Access to Palliative Care Bill [HL]
Lord Elton Excerpts(8 years, 9 months ago)
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Lord Elton (Con)
My Lords, I begin, as we all do, with thanking the noble Baroness and congratulating her on getting this slot. I also thank her for the enormous dedication, expertise and persistence with which she has pursued this task—this calling—of easing the way out of this world for so many hundreds of people. I should say that I come to this debate as a learner, not as a teacher. I am far from certain that I have grasped all the issues—I have certainly not grasped the final solution—but I would like to make a couple of observations and one suggestion.
My noble friend Lord Crisp was advocating greater openness in discussion about death. I reflect that, to initiate that, you need a largish community with a high average age containing a number of medical professionals and a scattering of clergy. Indeed, here we are, doing what he asked.
My interest and motivation, apart from that which all of our age share, comes from having contrasted the experience of a close friend of mine, whose death at home I observed, wonderfully supported by the local palliative care team, and a report from another friend of an appalling end of life where the person was for several days in such pain that, whenever the person was conscious, the bed was vibrating. That is an inequality which is absolutely insufferable in a civilised society.
Two images float into my mind that suggest how compassion enters into this. The first is the telephone answered after midnight for the noble Baroness, Lady Byford, when her husband was dying. The other was the bowl of porridge mentioned by the noble Lord, Lord Howard of Lympne, brought to a man coming from a hospital into a hospice and, I fear, on the way out.
The number and diversity of people involved in evolving a proper, coherent service seems to me one of the biggest difficulties, and there is the question of establishing communications between them, one with another. We are talking about professionals, who have the royal colleges, and clinicians, who have endless conferences around the world, all of them highly productive, but we are also talking about non-professionals, non-clinicians —care workers, paramedics, sometimes policemen or prison officers, all of whom have been mentioned. There is no forum for them.
It would be wrong to try to attempt that in legislation, but an early focus of attention after the Bill either goes on to the statute book or does not ought to be how to remedy that. How good are communications between different clinical commissioning groups? Should there not be a central, national forum for them—perhaps there is, I do not know, I am a novice—in which each group or cluster of groups could exchange notes on their practice? From the evidence that we have been sent and the stories we have been hearing, practice differs violently between one area and another.
There should be an established, respected and, I think, independent but supervised forum that could begin to generate a corpus of accepted best practice that could be shared around the country—indeed, across the nations; we have three nations represented here, and how much other groups seem to be able to learn from the Welsh groups. This is the beginning of that process. How it gets carried down to the next level of the variety of people involved is for another debate, and certainly for someone more learned in these things than I am, but I hope that we can get the fertilising cross-flow of experience between groups to begin.
The Parliamentary Under-Secretary of State, Department of Health (Lord Prior of Brampton) (Con)
My Lords, first, I join with everybody else in thanking the noble Baroness, Lady Finlay, for raising this issue and bringing the Bill before us. She has a long history of passion, commitment and experience in this area, and we all recognise that. There seems to be violent agreement from all sides of the House on the substance of her Bill, and so I congratulate her on the support that she has garnered, which of course goes way beyond noble Lords in this House.
Before I address the Bill directly, I want to draw out three themes that have emerged out of the debate today. The first is that, despite the report from the ombudsman and some very upsetting individual stories, the UK does pretty well in this area. My noble friend Lord Howard referred to the report in the Economist. For the second time—the first being five years ago—out of all 80 countries surveyed, the UK came top, and that includes all the richer nations. We come significantly higher than most other European countries. In part, that is because the hospice movement in the UK has been extraordinarily successful. My noble friend Lord Howard referred to the CQC report. It is quite extraordinary that 90% of all hospices inspected have been “good” or “outstanding”.
However, in praising the hospice movement and the care that it delivers at home, let us reflect for a minute on how difficult it is to provide good-quality palliative care in a very busy acute hospital. It is true that they probably do not do it as well as it is provided in hospices, but, given the circumstances, they often do a remarkable job. My noble friend referred to the bowl of porridge that was provided in a hospice. I refer him to the Wrightington Hospital, where a lady coming near to the end of her life said that her one last wish was to see her horse. They brought the horse to the hospital and wheeled her down to see it. We do see these extraordinary acts of kindness and compassion in NHS hospitals as well. That is the first point that I would like to make: the UK does this pretty well.
Secondly, the most important point to come out of today’s debate is the patchiness of how we do it. Variation, I am afraid, is a problem that runs right through the NHS. The noble Lord, Lord Davies, went right back to 1946. Whether it is in end-of-life care, orthopaedics, stroke care or cancer care, there has been this level of variation since the inception of the NHS in 1946. The way that this Government have decided to try to confront this level of variation is through transparency.
It is a fact that, outside healthcare, the only way to drive out variation is through a market—we all know that. If you have choice and competition, they will drive out variation. It is much more difficult in an area such as healthcare, where there is such imperfect information and such imperfect choice. Our approach is to try to confront this issue of variation through transparency. It is not just through CQC reports but through having a much more open culture within the NHS. I say to the noble Lord, Lord Warner, that choice is also a key factor in that, where it is possible.
The third key theme to emerge from this debate is the importance of out-of-hospital care. Where we can deliver good-quality, safe care outside hospital, it tends also to be at lower cost. If it is at lower cost, we have more resources to spend elsewhere in the system. I say in response to my noble friend Lord Howard that I know that Hospice UK is in discussions with NHS England about whether it can help us deliver more care outside hospital. Other noble Lords referred to the huge importance of district and community nurses. Delivering out-of-hospital care to people who are at the end of their lives requires considerable expertise; you need district and community nurses on hand to administer pain relief and the like. In the case of my own mother, who died very recently in an NHS hospital, it was essential to have people there all the time who could adjust the level of pain relief, oxygen and the like.
Those were the three general points that I wished to make. I am afraid, however, that the Government cannot support the Bill and I will set out the reasons why. The most important reason is not that we disagree at all with the underlying intention of the Bill—we are in full agreement with it—but that we do not feel that primary legislation is the right way of tackling the issues raised because it could lead to unintended consequences. Most importantly, we feel that it attempts to deal with issues that, in the main, are best tackled by clinicians, ideally together with patients, carers and loved ones, based on a combination of the patient’s individual condition, preferences and the clinician’s professional expertise.
There is no other part of the healthcare system, be it cancer, stroke, maternity—the beginning of life as well as the end of life—where we have the mandated system that is proposed in the Bill. I will withdraw the following analogy if it is not fair. When the Liverpool care pathway was introduced—I was a huge supporter of it—there many parts of the country and many hospitals where it was implemented sensitively and where it contributed greatly at the end of many people’s lives. Yet, because in some parts of the system it became a tick-box solution where people were ticking the box and missing the point, I sometimes feel that a top-down, central directive, be it through legislation or from another source, can interfere with best-practice decision-making. That is the primary reason why we oppose the Bill.
However, there is a second reason—it is probably less strong, but it is strong nevertheless. It is that we feel that the Bill goes against the whole concept and principle of local autonomy that was established in primary legislation through the Health and Social Care Act 2012. I accept that clinical commissioning groups are still in their infancy—they have only been there for just over two years—but they are bound by a duty to commission health services based on the assessed needs of their local population, and palliative care is included in that stipulation. There is also concern that legislation on this issue as set out in the proposed Bill could stifle local innovation by NHS bodies, including commissioners, as they seek to improve the quality of care and provision.
As well as the responsibilities given to the local commissioning bodies, the 2012 Act also enshrines specific responsibilities for health education and training on Health Education England. This Bill would supersede those provisions, thus undermining the role and responsibilities of Health Education England, which works in partnership with local training and education boards to commission and deliver appropriate training and education.
I could go on and talk about what the Government are doing in this area, but that is the fundamental point and I should probably leave it there. We have huge sympathy for the underlying intent of the Bill.
Lord Elton
My noble friend has put local autonomy at the centre of his argument. If local autonomy results in unacceptable variations between localities, will the Government be on the look-out for this? It has only been running recently, as my noble friend says, but will he keep it at the forefront of his watch? If it increases or does not diminish, then something will have to be done about local inequalities.
Lord Prior of Brampton
My noble friend makes a good point. There is tension in the health service between local autonomy, local accountability and the National Health Service. There has always been this tension. We believe that in driving up standards it is best to have the local autonomy. However we must also have transparency so that we know who is falling behind and who is forging ahead. As to transparency at a clinical level, I was talking to a former president of the Royal College of General Practitioners recently—she comes from a different political background from myself—and she said that within the DNA of all doctors is a huge sense of competition: they want to deliver better care than the next-door doctor. That is true of surgeons probably more than anyone, but also true of GPs, physicians and hospitals, and increasingly it will be true of CCGs as well. My response to my noble friend is that we are embedding a much higher degree of transparency into the system and it is through that transparency that we will drive improvement by highlighting the best and the worst.
Mental Health Services: Young People
Lord Elton Excerpts(9 years ago)
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Lord Prior of Brampton
The use of police cells for anybody suffering a mental health crisis, but particularly for children, is wholly unacceptable. Last year, the number of children who were held in a police cell was 160. That has come down from a much higher number. The Government and my right honourable friend the Home Secretary are determined to stop this happening—indeed, legislation is about to go through the other place to ensure that it does not happen. But that leads to the question of where, if not to a police cell, they should go. I have been told that there is a risk that young people going through a mental health crisis might actually be arrested to make them eligible to come into a police cell, which would of course be equally unacceptable. The number is getting much smaller and I hope that if I am here in a year’s time it will be down to zero.
The Lord Privy Seal (Baroness Stowell of Beeston) (Con)
My Lords, we have not heard from the Conservative Benches yet on this Question. I think my noble friend Lord Elton is next.
Lord Elton
My Lords, the previous answer made it clear that a significant proportion of the pupils and young people the Question refers to are in custody. Can the Minister assure us that there is equality of treatment, within both the spend and the survey he referred to, for those children in these dire circumstances?
Lord Prior of Brampton
I thank the noble Lord for that question. I am not sure that I totally got the question, but I can say that keeping a young person in custody is the absolute last resort. The police do not wish to do it and do so only when there is no bed available in an appropriate, safe setting. The issue is the availability of beds. It is better for a child to be in a single room on an adult psychiatric ward than in a police cell.
Health and Social Care (Safety and Quality) Bill
Lord Elton Excerpts(9 years, 4 months ago)
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Earl Howe
I am very sorry that I have not given that explanation clearly enough. The point was well drawn out at Second Reading by my noble friend Lord Ribeiro that what Clause 1 essentially does is to bring patient safety absolutely to the fore in the context of the CQC’s work. That is entirely consistent with the approach that we took in the fundamental standards regulations which, as the noble Lord knows, flowed out of the work done by Sir Robert Francis QC in his report on Mid Staffordshire. If I can be clearer to the noble Lord before the conclusion of this debate, I will be glad to do so but I find it difficult to say more than I already have on this.
The noble Lord, Lord Turnberg, asked about the CQC’s guidance. Its guidance on the new fundamental standards has been consulted on. The CQC has a range of actions that it can take when a provider does not meet the fundamental standards, ranging from a warning notice to cancelling registration. The CQC’s enforcement policy is clear that any action that it takes will be proportionate to the risks to patients and that its most serious sanctions will be used only in response to the most serious service failings.
Lord Elton (Con)
My Lords, would another way of addressing the concerns of the noble Lord, Lord Warner, be to say that Clause 1 removes from the Secretary of State a discretion to produce regulations which are not as satisfactory as the current ones are?
Lord Elton
My Lords, given the undertaking that we are not going to divide on this, I am tempted on to my feet to remind your Lordships that, although we have talked about the Climbié case, this goes back to the case of Maria Colwell in 1975, when Lord Goronwy-Roberts, the Labour Minister for Health in this House, was successful in beginning the setting up of at-risk registers. That was a long time ago and yet we still have not solved the issue of the breakdown of information sharing between agencies, voluntary and otherwise. I encourage my noble friend to leave a note on his desk, to which we all hope he will return after the election, reminding himself to get on with this.
Lord Hunt of Kings Heath
My Lords, I am not sure about the noble Lord’s latter point. I think my noble friend has done us a great service in raising this issue. Since we are talking about unique personal identifiers again, perhaps I may first remind the House of my presidency of the bar-coding association, GS1.
As a resident of Birmingham, I thank my noble friend for his work as the Children’s Commissioner, which has been invaluable. Your Lordships will have a great opportunity to discuss these matters further on Monday night after we debate standardised packaging of cigarettes, because I have a Motion to Take Note on the Birmingham electoral order, which changes the electoral cycle in Birmingham following the work of the three commissions and the Permanent Secretary at the DCLG.
On the substantive point, my noble friend raised the case of Victoria Climbié, on which I well remember making the Statement to this House a long time ago now. What was so striking in that report was that she went through, I think, at least eight or nine public agencies. If any one of them had talked to another, it is likely that she would still be alive today. It was a shocking report, because there were so many failures by so many different organisations. Although, inevitably, the local authority always tends to be the focus of concern, neither the health service nor the police covered themselves in glory. I am not really in a position to commit the Opposition in exactly the way that my noble friend wants, but if the noble Earl would like to institute some urgent cross-party discussions with my noble friend, we would certainly be very happy to take part.
Earl Howe
My Lords, to start with a given, I am sure I speak for the whole Committee when I say that we are all committed to taking whatever steps are necessary to protect children from abuse and neglect. Clauses 2 and 3 are, as they stand, based on long-standing policy intentions. They have real buy-in and support from those who will need to deliver them.
As regards children’s social care and wider children’s services, the difficulty with proceeding without delay in the direction that the noble Lord, Lord Warner, is advocating is that we do not yet have robust evidence on the impact of the potential burdens and risks of an extension of these duties. Moving to the use of a common identifier for the education and children’s social care sector would represent a substantial change. In the discussions that I have had on this, I have been persuaded that it is only right that we fully understand and assess the impact before considering legislation.
However, I can give the noble Lord, Lord Warner, some hopeful news. I am pleased to inform him that the Department for Education has committed to undertake an evidence-gathering exercise to understand fully the impact of adopting a consistent identifier for these types of provision. That exercise is expected to report before the end of the year. I hope the noble Lord will understand that we would not want to pre-empt the outcome of that or make decisions now on behalf of Ministers in the next Government, who will wish to consider the evidence once it is available.
The amendment would also have the effect of creating a power to extend Clauses 2 and 3 to other public bodies where there was evidence that this would benefit the health and well-being or protection of children. I recognise and welcome the sentiment and reasoning behind the desire to extend the information-sharing duty under this Bill to encompass child protection issues. As I have already assured the noble Baroness, Lady Finlay, there are clear requirements on professionals to share information to protect children. I hope that reassurance is helpful.
Lord Elton
In fact, Reg Wells-Pestell, not Goronwy Roberts, was the Minister. I want to get that right for anyone who is old enough to remember and reads Hansard.
Lord Ribeiro
My Lords, the amendment tabled by the noble Lord, Lord Warner, seeks to extend the use of the NHS number to services that benefit children, particularly those in social care, and which protect them from abuse. The Minister addressed the amendments in some detail and I was pleased to hear the assurances he gave, which I hope will have an effect. But I also note that the noble Lord, Lord Warner, was pretty impartial in his criticism of both Front Benches, and the suggestion that they come together and provide some movement is something that perhaps could happen when we have the report from the Department for Education at the end of the year. I will leave it to the noble Lord to decide. He has already intimated that he will not be pressing his amendment.
Human Fertilisation and Embryology (Mitochondrial Donation) Regulations 2015
Lord Elton Excerpts(9 years, 4 months ago)
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Earl Howe
I can only say again that the legal advice I have had is that the charter cuts in only when there is an issue of European law. We do not consider that treatment services, which are what we are talking about here, are covered by EU law. The noble Baroness made a point of saying that my right honourable friend the Attorney-General did not vote in favour of the regulations, but it is difficult for me to comment on that. There was, rightly, a free vote in the other place, just as there is here. I cannot comment on the personal view of the Attorney-General—and I have to say that I do not think that anything said or quoted by the noble and learned Baroness threw much light on that issue.
I repeat that my department is confident that these regulations are necessary and have a sound legislative base in the Human Fertilisation and Embryology Act 1990, as amended. As my noble and learned friend Lord Mackay rightly pointed out, it was the clear intention of Parliament that this provision would enable mitochondrial donation to take place in a clinical setting.
On the issue of safety, my noble friend Lord Deben urges us to delay until further research is carried out. However, we could wait indefinitely for research and follow-up and still not have a 100% assurance about safety, because that is the nature of science and research. The standards of assurance that some are seeking are considerably higher than those for cancer treatment or heart disease. As far as the expert panel convened by the HFEA is concerned, there is no evidence to suggest that these techniques are unsafe. The critical experiments are progressing positively.
As I said, the mitochondrial donation regulations require the HFEA to assess each application for mitochondrial donation on a case-by-case basis. That will include consideration of the evidence on safety and effectiveness. As a statutory independent regulator, it is for the HFEA to determine its own procedures for assessing applications to carry out treatment regulated by the 1990 Act. Applications to provide mitochondrial donation treatment are no exception to this rule but, clearly, the HFEA will not authorise the treatment if it does not consider it safe to do so.
It is never possible to answer every safety question before new medical procedures are used in people for the first time. New techniques can be refined and reviewed. Even the most exhaustive research can establish only that a technique is sufficiently likely to be safe to justify “first in human” treatment. However, if medicine is to progress, clinicians should in my submission be permitted to use new techniques when evidence suggests these are sufficiently safe and effective. It is the Government’s view that medical knowledge in the field of mitochondrial disease and donation has now reached this stage and it is time to progress. The legislative framework of the HFE Act provides for Parliament to endorse the Government’s view before proceeding and, following the extensive process of consideration that I have already set out, we have properly brought this to Parliament for debate on affirmative regulations.
I listened with care to the noble Baroness, Lady Hollins. I absolutely concede that there is a balance of risks to be considered. As I have said, it is not possible to be certain that new medical procedures will be 100% safe or effective. These risks must be balanced with the risk of ongoing suffering for families with mitochondrial disease. For me, the simple point is this: scientific evidence suggests that any risks of mitochondrial donation are proportionately less than the significant risk that children will continue to be born who will develop severe mitochondrial disease if these techniques are not used. As the noble Lord, Lord Patel, pointed out, ultimately it will be up to affected families to judge the balance of these risks with advice from their clinicians and then to decide whether they choose to proceed with treatment, subject to authorisation by the HFEA.
My noble friend Lord Deben mentioned the Chinese study. That study has not been published and we understand that it will not be. It concerns one pregnancy, using an earlier form of pronuclear transfer. One of the clinicians involved gave a full interview to the Independent recently and explained that the complications that occurred related to multiple pregnancies from multiple embryo transfer, rather than from the mitochondrial donation process. As I understand it, there were no genetic abnormalities in the foetuses.
Turning again to the speech by the noble Baroness, Lady Hollins, the HFEA-convened expert panel considered the issues that she raised: if the patient and the donor have different mitochondria, known as haplotypes, the donor’s mitochondria may not, as it were, “talk properly” to the patient’s nuclear DNA, causing health problems. The panel considered that as part of its third scientific review. However, it was of the view that the data submitted to it about this potential problem were not relevant enough to raise safety concerns. However, the panel has recommended, as a purely precautionary step, that consideration be given to the mitochondria haplotype when matching donors to patients, even though the risks of not doing so are assessed to be very low.
The noble Baroness questioned whether successive generations, particularly girls, could have the same problems arise from unhealthy mitochondria. The principle behind the treatment is that the mitochondrial DNA that the child will inherit will be the disease-free mitochondrial DNA of the donor, not the faulty mitochondrial DNA of the mother, although there is a small risk that the low level of unhealthy mitochondria may be carried over when the patient’s nuclear DNA is moved from her egg or embryo to the donor’s. Evidence continues to be reassuring that carryover after mitochondrial replacement is very low and unlikely to be problematic. The risk of mitochondrial disease being present in these generations will, we believe, be low.
The noble Baroness also said that we still do not know enough about the relationship mitochondria have with the human body. This is true of many aspects of human physiology, not just mitochondrial DNA. The majority of the evidence indicates that mitochondria are primarily concerned with generating the power that every cell in the body needs to function. It is generally accepted that, as vital as the function of the mitochondria undoubtedly is to the human body, they do not play a role in developing a person’s physical appearance or personality traits, which are derived solely from nuclear DNA.
Lord Elton (Con)
Before my noble friend leaves the question of risk, may I ask him to close a little chink in the reassuring curtain that he is drawing before us? We are assured by the HFEA that there is no evidence of risk in what is proposed, but it also proposes quite a large phalanx of experiments that should be completed before proceeding. First, there appears to be a slight logical discontinuity there. Secondly, can we be reassured that, in the Minister’s view, the HFEA will not proceed to licensing anybody until they have completed that programme of experiments?
Earl Howe
My Lords, I can confirm to my noble friend, and to the noble Lord, Lord Hunt, who asked a similar question, that the expert panel stated that the further experiments that it recommended could take place either before or after the passing of these regulations. However, they must be done before treatment can take place. I hope that that is sufficient reassurance.
The noble Lord, Lord Alton, and the noble Baroness, Lady O’Loan, spoke about the risk of ovarian hyperstimulation syndrome. OHSS is a well recognised side-effect of the drugs used to stimulate a patient’s or donor’s ovaries to collect multiple eggs for use in fertility treatments. The risks of OHSS are very well understood, with patients and egg donors carefully monitored. The HFEA’s code of practice requires women undergoing ovarian stimulation to be given information about the possible side effects and risks, including OHSS. Women are informed of the symptoms to look out for and are warned to contact their clinic if they feel unwell. Women donating eggs for use in mitochondrial donation will not be at any increased risk of developing OHSS.
The noble Lord and the noble Baroness both questioned the practice of paying for donated eggs. I submit that there is nothing sinister in that. Within the legal framework of the HFE Act, the HFEA sets the rates for compensation to donors of eggs or sperm; £500 for an egg donor is well within those limits. It certainly is not a sign that Newcastle University is anticipating the introduction of the regulations to allow mitochondrial donation. It is continuing its research and has an ongoing need for donated eggs for that purpose.
I turn now to the issue of definitions. In making the regulations, the Government have been clear about their approach, the definitions used and the source of their material. The Government’s consultation on the detail of the regulations set out very clearly: the definitions of scientific terms; the detail of the techniques that the draft regulations would cover; the terms that others might use, such as “genetic modification”; and the proposed approach to information for donors and those conceived through mitochondrial donation.
Health and Social Care (Safety and Quality) Bill
Lord Elton Excerpts(9 years, 5 months ago)
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Lord Elton (Con)
My Lords, I am the least qualified contributor to the debate, so I shall make my speech suitably short as an act of humility in deference to those who are so much my senior in this field. It was the Mid Staffordshire disaster and the reports following it which focused public attention on the risks to patients in the health service in this country. It is appropriate that it was my kinsman, Jeremy Lefroy, the honourable Member for Stafford, who brought the Bill to the other place. I congratulate him and my noble friend on the style in which they have done it.
I share the anxiety of many of your Lordships about the fact that it has to be debated in a truncated form. We are diminishing the effectiveness of this House if we do not give it the full treatment. On the other hand, we have to balance the possibility that there will be no opportunity in the next Parliament—depending on what political colour emerges from the election—and that it is better to take what we can get than to hope to get a lot more.
In trying to express that, I was looking for a simile. When my eye fell on the mammoth legislation proposed by the law commissions, I realised that the simile for me is that the Bill is like a dolphin leaping just under the bows of a mammoth tanker. We need the mammoth tanker but the dolphin has its own value, in ways which my noble friends have already so adequately explained.
Two phrases caught my attention in the debate. The first was the need for a culture change. I am not actually sure what the other was. However, it seems that we are looking at the mechanisms to regulate people in the health service but not looking at the people themselves. What is needed for the prevention of harm is that first of all qualities laid down by the lady with the lamp, Florence Nightingale: tender loving care.
When I read stories of elderly people and demented people being brutally treated, I recall my very short time as a Minister in the Department of Health, when I was given special responsibility for mental health—for only six months, which was probably a good thing. I visited a large number of hospitals and wards specialising in mental health and what astounded me was the patience of the people looking after the affected ill. When I hear of the very different treatment of people with mental afflictions now, particularly in old people’s homes and nursing homes but elsewhere as well, it strikes me that that conduct could not have been perpetrated by the people whom I saw nursing in those institutions.
Apart from these mechanisms for regulating people in the service, what we need is some procedure to identify those who are fitted for particular parts of that service. The person who is perfectly adequate, even brilliant, as a theatre nurse might find that her patience snaps after six months looking after people who are doubly incontinent, incapable of speech or intermittently violent. That must go also for those dealing with people with dementia, who are unable to recall who or where they are and ask the same question 75 times a day. That requires very special characteristics, which need to be identified, and the people who have them need to be directed where the work is most difficult.
I hope that the Bill gets on to the statute book. While I understand the enthusiasm of those who want to make it perfect, I repeat my position: it is very much better than leaving it to chance. All the authorities should be singing from the same hymn sheet in the coming years, and the enormous legislation proposed by the law commissions should be enacted as soon as possible. I have detained your Lordships long enough. I might say that I have come to the place where there is a dotted line on my paper, which says “Cut here”—and, unlike my noble friend, I will.
Health: Talking Therapy
Lord Elton Excerpts(10 years, 7 months ago)
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Lord Elton (Con)
Will my noble friend assure the House that this rule of parity will be introduced in the Prison Service as well as the National Health Service generally?
Care Bill [HL]
Lord Elton Excerpts(10 years, 8 months ago)
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Baroness Barker (LD)
My Lords, I thank the noble Lord, Lord Hamilton, for his kind words about the work I did on this issue. On Report, I tabled the amendment which stands in his name today because at that point the Government were working to a definition of well-being which was about emotional well-being, and it was my view that it did not sufficiently encapsulate the matters we would define as spiritual. My name is not on the amendment today because over the past few weeks I have discussed this at some considerable length with a number of people, not least with the Minister and the noble Lord, Lord Warner, on BBC Radio 4 at some unearthly hour a couple of Sundays ago.
I think the Minister has met us where we need to be because his amendment refers to “feelings and beliefs”, which is a fairly wide and inclusive term. It is important that we take his words, not the wording proposed by the noble Lord, Lord Hamilton, because most of the discussion this afternoon has been about health and healthcare in healthcare settings, such as end-of-life settings, but this Bill is about social care at its widest in the community. Therefore we are perhaps not talking about the well-being of people at the end stage of their life, and it is important that we stick to a wider definition of a person’s beliefs because we are not talking just about medical matters.
The way the Government have framed the argument is sufficiently wide to include spiritual beliefs. I think in the normal course of conversation, when we talk about beliefs, we have almost a hierarchy of them. Religious beliefs perhaps come fairly high at the top; then people would secondarily think about spiritual beliefs. They might go on to talk about political beliefs being important to a person’s well-being. That is why I think that this time the Government have got this right. It is sufficiently clear and sufficiently inclusive to reflect all the concerns that remain legitimate on behalf of people backing my noble friend Lord Cormack’s amendment.
On this occasion the belt and braces are unnecessary and the noble Earl, Lord Howe, has got the House to the point where it wants to be. I will be quite happy to support that, not least because I think if we reform it we go with that formulation of words. Then we will be able to do the one thing which I think the law has to do, which is to be there as a backstop for those people who believe that their feelings and wishes are not being acknowledged and are being abused. That is the primary purpose of this legislation. Therefore, it should be as wide as possible.
Lord Elton (Con)
What the noble Baroness has just said prompts me to point out a difficulty. We are in an age when there is controversy about spirituality, when people can actually lose their jobs over issues of spirituality. If there were to be a case arising under this legislation in which such a matter arose and spirituality was not mentioned in the Bill, the position of those people would be a great deal weaker than if the Bill was amended as my noble friend suggests. Like the Chief Whip, I know that it is contrary to our normal custom to divide at this stage, but it seems that this is an issue of sufficient importance on the one hand and of narrowness of scope on the other to make it both necessary and painless.
Lord Hunt of Kings Heath (Lab)
My Lords, as this is a new stage I will just declare my interest as chairman of an NHS foundation trust, president of GS1, and a consultant and trainer with Cumberlege Connections. With the noble Baroness, Lady Barker, I, too, was very interested in this discussion at an earlier stage of the Bill. Our concern is that the original Government view is that spiritual issues would be embraced by Clause 1(2)(b) under the words “emotional well-being”. The noble Baroness, Lady Barker, and I did not feel that that was sufficient. Indeed, we had some worries that spiritual well-being could actually be subsumed under the terms “emotional well-being”.
The noble Earl, Lord Howe, has, I think, met our concerns. As he said in his letter to us, adding “beliefs” to Clause 1(3)(b) enables spiritual beliefs to be encompassed within that term without excluding any other forms of belief that may not be described as spiritual. I think that meets the concerns that I had about this matter. I would like the noble Baroness, Lady Barker, to draw a distinction between that and the specific issue that noble Lords have raised in relation to the health service, which is clearly designed to ensure that the NHS employs a chaplaincy service and which I absolutely subscribe to. Indeed, I pay tribute to the chaplaincy service up and down the country. However, this Bill is about a different set of circumstances. To the noble Lord, Lord Elton, I say that employment issues do not arise in this regard. We are talking about Clause 1 of the Bill, which is about promoting the individual well-being within the context of the Care Bill. I understand the point that he raised, but I do not think it arises in this context.
I would, though, say to the noble Lords, Lord Hamilton and Lord Cormack, that, reading the Companion, they are definitely right to bring this issue up on Third Reading. It is quite clear that an issue was raised in the debate on Report and the noble Earl agreed to look into it. He has now brought forth an amendment, and the Companion is absolutely clear that amendments on Third Reading are,
“to enable the government to fulfil undertakings given at earlier stages of the bill”.
Lord Elton
My Lords, on the noble Lord’s response to me, if an employee is able to point to statute and say that they are carrying out a requirement of statute, that has a very considerable bearing on tribunal cases and should not be brushed aside.
Lord Hunt of Kings Heath
My Lords, I do not seek to brush it aside. However, this clause relates to the responsibility,
“of a local authority, in exercising a function under this Part … to promote that individual’s well-being”.
Spiritual issues are subsumed under the amendment moved by the noble Earl, Lord Howe. With the greatest of respect, this does not relate to an employment law issue between an employer and an individual. This is very much around the kind of support that should be given to an individual by the local authority. There is a distinction between the situation that the noble Lord raised, and the issue that is set out in this clause.
Winterbourne View
Lord Elton Excerpts(11 years, 8 months ago)
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Lord Elton
My Lords, my noble friend is right: the care of people with learning difficulties requires a different order of commitment, compassion and patience. The Government are putting some weight on referring and sending people with learning difficulties out of institutions and into private homes. Can he give us reassuring news about the ease or difficulty of supervising the quality, consistency and continuity of the care which can be given in circumstances where these people are dispersed and each individual needs some kind of monitoring allocation of their own?
Earl Howe
My noble friend is absolutely right: this is not a simple matter. That is why we believe that commissioning should not be remote from those for whom care is commissioned. There needs to be regular monitoring by commissioners of the quality of the service that has been commissioned. Equally important, commissioners need to satisfy themselves on the suitability of the placement in the first instance. Best practice and guidance are clear: people with learning disabilities, autism or behaviour that challenges should benefit from local, personalised services and should be supported to live in the community wherever possible. The creation of clinical commissioning groups and health and well-being boards will encourage that local dialogue and insight to make sure that the services available in an area are appropriate and of a capacity for those who require them.
Earl Howe
My Lords, I am very grateful to my noble friend because it is all too easy to sink into a state of despair over these services. He is absolutely right: many, many good examples of excellent care are being delivered to those with learning disabilities. The challenge is to ensure that best practice is spread, but I am grateful to him for reminding the House of that important fact.
Lord Elton
My Lords, learning-difficulty patients are extremely aggravating at times and their carers have enormous power over them and can be tempted to abuse it—hence the results we have seen. The same can be said of prisoners and prison officers. When I was Minister for the Prison Service many years ago I was aware of the problem of the abuse of prisoners by prison officers who had a tendency to bully. I commissioned work on identifying the psychological profile of potential bullies, which was useful in reducing that invasion of human rights in prisons. Will my noble friend look into a similar approach when it comes to the way in which carers are recruited?
Earl Howe
My Lords, my noble friend makes an important point. The thing that shocked us all in the context of the BBC programmes was the extent to which restraint and physical abuse occurred in care settings, which was clearly inappropriate and also extremely distressing and damaging to the individuals involved. We are working with the DfE, the CQC and other stakeholders to drive up standards and promote best practice in the kinds of areas my noble friend is no doubt thinking of, particularly in the use of restraint. We believe that there should be a set of core principles to govern restrictive physical interventions. We think the guidance needs to be updated and that there needs to be improved training in this area. We will particularly consider in our review what additional guidance is needed for specific groups, including people with learning disabilities and behaviour that challenges.
Abortion
Lord Elton Excerpts(11 years, 9 months ago)
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Lord Elton
My Lords, my noble friend Lord Hamilton referred to abortion on demand and the right reverend Prelate referred to the great increase in the number of abortions. Can my noble friend tell us how many abortions there have been in the past 12 months for which he has figures and, if possible, how many of those were for mothers who have previously had abortions?
Earl Howe
My Lords, in 2011 in England and Wales there were 189,931 abortions. On the question of repeat abortions, I can tell my noble friend that there is a mildly encouraging statistic in that the number in the very young is going down. I am happy to write to my noble friend with further particulars.
Care Homes
Lord Elton Excerpts(12 years, 1 month ago)
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Earl Howe
The noble Baroness is of course right, which is why it is so important that we reach what I hope will be a cross-party consensus on the future funding of long-term care and social care generally. We have committed to legislating as soon as we possibly can on that subject.
Lord Elton
My Lords, does my noble friend agree that the delivery of a caring and efficient service is dependent not only on training but on character? Is it not true that throughout the health service, and not merely in this area of welfare, there has been a sad departure from reliance on something which was fundamental to the hospital service when it was invented: tender loving care? When will there be an insistence that the right sort of people are admitted to the profession of caring for the elderly and the sick, as well as on proper training?
Earl Howe
My noble friend makes an excellent point. I expect he knows that in the selection process for nurse training, greater emphasis is now placed on the applicant’s suitability as a person to undertake caring duties. As regards healthcare assistants who may not be qualified, it is of course up to the employing organisation to make checks of that kind. We believe that to be a variable practice. We need to focus on that issue more than ever.