Health: Healthcare Assistance

Lord Hunt of Kings Heath Excerpts

Wednesday 13th February 2013 Lords Chamber

Asked by

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government whether they will reconsider the decision not to regulate healthcare assistance in the light of the Health and Care Professions Council’s preliminary finding, published in December 2012, that there are significant shortcomings in a voluntary register.

[Lord Hunt of Kings Heath]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper, and refer noble Lords to my interests in the register.

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

The department notes the Health and Care Professions Council’s findings. Levels of assurance are already in place for healthcare assistants, including supervision by regulated professionals and registration of their employer with the Care Quality Commission. In addition, new training and conduct standards for healthcare assistants will be published shortly. We will review the need for further assurance of healthcare assistants in light of the recommendations of the Francis inquiry.

[Lord Hunt of Kings Heath]

I am grateful for that response. Does the Minister agree that the significance of the council’s report is that in relation to social care assistants it has concluded that a voluntary register is not sufficient? Does he agree that the same argument applies very much to healthcare assistants? With regard to the Francis inquiry recommendations, will he undertake for the Government to seriously consider reversing their policy on this matter?

[Earl Howe]

My Lords, we have made it clear that each and every one of Robert Francis’s recommendations will be considered extremely carefully, including the recommendation in relation to healthcare assistants. However, it is worth noting that while the Health and Care Professions Council has signalled some potential limitations to a statutory regulator holding a voluntary register, and we take account of that, nevertheless that does not mean that these potential limitations would apply to other organisations wanting to set up a voluntary register. Our view is that that avenue should be explored. The HCPC also flagged up some major limitations in attempting to regulate healthcare assistance. Those messages bear thinking about.

Social Care Funding

Lord Hunt of Kings Heath Excerpts

Monday 11th February 2013 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, we are grateful to the noble Earl for repeating the Statement.

It is accepted on all sides of the House that our current social care system is living through the worst of all possible worlds: a cruel lottery in which people who go into later life with everything for which they have worked so hard on a roulette table and the most vulnerable are always the biggest losers. So it needs to change. The Secretary of State has today published a modest plan that will make the system fairer than it is today, and he is to be congratulated on that. We welcome elements of what he has announced. A cap of £75,000 is certainly better than no cap at all. Raising the means-test threshold will help more people on lower incomes to get some help with their charges. It is a step forward, but it is a faltering one, and only one of a series of measures that are required if older people and people with long-term conditions are to be given sufficient care and support. We need a holistic, cross-party approach.

Last week, the Francis inquiry exposed some very serious issues within the National Health Service which impact on the quality of care for a growing number of older people in our hospitals, often with several different illnesses. The NHS is overwhelmed with the demands being made on it, the tightening of its finances and the rightful emphasis on safety and quality. The changes being made by the Health and Social Care Act focus on the commissioning responsibility of general practitioners but, overwhelmingly, the real need for GPs is to focus on improvements in primary care, including accessibility and support for older people in their homes. Just when local authorities are needed to do so much more to help prevent admissions to hospital and to have much faster and more sensitive support for people discharged from hospital, they are having to cope with huge reductions in expenditure.

It is hard not to feel a sense of disappointment when listening to the noble Earl—first, because a Statement on a subject of such importance was briefed to the media before Parliament; because the Government have abandoned any efforts to build a cross-party consensus before rushing to announce their proposals; and because they have chosen to rewrite the Dilnot report with figures of their own, breaking the careful logic so apparent in Dilnot’s report.

There are four problems with what has been announced today, which I will address in turn. First, it fails the fairness test. We will have a durable solution to the problem only if we can answer this question: will it help every person and every couple to protect what they have worked for, whatever their wealth and savings? This package falls way short. According to Demos, the £35,000 cap, as recommended by Dilnot, would benefit about 3.2 million pensioners. A per person cap of £75,000 will benefit only 1.4 million. For the average couple, the cap is £150,000. That might be enough to protect detached houses, but it will not protect the average semi-detached home in large parts of England.

The Secretary of State selectively quoted Andrew Dilnot and, specifically, what he said about the £75,000 cap. I remind the House that Dilnot said that the cap was,

“higher than we would have wanted—£11,000 higher than the top end of our range —and I regret that”.

Will the noble Earl confirm that people with modest to average homes and savings are not protected under this plan? The Secretary of State claimed that insurance companies will step in with new products so that more people can protect their assets but, in oral evidence to the Health Committee, the Association of British Insurers said that it did not believe that the capped-cost model would result in a market for pre-funded care assurance. I would be grateful if the noble Earl could say what confidence he can give the House that a market will emerge. What discussions have been held recently with the insurance market?

The second issue that I am concerned about is that this addresses only a small part of the overall social care funding problem. With this decision, the Government have prioritised the funding of a cap on care costs with new money, over and above addressing the crisis in council social care budgets. Will the noble Earl confirm that this was against the advice of Andrew Dilnot to the cross-party talks? What it means in practice is that vulnerable people will continue to face rising charges as councils put up fees to cope with the growing shortfall in their budgets. This is the effect of the Government’s care policy in practice: they are asking people to make up the councils’ shortfall, making it more likely that they will have to pay right up to the new £75,000 cap. To many people, that will not feel like progress.

More than £1.3 billion has been cut from local authority budgets for older people’s social care since the coalition came to power. Care charges are rising well above inflation and councils are warning that by 2024, they will be overwhelmed by the cost of care. Does the noble Earl accept that forecast and, if he does, how will the plans announced today help to address it? It is true that the Government have raised the capital threshold to £123,000, and we welcome that, but can the noble Earl give the House any confidence that the extra support people will receive through a more generous means test will not be more than offset by increasing care charges, caused by collapsing council budgets? Many people may not know that the cap does not reflect what people actually pay for care but a local authority average, and does not include accommodation costs. As the noble Earl will know, accommodation costs can be considerable. Do the Government have any proposals at all to cap those costs, given the risk that they might rise as care home owners take advantage of additional state support?

The third element relates to inheritance tax. In 2007, a flagship pledge was made to increase the inheritance tax threshold to £1 million by the party to which the noble Earl has the honour to belong. Just eight weeks ago, the Chancellor said that he would increase the threshold in two years’ time, so what has happened in the past two months to make the Chancellor change his mind? The irony will not be lost that they are now increasing death taxes to pay for their plan. The noble Earl has said that the rest will be made up from national insurance. Does he think it is fair to ask the working-age population to pay for something else, rather than older people? Also, what safeguards will be available for people who have paid for their own care costs up to the cap and then have responsibility taken over by the local authority? What happens when the fees paid by that person are more than the local authority is willing to pay? Would that mean the person having to move from the home they are in to another and, if so, is the noble Earl aware of the risks involved in moving frail, elderly people from the environment that they have become used to?

What is the impact of this announcement on the considerations of the joint Select Committee that is now considering the draft Bill? I understand that it is shortly to report. Will it be asked to reopen its discussions and, if the noble Earl intends to publish further draft clauses, can he say what parliamentary process will be arranged for their scrutiny? I should also like to ask the noble Earl whether, through the usual channels, we might have an early opportunity to debate this announcement. The noble Lord the Leader of the House was very kind last week, when the Francis inquiry Statement was made. He said that he would see whether a debate on the Francis report could be arranged and, to his great credit, my understanding is that a Question for Short Debate tabled by the noble Lord, Lord Patel, has been prioritised for debate. I think it will be on 11 March. Could the good offices of the noble Earl be put to the same effect, so that we could indeed have a very early debate?

In conclusion, up to a point we of course welcome what has been announced today. It is a start but it will not lead to more integration of care. Indeed, it may well entrench the separation between two systems: of free at the point of use NHS and of charged-for social care. It is interesting that Demos described it this morning as being “unambitious” and “miserly”, and that it,

“will do little to solve one of the most vital social problems facing our generation”.

Would it not have made more sense, rather than developing these piecemeal plans in isolation, to have set them out as part of a single vision for a sustainable health and social care system in the 21st century?

NHS: Clinical Commissioning Groups

Lord Hunt of Kings Heath Excerpts

Wednesday 16th January 2013 Lords Chamber

Asked By

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government why the NHS Commissioning Board is discontinuing the poverty element in the funding formula for allocation to clinical commissioning groups.

[Lord Hunt of Kings Heath]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and declare my interests on the register.

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

My Lords, I can reassure the noble Lord that the board has not discontinued the poverty element of the funding formula. The board was concerned that while the formula provides an accurate model of healthcare need as currently met, if implemented it would target resources away from those areas with the worst health outcomes. It has therefore decided to give all clinical commissioning groups the same growth while launching a fundamental review of allocations.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the noble Earl for that explanation and understand that a flat-rate increase is to be given next year on top of the existing formula. Will he assure me that if the national Commissioning Board, after this review, decides not to go down the route that the previous Secretary of State, Mr Lansley, wanted this review to take—namely, to take money away from the poorer areas and give it to the well off areas—it will see no interference whatever from Ministers in relation to that decision?

[Earl Howe]

My Lords, that is a very important principle. It is one of the reasons why we felt that the NHS Commissioning Board should be responsible for the allocation of resources to CCGs and not Ministers, to avoid any perception of party-political interference. However, the Government’s mandate to the board makes clear that we would expect the board to place equal access for equal need at the heart of its approach to allocations. That is why ACRA has been charged with developing formulae independently to support the decision that the board takes.

--- Later in debate ---

[Earl Howe]

My Lords, we are determined that it should not happen. I am as aware as the noble Lord of the perception of party-political bias, and it is highly undesirable that there should be such a perception. That is why, in the mandate to the NHS Commissioning Board, we have stated simply that we believe that the right basis for allocating resources is to place equal access for equal need for healthcare services at the heart of whatever formula the board decides to follow.

[Lord Hunt of Kings Heath]

My Lords, perhaps I may come back to that very important point. The fact is that the advisory committee, presumably following guidance from Ministers and officials, came up with a formula that would have taken money from poorer areas and allocated it to richer ones. That is why the national Commissioning Board decided not to accept it and to go for an across-the-board increase. In the noble Earl’s discussions on the mandate, will he ensure that the Commissioning Board is enabled to come to its own view on these decisions?

[Earl Howe]

Yes, my Lords. In this case, the board concluded that the formula proposed by ACRA accurately predicted the future spending requirements of CCGs, but it was concerned that the use of the formula on its own to redistribute funding would predominantly have resulted in higher levels of growth for areas that already have the best health outcomes compared with those with the worst outcomes. In other words, the formula on its own would have disadvantaged precisely the areas that the noble Lord is most concerned about. On the face of it, this would appear to be inconsistent with the board’s purpose, which is to improve health outcomes for all patients and citizens, and to reduce inequalities, which is a key aspect of the mandate.

NHS: Reconfiguration of Services

Lord Hunt of Kings Heath Excerpts

Tuesday 15th January 2013 Lords Chamber

Asked By

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what the implications are for the future reconfiguration of NHS services in the light of the decision by the Office of Fair Trading to refer the proposed merger of hospitals in Dorset to the Competition Commission.

[Lord Hunt of Kings Heath]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer noble Lords to my health interests in the register.

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

My Lords, patients’ interests must remain the paramount consideration in any NHS reconfiguration, including merger. We expect the competition authorities to consider the costs and benefits of proposals and to make a final decision based on the balance of impact on patients.

[Lord Hunt of Kings Heath]

My Lords, the noble Earl will recall that the Health and Social Care Bill was amended to emphasise the importance of the integration of services. This merger was designed to integrate services and to provide a higher quality of care in the hospitals concerned. Does he recognise that this intervention by the OFT, which knows virtually nothing about the health service, will send a signal throughout the National Health Service that the ideology of competition is graded as being more important than either the integration of service or the quality of service? Can we expect the Government to send a signal to the OFT that it should desist? Otherwise, this will cause great concern in the National Health Service.

[Earl Howe]

My Lords, the referral of this merger proposal by the OFT to the Competition Commission is not at all a result of the measures brought in by the current Government; it is a result of the provisions of the Enterprise Act 2002. Even if there had been no Health and Social Care Act last year, we would have found ourselves in this situation. This is the very first time that a proposed merger of two foundation trusts has raised competition issues and there is no doubt that the OFT would have had an interest whatever the situation. In the Act we avoided double jeopardy, whereby the Co-operation and Competition Panel, set up by the previous Administration, might have determined its view on this merger and then there would have been a second-guessing process by the competition authorities. We have avoided that and that is very positive. Aspects of this merger obviously impact on patients and patient choice, and it is right, in the judgment of the OFT, that scrutiny should be given to the matter.

Health: Cancer

Lord Hunt of Kings Heath Excerpts

Monday 14th January 2013 Lords Chamber

[Earl Howe]

My Lords, the UK now has the highest national per capita rate of cancer trial participation in the world, which is something that not everybody realises. We have improved the amount of information available to patients, clinicians and the public about clinical trials by establishing the UK Clinical Trials Gateway. I will write to the noble Lord with information about specialist centres, but he will know that surgery for pancreatic cancer is a complex business and needs to be undertaken by those who are very well versed in that particular line of clinical activity. I am sure that a high proportion will be treated in those centres but I will find out more if I can.

[Lord Hunt of Kings Heath]

My Lords, I refer the House to my health interest. On the question of variation, the noble Earl mentioned earlier the role of GPs. Will he accept that there is a wide variation in the performance of GPs? Can he confirm that we can expect the NHS Commissioning Board from 1 April this year to start taking action where GPs are not doing what is required?

[Earl Howe]

Yes, my Lords, because a major role of the Commissioning Board is to support general practice and, indeed, vice versa. In the current year, cancer networks are continuing to support GPs to diagnose cancer earlier through a range of work including continual professional development, primary care-led audits of cancers, and ensuring that GPs are prepared when patients present in response to public cancer awareness campaigns. Therefore, there is a range of work going on to ensure that GPs are better versed in this area.

Nursing Quality and Compassion: The Future of Nursing Education

Lord Hunt of Kings Heath Excerpts

Tuesday 11th December 2012 Grand Committee

[Lord Hunt of Kings Heath]

My Lords, I, too, must declare a number of health interests that are on the register—principally as chair of the Heart of England NHS Foundation Trust. I also thank the noble Baroness, Lady Emerton, for initiating this debate. In fact, only two weeks ago she presented badges to some of our nurses who had passed the trust’s intensive internal examinations. I am particularly indebted to her for doing so. I am also glad that my noble friend Lord MacKenzie, the other nurse speaking in this debate, spoke so eloquently and provided a background to some of the issues that laid the foundation for some of the concerns about the quality of nurse education.

In discussing the concerns, I hope that we acknowledge the tremendous strides the profession has made in the past 20 years. Nurses have taken on a lot of specialist skills and are looking after a much higher proportion of frail elderly patients with comorbidities. They have taken on other responsibilities as well. The noble Baroness, Lady Cumberlege, was very much responsible for that. I think of the work that she has done as regards childbirth and nurse prescribing. However, as the noble Lord, Lord Kakkar, suggested, we have this irony that at the same time as we have seen the huge potential of nurses there is concern about neglect of basic standards of care. We have all heard Ann Clwyd MP’s moving and distressing description of her husband’s last days and what he described as the indifference of some nurses.

The noble Baroness, Lady Emerton, referred to Project 2000, at which many point the finger of blame. However, I am glad that in his excellent report the noble Lord, Lord Willis, endorsed the ambition of a graduate nursing profession. I am sure that that is important, but I hope that the Minister will reflect on problems regarding the education of nurses within our universities. Clearly something is wrong. I believe that the monitoring of the curriculum has been left in the main to HR people in the health service and to the universities themselves, and that that has often led to major problems. HR people do not know about standards of nursing care—they are not in a good position to make decisions about these commissions—and universities are concerned with academic issues. They are not concerned with practical nursing standards on the ward. I believe that the answer—I am biased—is to allow the NHS to have much more involvement in the training and selection of nurses in the future. I am not suggesting that we go back to the old hospital nurse training schools, but NHS trusts need to be much more involved in future. My own trust is in discussions with the university hospital in Birmingham and the University of Birmingham about a tripartite approach to nurse training. That must be the way forward. I hope that the new regional structures will not get in the way of that.

My understanding is that the Nursing and Midwifery Council intends to deal with revalidation in about 2015, after clearing up the problems that it has. I very much welcome its approach. I also welcome the current leadership of the NMC, who show every sign of getting to grips with the many problems that they have inherited. I hope that the noble Earl agrees with the comments made on research. It is so important that we give more emphasis to nursing research.

My noble friend Lord MacKenzie spoke about the importance of supernumerary status. I agree, but I say to him that there is an issue of resources—I need to come back to that—and of being able to afford it. The noble Lord, Lord Patel, spoke about workforce planning. I urge the Government not to not leave it to local people to decide the number of commissions. We know that that will be a failure. I remember appearing before the Health Select Committee about five years ago to explain why education commissions had been reduced. I endured two not very happy hours doing so. I assure the noble Earl that his ministerial team will have the same problem. I gather that doctor commissions are also being reduced. This will prove to be a major mistake which the NHS will pay for one way or another in about five to 10 years’ time.

I will not repeat what other noble Lords have said about healthcare assistant regulation. The Government have been wholly unconvincing on this as, frankly, has the central health regulatory authority. We have to have the regulation of healthcare assistants; patient safety demands it. There is a clear consensus, and the only people opposed to it are the central regulator, which for some bizarre reason seems to cling on to this idea that you can do it through voluntary accreditation, and the Government. The intellectual argument against regulation seems very weak indeed.

Finally, before we put all responsibility for lapses in care in the hands of nurse education and the lack of regulation of support workers and of nurses themselves, we cannot ignore the huge nursing challenge posed by the increasing number of frail elderly people in our hospitals who are suffering from multiple chronic conditions. It is also grossly unfair not to recognise the financial pressure on the NHS at the moment. Nurse to patient ratios are being squeezed, and the reduction of the number of nurses in employment is an indicator of that. The Government must own up to the fact that they themselves are creating some of the pressures that are making it harder for nurses to do the job they want to do. I believe that we will come back constantly to these issues until we are able to resolve nurse education training, sort out the regulation of healthcare assistants and create the conditions in which nursing care can thrive.

Care Services: Winterbourne View

Lord Hunt of Kings Heath Excerpts

Monday 10th December 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, I thank the noble Earl for repeating the Statement. I know that Members on all sides of the House were appalled by the terrible incidents at Winterbourne View. I say to the noble Earl that we share a determination to ensure that all necessary steps are taken to prevent a similar tragedy happening again. Our goal must be to ensure that everyone with learning disabilities, including those with challenging behaviours, receives high-quality, decent and humane care and support; and that we finally end up with the practice of sending people with learning disabilities to long-stay institutions far away from their family and friends being a practice of the past.

The noble Earl has announced a number of welcome measures that are certainly a step in the right direction, but we remain concerned that the proposals may not be clear or strong enough to guarantee the changes that people with learning disabilities and their families urgently need. I refer the noble Earl to the NHS mandate, published only a couple of weeks ago, which says that there should be a substantial reduction in reliance on in-patient care. The noble Earl has clearly reiterated that in the Statement. Can he put a figure to that reduction? Is there not a risk that, unless the noble Earl is more precise about how and when that will be accomplished, we may not see the progress that we would wish to see?

Similarly, the Government say that they wish every local area to provide appropriate care and support. Can the noble Earl define what care is considered to be appropriate, and how it might be measured?

The noble Earl will probably know that I am somewhat dubious about the commissioning function in the National Health Service. We have, after all, had commissioning for more than 20 years under different Governments. One has to ask whether commissioning has led to enhanced outcomes. We see in what happened at Winterbourne View a catalogue of failure by commissioners. Vulnerable adults were placed in unsuitable places, often miles away from their homes. This dislocation, as a recent BMA paper pointed out, can further disturb adults who may already have had traumatic lives. These distances have made it difficult for families and carers to provide oversight and protection. As the BMA said following a round-table discussion in your Lordships’ House, commissioners need better to reflect the individual’s needs and relationships. It must be more local and less institutionalised. Containment must give way to personalised care. Would the noble Earl agree with those sentiments?

Can the noble Earl explain how the Government will ensure that all local commissioners have the necessary skills to make these changes? Clearly there was a problem with 150 primary care trusts. The question now arises: what will happen with the 212 clinical commissioning groups? Of course, they can rely on and draw on the experience of local authorities. I wonder whether the noble Earl can recollect our discussions during the passage of the Health and Social Care Act, when we on this side of the House argued that the commissioning plans of clinical commissioning groups should have to be signed off by health and well-being boards in order to draw the commissioning plans of both the local authority and the CCGs together into one cohesive approach. Would the noble Earl be willing to consider this issue again?

I am concerned that the authorisation process for CCGs does not mention learning disabilities as an area where competence is required. If this is such an urgent and important priority for the Government, can the Minister explain why this is the case?

I come back to the continued use of long-stay institutions because alternative care has not been developed in the community and at home. In a time of constrained resources, when we need to make the best use of taxpayers’ money, there should surely be one budget for people with learning disabilities, not separate funding for health and council care. How will the Minister ensure that there is a cohesive response at the local level from both the NHS and local government, with the budgetary allocation to make sure that that happens? Will the noble Earl name the specific individual leading this work within the NHS Commissioning Board so that Members of this House are clear who should be held to account?

On the regulator, the serious case review of Winterbourne View said that light-touch regulation by the Care Quality Commission was not appropriate for closed establishments, which should instead be treated as high-risk, with frequent unannounced, probing investigations. The review strongly recommends that these investigations speak to residents’ families and to patients, including those who have left the institution and who may feel more able to speak out and speak up. The Care Quality Commission has just completed a focused probe of inspections of long-stay institutions for people with learning disabilities. I think that the implication of what the noble Earl said is that that work will continue, but it would be good to have some confirmation from him.

Can the noble Earl tell me about the CQC’s capacity to undertake this work? I am one who believes that the previous leadership did the best that they could in the circumstances in which they found themselves, notwithstanding the great deal of criticism that they had to take. I have been very impressed by the approach of the new chief executive of the CQC, David Behan. However, I remain concerned that too many responsibilities may have been put on the CQC for it to be able to discharge them effectively. Clearly, in relation to places like Winterbourne View, this has to be an important priority for the CQC. Can the noble Earl reassure me that he is convinced that the CQC can take this on without being submerged by all the other responsibilities, including the whole of primary care which it has been given to address?

Whatever the shortcomings in commissioners and regulators, responsibility ultimately lies with those who provide the services; I agree with the sentiment of the Statement on that. One of the most disgraceful aspects of Winterbourne View was that vulnerable people were neglected and abused while the hospital’s owner, Castlebeck Care, charged huge fees and apparently made huge profits. The serious case review says that Castlebeck made decisions about profitability, including shareholder returns, over and above decisions about the effective and humane delivery of assessment, treatment and rehabilitation. My understanding is that the average weekly fee for residents at Winterbourne View was £3,500, rising to £10,000 for one patient.

While the hospital generated profits of almost £5 million, the review could not determine how much money went back into the hospital, and how much was creamed off for profit. The reason for that is the company’s complex financial structure, with Castlebeck itself owned by private investors based in both Jersey and Geneva. That has made it virtually impossible to hold the company to account. Can the noble Earl confirm that the company has so far failed to meet two of the serious case review’s key recommendations: that it should fund therapeutic services for all ex-patients, and pay for the cost of the review itself which has so far been entirely borne by the taxpayer? The review’s authors say that the corporate responsibility of Castlebeck remains to be addressed at the highest level.

In that regard, I very much welcome the commitment made in the Statement by the noble Earl to the Government examining how corporate bodies and their boards of directors can be better held to account, including a “fit and proper” test for the directors of those companies. Will the noble Earl consider requiring private companies to publish the names of their owners, the members of their boards and the details of their financial structure before they can be licensed and registered to provide publicly funded care? We cannot let the excuse that information is too commercially sensitive be considered acceptable, when what is at stake is the care of very vulnerable people, paid for using substantial amounts of taxpayers’ money.

Finally, perhaps I may ask the noble Earl about carers and the vulnerable adults themselves. As the BMA report says, carers and adults have important roles to play in identifying needs and helping to co-ordinate and supervise their care. Can the noble Earl confirm that the involvement of carers and the vulnerable adults concerned will come to the fore when taking forward the work of his department, the CQC, commissioners and providers?

How we care for the most vulnerable people is clearly a hallmark of a decent society. The scale of abuse at Winterbourne View was simply unacceptable in the 21st century in one of the most prosperous nations in the world. I have been encouraged by the tone of the Statement repeated by the noble Earl. There are clearly issues that we would like to see addressed and I look forward to his comments. I also look forward to the debate in your Lordships’ House on Thursday, when we will no doubt have a more detailed go at this. However, it is clear that there is considerable support for the kind of decisive actions that need to be taken to ensure that this cannot happen again.

Department of Health: Budget

Lord Hunt of Kings Heath Excerpts

Thursday 6th December 2012 Lords Chamber

Asked By

[Lord Hunt of Kings Heath]

To ask Her Majesty’s Government what proportion of the Department of Health’s budget for the 2010-11 and 2011-12 financial years was unspent.

[Lord Hunt of Kings Heath]

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

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

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

[Lord Hunt of Kings Heath]

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

[Earl Howe]

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

Contracting Out (Local Authorities Social Services Functions) (England) (Amendment) Order 2012

Lord Hunt of Kings Heath Excerpts

Tuesday 20th November 2012 Grand Committee

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

My Lords, in 2011 an order was passed by noble Lords under the Deregulation and Contracting Out Act 1994 to allow local authorities taking part in two pilot schemes to contract out to outside organisations certain adult social service functions. The order under discussion today amends the original order to allow local authorities to continue this contracting out activity in respect of the pilot programmes beyond the period provided by the original order. The pilots are, first, adult social work practices pilots and, secondly, Right to Control pilots.

The social work practice pilots are testing various models of social worker-led organisations undertaking adult social care functions for which local authorities are currently statutorily responsible. The Right to Control pilots are testing the rights of disabled people to manage some of the state support they receive to live their daily lives. As these are established pilots, I will briefly outline each pilot programme before describing the rationale behind the extensions.

The social work practice pilots were announced in 2010 and the programme has been running for more than a year. The scheme has seen the creation of seven social worker-led organisations that discharge the functions of the local authority in providing adult social care services. On a day-to-day basis, the pilots are independent of the local authority but work closely with it and in partnership with other providers. The local authority pays for the services but maintains its strategic and corporate responsibilities through its contract with the social work practices. We are looking at the pilot sites to test the potential benefits of the social work practices, and whether the innovative approaches improve outcomes and experiences for the people who use them.

The programme aims to bring people who need health and care support closer to those who provide the services they need by reducing bureaucracy, encouraging innovation and increasing the personalisation of services. The Department of Health has provided funding of £1.1 million to help the pilots get up and running and to provide initial support. The pilots are an opportunity to test different models to see what works well. They will be fully evaluated throughout the pilot period, with the final report planned for winter 2013. In considering the need to extend the pilots we listened to the advice of the social work practice working group, which incorporates the sites themselves, and representatives from ADASS, SCIE, the Department of Health and the independent evaluators.

There are two main reasons why we seek an extension to the social work practice pilots from their planned end in summer 2013 to 31 March 2014. First, it has taken longer than we anticipated for many of the sites to become established and begin providing services. This point was highlighted in the recent interim report on the pilots published by SCIE. The proposed extension will ensure that the pilot sites have an increased opportunity to feed into the independent evaluation planned to report in winter 2013.

Secondly, my department must own up to the fact that, in planning the scheme, it did not take into consideration that there would be a gap between the pilots ending and the evaluation reporting. Therefore, extending the pilots to 31 March 2014 will ensure that no pilots will need to end before the evaluation has reported, and that users will continue to be able to access the service. The local authority in each pilot area will have the final say on whether sites are extended. This order creates the opportunity to do so.

The Right to Control, introduced by the previous Government in the Welfare Reform Act 2009 and launched in 2010, gives disabled adults greater choice and control over certain state support they receive to meet their individual needs and ambitions. Disabled adults in the pilot areas are able to combine the support they receive from six different funding sources and then decide how best to spend this to meet their needs. The pilot is due to end in December this year and my honourable friend the Minister for Disabled People intends to extend the pilots by a further 12 months to gain more evidence of the benefits during the pilot programme. A public consultation seeking views on the plans to extend the Right to Control pilot ended on 21 September and among those who commented there was solid support for the extension for a further 12 months.

The Right to Control pilots are being tested in seven trail-blazing areas in England. These trail-blazers, funded by the Department for Work and Pensions, are testing the best ways to implement the right and the results will be used to inform decisions about options on the right in future. Since Right to Control was introduced in 2010, a great deal of progress has been made and over 34,000 people have benefited from it. The interim evaluation of the pilot scheme concluded that there was insufficient evidence on which to make an informed decision about the long-term future of Right to Control. The Government concluded therefore that the best solution was to extend the pilot scheme by a further 12 months to enable us to gather more evidence of what works best, both for disabled people and for the local authorities delivering the Right to Control.

One of the authorities delivering the Right to Control has also been testing delegation of its statutory duty to review social care assessments to third parties, such as user-led organisations. Disabled people have often told us that having their support arrangements reviewed by fellow service users leads to greater satisfaction with the outcome and that the support of their peers gives them greater confidence to request a direct payment and to take control of their own support arrangements. The proposed extension will allow the trail-blazers to continue to test the delegation of this statutory duty. In conclusion, we see the proposed extension in the order as a continued commitment to the developing world of personalisation and one that fully supports the aims set out in the recent care and support White Paper and draft Bill.

This order has the support of councils and their representatives, as well as service users and their carers. It will allow the continuation of new and innovative ways of working to the benefit of individuals and their communities as a whole. More importantly, it will also maximise the evidence and outcomes available to the independent evaluation in both programmes. I commend the order to the House.

[Lord Hunt of Kings Heath]

My Lords, I thank the noble Earl, Lord Howe, for his full explanation of the order before us this afternoon. I find the contents to be unexceptional and it is right to avoid a hiatus in the pilots’ evaluation. The people affected should not have to go back to an old system before knowing whether the Government have decided that they should be extended, so the logic of the order is clear. I will ask the Minister about a couple of points. He mentioned evaluation. In relation to the trail-blazers pilots, he referred to the interim evaluation which, as he said, found the Right to Control had not been extended to a sufficient number of people to provide evidence to inform a decision about the future of the Right to Control approach. Will he say more about the emerging findings as to the impact on disabled people? He made a few comments about that and suggested that the signs so far are encouraging, with some positive outcomes. Could I tempt him into explaining a little more to the Committee?

I also ask the Minister about potential links between the Right to Control trail-blazers and initiatives taking place on public health. Following the debate when the order was first brought before your Lordships’ House in 2011, the noble Earl wrote to Members who had spoken to the order to say that the Right to Control trail-blazer pilot was intended to be run simultaneously with the public health budget pilots. In particular, he mentioned Manchester, where he said that there was one in-depth public health budget site—Manchester—alongside a Right to Control trail-blazer site. I wonder whether he could report anything on that. I also ask the noble Earl what feedback there has been from users of the service on Right to Control pilots.

On the adult social work practice pilots, I understand that the evaluation has been carried out by King’s College London. I have yet to track down any KCL publication on any emerging findings from those pilots. Perhaps the noble Earl could confirm whether anything has been published so far. I understand, however, that the Department for Education has published an evaluation report by King’s College London and the University of Central Lancashire on the original pilots for children and young people in care, in September 2012. That might be of interest in comparing those pilots with the pilots that are now being undertaken. That evaluation, I understand, found mixed views as to whether the pilots performed better than their local authority counterparts, or whether they represented good value for money. Would the noble Earl be prepared to comment on that? Overall, though, we of course support the extension of the pilots.

[Baroness Barker]

My Lords, I very much welcome the extension of these pilots. I am not quite sure why the order has to come back to the House; that seems rather strange.

I say that I welcome the extension as somebody who has been consistently critical of the premature way in which the previous Government seized upon the then interim findings of the IBSEN report into personal budgets for social care and proceeded to extend that away from the original client group on the flimsiest of evidence. I am therefore extremely pleased that the present Government are going to take a lot more time and care over these pilots. A lot is changing. A great deal has changed since 2009 when these pilots began, but there is massive, rapid and in-depth change going on in social care. I was talking the other week to a colleague who works for a major national charity and who has done some forward projections of the funding of services of some of the organisations with which she works. Believe me, if people are worried about the American economy and the cliff edge that it is coming to, they really ought to look at voluntary sector funding for the next two years. That is important and relevant, because many of the generic sources of advice to which people in need of social care go are currently under threat. In addition, health and well-being boards are in the process of being set up. That is a major change in the health and social care landscape in which these pilots are taking place. It would be advantageous if the Government were to extend, at least until 2014, its analysis of how these are working.

NHS Commissioning Board: Mandate

Lord Hunt of Kings Heath Excerpts

Tuesday 13th November 2012 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, first, I thank the Minister for repeating the Statement and for the briefing that he gave me earlier today. I also refer noble Lords to my interest in health, contained in the register.

This morning I had the great privilege of hosting a ministerial visit to Birmingham Heartlands Hospital by the Minister’s honourable friend, Mr Norman Lamb. He came to see the Birmingham and Solihull Rapid Assessment, Interface and Discharge service—RAID—which essentially is a partnership that has placed mental health professionals inside the emergency department of my local hospital to give people a holistic physical and mental health response. In that context, I very much welcome the emphasis in the mandate on mental health priority and the promise to implement the amendment that we tabled in your Lordships’ House in relation to parity of esteem between physical and mental health.

But—and there is a but—the problem at the moment in the National Health Service is that mental health has been first in line for reductions in expenditure. Is the Minister in a position to confirm that mental health spending was cut in real terms last year, and to say what the Government intend to do to reverse that? Will he also confirm, in relation to mental health, that he is determined to see that primary care plays its role and that we will see more mental health specialists working in teams with GPs, nurses and carers? Will personal health budgets be extended to enable patients with mental health issues to select the best combination of services and treatments for themselves? Furthermore, does the Minister agree that good mental health does not start in the hospital or treatment room but in our workplaces, schools and communities? For example, poor mental health in the workplace costs the UK an estimated £26 billion a year. Does the Minister accept that this requires a cross-government approach, and is he as disappointed as I am at the news of the apparent demise of the Cabinet Sub-Committee on Public Health—due, it is said, to a lack of interest from other government departments?

The mandate contains a number of welcome references to helping to improve people’s health. I would be grateful if the Minister could tell me what the Government are doing to reawaken interest across Whitehall. The whole architecture of the NHS that the Minister brought to your Lordships’ House in the Health and Social Care Act was about the Department of Health passing over day-to-day concerns about the NHS to the national Commissioning Board, giving itself time to work on wider public health issues—and, I have always assumed, to seek to influence the rest of Whitehall. Would he accept that the demise of this Cabinet sub-committee is a very disappointing signal?

I have three fundamental questions concerning the mandate, which relate to funding, the measurement of performance and the role of Ministers. As the Minister has intimated, this is a multiyear document, setting objectives for the period April 2013 to March 2015 but subject to revision at the end of each year—or, in other special circumstances, including a general election. We can only hope that we might be coming back to this mandate sooner than the Government perhaps would wish. I have noted that the mandate has been restructured around the outcomes framework, which is to be welcomed, and that some of the specific levels of ambition that were placed in the consultation on the mandate have now been replaced by what the Minister described as stretched levels of ambition. Has the mandate been costed out? I could not help but contrast the optimistic claims of Ministers with the everyday financial realities of life in the NHS. Is the mandate a realistic document about what the public can expect to happen or is it little more than a Christmas shopping list which is unlikely to be realised in full?

The noble Earl will have seen the RCN’s warning today of thousands of job losses among clinical staff. That appears to be the reality of life in the NHS. Emergency services are under pressure and a toxic mix of reorganisation and real-terms cuts risks plunging the NHS into a very difficult situation. There has been a great deal of publicity and concern about the decision of the BBC in relation to the retirement package, as it were, of the former director-general. However, the Government stand accused of wasting a full £1 billion on redundancy packages for health service managers as a result of the recent reforms. That money could have been spent on patient care.

I note that most of the time the Statement seeks to create a consensus but every so often it descends into political rhetoric, which I regret. I was pained to hear the noble Earl say that the previous Government sent endless instructions to the health service and constantly bombarded it with new targets. However, those targets, which focused on reducing waiting times and improving clinical performance, were absolutely pivotal to improving the performance of the National Health Service. We will, of course, always find ways to make further improvements, but there is no doubt whatever that between 1997 and 2010 the NHS was vastly improved.

The new architecture which the Government have set in place feels very bureaucratic to those working in the National Health Service. Instead of clear departmental direction, three major agencies have been created, which often row in different directions. Monitor, the economic regulator, has conflicting roles. It is unsure about how to incentivise integration but is stuck with the mantra of the market and enforced competition. The CQC lacks confidence and credibility and awaits the Francis verdict, although the appointment of the new chief executive, David Behan, is a very good step forward. The national Commissioning Board is all-powerful and talks the talk of devolution but I am afraid to report that it displays some centralist tendencies. Indeed, I have heard that “aggressive commissioning” is the buzzword around the national Commissioning Board. I certainly hope that it can do better than that. I do not think that the frail elderly, who comprise the patient group that makes the most demands on the health service, need aggressive commissioning. They need an integrationist approach whereby the architecture and the key national players—the department, Monitor, the CQC and the NCB—work together to get the conditions right for an integrationist approach.

I urge the national Commissioning Board to focus its attention on primary care, community care and adult social care. Does the noble Earl agree with that? We are seeing in the health service the development of seven-day working in acute hospitals. I welcome the mandate’s emphasis on mental health playing its full part, but it requires the same commitment from GPs, community services and adult social services. The contrast between what is happening in some parts of the NHS with the desperate struggle that local authorities are facing to keep council social care services for adults going could not be wider. Indeed, millions of people face higher care charges as councils are forced to put up the cost of meals on wheels and other services. The response from local government to the need for a seven-day service is extremely patchy and very worrying.

I would like also to refer to the comment made in the Statement about the performance of the NHS in relation to certain clinical services. If the Government are so concerned, why on earth are they proceeding with cuts to the cancer, heart and stroke networks? Surely that needs to be reconsidered.

Turning to the performance of the national Commissioning Board and how it is to be measured, the mandate contains a long list of improvement areas —as they are called—and says that it is the Government’s ambition,

“for England to become one of the most successful countries in Europe at preventing premature deaths, and our objective for the NHS Commissioning Board is to make measurable progress towards this outcome by 2016”.

What do the Government mean by “measurable progress”? Are there going to be some numbers or is this going to be a vague promise by the national Commissioning Board? What will happen if the national Commissioning Board does not meet those objectives and ambitions? Will there be any sanction placed on it?

The noble Earl repeated the mantra that the NHS is being liberated from day-to-day, top-down interference in its operational management. The mandate seems to have issued an uncosted wish list and is hoping to contract out responsibility to the national Commissioning Board, but it does not absolve Ministers of their accountability for giving Parliament as much information as possible and, ultimately, accepting their responsibility to Parliament for the performance of this great public service.

--- Later in debate ---

[Baroness Northover]

My Lords, it is the turn of the Conservatives.

[Lord Hunt of Kings Heath]

My Lords, there was an agreement between the usual channels that it is the Government Benches, then the Opposition and then the Cross Benches. The noble Baroness is seeking to reinterpret what has already been agreed.

[Baroness Northover]

It is the turn of the Conservatives.