NHS Funding

Lord Sutherland of Houndwood Excerpts

Monday 31st October 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, I am sure that the noble Baroness will be here well past the age of 75, and that there are many years to come before she reaches that age.

The noble Baroness is absolutely right: for many elderly people, the worst way to be treated, frankly, is to be blue-lighted in an ambulance into an A&E department of a very busy acute hospital. The whole purpose of the five-year forward view is to deliver care to many more such people outside. I think we all agree with that. The noble Baroness’s party, like ours, agreed with the £8 billion of extra government spending over the course of this Parliament, and accepted the fact that very significant efficiencies could be generated from the NHS. We still subscribe to that view, and the STPs will be the right vehicle for delivering many of them.

[Lord Sutherland of Houndwood (CB)]

My Lords, the Minister rightly referred to the realities that are required of a fundamental redesign of care. The point has just been made, and was made in the report from the House of Commons this morning, that that must include looking, at last, at the connection between social services budgets and the health service budget. This is one of the major factors. It will not solve all the problems, but it is a critical point that Government after Government have ignored for the last 20 years.

[Lord Prior of Brampton]

I entirely agree with the comments made by the noble Lord. We have to integrate health and social care to a much greater extent. We also have to integrate healthcare: healthcare is delivered in silos and is highly fragmented around the country, and that comes out of the same budget, so he is absolutely right. However, we have to recognise that another massive reorganisation between social care and healthcare could be highly disruptive. The great beauty of the STP process is that people in local areas—local authorities, health providers and commissioners—are sitting around tables coming up with plans for their local areas.

Four Seasons Group

Lord Sutherland of Houndwood Excerpts

Monday 11th January 2016 Lords Chamber

[Lord Prior of Brampton]

My Lords, it is up to local authorities to have contingency plans in place in the event of the closure of a home in their area. As I said earlier, the Local Government Association has indicated that at least 95% of local authorities have contingency plans in place.

[Lord Sutherland of Houndwood (CB)]

My Lords, the problems of care home residents through the demise of Southern Cross was dealt with very significantly by the rest of the care home sector; a condition of that happening was that it was in “robust condition”. Can the Minister reassure us that the care home sector is currently in equally robust condition?

[Lord Prior of Brampton]

My Lords, it is true, as the noble Lord says, that the fallout from the collapse of Southern Cross was that the industry took on most of the homes currently owned or operated by Southern Cross. I think that if a large provider went into insolvency, many of those homes would be taken over by the industry. The important thing is that the industry has confidence in its long-term future. As I said earlier, I believe that the commitment to increasing the better care fund and allowing local authorities to have a 2% precept for social care will provide that level of long-term confidence.

Residential Care: Cost Cap

Lord Sutherland of Houndwood Excerpts

Thursday 10th December 2015 Lords Chamber

[Lord Sutherland of Houndwood (CB)]

My Lords, I, too, thank the noble Baroness, Lady Wheeler, for giving us the opportunity to debate these issues, but I have to add the word “again”. My noble friend Lady Pitkeathley smiles at that. She coined a lovely expression in a previous debate; she referred to “the usual suspects” turning up. They are mostly here again; one is even on the Woolsack. The usual suspects are turning up and we have some new friends who will join the band. That is a good joke, but the disgrace is that we have to keep doing it. We have been doing it for more than a decade, often on the same critical issues. I pay tribute to my noble friend Lady Pitkeathley’s analysis of the need for the integration of health and social care services. This is the nub of providing good care. It will not deal with all the financial problems, but I will come back to that in a moment. Here we are again, and I will return to this point.

I should declare an interest as president of Scottish Care, which is the care home owners’ association. I have had briefs from Care England and Four Seasons Health Care. The most chilling part of the brief from Care England has already been mentioned. The chief executive is advising his members to consider the possibility of getting out of public sector provision. That is the size of the problem, and it is frightening.

A year or two back, Southern Cross Healthcare turned up its toes and gave up. The rescue that was mounted by the community of care home owners and groups of care homes was magnificent and meant that many of the clients of Southern Cross Healthcare did not have the great worry and concerns that otherwise they would have had about where they would be the next week and the week after. It was done by the community of care home providers, yet I doubt we could do it today. My first question to the Government is, do they have an analysis of the risks of that happening, of the risk of financial fall-out in the sector for reasons already given and of the risk if people are effectively on the street? I have seen at close quarters one care home close because of a fire. It was horrendous. It was 60 beds having to be vacated virtually overnight, but the troops rallied round. However, the question is, could we do it again?

In the few minutes I have left, I want to focus on viability. There are at least two key factors for viability, in addition to the funding issue that keeps recurring. The viability factors I want to point to are a high percentage of bed occupation and how much is paid for those beds. Unless there is, first, continually a high percentage and, secondly, confidence that the contacts currently being entered into with local authority commissioners will continue in future you cannot borrow money—it is difficult anyway—and you cannot get investors to put money into the system, so there needs to be both those things as well as adequate funding.

Why are these two factors so important? There is a shortage of cash in the public sector and therefore commissioning from local authorities is falling away. The criteria are tighter, and we have to live with that, apparently. There is also a malfunction in the conjunction between social care and healthcare, as my noble friend Lady Pitkeathley pointed out. We have talked about this for 20 years. In my 15 years in this House, this has kept coming up and yet it has not been solved. Oh, there are steps being taken. We will hear about these, doubtless. But it is not being dealt with adequately.

Let me give one or two facts and figures. We all know about what is referred to as bed blocking. That is at the extreme end of the malfunction, but of course there are many people—again referred to in the debate earlier—who are in hospitals and hospital beds, who neither want to be nor need to be. As for the figures, we have had 20,000 mentioned, 30,000 mentioned; these are the real numbers. This is not good enough. Put alongside that the fact that the 10 largest care home providers in Britain have 10,000 empty beds of high quality and providing nursing care. Those two numbers suggest something, do they not? We have to deal with the problems.

Add to that the further point that a delayed transfer—a bed blocking—will fill a bed that is costing between £1,750 a week up to £2,500 or £3,000 a week, while you can get good care home provision with nursing care provided for between £800 and £1,000 a week. That is half the price. Just put all these numbers together. I am not doubting the capacity of the Minister and his colleagues to count. Indeed the Chancellor of the Exchequer deals a pretty good hand of numbers himself; he could do well in Las Vegas. But actually putting these numbers together suggests obvious ways to go. Why are we not doing that? That will not solve the whole problem but it will begin to deal with the need to provide an adequate quality of care: how people want it, where they want it and how they need it.

NHS: Keogh Review

Lord Sutherland of Houndwood Excerpts

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

We are indeed looking at it very urgently at the moment in the light of the review published a few days ago by Camilla Cavendish, which focuses on exactly that issue.

[Lord Sutherland of Houndwood]

My Lords, one thing that is very positive in the Minister’s Statement, and in the way in which he responds to questions, is that he clearly understands that this is a multifaceted problem and that there is no single way in which to deal with the whole set of issues. That being said, there is, of course, a “but”. The “but” is that one element of the government response—already referred to at least twice—is the role of the future Chief Inspector of Hospitals. The view taken, and reiterated again today, is that the inspector should be within the umbrella of the CQC. For some of us, at the moment, the CQC is part of the problem. It has not solved all our problems. I share the hopes of the Government that the CQC will remove itself from its current difficulties. However, in the mean time at least—or, in my view, in the longer term—a chief inspector should have both the responsibility and the authority of reporting directly to Parliament, as does the Chief Inspector of Schools. That would be a helpful element of transparency.

[Earl Howe]

I would have agreed with the noble Lord had he made those comments 18 months or two years ago. However, the CQC has turned a very important corner. It has new leadership and has articulated new ways of working. The leadership of the CQC commands high levels of confidence in every quarter of Parliament. I am encouraged by that. However, the point that the noble Lord makes about transparency is vital. The CQC is very clear that it is not its function to gloss over poor care when it is found, nor indeed to fail to celebrate good care when that is found.

Care Bill [HL]

Lord Sutherland of Houndwood Excerpts

Tuesday 9th July 2013 Lords Chamber

[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.

Care Bill [HL]

Lord Sutherland of Houndwood Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Baroness Greengross]

My Lords, I shall speak to Amendments 76ZZA and 76ZAA in my name. I thank the noble Lord, Lord Hunt, for the support he expressed earlier. On Amendment 76ZZA, we know that one of the major problems identified in the Francis report was the inadequate handling of complaints and concerns. This issue has not been addressed in the Care Bill. My amendment would enable the Care Quality Commission to introduce more rigorous complaint systems across all care settings. I hope the Minister will consider this because it is very important to get this right now. This is about the way in which a registered service provider or a local authority will handle complaints and concerns, and it is very important.

Amendment 76ZAA is about continence care. I declare an interest as chair of the all-party parliamentary group on this subject. It is hardly spoken about, but it is terribly important; people just do not recognise how many people have some problem with continence. The NHS services should have continence care as an essential indicator of service quality. It therefore needs to be established as an essential indicator of high-quality services across the NHS and care settings within the periodic assessments of care standards undertaken by the CQC.

A number of recent assessments have demonstrated that continence care is still a low priority across NHS settings, with poor treatment resulting in escalated and more costly care needs and poorer patient outcomes. This is in spite of the fact that good bladder and bowel control are fundamental to people’s dignity and independence and that NICE has published a wealth of best practice recommendations to effectively assess and treat the condition. The Francis report included an entire chapter outlining the scale of failures in continence care. Given the expected rise in prevalence of incontinence and the impact that poor care can have on patients and the NHS, continence care must be seen as a key indicator of high-quality provision across care settings. An explicit requirement within the Care Bill for the CQC to assess providers for the quality of their continence care would directly respond to the failings in this field which the Francis report identified—the stated purpose behind Part 2 of the Bill. That would encourage providers actively to address how they manage incontinence by assessing their local protocols and policies about the condition, taking steps to improve awareness among staff about incontinence and undertaking internal audits in order continuously to improve care standards.

[Lord Sutherland of Houndwood]

My Lords, I wish to register my support for the proposals in some of these amendments. The integration of services should always be highlighted. We have a long way to go and, since we are not providing an integrated budget, every encouragement short of that should be given, so I support the amendments that propose this.

The amendments and stand-part question in the name of the noble Lord, Lord Hunt, have to do with the standing of the CQC. CQC has been through a very rough patch, and to some extent, responsibility lies as much here as elsewhere. I remember the debates a number of years ago, when we changed the structure of the regulation that should be provided in this area three or four times within four or five years and always handed the ball on to a new organisation that we thought would solve all the problems. We failed consistently to answer the question: what are the signs that the new organisation will succeed in all the tasks being given to it? We now see that there have been difficulties. Moving with a degree of caution has a great deal to commend it, and I look forward to the Minister’s response to the questions raised by the noble Lord, Lord Hunt.

The rhetoric around the comments of politicians, those in health regulation and the press continually refers to Ofsted and Ofsted-style inspections. I declare an interest, in that I had something to do with founding Ofsted and the type of inspections that in due course developed. Ofsted is a rather a different beast, and these comparisons do not help. For example, the chief inspector is independent of the control of the department, which seems not to be the case in the plans for the future. That means that the relationships with the Minister and Secretary of State will have to be very carefully managed. I am not sure that sufficient thought has been given to that. That is part of the case for asking whether Clause 80 should stand part of the Bill.

The other pressures being put on CQC have to do with financial assessment. These are additional responsibilities for which CQC is hardly prepared. There is a need for specialist staff and specialist abilities to decide whether companies providing care at all levels have the ability to continue sustainably to do that—but that does not, as we have seen in other forms of financial regulation, come easily to regulatory bodies. This has to be looked at very carefully, along with the pace at which change is introduced into the practices of CQC, which is under, we hope and expect, good new management.

--- Later in debate ---

I hope that I have answered most if not all the questions. Naturally, I shall reply in writing to any noble Lords whose question I omitted.

[Lord Sutherland of Houndwood]

Perhaps I may ask for clarification on one further point relating to complaints. Amendment 76ZZA does not propose that the CQC should handle complaints, which was the gist of the Minister’s response. Rather, it proposes that there should be a clear and transparent method of handling complaints within each trust and relevant area. The role of the CQC is to open up that window, very much in line with the Francis report, so that we can know that complaints will be handled at the appropriate level and in the appropriate way.

[Earl Howe]

I completely understand the noble Lord’s point. He will remember that in the registration requirements for providers of health or social care, the existence of a complaints system is one factor on which the CQC will need to satisfy itself. On the quality of the complaints-handling system within that provider, my answer is that it is a powerful point and an important area, but in the end it is one on which we should let the CQC decide as it develops its methodology. I do not in any way dismiss the noble Lord’s suggestion, but it is one for the CQC to take forward.

--- Later in debate ---

[Baroness Campbell of Surbiton]

My Lords, I had thought that I would not respond to the amendment of the noble Lord, Lord Best. However, I feel I must because there seems to be a missing voice in this debate—the voice of the thousands of people who use social care, over 70,000 of whom receive some form of direct payment. Ten years ago, when direct payments were successfully introduced and allowed disabled people to live independently in this country, we were proud to be employers. We were able to employ RPAs at a good rate, with holiday pay, and we were able to advertise. We were equal to those who employed individuals in their own companies. Ten years on, many cannot even give holiday pay and cannot advertise. They fall back on costly social care services or enter hospital as a result of not being able to employ assistants.

We, too, want to know the costings before new services come into effect. Disabled people may have to accept these services and find that they lose choice and control over their lives. So please do not forget the voice of those who say, “We, too, wish to know that the money is settled. We, too, need a voice to remind people that, in order for us to employ or control our services, we must feel that we can do this with equality and dignity and do it absolutely properly”. Otherwise independent living will become just a memory.

[Lord Sutherland of Houndwood]

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

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

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

[Lord Beecham]

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

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

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

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

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

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

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

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

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

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

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

Care Bill [HL]

Lord Sutherland of Houndwood Excerpts

Monday 10th June 2013 Lords Chamber

[Baroness Emerton]

I entirely support the amendment on integration, particularly across the boundaries between acute and primary care. When we consider discharge policies and mechanisms, it is terribly important that those working in the acute sector understand what they need to look at to integrate with the services that will take over the care. There is division where, through the education programme, we need a holistic approach to the patient pathway.

[Lord Sutherland of Houndwood]

My Lords, I very much support the intention behind the amendment. It points us where we should be going. It is evident that the way in which professionals are trained deeply affects how they carry out their duties for the rest of their lives. That is a sign of good education. The noble Lord, Lord Warner, has been pointing the direction in which health and social care will and must go. It is essential to lay down the basis so that professionals accept that it is the shape of things to come.

[Baroness Finlay of Llandaff]

My Lords, for many years in medicine, there has been a move to try to ensure training in the community, but its implementation has been woeful. It has not been instigated as rapidly as people have been campaigning for over many years. I hope that the Government will look favourably on the spirit behind the amendment, although, in an odd way, the wording may be a little too restrictive. It is a very important move to ensure that, as more patients are moved out to be cared for in the community, community services can deliver what they need. With very sick people in the community, a different skill set will be needed from that which is currently available.

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[Lord Campbell-Savours]

My Lords, from what I hear and from what I have been told, the problem seems to be that no one wants to do this job. A number of organisations have been approached, and many of them have made it clear that registration would be an impossible task. However, when you talk to healthcare assistants in nursing homes or wherever, you find that among them are some who strongly believe in it, because they want to see weeded out the people who they believe should not be practising. If they want it, and they believe that it potentially defends their professional position, why can they not be given some organisation, some kind of structure to which they can belong and be registered with, which would give them confidence within their working conditions?

I understand that the Government’s response will be the vetting and barring scheme. However, despite that scheme, there is still strong support for the principle of a registration scheme. Perhaps the Minister might give his response to that, setting out the reasons why some people do not have confidence in this vetting and barring system.

Finally, in the event that we do not make progress on this matter during the course of this Bill, the best way to deal with it might be to refer it to the Liaison Committee when it is next considering applications for ad hoc committees. Perhaps those who are interested in this subject can make a joint application to the Liaison Committee to set up a House of Lords inquiry into what the blockage has been historically, what the benefits would be, and to look at the way forward in the future.

[Lord Sutherland of Houndwood]

My Lords, as has been claimed in the course of this short debate, this amendment should be seen in the same context as Amendments 23 and 23A. However, together they have one common difficulty, which I think has been highlighted. The first point they make is that there should be proper training and education in this area, which is absolutely right; it should be a matter for Health Education England. Secondly, there is still a residual concern, which is very real, that the presence of training does not always guarantee that the care will be of the level and quality that we reasonably expect. So there may be a separate question about imposing some degree of regulation on employers. It is hinted at in Amendments 23 and 23A that employers could suffer a liability were they to put into the field, be they agencies or statutory employers, someone who evidently is unable to provide a decent quality of care. So the separation of these two issues is what I propose.

[Baroness Masham of Ilton]

I would like to ask the Minister a question. I do so agree with the noble Baroness, Lady Browning, over Winterbourne; we do not want any more Winterbourne Views—and they can happen in any part of the country.

My question to the Minister is whether he would agree with me that, when it comes to crisis intervention and physical restraint techniques, all front-line staff should receive a national standard of training to deliver the best possible quality care and health services. Undermining best practice in this area is driven by three elements: a fragmented, unregulated training provider sector; procurement pressures, and commissioners’ and regulators’ roles in quality monitoring; and practice application. The people who have to be restrained are very vulnerable and, usually, mentally ill in some way. Is it really suitable for untrained people to do this job?

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[Earl Howe]

That indeed is the ambition whereby there should be consistency of standards throughout the country and people should know precisely what those standards are. The problem with this sector of the workforce is that the standards have not properly been defined until now—hence the work that Skills for Health and Skills for Care are doing. However, we will see from that work and the work of Camilla Cavendish where the gaps are and where we need to focus our attention. The noble Lord is certainly right to say that once we have these standards in place, Health Education England will be responsible for ensuring that they are properly promulgated and rolled out.

[Lord Sutherland of Houndwood]

My Lords, I thank the Minister for giving way. I appreciate his point about the responsibility of employers. They are immensely important. However, would he be prepared to extend the language of responsibility to liability, either of a fiscal, legal or right-to-practise nature? I am not asking for a detailed answer, but it would be a shift that many of us feel would be moving in the right direction.

[Earl Howe]

As a result of the Francis report, we are indeed looking at the whole question of the liability of employers in the NHS as much as anywhere else. No doubt we shall be debating those issues when we reach Part 2 of the Bill. However, I can reassure the noble Lord on that point. We have here a vital segment of our health and social care workforce. I hope that the noble Baroness, Lady Greengross—

Care Bill [HL]

Lord Sutherland of Houndwood Excerpts

Tuesday 21st May 2013 Lords Chamber

[Lord Sutherland of Houndwood]

My Lords, it is, of course, a pleasure to follow my colleague, the noble Lord, Lord Warner, whose experience contributed so much to the outcome of the Dilnot review, and who has regularly drawn the attention of this House to the importance of its conclusions. I also thank the noble Baroness, Lady Barker, for her kind remarks. Suffice it to say that I remain one of the usual suspects and will continue in that gang for the foreseeable future.

The context of this Bill has a history. The post-war creation of the modern welfare state as we know it was momentous, and many of us have benefited from that for most of our lives. The two Bs, Beveridge and Bevan, gave us two structures. The first is the National Health Service, which in principle offers healthcare free at the point of delivery, and the second offers other benefits that cannot be defined as healthcare, including care services deemed to fall outside healthcare. These are not free at point of delivery but are subject to two constraints. The first is means-testing and the second is that responsibility for delivering these benefits lies currently with local authorities, and so is not currently in national service as is the National Health Service. This Bill goes some way, but not the whole way, towards changing that situation, and I will come back to that. It contributes to a redefining, but I agree with the noble Lord, Lord Warner, that the role and the difference between healthcare and social care still remains unclear.

The second and last relevant point of difference from when the national services—the health service and the local authority care service—were set up is the growing demographic change in our country and in every country. Demographic shifts have created a completely new situation which, whether we like it or not, will have an impact on how and where we spend money. We simply live in a different world. For 50 years, we got away with trimming at the edges, changing bits here and there in relation to health and social care spending. That can no longer be the case. It is clear, at last, that something must be done. This Bill does something, and it is very welcome. That is the strength of the Bill. However, it is, at best, a good start, for many of the reasons that have been given already. Its strength is that a peg has now been put in the ground, and there is a commitment to having a national strategy and policy that we have simply avoided because of the huge fissure that runs between health services and social care services. That is part of the world in which we live and it has very significant consequences.

The fundamental recommendation of the Dilnot report, that a cap be put on the cost of care for any individual, has been accepted. All credit is due, for this is at last an acceptance by the Government, including, therefore, the Treasury, that the risks involved in the frailties of old age, like those involved in cancer, stroke and diabetes, should be shared across the whole community. I hope that that principle has been established in the Bill before us.

Of course, the fears of the Treasury, which are always there, are already being realised. Inevitably, a chorus of voices points out that there is less to this than meets the eye. The Bill does not commit the resources that we all know are necessary if you are to duplicate the quality in social care services that we have in the National Health Service. As we have heard, Dilnot’s proposal included the possibility that a cap might be as low as £25,000. In the event, it is eventually £72,000, with the possibility of deferred payment. Again, as we have heard from the noble Lord, Lord Bichard, local authorities are vigorously pointing out that there is already a shortfall in funds made available before account is taken of this new proposal. They estimate that the current round of cuts to the adult care budget amounts to £2.68 billion—or 20% of previous provision—and that is before the provisions of this Act are dealt with. At the same time, as has also been mentioned, care home owners often subsidise local authority-sponsored residents from the charges made to those who are self-financing. That cannot be right. There should be a single charge, and a single cost that applies to everyone. However, the rich—or the moderately rich—are subsidising others. That is the position in which they have been put.

Of course, we all know that we are now in the worst financial crisis in living memory. Account has to be taken of that—and I put it to you that account has already been taken of it. What that does—and the noble and learned Lord, Lord MacKay of Clashfern, made this point very fairly—is to raise expectations, in the way in which this Bill is being canvassed, which will come home to roost. People who have legitimate hopes that their old age will be comparatively secure will be disappointed.

Equally important in the Bill is an implicit bet—and that is the best of it, as far as I can see—that the principle of a cap on care costs will stimulate a strong insurance market to cover pre-cap and possibly post-cap costs. We shall see, but there is no guarantee about that. Of course, conversations have been held, but my previous experience on the royal commission was that those providing insurance products were not interested. We shall see if a cap makes all the difference. Let us hope that it does.

The Government, while being commended on a good start, or indeed on facing up to demographic change, must accept, however, that as we stabilise our economy—and the expectation and hope is that we will do that—a reordering of priorities will be the only rational response to the empirical realities of the huge demographic change. We must accept, as a Government and as a Parliament, that these priorities will have to be looked at. The world out there is different. The facts and the shape of the population are different. If there is no more money, priorities have to move around a bit. That is the reality, or we will be having desperate scenes in the houses, streets and care homes of our country.

One change which cannot and should not wait until then is the need to ensure that the huge sums already being spent on care, social care and even more so on healthcare—the noble Baroness, Lady Greengross, referred to this—are spent in the most efficient and effective way, and to maximum standards of the quality of care.

In two successive parliamentary Sessions we have had two relevant major Bills. The first, now an Act, was, despite its Title, almost wholly concerned with healthcare. It is called the Health and Social Care Act but there is not much social care in it. This second Bill, as its Title says, has to do with care. However, there is the rub. Why were these two not one Act? There is a legal, financial, and administrative fissure in our society that runs through our attitude to the provision of care. We simply cannot continue like this. It is at government and at professional level. Doctors and social workers are the best of friends in the pub, but you should hear them when they talk about each other when it comes to money. There is a fissure there.

On the royal commission, we reran the hoary old joke about the difference between a health bath and a social bath. You had to divide them up in those days to decide which fund provided the money to provide the bath. Both the commission and the Dilnot report firmly made it plain that bringing together health and social care provision and, ultimately, budgets, is essential if we are to maximise value for money in this massive and increasing spend—and it will not go down.

There are some good pilots taking place. I would find it very helpful if the Minister could tell us what the outcome of the pilots would be. What process is there for taking account of the evidence of what they provide in terms of shared facilities, budgets and provision? The message is very clear: combining budgets provides better administration, improves the effectiveness of spend and, importantly, has a huge potential vastly to improve the quality of care.

I would like quickly and briefly to make two points that have come up in the debate about the assessment and evaluation of what is going on. The first is that there is provision, rightly, to deal with what I can refer to only as the Southern Cross problem. We cannot have major providers going bust on us. That is right—but I wonder whether it is right to ask the Care Quality Commission, whose expertise is in a wholly different field, to take responsibility for this. Is there not even a group within the department of health economists, or economists, who know about running big businesses—they are essentially property businesses—and can give a proper health reading? Those responsible for assessing the quality of care are not those people. Yes, they will employ others. But if it is to be a kingdom within a kingdom, why not charge reasonably well paid civil servants with doing that?

Lastly, although it is not mentioned in the Bill, the Minister made mention of a new inspector. I simply ask whether we can have some information about the context in which such an inspectorate will work. It is canvassed as being like Ofsted, which is of course a great reassurance to those of us who were involved in setting up that body. However, it does not seem at all like Ofsted. Does this new inspectorate have a statutory basis? Is it independent of Ministers? We have had a row within recent weeks about who can close down a unit within a hospital—for example, for the heart surgery of children. Where are the lines of accountability? What is the new inspector responsible for? The chief inspector of schools is accountable to Parliament, not to Ministers. That gives it an independence and certainty about being taken seriously that will not necessarily be the case for an inspector within the employ of the department. So there is a lot of room for clarifying the provision there, but I am sure that we will come back to that in Committee.

Social Care Funding

Lord Sutherland of Houndwood Excerpts

Monday 11th February 2013 Lords Chamber

[Earl Howe]

My Lords, I hope that I can put the noble Lord’s mind at rest. In doing so, I thank him once again for the work he did on the Dilnot commission. It is our intention that the eligibility criteria will be introduced from April 2015—so, in advance of the Dilnot arrangements. As he well knows, that national minimum eligibility will be set to make access to care more consistent around the country. In addition, carers will have a legal right to an assessment to care for the first time. I take his point about trying to achieve cross-party consensus on social care funding.

As for funding in the existing system, in the last spending review we made, as he knows, an additional £7.2 billion over four years available for care and support. Since then, we have provided local authorities with an additional half a billion pounds. We believe the challenge creates an opportunity for local authorities to innovate and to explore new ways of working better to meet the needs of their local populations and to optimise the use of the resources that they have. Many local authorities are already innovating, and we are committed to supporting them to deliver further service improvements.

[Lord Sutherland of Houndwood]

My Lords, I am pleased to welcome the Government’s Statement today. This has been a long time in the waiting, not simply from this coalition Government, who have done well to get this far, but from previous Governments. There has been prevarication for more than 10 years, and it is about time we got started. We have now started. As has been said, this is a first step on the way. There are many steps to be taken thereafter, and a great deal of discussion and, if possible, cross-party consensus would be useful.

Will the Minister confirm that an adequate length of time will be made available for that, not simply a Question for Short Debate, in the near future? Secondly, will he confirm that it would be open to any Government, perhaps his own Government, to look again at the financial thresholds that they are setting in this Statement as and when, as we all hope, the economy improves?

[Earl Howe]

I am grateful to the noble Lord, Lord Sutherland, and pay tribute to his work over many years in this field and in the royal commission some years ago. I will convey his wishes to my noble friend and other members of the usual channels. I agree that it would be unsatisfactory to have an unduly short debate on a complex and important subject.

As regards the thresholds, I hope I can reassure him. It is our intention, as I mentioned, to introduce clauses into the care and support Bill when it reaches Parliament that would embody the essence of the Dilnot proposals but to leave it to regulations to set the relevant numbers for the cap and the means test, for example, so that it would be a relatively easy matter for a future Government, if they so wished in brighter economic circumstances, to change those figures if they felt that that was the right thing to do.

Social Care: Funding

Lord Sutherland of Houndwood Excerpts

Monday 21st January 2013 Lords Chamber

[Earl Howe]

Yes, my Lords, my noble and learned friend is right. The Dilnot proposals focus primarily on social care although there are always knock-on effects for the health service. In theory, it will be possible for us to produce clauses covering the Dilnot proposals for scrutiny by the Joint Committee but I am not in a position to give that undertaking at present.

[Lord Sutherland of Houndwood]

My Lords, I welcome the announcement that has been made and I hope that it will please more of us than seems to be the case at the moment. We shall see. Does the Minister agree that the effectiveness of the Dilnot proposals for a cap depends on adequate insurance products being available to cover pre-care costs or costs that arise before that cap is reached? If so, have the Government had any discussions with the insurance industry or are any planned?

[Earl Howe]

My department is engaging actively with the financial services sector for the very reasons that the noble Lord suggests. As I have said, care needs are very difficult to predict and care costs can be open-ended in the current social care system. At the moment, that makes financial products very expensive to buy and difficult to develop. There are many reasons why people do not consider financial products for their care at present, including a lack of awareness that they have to pay. We very much hope that the introduction of a Dilnot-type solution to this problem will encourage the financial services sector to develop these products and we believe that that will happen.