that takes us quite a lot further. I am grateful to the Minister for what he has said and I beg leave to withdraw the amendment.
NHS: Accident and Emergency Services
Lord Dubs Excerpts(11 years, 4 months ago)
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Earl Howe
Not for the first time, the noble Lord hits on an extremely important aspect of the problem that we are facing. It is the frail elderly who often turn up at A&E with a crisis in their health when that crisis could have been averted. That is why Sir Bruce Keogh has been tasked to look across the piece at the whole system to see how we can ensure that the frail elderly in particular are served better by the health service, not least to prevent the exacerbation of long-term conditions.
Lord Dubs
The Minister has suggested that the problems of A&E are going to get worse in future. How will the Government’s attempt to tackle those problems be helped by the closure of A&E departments in many parts of the country? In particular, how will they be helped in west London with the impending closure of A&E departments at Hammersmith and Charing Cross hospitals?
Earl Howe
As the noble Lord will be aware, the latter issue is currently being scrutinised by the Independent Reconfiguration Panel, so it would be wrong of me to comment on that. On the question of reconfigurations generally, we are clear that this is a matter for local decisions by doctors, nurses and all those with a stake in the system. It is not for Ministers to issue edicts from the top. We are clear that any reconfiguration of A&E services has to take into account the capacity of the system to absorb any closures of A&E and the capacity of community services to step in where that is appropriate.
Care Bill [HL]
Lord Dubs Excerpts(11 years, 4 months ago)
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Baroness Browning
My Lords, I will speak to two amendments in this group: first, Amendment 92ZZK in my name and those of the noble Lord, Lord Touhig, and the noble Baroness, Lady Tyler of Enfield. This is very similar to an amendment that I tabled to an earlier part of the Bill, and it focuses in particular on transition:
“In preparing a care and support plan, the local authority must have regard to the young person’s education, health and care plan, where such a plan exists, and integrate the care and support plan with the existing education, health and care plan”.
I will not repeat what I said earlier, but this certainly applies to this clause because the integration is very important. This amendment is supported by the Care and Support Alliance, and particularly affects young people who are coming from adolescence into adulthood, where the seamlessness of their care package is very important. As I mentioned in moving the earlier amendment, this has, of course, a read-across into other legislation. I know that my noble friend gave me a reassurance last time, but it is important that the Bill requires that double-banking, if you like, to make sure that there is joined-up government here between not just two government departments but two plans that affect an individual’s future.
I also briefly raise the question of a probing amendment—Amendment 92ZZGA, in the name of the noble Baroness, Lady Emerton. In Clause 25(1)(e) the amendment seeks to change the words,
“includes the personal budget for the adult concerned”,
to “can include”. What has concerned the noble Baroness, Lady Emerton, here is that, although there may well be sanction for a personal budget for the adult concerned, the impression given by this particular wording is that it could possibly constrain the choice as to how that personal budget was spent. I appreciate that the care plan or the support plan would identify that sanction had been given for a personal budget. However, it is very important that it in no way presumes the choices in a prescriptive way that would take away from the individual concerned what is at the very heart of personal budgets—the right to choose services and items, which might well be something that they have a preference for and on which the local authority should not get too much into the detail, having sanctioned the personal budget in the first place. It would be helpful, when my noble friend responds, if he could give some reassurance on that matter.
Lord Dubs
My Lords, I shall speak to two amendments in this group, both of them amendments to Clause 25 —Amendments 92ZZH and 92ZZJ. I must say that I do struggle with all these initials; they make it hard to spot which amendment is which—but it may be that there is no better way of doing it.
Amendment 92ZZH is about people who have fluctuating needs for support because their condition is not constant. A fluctuating condition is a chronic condition, physical or mental, of which a characteristic feature is a significant variation in the overall pattern of ill health and/or disability. There are many millions of people in the UK with fluctuating conditions. Those could include MS—I am an officer of the All-Party Group for Multiple Sclerosis—rheumatoid arthritis, HIV, Crohn’s disease and colitis, epilepsy and Parkinson’s disease; there may also be others. Those conditions cover a large number of people.
The problem is that when people have fluctuating conditions it will be much harder to plan ahead on the basis of the present drafting of Clause 25. There is not the flexibility to enable account to be taken of the ups and downs associated with fluctuating conditions. If the plan could take account of fluctuating conditions, individuals could be assured that they would get the level of care they needed, consistent with the fluctuations in their condition. By allowing for that, we can also prevent costly hospital admissions. That in itself is an important aim both for the well-being of the person concerned and, in terms of cost, for the health service.
For example, a snapshot survey of individuals showed that 30% of respondents with rheumatoid arthritis had been admitted to emergency care as a result of a flare-up of the disease in the past year—of which, of course, no account is taken by the Bill. The benefit of my suggestion is that it would make it possible to plan ahead for variations in care and support, in advance of those variations being required.
Amendment 92ZZJ is about the period over which care will be made available before the need is reviewed. The current wording of Clause 27 gives local authorities the power to,
“keep under review generally care and support plans”.
“Generally” is an all-purpose word which can mean anything. Local authorities are not required to specify when they expect such reviews to take place. Anyone who is subject to something “generally” lives in uncertainty, and what I would like to achieve with my amendment is some element of certainty.
The key benefit of the care and support planning process would be to allow a discussion between the local authority and the person concerned about the best way their care needs could be met. Then there could be an agreement between the local authority and the adult or carer. It is important for such an adult to be confident that their care will remain consistent until their circumstances change. Under my amendment they would not be subject to an early review if there was no need for it, but when things happened, that could be reflected in their care plan. The amendment would give that adult the confidence that their care would continue as agreed until the specified date, or until the adult himself or herself chose to request a review in line with Clause 27(1)(b). That may seem a small change but it would be important to the individuals affected.
Lord Sharkey
My Lords, I shall speak briefly to my Amendment 92ZZS. Its purpose is to ensure that the direct payment system works well. In particular, it would ensure that all parties to the decision to use direct payments fully understood the implications of that decision.
I raised this matter at Second Reading because I was concerned that some successful applicants for direct payments may underestimate the difficulties involved in administering those payments. I was concerned that there was no clarity about exactly how local authorities would make the decision about who was and was not a suitable recipient for direct payments. For example, it is likely that many in receipt of direct payments will want to employ people directly. Will they understand how very complicated it is to employ even one person? How will they find out? Exactly how will local authorities assess their ability to do this, and will people properly understand any contractual arrangements they may enter into? Who will help them understand? Exactly how will local authorities assess their likely abilities in this area?
I suggested at Second Reading that a way of dealing with this was to give local authorities an obligation for friendly oversight of the administration of direct payments for an initial period of six months or so. In his very thorough and helpful letter of 5 June to those who spoke at Second Reading, the Minister pointed out that Clauses 31 and 32 set out that, before a direct payment is made, the local authority must be satisfied that the adult or someone nominated on their behalf is capable of managing the direct payment. He felt that these and other provisions in Clause 4 should ensure that direct payments are used appropriately.
I am sure that these provisions will be very helpful, but they would be more helpful if the local authority had to explain to applicants on what basis their capability was being assessed and the exact criteria for assessment. It would be more helpful still if the explanation was in written form and followed by discussion with the applicant. That is what my Amendment 92ZZS would put in place. It simply requires the local authority to make known in writing and discuss with the applicant the criteria that it uses to satisfy itself that the adult is capable of managing a direct payment. This would have the effect of bringing about a proper discussion of the implications for the applicant of managing direct payments and provide a proper and informed basis for the local authority to make a judgment. I hope that it would also ensure that the criteria for judgment were clear, understandable, user-friendly and completely transparent. Making this simple change would greatly improve the chances of correctly matching direct payments with those who understand the implications and can effectively manage the system. I very much look forward to hearing the Minister’s thoughts on the matter.