Health and Social Care

Lord Wigley Excerpts

Thursday 24th November 2016 Lords Chamber

[Lord Wigley (PC)]

I am delighted to follow the noble Lord and the trenchant points he has made. I thank the noble Baroness, Lady Finlay of Llandaff, for initiating this timely and far-reaching debate. I also take this opportunity to thank her for her tremendous contribution to the health and social care services in Wales over many years. She spoke today from a position of immense knowledge and experience. The Government would be foolish to ignore her warnings and, indeed, the warnings of others who have brought their expertise and viewpoints to this debate.

I wish to make it clear where I am coming from on this issue. I have always been an ardent European and regard the Brexit vote as an absolute tragedy. Therefore, before I address the specific healthcare dimension, I wish to say a word about the state of play on Brexit. I accept that, regrettably, we are likely to leave the EU. The vote on 23 June in the advisory referendum asks the Government to take such a step. The referendum did not in any way advise the Government on what new alternative relationship the UK should have with our current 27 European partners. Several alternatives were mooted during the referendum campaign by the Brexit backers. Some advocated a Norwegian-type relationship, some an arrangement more similar to that of Switzerland, and some even proposed Albania, Turkey or Ukraine as possible models. Others looked to the long-negotiated deal that Canada has secured. Others on the hard Brexit extreme advocated basing new arrangements on World Trade Organization rules, and essentially walking away from our European neighbours.

Not one of these alternatives was endorsed or rejected by the referendum. The Government have no mandate from either the referendum or the 2015 general election manifesto to adopt any of these alternatives as the way forward. They have not yet even asked Parliament to endorse any preferred course of action. Unless they secure a prior mandate from Parliament laying down the negotiating objectives—not necessarily in all the intricate detail, but by way of broad strategic targets—they must face the possibility two years down the line of returning with a set of proposals that Parliament then rejects. In these circumstances, Parliament would have every entitlement to instruct—yes, instruct—the Government to withdraw their Article 50 application, which lawyers now accept is legally possible. It therefore now behoves the Government to seek a mandate from Parliament for their strategic objectives, and I approach this debate on the potential implications for the NHS from that angle.

Improving, not undermining, the NHS was a serious factor which influenced many people to back Brexit, believing that the NHS would gain £350 million a week and thereby recruit more doctors and nurses, many of them from the European Union itself. The NHS is massively dependent on staff who have been recruited from overseas. Some 20% of the entire NHS workforce is from overseas: about half from the EU and half from other overseas countries. More than 10,000 NHS doctors come from other EU countries, as do more than 20,000 nurses, and they come predominantly from Ireland, Poland, Spain, Portugal and Italy. In Wales, a staggering 30% of all doctors were trained abroad—2,687 of them.

The Brexit vote has done two things. It has raised in the minds of NHS staff from other EU countries the question of whether they will be sent home when we quit the EU. These fears were exacerbated by the Prime Minister’s ill-advised comments at the Tory Party conference and her subsequent refusal to give assurances that all EU citizens currently working in the UK will, in all circumstances, be guaranteed the right to continue to work in the UK indefinitely. The only definitive statement made by the Prime Minister on these matters has been to rule out the Australian-style immigration system. The uncertainty created by the inept way the Prime Minister has dealt with these issues has led NHS staff, particularly in specialist jobs, to start looking around for suitable vacancies in other countries. No one can blame them. If in two years they find that they have to go, they might not then easily find a job in their home country. Indeed, they might face much greater pressure as other medical specialists in the UK also turn back to look for jobs at home.

The pressure to leave the UK is not just on EU-originated NHS workers. Many from Commonwealth countries have faced the horrid racial abuse that has mushroomed as a direct result of the Brexit campaign. Racially motivated crime has escalated, as the police have told us, and many NHS staff from non-EU countries are asking themselves whether they want to remain in a narrow, inward-looking, racially prejudiced Britain—indeed, whether they want to bring up their children in such a hostile climate. It is an absolute tragedy that all the hard work that has been done to break down the barriers of prejudice and racial hatred have been so disastrously undermined by the tone of the Brexit campaign, the outcome of the referendum and the Government’s inability to handle the situation.

I ask everyone, throughout the UK, to look around when they go to their hospitals and note the number of overseas workers on whose backs all that depends, and to look at the lists of names of doctors in the departments they visit and see the many names from foreign countries. My wife recently went to an NHS hospital in Wales, and of the 14 names on the plaque by the department no fewer than 12, at least ostensibly, were from overseas. I ask people to think what they would do if such staff went home, as some are told to do on the pavements of British cities. I ask them to consider the dependency of other services, such as home helps to support disabled people, or the staff in homes for the elderly who look after their parents or grandparents.

I ask the Government, taking all these aspects into consideration, to do three things. First, they should announce forthwith that every EU national—indeed, every overseas national—working in the UK will be entitled to remain here irrespective of the Article 50 negotiations and their outcome. Secondly, such a guarantee will have no ifs, no buts and no conditions; it will be absolute and not time-limited. Thirdly, it will be in the UK’s negotiating position, if we are leaving the EU, to retain our rights vis-à-vis the single market—if necessary, specifying a customs union deal—and accept the free movement of working people throughout the EU into the UK. Anything less than this will leave a bleeding wound that will hit many sectors of the UK economy, but none worse than health and social services, from which the haemorrhaging of vital staff could lead to the end of the NHS as we know it.

Learning Disabilities: Premature Deaths

Lord Wigley Excerpts

Wednesday 30th July 2014 Lords Chamber

[Earl Howe]

My Lords, many of the issues that apply to those with learning disabilities also apply to others with different disabilities, and the work currently going on in the context of the noble Baroness’s Question will, I think, have a beneficial impact across the piece.

[Lord Wigley (PC)]

Does the Minister accept that a number of the points arising out of the confidential inquiry were touched upon by the earlier DRC report published more than six years ago, Equal Treatment: Closing the Gap, and that progress since then has been patchy? In the light of that, will he give a commitment that there will be an annual review of progress made on the confidential inquiry recommendations and a report to Parliament?

Learning Disabilities: Community-Based Support

Lord Wigley Excerpts

Tuesday 22nd July 2014 Lords Chamber

[Earl Howe]

My noble friend is absolutely right to focus on the role of commissioners. The Winterbourne View joint improvement programme has already stepped up its activity in working with local areas, including identifying 35 areas for in-depth review. NHS England is engaging with commissioners to reinforce the importance of ensuring appropriate services for people with learning disabilities close to their homes and families. That includes looking at how funding streams can be shared with local authorities so that there is no procedural blockage in the way that money moves across the system.

[Lord Wigley (PC)]

My Lords, on that very point of funding, how will the Government ensure that funding in fact follows the individual and does not, as so often currently occurs, remain locked into the funding of the wrong kind of provision? In asking this, I draw attention to my registered interest as vice-president of Mencap.

People with Learning Disabilities

Lord Wigley Excerpts

Thursday 12th June 2014 Lords Chamber

[Lord Wigley (PC)]

My Lords, I am very glad to speak in this important debate on tackling the inequalities that people with a learning disability face within healthcare. I declare my interest as a vice-president of Mencap.

My noble friend Lady Hollins set out very clearly the Government’s failure to implement fully the findings of the confidential inquiry, which was set up following the publication of Mencap’s report, Death by Indifference. The lack of progress reflects badly on the Government. It is completely indefensible when we consider that the inquiry found that 37% of deaths investigated could have been prevented with better healthcare. How many more will die before more purposeful action is taken?

I strongly support the central point the noble Baroness made—namely, that there must be robust national oversight—and I look forward to the Minister’s response to that. However, I will focus attention on how to ensure that reasonable adjustments are made so that people with a learning disability have fair access to healthcare, their voices are heard and they get the right treatment.

Hospitals and other healthcare settings are under a legal duty to make reasonable adjustments for people with a learning disability to access healthcare effectively. That might include simple things such as making appointments by e-mail, providing treatment information in easy-to-understand formats, sending text or phone appointment reminders, or offering longer appointments. Such adjustments are not costly. Despite legal duties under the Disability Discrimination Act and now the Equality Act to make reasonable adjustments, they are often not undertaken, which leaves those vulnerable people undiagnosed, misdiagnosed or without the information they need to make informed choices.

Some noble Lords may know that I was a commissioner at the Disability Rights Commission back in 2006 and worked on an 18-month investigation into this very subject. The final report, Equal Treatment: Closing the Gap, exposed that reasonable adjustments were not being made across the board, so it came as no surprise when the confidential inquiry highlighted the very same problem.

We desperately need to move forward on this. However, we should also highlight where good work has been done, and I will draw on an example from the Royal College of Nursing report, Strengthening the Commitment. The report details some of the steps taken by St George’s Hospital to make adjustments for people with a learning disability as well as to help reduce anxiety, permit family members to provide emotional and advocacy support, and enable professionals to treat people in an efficient and timely way.

Those steps include no fixed visiting times for family, carers or friends, so that they can be with patients for as long as they want. Food and drink is offered to family and carers to ensure that they can be with the person they are supporting at any time; and, when staying at the hospital, family members or carers are provided with a chair or even a bed if they prefer. They also offer the first or last appointment of the day so that people who find it traumatic to wait do not have to do so, and double appointments are made available because they permit a fuller assessment of people’s needs, which is likely to result in more effective treatment.

A specific example of how reasonable adjustments were made at the hospital involved a person called Trevor. Trevor had capacity to consent to have dialysis but pulled out the tubes after 30 minutes because he was unable to judge how long the procedure had taken and wanted to leave. The reasonable adjustment which was made in his case was to provide a healthcare assistant to be with him throughout the four-hour treatment to talk with him and to encourage him to complete the dialysis. Over time, he stopped needing to have someone with him and he now does the dialysis by himself—a very reasonable adjustment.

Noble Lords may agree that encouraging hospitals and healthcare professionals to make reasonable adjustments, often at little or no cost, will go a long way to tackling these appalling health inequalities. I look forward to the Minister’s reassurances that when innovation and good practice are evident they will be promoted and replicated so that reasonable adjustments are the norm rather than the exception. Will the Minister give his absolute commitment to these matters and not accept second best for some of the most vulnerable people in our communities?

Health: Multiple Sclerosis Nurses

Lord Wigley Excerpts

Wednesday 5th March 2014 Lords Chamber

[Earl Howe]

Yes, my Lords, that is why we are creating the Better Care Fund, with £3.8 billion worth of shared money between the NHS and social care, starting in 2015, to make care seamless for the patient, whether it is NHS or social care. That fund has scope to do exactly what the noble Lord wishes to achieve.

[Lord Wigley (PC)]

My Lords, does the Minister appreciate the cross-border issues that sometimes arise between north-east Wales and north-west England, where multiple sclerosis patients may get some primary treatment in England but the level of support services, such as nurses, may be different over the border? Can he ensure that there is discussion on this between his department and the National Assembly in Cardiff to ensure that people do not miss out for that reason?

[Earl Howe]

I will gladly take that point away, but I know that I and my colleagues and the officials in my department are careful not to appear to lay down the law to our friends and neighbours in Wales as to the services that they should offer patients there.

Mesothelioma: Research Funding

Lord Wigley Excerpts

Thursday 16th January 2014 Grand Committee

[Lord Wigley (PC)]

My Lords, I am grateful to my noble friend Lord Alton for securing this debate. I pay tribute to him for his perseverance with this most distressing of subjects. We seem to be fighting a battle of attrition, one step backwards regularly following what we had thought to be two steps forward.

The importance of not letting up in our fight for mesothelioma sufferers came home to me last month, when the Christmas card from my closest school friend, Peter Wolfe, told me that he had been diagnosed with the condition, despite never having worked in any industry that could have triggered the disease.

We have been reminded of the estimated 50,000 people who may die over the next 30 years unless adequate treatments are found, and I suspect that this could be an underestimate. In Wales, cases of mesothelioma have risen sharply over the past 20 years. Whereas 23 cases were reported in 1990, by 2008 that number had jumped to 90, and according to Cancer Research UK, the latest estimate is about 109 new cases annually. That is partly because of Wales’s industrial legacy.

However, there are dangers for younger generations too. Some 85% of schools in Wales contain asbestos, compared to some 75% of schools across the UK. Almost 400,000 children and young people in Wales are exposed to the risks of this deadly material. The Cwmcarn High School is a case in point: it was forced to close in October 2012 after a survey found that pupils and staff were at risk from airborne particles of amosite asbestos. Responsibility for the management of asbestos in schools rests with the Welsh Government, but that of research rests primarily in the hands of the UK Government. As has been said, investment in such research is woefully inadequate. According to the National Cancer Research Institute, £400,000 was invested in mesothelioma research by its partners in 2011, compared with £5 million for myeloma and £5.5million on melanoma—two cancers with similar fatality rates.

The agreement in place over the past three years with the four leading insurance companies, generating £1 million a year for research, cannot be funded in the longer term. We tried but failed to get provision for a statutory levy during the passage of the Mesothelioma Bill. That could have raised £1.5 million a year for research.

As has also been mentioned, a similar amendment was tabled in the Commons by the late Paul Goggins, aimed at ensuring that research funding in this area would be permanent and effective. As he said in Committee:

“The problem, as the industry itself says, is not that some companies are not prepared to fund this; it is that not all of them are prepared to do so … we must have a formula and a system that means that everybody contributes according to their market share”.—[Official Report, Commons, Mesothelioma Bill Committee, 10/12/13; col. 15.]

As a result of his remarks, the Minister, Mike Penning MP, agreed to talk to the ABI about setting up such a broader agreement. I understand that a meeting has taken place, although nothing concrete has yet come out of it. Perhaps the Minister could clarify that in due course.

I associate myself with the tributes paid to Paul Goggins. It was poignant that Tracey Crouch MP had to move the amendments tabled in his name on Report shortly before he died. That amendment was defeated by 266 votes to 226. Responding to that debate, the Minister claimed that the additional research levy would nullify the deal reached by the Government, because the industry claims that a voluntary agreement with all 150 firms would be unmanageable. Is the industry to be granted a veto in this most vital area of research? The Government really must find a solution. If they cannot establish such a voluntary scheme, they must find other means of providing statutory funding. The more time that we waste in deferring this decision, the greater the number who will die.

It is not only people in the UK who are at risk. I conclude with Paul Goggins’s words in Committee in the Commons:

“We have the dreadful problem of mesothelioma in this country, and people will die from that dreadful disease, but we know that, because of the export and use of asbestos in the developing world—the so-called BRIC countries—the issues that we face now are issues that other countries will face in future. If we can advance the science and understanding of mesothelioma now, that might do great good not only in this country, but throughout the world”.—[Official Report, Commons, Mesothelioma Bill Committee, 10/12/13; cols. 9-10.]

I hope that the Government will listen.

Children and Families Bill

Lord Wigley Excerpts

Wednesday 20th November 2013 Grand Committee

[Lord Judd (Lab)]

My Lords, my noble friend just referred to how difficult it is to break the habit once you have formed it. I was a smoker in my youth. I progressed to a pipe, and on one occasion I was in some gathering with fellow young people when the bowl of my pipe dropped off into a pint of beer. I realised that this was a message from God and that one or other had to stop. I had little difficulty in choosing beer with which to continue. We all have these experiences. I am sure I am not alone in remembering with some guilt that, having joined the smoking culture—certainly the presentation of tobacco and cigarettes was an important part of the wooing of a person into the habit—I used to take tremendous pride in choosing the right cigarettes for my father on his birthday or at Christmas. That was very important, because he was a smoker and I was able to present him with a well wrapped packet of what he would like. Later in life, he suffered a severe stroke which left him speechless for the rest of his life, and I have always had an element of guilt about the fact that I no doubt contributed to that development in his health.

I do not understand why we prevaricate on these issues, as we are talking about a killer. Let us get this absolutely straight: it is a killer. We have no hesitation in saying that we must have rules about seat belts in cars because children get killed in accidents. We have special rules about children in cars because of how vulnerable they are. Why, if we take this seriously for seat belts and the rest, do we not take it equally seriously for tobacco?

My final point is that, as a society, we are agonising over the difficulties faced by our health service as it tries to grapple with the pressures on it. By enabling and encouraging young people to become part of the smoking community—by allowing them to drift into it or, indeed, by encouraging the deterioration in their health because of our failure to take rigorous action—we are deliberately adding to the problems of the health service. It seems to me that this is not only wrong but irresponsible. On the one hand to be grieving and agonising about the problems of the health service and the shortage of funds, and on the other hand to be aggravating it by our failure to act where we could act, seems to me irrational behaviour.

I commend noble Lords who have tabled these amendments, which certainly deserve support. I believe we shall be looked at very critically indeed in history for having prevaricated and pussyfooted for so long on such a crucial issue.

[Lord Wigley (PC)]

My Lords, I was going to make rather a longer speech the other night, but when I listened to the noble Baroness, Lady Finlay, present Amendment 263, most of the points in my speech were covered. However, I add my voice in support of what she said and of the other amendments before us today.

When I was 15, I remember being called home from school, as my father had had a very severe heart attack. He smoked between 40 and 60 cigarettes a day. I was there when the doctor told him, “You know what has caused this: it is your smoking”. I avoided smoking as a result—it brought the message home to me. When I used to travel in the car with him, invariably the little side window on the driver’s side would be slightly open, and most of the smoke would come back to me. We have legislation that protects people who have to work in vehicles from exposure to smoke—my goodness, we should be protecting children in a similar situation.

People say, “What next? You’ll be saying that people cannot smoke in their own homes”. The difference is that, in their own homes, children can go to another room—up to their bedroom or wherever—but when they are travelling in a car they cannot do anything like that. I very much hope that the Committee, and in due course, on Report, the House, will take on board an amendment along the lines of that moved by the noble Baroness, Lady Finlay. There is certainly widespread support on the Cross Benches for these amendments. If the Government do not move something themselves, I suspect the House will move on their behalf and that this will go forward into legislation.

[Lord Palmer (CB)]

My Lords, I fear that I may well be a lone voice in not supporting this amendment, even though I think smoking is a revolting habit and that everything must be done to encourage young people to refrain from it. There has been a lot of research into this, and a far more effective way to reduce youth smoking would be to ban the proxy purchasing of all tobacco products for under-18s, as is the case currently for alcohol.

I declare an interest as chairman of the Lords and Commons Cigar and Pipe Smokers’ Club and am, for my sins, a shareholder in BAT.

It must not be forgotten, particularly following the points made by the noble Baroness, Lady Young, and the noble Lord, Lord Judd, how much revenue is raised by the sale of legal tobacco products and, more importantly, how much income the Treasury is deprived of through illicit imports. I have a nasty feeling that if this amendment is agreed to, or voted on on Report, it will only compound that terrible figure.

Care Bill [HL]

Lord Wigley Excerpts

Monday 22nd July 2013 Lords Chamber

I would welcome clarification from the Minister about the Government's intentions and that not only settings regulated by the CQC will be included. The regulations need to be clear. It is essential that councils are left in no doubt about which types of accommodation have a care element and which do not, otherwise this will become a new area for dispute. Some types of accommodation, such as a residential home, clearly have a care element but with others the picture is far less clear. For example, there is considerable diversity of definition about what constitutes domiciliary care as compared with supported living and what the differences are. This just indicates the sort of issues that need to be addressed if continuing disputes are to be avoided. These regulations provide an opportunity to end the needless consignment of vulnerable people and their families to limbo, avoiding the waste of time and resources caused by disputes and thereby give those who rely on social care and support more choice, control and independence in their lives.

[Lord Wigley]

I would like to put on record my support for the points made by the noble Baroness, Lady Campbell, and those just made by the noble Lord, Lord Low. I wish to speak to the two amendments in my name in this group; Amendments 92ZZAG and 107. These are probing amendments to try to get something on the record with regard to the way in which care issues covered by the Bill and which have cross-border implications between Wales and England will be handled in the future.

Although Clause 112 says that the Bill extends to England and Wales, the Bill is ostensibly to do with care provision in England only, which is why I have exercised a self-denying ordinance and not imposed my opinions on the House or the Committee in recent weeks—other than at Second Reading when I flagged up these matters, which I wish to pursue today.

There are two distinct issues although they can in some circumstances be linked. The first relates to the people who move between Wales and England and England and Wales and how differing care regimes in the respective countries will affect their entitlements. I am talking about people who move voluntarily and not those who may be placed by local authorities or a health authority. The second relates to the funds associated with this Bill and how they impact on the two respective countries, and to that extent the Bill certainly has implications for Wales, Scotland and Northern Ireland.

I first remind the Committee that the social care dimension is a wholly devolved subject, and the policy in Wales may be totally different from that in England. The National Assembly is now considering draft legislation which no doubt will lead in coming months to the evolution of a new statute in Wales. The Welsh Government have a commitment to a new system that is fair, affordable and sustainable within a Welsh context. The legislation being considered in Wales is likely to increase the number of services where people can claim a direct payment from local councils; introduce national eligibility criteria that may be different from those in England; create portable assessments within Wales that do not extend to England as I understand it, and establish a national adoption service and allow council officers greater powers in helping those suspected of being at risk.

In Wales there is a substantially greater proportion of older people—greater than any other country or region in the UK. I also maintain in that context that the GVA levels in Wales are in some areas 40% below the average levels of the UK. The financial profile against which any new policy is set will inevitably be different between Wales and England. They will also have to allow for the fact that disability levels are significantly higher in Wales. Wales has already set a cap of £50 a week on charges for home care. The Welsh Government have, wisely to my mind, waited to see the sums involved in England before deciding on the best policy for paying for care in Wales.

There has been pressure on the Welsh Government from Age Cymru and others pressing for a lower cap in Wales than in England and there has been talk of caps of £23,000 and £35,000, which is the figure recommended by Dilnot. There are serious questions about how the Care Bill in England may affect Wales and vice versa, both in terms of whether there is any full Barnett consequential accruing to Wales from the £1 billion cost of the package in England, and with regard to the entitlement of people who have moved informally—not by placement but informally—between the two countries. For example, what is the portability of assessments of need made in Wales for people who move to England and vice versa—not cross-border placements but those who move voluntarily?

To put it simply, what is the position of Mrs Jones who lives in Prestatyn and goes into residential care in Prestatyn? At the behest of her daughter who lives in Chester she moves to a residential home over the border to be closer to her grandchildren. Will the cap operational in Wales or in England be applicable? Likewise, what if Mrs Smith experiences exactly the same problem in the converse direction? Who will explain the situation and the implications of the situation to both Mrs Jones and Mrs Smith before they decide to move?

Incidentally, the definition of “ordinarily resident” in Clause 38(1) seems to be inadequate to deal with the situation of someone who may move from supported accommodation in one country to another as the location at which she or he lived prior to coming into supported accommodation might be totally irrelevant—for example, if they lived for a period with their daughter in, say, Dublin, Brussels or the Isle of Man.

There is then a question about the duty of the health research authorities covered by Clause 98 of co-operation between England and Wales. Clearly the duty of co-operation needs to be considered, not only in the context of the health authorities but in the general context of these amendments, but who will enforce that duty? What will be the fundamental long stop to ensure that Mrs Jones and Mrs Smith are not caught in the crossfire between the policies of two Governments?

I do not know whether any of the government amendments in this group have an implication for the question I am raising but I would be grateful if the Minister can address these issues so that between now and Report I can discuss them with colleagues in Cardiff to ensure that when the final legislation goes on to the statute book everyone will know exactly where they stand.

[Baroness Wilkins]

My Lords, I strongly support the amendments of the noble Baroness, Lady Campbell, and the noble Lord, Lord Low. The noble Baroness has been very keen in pursuing these issues for the past five years and her tenacity has been outstanding. I am sure we all recognise that. She has argued comprehensively and excellently for these amendments. We all know that there is huge stress in moving home and, if you are a person in need of care, that stress is beyond words. As the noble Baroness said, it is a monumental risk. I hope that the Committee will wholeheartedly support these amendments.

--- Later in debate ---

[Baroness Northover]

My Lords, adults with care and support needs may want to move home, just like anyone else, but co-ordination between local authorities can sometimes be variable and, as a result, we often hear that people are worried that they will face gaps in the care that they need. The Bill sets out to change that. Clauses 36 and 37 set out a new process to support people moving between areas in England with a guarantee that their needs will not go unmet during the transition.

I turn, first, to the amendments tabled by the noble Baroness, Lady Campbell, who has a long-standing interest in this issue. As the noble Baroness, Lady Wilkins, and the noble Lord, Lord Hunt, emphasised, the noble Baroness has fought on this issue for years and I thank her for her gratitude to the Government for taking action in this area, even if she has some residual concerns. I hope that I can reassure her and, should she wish to move, that she will be able to contemplate a move as feasible in a way that she never felt it was before.

Amendment 92ZZAB seeks to ensure that the adult remains informed during the process. It is important, as the noble Baroness, Lady Campbell, has made clear, that this is the case so that the adult can plan for their move. Clause 36(6) requires the second authority to carry out an assessment as soon as it has established the adult’s intention to move. This requires interaction with the adult from an early stage and thus provides the opportunity to inform them of progress. We intend to clarify this area in statutory guidance and I am sure that the noble Baroness will wish to feed into this.

Amendment 92ZZAC would require the second authority to have due regard to the care and support plan provided by the previous area and Amendments 92ZZAD and 92ZZAE seek to ensure that the focus is on securing equivalent outcomes as in that plan. I fully understand that the noble Baroness is not seeking equivalent services and that this is different from outcomes, a point emphasised also by the noble Lord, Lord Hunt. Of course, when a person moves it is possible that their needs for care and support may change; for example, if they move closer to their family. The noble Baroness is right to focus on outcomes and we recognise that in the Bill. For example, Clause 25(1)(d) would include all the matters identified by the person, including the outcomes they want to achieve. We very much sympathise with these points and indeed have already revised the provisions following consultation on the draft Bill. Clause 36(7) requires the second authority to have regard to the plan or plans provided.

A further change following consultation is the introduction of Clause 25(5), which requires that when preparing to meet an adult’s needs,

“the local authority must take all reasonable steps”,

to agree with the adult how it will do so. Together, these provisions allow adequate scope for the existing plan to be reflected, so far as is agreed and appropriate, in the way in which the second authority meets the person’s needs to achieve the outcomes that the noble Baroness speaks of. I hope that the noble Baroness, Lady Campbell, agrees that the changes we have introduced will ensure that the person will be fully involved in the development of their care and support plan, and as such, can ensure that this continues to meet the outcomes they want to achieve.

Amendment 92ZZADA, in the name of the noble Lord, Lord Hunt, proposes that we replicate Clause 36(10) for carers. I will explain why this is not required. Clause 36(10) has been inserted as a result of our proposals for funding reform, which we discussed earlier in Committee. It requires the second local authority to inform the person receiving care and support if the cost of their eligible needs is different from that provided by the first authority. This relates to the individual’s care account and it is right that the authority informs the person if the amount that counts towards their cap on care costs has changed. However, carers will not have a care account as they are not eligible for a cap on costs and there is therefore no need to require the second authority to inform them of any change in the cost of meeting their eligible needs.

Where a service user is moving to a new local authority in England and the carer is also intending to move with them, the continuity of care provisions will apply to the carer in the same way as they do to the service user. I hope that this reassures the noble Lord. Where the service user is not moving but the carer is moving home to another authority, these provisions will not apply. The carer is still providing care in the original authority and it will continue to be responsible for meeting their care needs.

Amendment 92ZZAF, in the name of the noble Baroness, Lady Campbell, would require the first authority to continue to meet any needs until it has satisfied itself that the second authority has met its duty in Clause 37(1). The noble Baroness explained why she felt this was important. The continuity duty in Clause 37(1) applies from the day of arrival in the new area. From that point, it is the new authority’s responsibility to meet the adult’s needs, and the first authority’s previous duties are discharged. There should not be a gap in these arrangements. In particular, the requirement on the second authority to assess the adult before they move is intended to ensure that the necessary preparation has been undertaken so that there is no delay. Therefore, this amendment should not be necessary. Moreover, there is a risk that such a provision could act as a disincentive on the second authority to meet its obligations in a timely manner, although I heard what the noble Baroness said in regard to that. We will develop statutory guidance to support local authorities in exercising these new duties. That guidance offers a further opportunity to clarify expectations and ensure that no gap occurs.

Amendments 92ZZAG and 107, in the name of the noble Lord, Lord Wigley, concern Schedule 1, which makes provision for cross-border residential placements. I thank the noble Lord for giving us the benefit of his knowledge of Wales and note his praiseworthy restraint with regard to English provisions, although I note that the noble Lord, Lord Hunt, did not share my view. Clearly, the noble Lord, Lord Wigley, has resolved the West Lothian question but I appreciate his offer to liaise with Welsh colleagues to ensure the greatest clarity. I will give him some further information that may be of assistance to him.

The Care Bill will make provision for cross-border residential care placements so that people can be placed in care homes in other parts of the United Kingdom. This will mean that if a local authority in England places someone in residential care in Northern Ireland, Scotland or Wales, that person will remain the responsibility of the English local authority. They will not acquire ordinary residence in their new location and will continue to benefit from the protection provided by the cap. For example, if people receiving domiciliary care move from England to Wales, or people in a care home move without being placed by their local authority, they will usually become ordinarily resident in the new area and the appropriate contribution they should make to the costs of their care will be determined by the arrangements in Wales. A person moving to another Administration and requiring domiciliary care will be reassessed under the system into which they are moving. The processes being proposed in England and Wales are different and we will work with colleagues in Wales to produce guidance to look at how continuity of care can work across borders.

Schedule 1 will end the untenable situation local authorities currently find themselves in when a person in their area who wishes to receive residential care in Wales, Scotland or Northern Ireland is unable to do so. The noble Lord’s amendments seek to delay commencement of Schedule 1 until a report is laid before Parliament outlining the issues connected with cross-border placements arising with the devolved Administrations. We believe that this would cause an unnecessary delay to enacting provisions that are long overdue.

However, we recognise the concerns about the practical challenges of cross-border working. I hope the noble Lord will be reassured that we are working with the devolved Administrations to create bespoke regulations to meet the diverse legislative and operational requirements of each Administration. The regulations will be subject to consultation and laid before Parliament. I expect the noble Lord to participate in those debates.

[Lord Wigley]

I do not want to delay proceedings. This is just a way of bringing focus on the issue. Can the Minister give any indication to the Committee as to whether the discussions and deliberations that have already taken place between her department and the National Assembly in Cardiff have gone well and that there is so far a meeting of minds, or are there issues over which there will be some clash? If there is a clash, how will it be resolved?

[Baroness Northover]

If need be, I will come back to the noble Lord with all the details because it is indeed a very complex area. There are a number of government amendments, as the noble Lord, Lord Hunt, pointed out, and these seek to address some of the issues that have arisen in trying to make sure that everything works as smoothly as possible. It would probably be most appropriate to write in detail to the noble Lord and for him to see and stress-test what is happening. I remind the noble Lord that these regulations will be subject to consultation and laid before Parliament.

I now move on to the government amendments that the noble Lord, Lord Hunt, referred to. Obviously, this is a complex area. Amendment 92ZZAFB is required to clarify the ordinary residence situation of a person who has an independent personal budget. The local authority where the person is ordinarily resident is responsible for preparing the person’s independent personal budget and keeping the care account. This amendment makes clear that if such a person is in residential care and moves to the area of a different local authority, they will be able to become ordinarily resident in that new area.

People with Learning Disabilities: Health Inequalities

Lord Wigley Excerpts

Thursday 18th July 2013 Lords Chamber

[Lord Wigley]

My Lords, I declare an interest as patron of Mencap Wales and Autism Cymru. I welcome the opportunity to speak in this most important of debates. As the noble Baroness, Lady Hollins, has set out very clearly, the figures are shocking and should rightly make us very angry indeed. The fact that 37% of deaths investigated by the confidential inquiry could have been prevented with better healthcare should rightly motivate us to do all that we can to tackle the startling health inequalities that people with a learning disability face. I share her concern that the Government have not gone far enough in order to bring about the change we really need to see. It is particularly disappointing in light of the fact that the issue was brought to the attention of the Government before and met with similar inaction.

In 2006, I was a commissioner at the Disability Rights Commission and worked on the formal, 18-month investigation into healthcare given to people with mental health problems and learning disabilities. It was then that I first came across the findings of the work undertaken by the noble Baroness, Lady Hollins, that those under 50 years of age with learning disabilities or mental health issues were 58 times more likely to die from medical conditions not associated with their disability than was the general population of that age group—58 times more likely is a staggering figure.

The DRC’s resulting report, Equal Treatment: Closing the Gap, found that those with learning disabilities or mental health issues regularly get worse treatment than others. The study, carried out in England and Wales, examined several million health records and found that people with learning disabilities and mental health problems were more likely to have a major illness, to develop a serious health condition younger, and to die sooner than the rest of the population. Despite this, the same group of people were less likely to have routine tests and screening to pick up signs of a problem at early stages. For example, people with learning disabilities who have diabetes have fewer measurements of their body mass index, while those who have had a stroke have fewer blood pressure checks. The investigation also identified a problem known as diagnostic overshadowing, whereby symptoms of physical ill health are often seen as part of a patient’s mental health problem or learning disability and are not properly investigated or treated.

One of the aims of the work was to see which areas of the NHS would need to improve in the context of the then recently introduced Disability Discrimination Act, including the duty to make reasonable adjustments for disabled people, something which was in place since 1999. We were clear that GPs needed to make reasonable adjustments in order for people with a learning disability to access healthcare effectively. This included simple things such as making appointments by e-mail, providing treatment information in alternative formats or sending text or phone appointment reminders. Also important in terms of reasonable adjustments was raising awareness and understanding among both GP clinic and hospital staff in terms of learning disability.

This is demonstrated powerfully through the story of Susan. Susan died on 1 February 2011 in St Christopher’s Hospice in Sydenham, having been transferred the previous day from Lewisham Hospital. She was 59 and had cancer. Although Susan had been diagnosed with breast cancer some years previously, she had lived happily with her sister Brenda. Both were actively involved with their local Mencap in Lewisham and Susan often volunteered at events and outings. Susan was admitted to Lewisham Hospital on 15 January 2011 with vomiting and jaundice. Like so many other family members and carers, Brenda visited Susan every day and made herself known to staff as Susan’s main carer. As there was no learning disability specialist nurse available on the ward, Brenda found herself regularly explaining to staff about Susan’s care needs and becoming increasingly frustrated by the general lack of understanding and awareness about learning disability, which seemed to permeate the hospital. At one low point, Brenda was told by the matron that her staff, “don’t encounter people with learning disabilities in hospital that often”. Consequently, no adjustments were made to accommodate Susan’s needs, leaving Brenda fearful and anxious for Susan’s treatment unless she was there on an almost round-the-clock basis. Despite a complaint to the hospital by Brenda about a potential breach of the Equality Act for a failure to make reasonable adjustments to accommodate Susan’s learning disability, progress was slow, and a year after Susan’s death, the hospital had still failed to demonstrated that staff had any more awareness about learning disability and their duty of care and duty to provide equal access to healthcare to patients with a learning disability.

I emphasise the need for reasonable adjustment. Sadly, it seems that things have not changed nearly enough since our investigation. In 2006, we made the point on numerous occasions that reasonable adjustments were not being made as a matter of course. The confidential inquiry builds on this by highlighting that:

“The lack of reasonable adjustments to facilitate healthcare of people with learning disabilities, particularly attendance at clinic appointments and investigations, was a contributory factor in a number of deaths. GP referrals commonly did not mention learning disabilities, and hospital ‘flagging’ systems to identify people with learning disabilities who needed reasonable adjustments were limited”.

Its recommendation therefore seems sensible and measured that reasonable adjustments required by, and provided to, individuals be audited annually and examples of best practice be shared across agencies and organisations.

The Government’s response to this is far from purposeful, saying that they will instruct NHS England to look at the possibility of strengthening provider contracts to include an annual audit. Public authorities have a duty to make reasonable adjustments, and that includes adaptations and accommodations to ensure that people with a learning disability can access healthcare on an equal footing. Back in 2006, we were clear that there was no excuse, the duty having been there since 1999. In order to move this forward, strong leadership is needed by the Government and key agencies if we are to avoid these failures persisting within the healthcare system and thousands of vulnerable people paying the price.

Care Bill [HL]

Lord Wigley Excerpts

Tuesday 21st May 2013 Lords Chamber

[Lord Wigley]

My Lords, I welcome this very important Bill. I do not want to repeat the points that have been made, but I will add my support to the comments made by the noble Baroness, Lady Campbell of Surbiton, on the need for real independence and dignity for disabled people and to the points made by the noble Baroness, Lady Wilkins, on the housing needs of disabled people of working age. I also share the concern expressed by her and by many speakers in this debate that this Bill will work only if adequate resources are available. I noted the comments made by the noble Lord, Lord Rix, that the system is now in crisis and that people with real needs are left without support, which is a worrying situation.

I want to highlight matters relating to the detailed working of this Bill and the complexity that arises in some areas by virtue of the fact that social care is devolved in Wales to the National Assembly, since some of the provisions in this Bill impinge on devolved responsibilities. First, can the Minister confirm that legislative consent Motions have been agreed with Ministers in Cardiff and that there are no outstanding issues that need to be resolved?

Secondly, on the issue of funding, the Secretary of State Mr Hunt said on 11 February:

“All the Barnett consequential issues are decided by the Treasury”.—[Official Report, Commons, 11/2/13; col. 601.]

I understand that additional spending in England of about £1 billion should generate about £60 million of consequential spending in Wales. Can the Minister confirm that a figure has been agreed, and can he tell the House what it is? There is the associated question of the Barnett formula being generally inadequate and particularly inadequate in this context, where the age and need profile in Wales differs from that in England. Wales has higher levels of disability for historical and industrial reasons, and thousands of people retire from England to the beautiful coastlines and countryside of Wales. They are very welcome to come, but there is a cost implication. Wales has the highest proportion of older people of any country or region in the United Kingdom. Nearly one in four are over 60 years of age, and that is expected to increase by a further 5% over the next 10 years. The noble Baroness, Lady Browning, rightly emphasised the need to be aware of the demographic changes that are taking place and the effects that they will have. Any funding system that is based merely on total population relativities will inevitably generate inequalities.

Thirdly, the Government of Wales are currently in the process of reorganising social care in Wales. The Social Services and Well-being (Wales) Bill is similar to this Bill in many aspects and will, inter alia, increase the number of services for which people can claim a direct payment from the local authority, introduce national eligibility criteria, and provide for portable assessments to avoid the cost and trouble of reassessment. These detailed provisions need not exercise your Lordships’ House. What is of concern, however, is that any provisions in this Care Bill with an England and Wales remit will impact on the changes taking place in Wales under the other legislation.

Equally, changes taking place in Wales will have an implication for cross-border placements and the portability of care packages. Can the Minister tell the House whether discussions have been concluded with Ministers and officials in Cardiff and whether all issues in this area have been resolved? In particular, has there been a resolution of the portability of social services assessment undertaken in Wales in the event of persons choosing to move to England, and likewise of the portability of care packages for persons choosing to move from England to Wales? I am not referring to cross-border placement, which is quite another matter. Will the UK government cap on social care costs follow an individual who moves to Wales from England and is already in receipt of a care package, and if the cap is different in Wales, which of the two would apply? There is a real danger of disputes arising. The Care & Support Alliance commented:

“The Care Bill could have gone further to set out a strong and clear dispute process”.

The difficulty to which cross-border issues give rise within England between local authority areas is covered by Clause 36. This provision deals with people choosing to move for genuine reasons, but it does not appear to deal with those moving between England and Wales for genuine reasons. Likewise, Schedule 1 deals with the cross-border placement question, and paragraph 1(2) deals with the placement from England to Wales, but it does not appear to specify who has the responsibility for paying. Perhaps the further provisions referred to in paragraph 1(5) are meant to cover this, but it is far from clear and we need some assurances on the matter. It is also less than clear that paragraph 6(2) of Schedule 1 is adequately rigorous to provide for full recompense or that it is relevant in all cases. I should say that the Social Services and Well-being (Wales) Bill also fails to clarify these cross-border issues. These are matters that we certainly will need to clarify and to follow up in Committee.

Finally, I refer to the proposed health research authority provided for by Clause 96. Clause 98 states that the HRA’s remit is to promote the co-ordination and standardisation of practice in the UK in the regulation of social care. The Bill places a duty on the HRA and the devolved Administrations to co-operate with one another, but how on earth is such a duty going to be enforced? And what happens if disagreement arises between conflicting expectations in Wales, Scotland and England? Does the Secretary of State in England have to act as a referee in such a dispute? I am not arguing against the need for such co-operation, of course, but legislating for these matters never guarantees the desired outcome. All these issues are points for further consideration in Committee. Meanwhile, I am very content to support the Second Reading of the Bill.