People with Learning Disabilities
Lord Rix Excerpts(9 years, 11 months ago)
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Lord Rix (CB)
I very much welcome the opportunity to speak in this important debate. As my noble friend Lady Hollins said, it was almost a year ago that we were here debating the appalling health inequalities faced by people with a learning disability. Of course, that was in the context of the Government’s response to the Confidential Inquiry into Premature Deaths of People with Learning Disabilities.
In that debate I told the House the fact that,
“over a third of those investigated died due to poor healthcare is nothing short of an outrage and should be front-page news”.—[Official Report, 18/7/13; col. 968.]
It never has been and the fact that a year on there has been little progress from the Government on this, and no Statement made on the subject in Parliament, should also be considered newsworthy. Would the media have such a blind eye for any other group in society?
As someone who has worked in the world of learning disability for many years, and indeed as president of Mencap, I am only too aware of the long-standing and pervasive health inequalities that exist. Mencap’s Death by Indifference, to which the noble Baroness, Lady Hollins, referred, is perhaps the organisation’s most powerful campaign and captures a number of distressing but important stories of people who have lost loved ones due to poor quality of care, neglect or indifference. In short, their lives have been valued less than those of others.
The campaign is as important today as when it was launched back in 2007, as is Sir Jonathan Michael’s inquiry which followed. Over the years Mencap has supported many families who have lost sons, daughters, brothers and sisters due to poor-quality healthcare. In 2012 Mencap published Death by Indifference: 74 Deaths and Counting, which showed the number of families who had reported deaths by indifference since 2007. Sadly, this number is now over 100. Many of those family members were in the Public Gallery at the debate last year and I know that many will be watching today on television as well. We owe it to them to make urgent progress on this. They are not standing alone. As my noble friend Lady Hollins said, Mencap will shortly hand in to the Department of Health a folder of nearly 3,000 personal messages from family members and campaigners urging the Government to take action.
I am, of course, fully supportive of the recommendations from the confidential inquiry. They take us a long way towards equality in healthcare for this vulnerable group of people. In particular, the central recommendation on an overseeing national body, described by my noble friend Lady Hollins, is critical. As my noble friend also mentioned, I understand that NHS England has committed to establishing a national mortality review by March 2015. That is one step forward but it is hugely disappointing that it has taken so long to agree this. People with a learning disability are still dying prematurely from this institutionalised indifference.
Mencap called for a number of commitments to bring about the basic right for equal healthcare. Annual health checks are available but not promoted by many and often conducted far too casually. This needs to change and should be a permanent part of the GP contract. All health professionals should of course act within the law and receive training around the Equality Act so that people with a learning disability get the reasonable adjustments they may need: longer appointments, easy to understand information, proper diagnosis and so on. Mencap has done some great work through the Getting it Right programme which provides training for healthcare professionals up and down the country, co-delivered by people with a learning disability themselves. Furthermore, we have great examples of standardised hospital passports working very effectively. These should be routine. I encourage the Government to consider this.
There are many more issues and suggestions that I know other noble Lords will cover but, essentially, this is about attitudes. People with a learning disability are simply not as valued by the health service or general public as others. That needs to change. It is not hugely dissimilar to progress on moving people from institutions such as Winterbourne View, that ghastly place where horrific abuse was uncovered a few years ago by the BBC’s “Panorama”. Progress, or lack of it, on that has been abysmal and it will come as no surprise to your Lordships that I also sought a debate on that subject as well.
People with a learning disability have suffered second-rate healthcare for far too long, resulting in premature and painful deaths. We owe it to the families who have lost loved ones to stop the need for debates like this and show the bereaved—and those about to go through the same heart-rending experience—that the NHS has learnt its lessons and that health inequalities for people with learning disabilities are indeed a thing of the past.
Care Bill [HL]
Lord Rix Excerpts(10 years ago)
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Lord Mackay of Clashfern (Con)
My Lords, as I took part in the debate in this House that secured the original amendment to the Bill, I should very much like to associate myself with the remarks of thanks to my noble friend Lord Howe and to Norman Lamb and others in the other place. I think the root of this difficulty was the decision of this House from which Lord Bingham dissented. That was an indication that the decision might require revision in due course.
Lord Rix (CB)
My Lords, on behalf of learning disabled people and other vulnerable people I should like to thank the Government for making this amendment, which certainly ensures that their care will be greatly attended to in the future.
Baroness Wheeler
My Lords, briefly, I also support the Government’s amendment on this long-running but vital issue. As the House knows, we strongly supported the need for the amendment. We, too, warmly congratulate the noble Lord, Lord Low, on his dogged determination and efforts to achieve this outcome. We also thank noble Lords from across the House who have helped to bring this about. On these Benches, we recognise that this was very much unfinished business from the Labour Government. We congratulate the Minister on the hard work he has put into finding a way forward and to getting cross-government departmental agreement, which has been important. We recognise that the amendment is a very significant step. I was going to ask for clarification on a couple of issues, but they have been raised in the debate so I shall leave it there.
Care Bill [HL]
Lord Rix Excerpts(10 years, 7 months ago)
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Lord Rix (CB)
My Lords, I lend my support to Amendment 77, tabled by my noble friend Lady Greengross. I would also like to express astonishment that we seem to have reached the target for tonight before the dinner hour.
My interest, of course, is with people with a learning disability and what is increasingly referred to as mate crime. This is where someone has befriended a person with a learning disability and is exploiting or abusing them in some way. In some cases this person may be living with them and, for example, concerns may have been raised by neighbours that the person may be being abused. Currently, the local authority would be unable to speak to the adult with a learning disability to establish if they are all right as the other person, the third party, always answers the door and will not let them in. This power would change that. I understand that the power on the statute book in Scotland is being used sparingly, and I believe that it is used appropriately.
I now turn to Amendments 79A and 81A, which are tabled in my name, on strengthening the safeguarding clause. Currently only financial abuse is defined in the Bill. However, there are of course many other types of abuse, such as physical, psychological and sexual abuse, as well as neglect. The amendment seeks to rebalance the definition. I understand that there has to be a definition of financial abuse in the Bill as there is not a legal definition elsewhere. However, limiting the definition to financial abuse, suggests that there are no other forms of abuse or that professionals and agencies should focus on financial abuse alone.
Although I do not doubt that people with a learning disability suffer financial abuse, other forms of abuse are far more common. Indeed, statistics on the number of safeguarding referrals detailed in the Abuse of Vulnerable Adults in England report for 2012-13 show that physical abuse and neglect were the most common. We would not wish inadvertently to elevate financial abuse above and beyond other forms of abuse. Of course, I understand that there is a reluctance to list types of abuse in case the list appears to be exhaustive and never-ending. The amendment adds the option to specify other forms as detailed in guidance, which I hope will allay such fears.
Amendment 81A, the second amendment tabled in my name, places a duty on safeguarding adults boards to send a copy of their annual report to the Secretary of State. These reports are important in that they detail the findings from safeguarding adult reviews that have been carried out. In addition, a welcome government amendment has added that these reports must now show the actions that boards have taken to implement the findings.
At the moment Schedule 2 says that a copy of the annual report must be sent to the CEO and leader of the local authority, the local policing body, the local Healthwatch and the chair of the health and well-being board. It is important that lessons are learnt nationally and sending these annual reports to the Secretary of State will allow us to understand the national picture and issue guidance as appropriate. People with a learning disability are some of the most vulnerable people in our country and not to monitor and respond to abuse at a national level is quite unacceptable.
Baroness Meacher
My Lords, I support Amendments 77, 80 and 82, to which I have added my name. I will also comment on Amendment 79.
I strongly support the need for adult safeguarding access orders and applaud the noble Baroness, Lady Greengross, for tabling the relevant amendments. As we discussed last week, as local authority resources shrink further—the Minister referred to a 5% reduction so far—the reality is that care will be left more and more in the hands of relatives, many of whom may themselves be elderly and frail; or indeed they may be younger, with childcare responsibilities and have great difficulty in providing support in all directions. Inevitably, many family carers will find it extremely hard to cope, and there will undoubtedly be situations when elderly or disabled people are neglected or in some way abused. I fear that the only way in which family carers will get the help they need will be if adult safeguarding access orders are available, so that following an alert the local authority can become involved, assess the situation and, where appropriate, prioritise further support.
As public services shrink, the neglect of elderly and disabled people—even gross negligence in some cases—will become a growing problem that could very easily become a national scandal. Having said all that, I part company with my noble friend Lady Greengross when it comes to Amendment 79. We have the criminal law. It may not cover absolutely everything but I would not want to see any increase in the likelihood that an overburdened family carer could face criminal charges if they reach the point where they cannot continue to care appropriately for a relative. For me, the purpose of adult safeguarding access orders is to ensure that problems are identified—they certainly need to be—and support is made available in order to enable a carer to cope in the style they would wish to provide.
Lord Rix
I fully understand the argument that the Government do not want a great list of what constitutes abuse. However, the Minister said earlier that it would be possible to give local authorities a batting order, as it were, of what is in legislation. I realise that abuse is covered in legislation, but would it be possible at least to make sure that local authorities do not suddenly think that only financial abuse is to be considered when they look at this Bill? That is all I am asking for.
Earl Howe
I will gladly look into that point. I am sure that it is possible to do that but, as the noble Baroness, Lady Barker, said, many provisions on the statute book are designed to protect individuals from abuse in one form or another and make criminal offences of those actions. Nothing has changed as regards those criminal provisions. If they need to be underlined, however, and if there is scope for misunderstanding what the Government are doing here, then I take the noble Lord’s point, and will gladly reflect and come back to him on that.
Amendments 80 and 82 emphasise the need for involvement of social work-qualified staff in boards and reviews. In Schedule 2 we make it clear that chairs and members of boards must have the “required skills and experience”. It would be impracticable to put into primary legislation every possible type of expertise and professional knowledge that might be needed. We must allow boards the flexibility to appoint members as they see fit. We will, however, ensure that the importance of social work is recognised in guidance, which will also cover the importance of ensuring appropriately qualified oversight of safeguarding adults reviews.
Government Amendment 81 responds to an amendment tabled in Committee by the noble Lord, Lord Rix, and the noble Baroness, Lady Hollins. On reflection, I see merit in placing a duty on safeguarding adults boards to publish an annual report. This amendment will increase the transparency and accountability of boards.
Finally, Amendment 81A, tabled by the noble Lord, Lord Rix, requires that safeguarding adults boards provide their annual reports to the Secretary of State. With a duty on boards to publish their annual report, we can be assured that they will be publicly available. We would expect the local Healthwatch and health and well-being boards to monitor the safeguarding adults board’s progress and report to the Secretary of State if there are particular matters of concern. To require the board formally to submit a report to the Secretary of State would, if nothing else, undermine the primacy of local accountability, which is at the heart of our approach to safeguarding. I hope that, on reflection, the noble Lord will agree with me.
I hope that I have convinced your Lordships that we have done all that we properly can to provide the right legislative framework for safeguarding and, in consequence, that noble Lords will feel able not to move their amendments.
People with Learning Disabilities: Health Inequalities
Lord Rix Excerpts(10 years, 10 months ago)
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Lord Rix
My Lords, as president of Mencap, I welcome the opportunity to speak in this important debate, having rushed from the other Lord’s in St John’s Wood to support my noble friend Lady Hollins in her battle to achieve health equalities for learning-disabled people.
As someone who has worked in the world of learning disability for more than 60 years, I am of course aware of the persistent health inequalities that exist. The figures from the confidential inquiry are shocking and the report makes sober reading. That over a third of those investigated died due to poor healthcare is nothing short of an outrage and should be front-page news. The fact that, on average, men with a learning disability die 13 years earlier and women with a learning disability die 20 years earlier than the general population should be reported alongside the horrific facts, figures and stories from the Mid Staffordshire scandal. Instead they appeared in only a handful of articles, well tucked away. It is a further disappointment that no Oral Statement was made, either when the inquiry was published in March or last week when the Government published their response. That is why this debate is so important.
As many of your Lordships know, I chair the All-Party Group on Learning Disability together with the right honourable Tom Clarke MP. For many years we have brought in people with a learning disability, their families, advocates and professionals, to create a dialogue with MPs and Peers. On Monday I chaired a well attended meeting on this very subject where we heard from the confidential inquiry team and the learning disability public health observatory together with people with a learning disability, family members, carers and the Minister, Norman Lamb.
The inquiry team is to be commended on an excellent, robust piece of work, exposing the stark health inequalities that people with a learning disability face and providing the Government with 18 excellent recommendations on which to move forward. As my noble friend Lady Hollins stated, it seems that the key recommendation, that a national mortality review body be set up to collate data and investigate and report on deaths, is critical in order to keep momentum going, as well as to start the kind of culture change that we must see within the NHS. It is therefore deeply disappointing that the Government have shied away from this critical recommendation, putting off any sort of decision until March 2014. Like my noble friend, I wonder how many more people will have died unnecessarily by that date.
The most powerful account given at the meeting was that of Christine, a mother who tragically lost her daughter Tina in 2009. Tina lived at home with her parents and her sister. She had learning disabilities, epilepsy, Russell-Silver syndrome—a form of dwarfism—and severe scoliosis of the spine. Tina had generally been physically well but developed a cough and a high temperature. Her parents called the doctor and Tina received a home visit from her GP during which she was prescribed antibiotics and paracetamol. Her condition deteriorated, however, and her parents rang the surgery to request a second home visit. This was refused, as was their first request to the out-of-hours service.
It was not until a second call to the out-of-hours service—which resulted in a home visit and a diagnosis of aspiration pneumonia—that Tina was referred to Basildon hospital. Once in hospital she was diagnosed as suffering from pneumonia and a chest infection. The hospital did not give her the treatment she needed or even meet her basic care needs. She suffered several seizures in hospital and went for four days without food. She died on 30 January 2009.
Tina’s death has had the most profound impact on Christine, of course, and her family. At the meeting she said:
“Our daughter was a human being and we protected her and cared for her all through her life until she became ill. We argued with the Doctors from day one; firstly the GP and then the hospital. They saw a child laying there with a disability and decided her life wasn’t worth saving”.
The Parliamentary and Health Service Ombudsman’s investigation of the case found failures and delays in diagnosing Tina’s condition, a failure to act in line with the Mental Capacity Act 2005, failures in the communication of Tina’s condition to her parents, a failure to implement Tina’s transitional care plan and a failure in meeting Tina’s rights as a disabled person.
Christine is rightly concerned about Vikki, her other daughter, who also has a learning disability. She described at the meeting how she and her family were fearful every time Vikki became ill and when she had either to visit the doctor or go to hospital.
We owe it to Christine and her family, as well as to countless others, to stop these health inequalities leading to death by indifference—the apt title of a report by the Royal Mencap Society.
Care Bill [HL]
Lord Rix Excerpts(10 years, 10 months ago)
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Baroness Jolly
My Lords, I, too, am delighted that these amendments have given us the opportunity to debate the eligibility criteria and I echo the comments of noble Lords who know better than I do how this will affect them. Eligibility is a critical issue, which affects both disabled people and older people with care needs—disabled people account for one-third of the people affected by the Bill and elderly people the other two-thirds.
The Joint Committee warmly recommended the introduction of a national minimum eligibility threshold as a key way of resolving the current postcode lottery in social care. The new eligibility framework and national threshold proposed in the Bill will go a huge way to alleviate the lottery of care and will be vital in ensuring that there is more clarity and consistency in the provision of care for disabled people and the elderly in England.
The focus on well-being in the Bill was hugely welcomed by the committee. This principle is the thread that runs through the Bill and will ensure that the care system not only delivers basic support but promotes older and disabled people’s independence, allowing them to realise their potential through participating more fully in their communities. This is a bold vision for the future and one that could truly revolutionise the care system. It is therefore key that these two elements of the Bill work seamlessly together so that the well-being principle is at the forefront of the Government’s mind when considering who will be eligible for care, something that the committee explicitly recommended in its report on the Bill.
However, as the Government have rightly recognised, social care is not merely about allowing people to “survive” but about enabling them to live full and independent lives. The Bill explicitly places a duty on local authorities to provide care that promotes the well-being of individuals. In a conversation yesterday with the Minister for Care and the noble Baroness, Lady Grey-Thompson, it was acknowledged that the draft regulations, which have already been referred to in this debate, were just that—draft. Much more can and needs to be done to make them asset or strength-based. Can my noble friend ensure that the work on the draft regulations proceeds at pace so that they are fit for purpose and meet the needs and requirements of all within the scope of the Bill? Can he also ensure that any work involves those from the sector and expert Members of this House?
Lord Rix
My Lords, the Minister knows perfectly well where I stand because I already talked about eligibility at Second Reading and in the debate last week on the future funding of health and social care, led by my noble friend Lord Patel. I was backed in that part of the debate on the question of someone having to reach a level of substantial disability before becoming eligible for care. It should be the right of all people with a disability at least to be assessed properly, from the lowest level of disability to the highest. A level may be set where tens of thousands of people are excluded, such as people with a learning disability. Many are already being excluded by local authorities and being denied the use of day centres, or whatever. I can only plead with the Minister to say something which would give a glow of optimism to all of us who are totally and utterly opposed to the level which the Government are likely to set.
Lord Touhig
My Lords, I support Amendment 88Q, which was so powerfully moved by the noble Baroness, Lady Grey-Thompson. I certainly welcome the Government’s intention to establish national eligibility criteria, so that local councils across the country will be required to provide care for all those with a minimum level of need. However, I share the concerns which were so well articulated by the noble Baroness and the noble Lord, Lord Low of Dalston, that setting the fair access to care services criteria at “substantial” is simply plain wrong. It is wrong because it will exclude many people who I know with autism, and who have a low-level need of support. They will no longer be able to live independently if the level is set at substantial.
Setting the threshold at this level also seems to be running counter to the Government’s stated intention in the Bill, which is to focus on prevention. The requirement for people to have a physical or mental impairment to qualify for support could mean that those without a diagnosis will be excluded and miss out altogether. A great many people with autism do not get a diagnosis. I have been dealing with a case recently where people have been waiting four years to get their daughter diagnosed. I join the National Autistic Society—again, I declare an interest as a vice-president—in urging the Government to reconsider this and set the threshold at something equivalent to “moderate”. That is by far the fairest and best way to do it.
I make no apology for saying something which I think I have said about three times in this Committee: there is substantial evidence from the National Audit Office and NICE to indicate that investing in services for those with a moderate need is cost-effective. New economic modelling by Deloitte, published recently, shows that every £1 invested in support for people with autism and other disabilities who have moderate needs, generates a return across the piece of £1.30. That is not to be ignored and should be part of our consideration. There is much merit in this and I rather feel that the Minister, who is a decent and honourable man, will see that there is. I am sure he is going to give us some good news; at least, I hope he will.
Lord Warner
I do not think we want to have a debate on our report, but I suggest that the noble Lord reads Chapter 2 which sets out the arguments why we should have consistency between the two age groups and why there was a fairness issue about that. If you distinguish between the two age groups, we favoured not being over-elaborate in means-testing working age people. If the noble Lord reads Chapter 2, he will see that we have in many ways discriminated in favour of working-age people in the treatment of them under a means-tested system. We were not being hard-nosed about it; we were saying that there was a general equity issue about treating people of working age and non-working age under the same architecture in this system. I do not want to detain the Committee with the Warner standard lecture on the Dilnot commission, but I recommend to the noble Lord that he refreshes his memory on Chapter 2, which sets out our arguments.
Lord Warner
I do not think that we said that they should fund the deficit. We said how they should be treated under the architecture of a new system for funding care and support in the future.
Care Bill [HL]
Lord Rix Excerpts(10 years, 10 months ago)
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Lord Rix
My Lords, having heard the words about Mencap spoken by the noble Baroness, Lady Wilkins, I, as president, must of course support this amendment. I say “must”, but I am surprised that these amendments have to be tabled at all. I would have thought that any Bill dealing with care must deal absolutely explicitly with housing. After all, noble Lords will remember when the long-stay, sub-normality hospitals were closed in the late 1970s, the 1980s and the early 1990s, the very thing that was required was housing. Mencap did provide the housing in those days, as best it could, with the Mencap Homes Foundation. It has progressed now to Golden Lane Housing, which allows people with a learning disability actually to own their own housing with the appropriate support. These provisions are necessary, and I am amazed that these amendments were necessary in the first place.
Baroness Jolly
My Lords, I support this suite of amendments—this flight of amendments—on housing. As noble Lords have eloquently said, housing is the third side of the care triangle. Those of us who sat on the scrutiny committee were absolutely clear on that. We thought that it had been extended to our report, but clearly it has not been reflected totally in the Bill. There was mention of it in Clause 1, the well- being clause, in Clause 6 on co-operation, and also in Clause 8 on how to meet needs. The noble Lord, Lord Best, has filled in the gaps, with Clause 2 on prevention, Clause 3 on integration, Clause 4 on the provision of information and advice, Clause 5 on market shaping and Clause 9 on the assessment of needs. In each of these elements of the Bill, housing is imperative. The anxiety that many of us share is that if housing is not in these clauses, it will not be dealt with when an individual is assessed, or when there are issues around integration.
In the Select Committee, the most compelling witnesses were from the housing sector. They understood the impact that appropriate housing, and any adaptations to houses, would have on the lives of the people living there—on the health and well-being of the individual. The amendments in this group put housing where it should be. It is core to assessment and core to integration of care. It is a preventive measure, and it is also core to the provision of information. There is no point in having a conversation as a result of your assessment and as part of the information process if you are not aware of what your housing needs are, because without housing, the conversation makes no sense.
Local authorities need clear direction from the Government. The noble Lord, Lord Best, articulated this clearly when he introduced his amendments. Some health and well-being boards have got it and some have not. Those that have not should have it spelled out, so the amendments in this group are absolutely appropriate. I hope that my noble friend, when he sums up, will reassure the House in this regard.
Baroness Greengross
My Lords, I rise to speak to my Amendments 87ZA and 104A. I thank the noble Baroness, Lady Wheeler, for what she said and I heartily agree with her.
We read far too often about frail older people blocking beds in hospital wards and, apparently unintentionally, making the health service very difficult to function properly. However, they are there due to inadequate planning. These two amendments are intended to try to ensure that the discharge process is started when somebody goes into hospital—that is, right at the beginning of their stay in hospital.
We all have experience of very poor practice. My personal experience is of a 94 year-old who was admitted to a London hospital as an emergency and therefore arrived in pyjamas and with bare feet. He was returned home in pyjamas and with bare feet in the late evening in winter. He had to cross a grassy patch, go into his block of flats and up a flight of stairs in that condition in order to reach his home. There was no planned process to look after him. That sort of thing is totally unacceptable. The aim of this Bill is to stop that sort of practice and to make sure that it does not happen in the future. I think that all your Lordships feel the same about this: we have to get it right. As I said, I feel that the discharge plan should be initiated when someone is admitted to hospital and it should be used as the template for the discharge, when it occurs.
I declare an interest as chairing the All-Party Parliamentary Group on Dementia. We know from one of the inquiries that we have carried out that most frail older people who go into hospital have comorbidity—that is, they have more than one condition. If they have gone into hospital for a fractured femur to be fixed or for some other physical condition to be dealt with, they will stay in hospital for much longer if they also have, for example, dementia. They stay in hospital longer partly for the same reason: that no plan has emerged to look after them when they come out. It is very bad for them to be in hospital and it is bad for all the other patients as well, for obvious reasons. We need to ensure that the local authority and relevant partners know about the special conditions of a patient to get the planning right. We need to ensure that special care and support needs are taken into account long before they leave hospital. That is the reason for those two amendments, which I very much hope that the noble Earl will accept as part of good practice.
Lord Rix
My Lords, I wish to speak to Amendment 87ZB, so wholeheartedly supported by the noble Baroness, Lady Wheeler. It would add providers of relevant services to the list of relevant partners of the local authority. The amendment lays the foundation for a number of amendments which I have tabled in the safeguarding section of the Bill, which will be taken later. There has been widespread concern that the mechanisms and procedures in place to safeguard adults at risk of abuse or neglect are totally inadequate.
Time after time, we have witnessed how processes have failed or safeguarding has not been taken seriously, which has led to serious consequences for people with a learning disability. For example, there is the death of Francesca Hardwick and her mother Fiona Pilkington, the murder of Steven Hoskin, and more recently, the abuse scandal at Winterbourne View. There have been a number of prominent cases where the provider has failed to co-operate in providing information on adults at risk or where cases have occurred such as that reported in the aftermath of Winterbourne, where the provider declined to share information for the serious case review and there was no requirement on it to do so.
The amendment is therefore intended to add providers as relevant partners, so that they are in the frame for further amendments to the safeguarding part of the Bill in Clauses 41 to 46. When we talk about providers, I am referring to those who are providing a service which has been commissioned from a person's care plan, such as care and support or education services. Although I appreciate that regulations will set out other relevant partners, we feel that providers should be named explicitly in the Bill. This will emphasise the importance of the provider of services being subject to the duty to co-operate and will bolster the safeguarding process accordingly. I look forward to hearing the Minister’s thoughts on the matter.
Lord Sutherland of Houndwood
My Lords, I give particular support to the amendment proposed by the noble Baroness, Lady Greengross, for two reasons. First, we all know from a passing acquaintance with hospitals either in our own or relatives’ cases that they are large and complex organisations. Unless a proper assessment is made early on after someone’s entry to hospital needing care, the entry will not be recorded. If it is not recorded, you can be sure that those responsible for the discharge of the individual will not have been present when the assessment was made.
The complexity of the system is such that that is how it is—would that it were better and, doubtless, it can be better, but the reality is that unless a proper assessment is made and recorded, those discharging someone from hospital will not be able to specify adequate provision. In education, we all talk about added value. That concept has a place in hospitals. What will be the added value that will allow a proper discharge and will, in that process of discharge, ensure that the patient in question will not return early to hospital? That is the second reason for supporting the amendment of the noble Baroness, Lady Greengross. The research that I have seen indicates that where inadequate care is provided—that includes care plans not made at the point of discharge—the individual is many times more likely to find themselves back in hospital within the month. It so happens that I have seen research related to intensive care units, where you might expect that to be even more prevalent, but it applies across the board. To be sure that the care is right is to be sure that the care plan is right. My argument in supporting these amendments is that that has to include an assessment at the beginning. It helps, too, when a patient is moved to another more specialised hospital. That happens quite often as the investigations take place, so there is a great need for this.
Baroness Hollins
My Lords, I want to speak briefly in support of Amendment 82B, tabled my noble friend Lady Meacher, which emphasises the need to facilitate access to information and advice services relating to care and support. This is particularly the case for vulnerable adults such as people with learning disabilities. They may benefit from specialist facilitation to access such information. I should say that I chair a social enterprise which makes information on health and social care issues easier to understand for people who find written information too difficult. I am also the carer for an adult who currently receives care funded by the local authority, and who himself needs easy information.
I hope that the Minister will agree that my noble friend’s emphasis on facilitation will add necessary strength to Clause 4(4), which states that information,
“must be accessible to, and proportionate to the needs of, those for whom it is being provided”.
Without appropriate facilitation, the information may not achieve its objectives for those for whom it is provided unless it is done in the right way and in a timely fashion. Certainly, my own experience as a carer is that at the moment far too much information of the wrong kind is often provided, which is confusing. Facilitation is also about helping to choose the right information at the right time so that people can make good use of it.
Lord Rix
My Lords, as we are approaching Statement time, I will be brief. I want to support the noble Baroness, Lady Browning, in her Amendment 88G, which advocates the need for advocacy. In the world of learning disability, advocacy is often totally essential. Information and advice which is not proportionate, frankly, can be quite useless. Advocacy may well come from parents and carers, but sometimes it can be the wrong advocacy. An independent advocate is essential to many people with a learning disability, so I wholly support this amendment.
Lord Mackay of Clashfern
My Lords, I have spent most of my life as an advocate, so I have to say how important advocacy is. I want to say a few words in relation to the point made by the noble Baroness, Lady Gale, about continuing NHS care. The point is important in that Clause 22, as the boundary between health and social care, is vital.
I would have thought—I may be wrong and obviously the noble Baroness will correct me—that it ought to be the general practitioner who advises a patient as to whether they need continuing NHS care. During our deliberations in the Joint Committee there was quite a lot of discussion about the question of continuing NHS care, and it is obvious that there is some conflict of interest. The local authority providing the care may wish to have it provided by the NHS since that would be free and not its responsibility, so the boundary between the NHS and local authorities is particularly relevant in this connection.
At the moment, I do not see how it can be for the patient to claim continuing NHS care. The GP should be able to say to the patient that they need it and that should be sufficient for it to be provided. The likelihood is that a patient would have great difficulty in assessing for himself or herself whether continuing healthcare was needed, so it must be a matter for professional advice. I think that the advice that we are talking about in this context is advice about local authority services, not about the services that the NHS can provide. However, as I say, the boundary between the two is vitally important. I hope that the point made so eloquently by the noble Baroness, Lady Gale, arising from her own inquiry, will be looked at with a considerable degree of care.
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Baroness Howarth of Breckland
My Lords, I rise briefly, as yet another mere vice-president of the Local Government Association, to bring a slightly different dimension to this debate. The noble Lord, Lord Best, pointed out that local authorities are finding a variety of different ways of delivering services. I have been looking at some of those and listening to messages about them. One issue is that they are delivering cheaper services, which often means commissioning them from providers which will then deliver them at a different level of quality. I declare an interest as a provider in the charity Livability, which delivers services to the disabled, the elderly and some children from residential care.
We need to know whether we are prepared to open the debate. Have the Government as a whole given thought to discussing with the community at large what we really can and cannot afford for the future? The noble Lord, Lord Campbell-Savours, raised the issue of the numbers of inspections. When I was involved in inspections, one issue was that you could deliver as many inspections as you had funding for. Now you can use that funding in a variety of different ways to get better options but, at the end of the day, resources count and, unless we know how far the resources will go, it is pointless to try to descend into the abyss, as the noble Lord, Lord Bichard, said.
If we are going to take this forward, we have to know what level of quality people are prepared to accept. Then, when there are failures in organisations, people are not blamed, because the failure is not necessarily one of individuals or even of groups but of the corporate whole simply not having enough resources to work across the whole piece. Until we start that debate, we will not be able to intervene in discussions about criticisms of local authorities giving only 15-minute slots to people when they have only enough resources for 15-minute slots. In residential care, we are taking away some of the extra services because there is no more money them. We are reducing staffing in various institutions because there are simply not enough resources.
I am not denying that because of the deficit we have to look at funding; I think we do. However, we have to open up the debate. Otherwise, we raise expectations in the country of what we are entitled to. I sat in this Chamber until 11 o’clock last night discussing the Children and Families Bill, and we were having exactly the same discussion. We all want these wonderful things. I want things in this Bill, but somehow we have to decide on some priorities between them all. Whatever we say, we cannot go on expecting to get the same out of the same.
Lord Rix
My Lords, I support this amendment in particular. I declare an interest as the president of Mencap. There is no doubt that the services that we are able to provide are being severely cut back because local authorities simply do not have the money to support those services. Where we used to get, say, £15 an hour, we now get £12 an hour. The implication is that we can lower the standard of our services, but we are not prepared to do that. Therefore, we will end up reducing our services and, as a result, people with learning disabilities, their families and their carers will suffer. This is exactly the situation at the moment. Local authorities will try to provide the services, but they are making it much more difficult for voluntary organisations such as Mencap.
Care Bill [HL]
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Lord Rix
My Lords, I wish to speak to Amendment 79D, which focuses on preventing adults at risk suffering abuse or neglect. I welcome the focus in Clause 1 on promoting well-being and the breadth of that definition, which includes protecting people from abuse and neglect. In addition, Clause 2 sets out an important duty whereby a local authority must take steps and provide services which contribute to preventing needs for care and support. However, this crucial clause on prevention makes no reference to abuse and neglect, and my amendment seeks to make this explicit.
Later in the Bill, in the safeguarding section, there is a focus on protecting people once that abuse or neglect is suspected. However, it would be hugely beneficial if local authorities and agencies were obliged and guided to prevent abuse and neglect taking place in the first instance.
Let me give you an example. Decisions were taken to send people with a learning disability and challenging behaviour far away from their homes to Winterbourne View, where they suffered the most horrific abuse. This could clearly have been prevented by local authorities and other agencies if they had taken the right decisions at the outset.
Prevention is recognised also in terms of disability-related harassment, and indeed the Equality and Human Rights Commission highlighted this in its report, Hidden in Plain Sight. It recommended that local authorities and housing providers work from the outset to reduce disability-related harassment by including safety and security measures in the design of social housing estates and facilities. In addition to good decision- making at the top, it is also important to consider how we can empower individuals to understand what abuse is and how they can protect themselves from it. This might be through providing information, advice and advocacy. Safeguarding procedures are vital in order to protect people suspected of abuse and I have tabled a number of amendments on this area under Clause 41. However, before safeguarding comes a strong commitment to preventing abuse occurring in the first place. I look forward to the Minister’s view on this matter.
Lord Low of Dalston
My Lords, I was waiting to see whether the noble Lord, Lord Hunt, was going to speak to his amendments in this group—
Care Bill [HL]
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Baroness Wheeler
My Lords, I shall speak also to Amendment 10. These two amendments seek to make sure that Clause 84 and Schedule 5 specify the responsibility of Health Education England to ensure, throughout its work, the promotion of a comprehensive health service which gives equal consideration to the importance of physical and mental health and the health of people with learning difficulties. This parity of esteem, putting mental health on a par with physical health, must be a key principle carried through HEE’s work and in the education and training of healthcare workers, and it is important that the Bill specifies this. Why is that? It is because the lack of parity continues to have a massive impact. The most recent psychiatric morbidity surveys show that, despite theoretical parity under existing legislation, only a minority of those with a mental disorder in England receive any intervention, in stark contrast to other disease areas, such as cancer, almost all of which have some intervention.
Labour is proud that it introduced the NHS constitution and is pleased that it now has widespread support. However, we acknowledge that it did not go far enough in ensuring that parity of esteem was entrenched into the constitution. This is especially important as the growing number of NHS bodies and organisations established under the Government’s NHS reforms are all required to take the constitution into account in all they do.
Noble Lords will recall that parity of esteem was a hard-fought-for, last-minute inclusion in the Health and Social Care Act. It is vital because it is important to do everything that we can to ensure that this key NHS objective is taken seriously and is underlined at every stage. We welcome the steps in the HEE mandate recognising HEE’s leadership role in this, including a focus on the mental health workforce to ensure that there are sufficient psychiatrists and other clinicians and specialist staff working to build the values and skills to facilitate continuous service improvement, developing training programmes which ensure that all staff have awareness of mental health problems and how they may affect their patients, and ensuring that the mental health needs of people with long-term health conditions are addressed concurrently and not as an afterthought.
We particularly welcome HEE’s leadership role in providing, through LETBs, training programmes to support staff in diagnosing the early symptoms of dementia so that they are aware of the needs of patients, carers and families. Building skills among GPs is especially important in this respect, as we know that patients often go undiagnosed for years. The target for Health Education England of 100,000 staff undertaking dementia foundation-level training by 2014 is a challenging one but it must be achieved if the current appalling level of undiagnosed cases is to be reduced. While focus on dementia is welcome, we must also ensure that other debilitating mental illnesses are addressed with equal vigour.
The lack of parity of esteem for mental health under the current system is widely recognised and acknowledged. The website of the mental health charity, Mind, sums this up well in reporting on the experiences of people with mental health problems. As it says:
“One person told us they get immediate attention for slightly high blood pressure, but face indifference and long waits about their mental health needs unless they are suicidal. Others have told us that they experience far better treatment in A&E for physical symptoms than when they need emergency help in a mental health crisis or for self-harm injuries. This is not acceptable—an emergency is an emergency”.
My noble friend Lord Patel of Bradford reminded us during the debate on the Queen’s Speech that only 13% of NHS funds are devoted to the treatment of mental health issues. Against this backdrop we strongly welcome the Royal College of Psychiatrists’ report, Whole-person Care: From Rhetoric to Reality, commissioned by the Department of Health and the NHS Commissioning Board last year. It sets out how progress on achieving parity of esteem can be made by,
“changes in attitudes, knowledge, professional training, and practice”,
and makes key recommendations to apply across the NHS on equivalent levels of access and waiting times for mental health services, specifically in emergency and crisis mental healthcare.
The RCP report has a number of recommendations relevant to HEE’s remit and role. These include how HEE should as a priority support the development of core skills and competences in health and public health professionals; the need for the General Medical Council and the Nursing and Midwifery Council to review medical and nursing study and training to give greater emphasis to mental health; and integrating mental and physical health within undergraduate medical training. I would welcome the Minister updating the House on what action the Government plan to take on this important report, the timescale for the Government’s response, and how any of the report’s recommendations will be fed into the Bill.
Whole-person care is Labour’s agenda for the future. It would bring together physical health, mental health and social care into a single service to meet all of a person’s health needs. Ed Miliband, in announcing Labour’s commission on whole-person care, emphasised that:
“In the 21st century, the challenge is to organise services around the needs of patients, rather than patients around the needs of services. That means teams of doctors, nurses, social workers and therapists all working together”.
In his landmark speech on mental health last year at the Royal College of Psychiatrists seminar, he acknowledged mental health as the biggest,
“unaddressed challenge of our age”.
He went on to say:
“We have to confront the unspoken discriminations too. Like the vast inequalities in funding for research. Like the lack of training in mental health of many NHS staff – whether in GP surgeries, outpatient clinics or A&E. Eight out of ten primary care professionals say they need more training in mental health than they have”.
Amendment 12 underlines the importance of HEE working,
“with persons who provide health services to ensure an adequate provision of continuing professional development for health care workers”.
That is particularly important in view of the recent findings in a member survey by the Royal College of Nursing, which pointed to a worrying decline in CPD training. The noble Lord, Lord Patel, has an amendment on CPD under the provisions for LETBs, so we will pick up this issue then.
As we progress through the Bill, we will argue strongly for parity of esteem between mental health and physical health to be underlined and specified in the Bill as a guiding principle. When the RCP report on whole-person care was published in March, its president, Professor Sue Bailey, called on government policy-makers, service commissioners and providers and the public to think in terms of the whole person, both body and mind, and to apply a parity test to all their activities and to their attitudes. For Health Education England, this parity test for the planning, education and training of healthcare workers is crucial. Our amendments give force to the HEE mandate provisions on parity of esteem, and we hope they will be accepted by the Government.
Lord Rix
My Lords, I support Amendment 10, but I should like to clarify one or two points in the wording. It is possible for a person with a learning disability to have a physical health problem. It is also possible for a person with a learning disability to have a mental health problem. But that is not the main cause or even sometimes the basic cause for their particular condition, which is learning disability. I would therefore have preferred the wording of paragraph (a) of Amendment 10 to have been “learning disability”. The same situation arises in paragraph (b) of Amendment 10. People with a learning disability have a learning difficulty. That is natural. However, there are plenty of people who are not learning disabled who also have a learning difficulty. I would like to have seen Amendment 10 include learning difficulties and learning disabilities, but I actually support the general thrust of the amendment. I hope that if it is accepted the wording of a learning disability can be made quite clear.
Baroness Wall of New Barnet
My Lords, I support Amendment 12 in particular. It will be no surprise to the Minister that my interest, even my passion, lies in the status of healthcare workers, which is hugely important. We are recognising that even more by the way in which the continuing change in the health service is coming about.
I wish to pick up on the way the Bill reads in the context of the amendment. The clause refers to, obviously, education and training for healthcare workers. It then refers to,
“the provision of information and advice on careers in the health service”,
but to know where your career is going you have to have a start point. The Minister knows that many of us have been asking for, in the first instance, a recognition of the skills that healthcare workers bring to the job. Across any organisation that has opportunities for development, there is always a start point. A healthcare worker would need to know, for instance, what skills they have and what skills they need to go on to the next stage of whatever career they choose. The ambiguity, at best—actually, it is probably even worse than ambiguity—under which healthcare workers currently operate does not help that process. It will be difficult for the Bill to achieve its objectives if we do not start from the point where healthcare workers have that recognition of their skills in a formal way.
Lord Hunt of Kings Heath
My Lords, we come to a series of clauses that deal with the functions and priorities of HEE. I have a number of amendments in this group. The first is Amendment 11. Clause 84(6) states:
“HEE may, with the consent of the Secretary of State, carry out other activities relating to … education and training for health care workers”.
I am curious to know why the Secretary of State has to give his consent. Does not the mandate in Clause 87 give the Secretary of State enough oversight, without the micromanagement that this part of Clause 84 seems to imply?
Amendment 12A relates to the duty of HEE to ensure that there are sufficient numbers of persons with skills and training. What does “sufficient” mean? Does it mean an equilibrium of supply and demand, or do the Government want an oversupply? This is a matter that the Select Committee looked into, and about which a number of royal colleges are concerned. They take the view that it takes so long for doctors to come through the training grades that one wants an equilibrium rather than a situation where people who have committed themselves to 15 years’ training find that there is no work for them at the end of it. Perhaps the noble Earl might take up that matter with me in writing.
Amendment 14 asks HEE to,
“have regard to any official guidance on staffing numbers and skills mix”.
We will come back to this issue. The Minister will know that the Francis report recommended that NICE essentially should produce benchmarking measures for minimum staff numbers and the required skills mix, including for the number of nurses on wards. It is too late to have a debate on issues to do with nursing staff ratios, but it would be good to know whether the Government will take forward recommendations 22 and 23, because that work will be very relevant to HEE’s own work on the number of staff required in future.
Amendment 19 relates to Clause 86 and deals with quality improvement in education and training. All I ask from the noble Earl is a recognition that in future we will need to revisit the curricula of the universities to make sure that when doctors, nurses and other practitioners leave those universities and are ready to go into employment, they will have some practical-based training from having undertaken clinical duties. I am not convinced that the bodies that set the curriculum have got it right yet. Whenever challenged on these issues, they always claim that everything is hunky-dory and that we should not worry and yet there is a complete loss of public confidence in those training programmes. I do hope that HEE is going to be able to give a kick to those bodies that are concerned with the curricula and those education institutions to ensure that people are ready to practise when they are given their ticket to go into the health service.
On Clause 87, which concerns the objectives, priorities and outcomes of the HEE, I have another series of amendments. I want to tease out the Government’s recognition that, although in the construct of the Bill HEE will have an annual plan, it will also be required to look three years ahead. I wonder whether that is long enough. The argument that has been put to me by a number of organisations is that the time between the commissioning of a training place and that person practising in the health service can be many years. One of the questions is whether it would be better if HEE had to develop five and 10-year plans and match those with the demographic and the demand pressures on the health service. It would be helpful if the noble Earl would recognise the need for much longer term planning.
Clause 88 sets out important matters to which HEE has to have regard. In Amendment 28 I ask whether HEE will have to have regard to a need for equality of funding across England and consistency in education and training opportunities. Given the mismatch between a population and the education and training facilities available, will HEE have a duty to balance where those resources go?
On Amendment 29, will the noble Earl confirm that specialist training-place issues will be dealt with nationally? I need hardly remind him of the sensitivity of this in relation to junior doctor training. I wonder whether it is good enough to leave it to local LETBs to decide. I do think that some national provision and direction is required.
Amendment 30 concerns HEE’s relationship with other countries of the UK. There is a reference to the need for HEE to undertake duties in relation to the devolved Administrations. Surely much more is required. We are talking about a UK health service. Scotland definitely trains more people than is required for the Scottish health service. The same may be the case in Wales which has big problems in attracting junior doctors. There needs to be a UK-wide view of education and training and I hope that the HEE has both the remit and the encouragement of Ministers to work across those borders.
Amendment 32A covers the matters to which HEE must have regard. I have put down an amendment to ask HEE to give specific focus to arrangements for end-of-life care. The noble Earl has taken part in a number of debates on the Liverpool care pathway which have served to raise issues not so much about the policy behind the pathway, although I know that a review is being undertaken, but more about the way in which that has been interpreted by some organisations. It suggests that more is required in relation to the training of staff in end-of-life care. I am sure that in Part 1 we will come back to the issue of social care provision for end-of-life care but it would helpful if the noble Earl could reassure me that this one of the matters that HEE may look at. I beg to move.
Lord Rix
My Lords, I wish to speak to Amendment 24, which explores the benefits of placing a duty on the Secretary of State to consult on the objectives and priorities of Health Education England. In particular, I wish to explore how the Secretary of State will consult vulnerable people, including people with a learning disability, to ensure that education and training provided by this body will create a workforce that meets this group’s needs. Consulting and listening carefully chimes with the Government’s intentions through their response to the Francis inquiry, which stated:
“We will listen most carefully to those whose voices are weakest and find it hardest to speak for themselves. We will care most carefully for the most vulnerable people—the very old and the very young, people with learning disabilities and people with severe mental illness”.
This is a most welcome commitment, as currently people with a learning disability are not receiving appropriate care. On Tuesday 21 May, the Parliamentary and Health Service Ombudsman published its report into the death of Tina Papalabropoulos. Tina was 23 and had a learning disability. She died on 30 January 2009 at Basildon hospital in Essex. The ombudsman found that the hospital did not give her the treatment she needed or even meet her basic care needs. Unfortunately, this is not an isolated incident, and there is substantial evidence that poor care exists across the health service.
Early this year, the confidential inquiry into the premature deaths of people with learning disabilities in the south-west reported on its study of the deaths of 233 adults and 14 children with a learning disability. It found that 42% of the deaths were premature and that 37% would have been avoidable if good quality healthcare had been provided. On a national level, this equates to over 1,200 adults and children with a learning disability across England whose deaths should have been avoidable with good quality healthcare. This comes as no surprise to many. The Department of Health highlighted the issue back in its Valuing People and Valuing People Now strategies, and the excellent report by Sir Jonathan Michael, Healthcare for All, set out a series of recommendations for improving care for people with a learning disability. It is these people whom the Secretary of State should consult when setting objectives and priorities for this most important of public bodies. Without the input of people with a learning disability and their families, we will fail to change a system and a culture that in many cases provide substandard care for the most vulnerable in our society.
I realise that the Minister will probably reply that in order to publish the objectives and priorities for the forthcoming year of Health Education England, the Secretary of State will have consulted the parties concerned. However, as an actor who, years ago, used to drop his trousers for a living, I nowadays prefer the security of belt and braces, and I hope that the Minister will be able to offer this.
Baroness Wall of New Barnet
My Lords, I would like to understand what Amendment 14 is suggesting, and maybe express some reservations. If I have read it wrongly, I apologise. It is important that Health Education England takes official guidance into account, but we have this dilemma in my own trust about what the Francis report is saying. To have a national edict about what staffing levels ought to be, and the ratios and numbers of staff as well as the skills mix, is not really ideal from the point of view of people operating in the health service, particularly in hospitals. Times change throughout the day on hospitals and on wards, and different levels of skills and different grades of staff are required at different times. You would have to have a permutation that was so huge that it would be less than helpful to have a national edict. I would be concerned that we should take notice of official guidance, but nothing more than that.
I support Amendment 27 and the view about longer-term stuff. In particular—I am sure this will come up later in our deliberations on the Bill, and it is very much in line with what we talked about for a long time in our consideration of the Health and Social Care Bill—the change that is happening as we speak, the evolution of moving, quite rightly in my view as the chair of a provider trust, from acute hospitals to other opportunities to deliver care, is hugely important.
I will share an anecdote with your Lordships. In a discussion with a previous director of nursing in my own trust, I asked her, with my vision of where things ought to be in the future, with nurses following the patient out to their home, how many nurses working on our wards are equipped and skilled to follow Margaret Wall or another patient out and say, “OK, she is now going home”. Her view was very frank: not many would be. I think that is hugely important, because different skills are required to work with someone at home and they need to be incorporated with the skills of nursing overall. It is important when looking at five-year plans, never mind 10-year plans, that we consider the education process in the sense of how people are going to deliver in different environments, which we are all working hard to make sure happens.
Lord Rix
The Minister appeared to say that most of the people being consulted were professional bodies. He did not mention that people with a learning disability and their families and autistic people and their families were also going to be consulted. He mentioned the list of professional bodies but not the parents, carers and the people themselves.
Earl Howe
My Lords, I understand the point. In view of the hour, if I may, I will write to both noble Lords to flesh out the remarks that I have made. I hope that I can give them some comfort in that area.
Amendments 25 and 27, tabled by the noble Lord, Lord Hunt, focus on the importance of long-term and national approaches to workforce planning in education and training, as does Amendment 26. We have strengthened the Bill, following feedback in consultation and at pre-legislative scrutiny, in Clauses 87 and 93 to reflect the importance of HEE and the LETBs taking a long-term perspective on workforce planning and education and training. It is the Government’s expectation that all workforce planning, be it national level planning by HEE or local planning by the LETBs, should be based on a well informed, long-term workforce strategy that looks at needs over the next five years, 10 years or beyond. Any workforce strategy to be credible and deliverable has to be developed in partnership with those partners and stakeholders who have a stake in it. The very same principle applies to the development of national workforce priorities and outcomes and the Government are committed to working with everyone involved in education and training to shape the education outcomes framework and the mandate for Health Education England.
Health Education England will be expected to develop a national workforce plan, building on the local plans developed across England by local education and training boards. I hope that the noble Lord will feel reassured by those comments.
I turn now to Amendments 33 and 14, which seek to amend the Bill to require HEE to have regard to any official guidance and standards on staffing numbers and skill mix. HEE must work with commissioners and healthcare providers to ensure that workforce plans focus not only on how many staff are required but the breadth of skills required to deliver safe services. These plans need to be integrated with service and financial planning so that the needs of all patients and local communities can be met. Individual healthcare providers are best placed to determine how many staff they need to employ, the skill mix required across the various teams and how they need to deploy them to support services and so on. It is the responsibility of individual healthcare provider boards to be accountable for staffing levels and the skill mix of staff in their organisations. Where changes are planned to the size and shape of the workforce, including the skill mix, healthcare organisations must provide assurance that the safety and quality of patient care is maintained or improved. The process should include clinical involvement, leadership and sign off. I hope that these comments will be reassuring.
The noble Lord, Lord Hunt, asked me about the definition of “sufficient” and whether we were talking about equilibrium or oversupply. I will write to him on that, but in delivering that duty, HEE will seek to match supply and demand so far as that is practically possible. It will also promote the importance of a flexible workforce that can adapt to changing circumstances.
I will also, if I may, write on the issue of staffing ratios. I would just say here and now that staffing is clearly not just about crude numbers and not just about nurses. It is also about how the staff work and ensuring that the right staff are in place to meet the needs of the patients whom they are looking after. Again, it is local healthcare providers that are in the best place to decide how to configure those staff in the right way and to ensure better outcomes and value for money. It really depends on the skill mix, the clinical practice and local factors. I think we would say that it is right that nurse leaders should have the freedom to agree their own staff profiles. But I shall follow up that point.
Amendment 19 seeks to amend Clause 86(2) to add to Health Education England’s main functions the promotion of the importance of practical based training in the education of clinicians. I wholeheartedly agree that practical experience while training is essential to ensure that clinicians have the necessary skills to deliver high-quality and compassionate care and have the correct values and behaviours to practise in the NHS and public health system. It is the responsibility of the professional regulators to ensure that the right standards are in place for professional education and training. Practical experience is already a requirement of the professional regulators. Nursing students, for example, are required by the Nursing and Midwifery Council to undertake half of their training in a practice setting. The GMC also expects every medical student to gain practical experience of working with patients throughout their degree. We have placed a strong duty to secure continuous improvement in the quality of education and training on Health Education England. HEE is already working with the professional regulators, as I have already mentioned, to ensure that the Bill remains clear and simple. However, we have not specified the integral elements of the training programmes to which this duty applies. I would add, though, that the need for practical experience is one of the key priorities that the Government have set for the Health Education England Special Health Authority in the mandate. Health Education England will work with the LETBs and healthcare providers to deliver high-quality clinical and public health placements that provide students and trainees sufficient time working with patients to gain experience.
On Amendment 29, I can reassure the noble Lord that, where appropriate, Health Education England will take a national lead in the planning and management of education and training activities. The Bill already makes provision for this in Clause 94(2). The HEE Special Health Authority has already taken on responsibility at national level for crucially important arrangements to manage recruitment into foundation and specialty training programmes for junior doctors. Where there are controls on workforce numbers at national level—for example, in medicine or pharmacy—it will work with partners such as the Higher Education Funding Council for England to develop national plans that will deliver the staff needed across England.
Amendment 30 seeks to amend Clause 88 to add a requirement for Health Education England to have regard to the need,
“to co-ordinate its activities with the NHS in Scotland, Wales and Northern Ireland”.
Of course, it is very important that HEE works closely with the other UK nations in developing workforce plans and shaping education and training. It will be important for it to take a UK-wide perspective and, where appropriate, an EU-wide or indeed global perspective in planning for the future and reforming education and training. I refer the Committee to paragraph 17 of Schedule 5, which enables Health Education England to exercise corresponding functions on behalf of the devolved authorities. The special health authority is already working closely with its partners in Scotland, Wales and Northern Ireland, building on previous arrangements.
I sympathise completely with Amendment 28 and I wholeheartedly agree that there should be equality of funding for education and training across England. Moving to a tariff-based system for funding clinical education and training would enable a national approach to the funding of clinical placements and would provide a more level playing field between different providers. It will ensure that providers are reimbursed fairly for the education and training that they deliver and are incentivised to provide high-quality clinical placements to their students and trainees. For consistency of opportunities across the country, Clause 85 places a duty on HEE to ensure that sufficient numbers of health professionals are trained and available to work in the health service throughout England.
I hope that noble Lords will feel reassured by those remarks. Before I close, I will quickly respond to my noble friend Lord Willis, who expressed concern about the mandate containing little on nursing and support workers. There is a clear and strong commitment to supporting the development of the care assistant support workforce. Similarly, there are clear national priorities focusing on development of the nursing and midwifery workforce. Again, if I can elaborate on that in writing, I would be happy to do.
Care Bill [HL]
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My Lords, the introduction of the Care Bill is to be welcomed. It provides the opportunity to fundamentally improve the lives of disabled people and the legal framework for the social care and support system. Social care is vital for people with a learning disability. Good social care and support empowers them to live independently and within the community. It means that they can be valued members of our society and not marginalised and hidden out of sight in institutions such as Winterbourne View.
The system, however, is in crisis. Social care for working-age adults is under funded by at least £1.2 billion and thousands are being excluded from services as local authorities tighten eligibility criteria. It is a situation that the learning disability charity of which I am president is only too well aware. Mencap research has shown that the vast majority of councils have tightened criteria from “moderate” to “substantial”, which is now by far the most common level. Put simply, people with a learning disability are being left without any care and support for basic needs, such as help with getting out of bed in the morning, making a home-cooked meal, communicating with friends and family and even getting out of the house.
The report, The Other Care Crisis, produced by Mencap, the National Autistic Society, Scope, Leonard Cheshire Disability and Sense, and supported by economic modelling by Deloitte, highlighted that alongside the moral imperative for action, investing in support for people with moderate needs will ultimately lead to savings for the taxpayer. Well, Clause 13 gives the Government the ability to set a national eligibility threshold in regulations; however, setting the threshold at “substantial” rather then “moderate” will result in more than 100,000 people being denied the support that they need. To prevent us going backwards, the Bill must be underpinned by an appropriate funding settlement in June’s comprehensive spending review.
I wish now to move on to safeguarding. Time after time, we have seen how agencies have not taken safeguarding seriously, with horrific consequences for people with a learning disability. There have been the deaths of Francesca Hardwick and her mother Fiona Pilkington, the murder of Steven Hoskin and, more recently, the abuse scandal at Winterbourne View Hospital, where it took a whistleblower and “Panorama” to expose the abuse meted out by staff.
The Bill does much to clarify and strengthen the law, and address the widespread concern that current procedures for safeguarding adults at risk of abuse or neglect are inadequate. Putting adult safeguarding boards on a statutory footing will better equip them to prevent abuse and respond to it when it occurs. Nevertheless, it must be made absolutely clear when safeguarding investigations are to be carried out, their threshold and the process. However, the Bill also introduces a welcome duty on local authorities to make inquiries when it suspects that an adult is at risk of, or experiencing abuse or neglect, but there is no duty on providers or other relevant partners to inform the local authority when they suspect that an adult is at risk. This appears to be an oversight that I hope will be addressed by the Minister.
I should like also to touch on the cross-over between the Care Bill and the Children and Families Bill, currently on Report in the other place. We all know the difficulties that disabled young people and their families face in transition to adulthood and how often young people fall through the gaps as they move from children’s to adult services. These two pieces of legislation offer a unique opportunity to make this better.
The Children and Families Bill will introduce education, health and care plans, potentially up to the age of 25—something to be widely welcomed. At the same time, the Care Bill introduces care and support plans for disabled adults over 18. Young people aged between 18 and 25 could therefore have two different plans. It seems to make sense that when a young person is eligible for both, they be brought together to create a consistent approach. I hope that the Minister and officials will work with interested parties, including Mencap and the Every Disabled Child Matters campaign to ensure that these plans are complementary and do not result in separate processes and plans.
Clause 55 of this Bill gives local authorities the power to assess children and young carers under the adult statutory framework in advance of their 18th birthday. This will be known as a child’s needs assessment. If a local authority does not comply with a request to undertake an assessment, it must give a written explanation for the decision. The clause is welcome and will allow young people better to plan their future because they know their entitlements. However, local authorities will have to assess children and young carers in advance of their 18th birthday only if they judge it will be of “significant benefit” and,
“it appears to the authority that the child is likely to have such needs”.
There are also repeated clauses about the potential contribution of “other matters” such as support from friends and family when determining necessary provision. This might well allow local authorities to use this wording as a way to pass on their responsibility to carers and family members or, frankly, to wriggle out of their responsibilities altogether.
Clause 63 creates welcome new protections to ongoing children’s services where a child’s needs assessment has been requested. However, this puts the onus on the parent or the child to request the assessment. If a parent or child is not told of their right to request such an assessment, and do not request one, they receive no protection under this clause. I therefore hope the Minister will consider extending this protection to all children and young people, not just those who have requested an assessment.
Part 3 of the Bill focuses on health, specifically on the establishment of Health Education England, which will be responsible for the planning and delivery of education and training for the NHS and health workforce. It is absolutely critical that the NHS meets the needs of people with a learning disability. This is simply not the case at the moment. The three-year confidential inquiry into the premature deaths of people with a learning disability published its final report in March of this year. The inquiry looked at the deaths of 233 adults and 14 children with a learning disability in the south-west. It found that 37% of deaths would have been potentially avoidable if good quality healthcare had been provided. As if to underline this, today there was a report by the NHS Ombudsman, Dame Julia Mellor, on how mistakes by an out-of-hours GP service and Basildon University Hospital in Essex contributed to the death of a young woman with both physical and learning disabilities.
Unfortunately, this is no surprise to many families, who feel that blunders, poorly trained staff and indifference are to blame for the deaths of their loved ones. We await the Government’s response to the confidential inquiry’s findings, and its recommendations on how to prevent the needless deaths of people with a learning disability. Clearly, the training of healthcare professionals is vital. I trust that appropriate and acceptable amendments will be made during the passage of the Bill through your Lordships’ House.
To conclude, I reiterate that the Care Bill is a very welcome piece of legislation. However, I cannot stress enough that if we are to meet the aspirations of disabled people we will need to ensure that the eligibility threshold is set at “moderate”, not “substantial”. “Substantial” should be used for the funding of social care for disabled people, but knowing this Government’s attitude toward adequate funding for this vital service, I can only say, “Don’t hold your breath”.