Ageing: Science, Technology and Healthy Living (Science and Technology Committee Report)

Viscount Hanworth Excerpts

Wednesday 20th October 2021 Grand Committee

[Viscount Hanworth (Lab)]

The Science and Technology Committee’s report on ageing was written before I joined the Committee. I have no hesitation in declaring that it is an excellent report. It is lengthy and comprehensive and it contains numerous important recommendations.

The report has disposed of the optimistic belief that citizens of affluent societies can look forward with equanimity to the prospect of increased longevity. However, in comparison to the experience of Britons 100 years ago, the average lifespan has already increased markedly. A century ago, average life expectancy at birth for men was 48 years, whereas for women it was 54. By 2015, life expectancy for a man was 79 years and for a woman it was 83 years. It should be noted, however, that it can be misleading to compare average lifespan statistics then and now. The earlier figures are affected by a higher frequency of infant mortality and death in childbirth, both of which have been radically reduced.

The process of increasing longevity has slowed and there is little prospect of further significant increases at the top end of the range. Nevertheless, there remains considerable scope for reducing the incidence of premature death associated with social deprivation. The prospects of a morbid senescence, in which people suffer from the ailments of old age, have increased disproportionately. Both the duration of that period of affliction and the incidence of the associated ailments have increased markedly. Although it should be possible to delay the onset of the diseases of senescence and to mitigate their effects, they will not be eliminated. As the report observes, few of these ailments are liable to be eliminated by natural selection, since they occur mainly after the age of reproduction.

The report also revealed the wide differences in health and longevity among individuals in different socioeconomic circumstances. The expected duration of a healthy period in life—the health span—for those in the most affluent areas is 18 years longer than for those in the most deprived areas. Those in poverty suffer more from the ailments of old age. If there is a realistic prospect of increasing longevity on average and of reducing ailments, it must be by addressing these inequalities.

The statistics of disease and mortality recorded 100 years ago are dramatically different from the modern statistics. The Office for National Statistics has a web page titled “Causes of Death over 100 Years”, which shows the top causes of death by age and sex from 1915 to 2015. The incidence of mortality through infectious diseases has been radically reduced over that period. Until after the Second World War, infections were generally the leading cause of death for young and middle-aged males and females. During the second half of the 20th century, polio, diphtheria, tetanus, whooping cough, measles, mumps and rubella were all virtually wiped out, largely as a consequence of childhood immunisation. Meanwhile, from 1945 onwards, heart conditions became a leading cause of death for middle to older-aged males, followed by cancer. A similar trend, occurring at older ages, has been seen in women during that period, while younger to middle-aged women have more frequently died of breast cancer.

The committee’s report remarks that modern medicine is still dominated by the objectives of defeating single diseases and single ailments. To be more appropriate to treating an ageing population, it should be addressing what is described as multimorbidity, which is the state of having two or more long-term medical conditions. Coronary disease, hypertension—or high blood pressure —diabetes, dementia and strokes are all highly correlated in the aged cohorts; that is to say, they occur together, but they are being treated as if they were isolated ailments.

The experience of death and the social attitudes towards it have changed markedly over time. In predominantly rural communities, the realities of birth and death, witnessed in both the animal and the human populations, are liable to be part of everyday experience. These experiences are curtailed in urban populations.

In late Victorian times, the decline in premature mortality was accompanied by a curious side-effect, which was the ritualisation of death. This can be witnessed by visiting the cemeteries that date from then that accommodate lavish funereal monuments. In London, the Brompton, Highgate and Abney cemeteries are prime examples. Later, when cremation became an acceptable means of disposing of bodies, the memorialisation of the dead was much diminished. The incidence of mortality per head has been much reduced by the increased longevity that we have witnessed in the past 100 years. Nowadays, death is marginalised. It is no longer ever-present in our consciousness. I suggest that this marginalisation has had some deleterious consequences.

Although we are aware that the population has aged, we have been unwilling to face the consequences. Our provision of care for the elderly has not adapted to these circumstances and it has become seriously inadequate. We are frequently surprised and resentful when relatives die. Many appear to believe that death occurs only through medical negligence or malpractice. Doctors are fearful of being blamed for the death of relatives and they seek to indemnify themselves against complaints by asking relatives to assent to “do not resuscitate” orders.

The report is replete with recommendations of what should be done to reduce the impact of the diseases of senescence. It emphasises the well-known circumstances that undermine health in later life. Foremost among these are smoking, alcohol consumption and obesity, but only the first of these has been consistently targeted by public health campaigns. Much less has been done to address alcohol consumption, obesity and the lack of physical exercise. It is notoriously difficult to change human behaviour merely by exhortation and there has been political resistance to the interference of what has been described as the “nanny state”.

The recommendations of the committee’s report are too numerous to recite, but some of them are striking and should be remarked on. The report declares that the piecemeal approach to the problems of ageing needs to be replaced by a co-ordinated approach that addresses the complex and interrelated problems. Patients are often prescribed a multiplicity of drugs, with little attention given to the potential for their damaging interactions or to the harm caused to a patient by a pharmacological overload. It has been recommended that ageing people should be assigned to a designated clinician who has a complete oversight of their care.

The report calls for further research into the processes and problems of ageing and asserts that not much is fully understood yet. It calls for fuller and more enduring longitudinal studies. However, cross-sectional studies are needed that would highlight the disparities in health that are attributable to the inequalities in our society. The Covid pandemic has revealed the health hazards associated with social and economic deprivation and the stark differences in health and mortality between ethnic groups. Surely the most effective means of promoting good health in an ageing population is by striving to achieve a just and equitable society.

Social Care

Viscount Hanworth Excerpts

Thursday 1st December 2016 Lords Chamber

[Viscount Hanworth (Lab)]

My Lords, many of the providers of residential care are on the verge of bankruptcy. They are unable to meet their mounting expenses, while the budgets of local authorities, which are responsible for paying for care in many cases, have been savagely cut.

The failure of the Government to address this problem is in spite of numerous warnings. One such warning was the collapse of the Southern Cross Healthcare Group in 2011. The group was the largest provider of care homes and long-term care beds in the United Kingdom, operating 750 care homes, with over 37,000 beds and with a staff of around 41,000 employees. The company was founded in 1996. It grew rapidly through acquisitions that were financed predominantly by a sale-and-leaseback strategy, which placed its residential properties in the hands of investors in return for large capital sums and at the cost of payments of rent on those properties. Already by 2004, its acquisitions were subject to an investigation by the Office of Fair Trading. In 2011, the company was in crisis on account of its inability to meet its annual rent bill, and it was begging the Government for support. In the event, the Government did not have to intervene, for the reason that the ownership of many of the care homes was transferred to the landlords, some of whom had links to social care provision and many of whom did not. Before its collapse, the value of the shares of Southern Cross fell drastically, and its market value was reduced from £1.1 billion to £12 million.

Another Government of a different political persuasion might have seized the opportunity to acquire the assets of the conglomerate at fire-sale prices, thereby returning the provision of social care to the public domain, where it had resided preponderantly before the era of privatisation. The ownership of care homes is now in the hands of venture capitalists, whose interests are confined to the financial returns of their holdings. The current crisis points to a further round of divestment with an even greater consequence than the failure of Southern Cross. The failed conglomerate was founded on the supposition that a steady and a reliable income would be forthcoming from local authorities. The sure-fire returns would have allowed a high degree of financial leverage on the basis of which there could have been further acquisitions. The fallacy of this supposition has now been demonstrated conclusively with the consequence that very little private capital will be forthcoming in future to sustain the sector. However, there are signs of a pushback from the private owners of care homes, and some are even investing to improve their services significantly. By so doing, they should be able to attract rich patients whose wealth would preclude them from receiving support from local authorities. What is now in prospect is a two-tier care system for the elderly. For the rich, there will be comfortable residences. For the rest, there will be what should best be described as poor homes.

The crisis in social care will be solved only when adequate financial support is forthcoming, and it is important to attempt to envisage how this could be achieved. First, we should observe that the manner in which we end our days is the subject of a lottery, but it is a lottery that has no winners. Some people will take their leave suddenly and without much forewarning. Others will experience a lengthy senescence, which is often a miserable one. If the present inadequacies of the care system continue to worsen, then such people will be amongst the greatest losers.

The appropriate way in which to finance this lottery is by an insurance scheme. In common with the noble Lord, Lord Patel, I propose that every income earner should contribute to a fund in the proportion to which they pay income tax. The fund in question should be used for the sole purpose of social care. The tax to sustain it should be set to a level that is appropriate to the nation’s need for social care, and the determination of that level should be the responsibility of an independent commission.

There have been proposals in the past that Governments have chosen to ignore. Those of the Dilnot commission are still hanging over us. The commission proposed a limit to the amount that any individual should contribute to their care over their lifetime. It also suggested increasing the wealth that an individual might own before being asked to contribute to the cost of their care. Both of these suggestions have found favour with those who wish to preserve their wealth to pass it on to their inheritors. I declare that I am not greatly sympathetic to this motivation.

Be that as it may. I suggest that matters of inheritance should be rigorously separated from the question of how to achieve adequate financing of social care. Much of the difficulty that we face in connection with social care is a consequence of the pernicious confusion of two issues that should be dealt with quite separately.

NHS: Health and Social Care Act 2012

Viscount Hanworth Excerpts

Thursday 8th September 2016 Lords Chamber

Moved by

[Viscount Hanworth]

That this House takes note of the impact of the Health and Social Care Act 2012 on the current performance of the National Health Service and its future sustainability.

[Viscount Hanworth (Lab)]

My Lords, the very existence of the NHS is in danger, as is the principle of a universal healthcare provision free at the point of delivery. The NHS is being turned into a market-based system. The proponents of these changes envisage that the system will be financed by private insurance policies that will allow individual policyholders to determine the extent of their insurance cover and the level of care to which they will be entitled. The services will be provided by commercial organisations under the rubric of the NHS. Many of them will be displaying the familiar NHS logo in a deceptive manner. These changes have been proceeding gradually for the past 25 years, but they have been accelerating under the coalition Government and under the succeeding Conservative Government.

Notwithstanding the rubric of this debate, which will be concerned mainly with the developments since the passing of the Health and Social Care Act 2012, I shall begin by recounting the slow and inexorable process by which the original intentions of the NHS have been subverted. It will be helpful to understand how the NHS has been brought to a state where it has become easy prey to the provisions of the 2012 Act. The NHS, at its inception in 1948, was an egalitarian system. In the alliterative words of one commentator, it was envisaged that “judges and janitors” would occupy adjacent hospital beds. The NHS was to be funded by taxation, and no one was to be charged for its services.

The 1948 Act took hospitals into public ownership, but it left GP surgeries in private ownership and seemingly allowed GPs the dignity of continuing to be self-employed. Indeed, many of these surgeries were located in the private residences of the practitioners. Latterly, group practices in dedicated buildings have become the norm; and most doctors are now virtually salaried employees of the state. However, the enduring private ownership of surgeries has allowed them increasingly to fall into the hands of commercial enterprises.

It has been said that the intentions of the Conservative Party to privatise the NHS have been hidden in full view of the rest of us, and it is a wonder that they have so often and for so long escaped our notice. A statement of these intentions was contained in a Conservative policy document of 1988, authored jointly by Oliver Letwin and John Redwood and titled Britain’s Biggest Enterprise: Ideas for Radical Reform of the NHS. Others have drawn attention to this text. The polemic of these authors centred on their unjustifiable claims of administrative inefficiency in the NHS. Their pamphlet also inveighed against the supposed discomfort of the service, which it likened to that of a prison.

The authors were irked by the absence of such modern facilities as private telephones and television sets which, in their opinion, should be available to all those who cared to pay for them. They appeared to dislike the prospect of rubbing shoulders with the masses. To them, the prospect of being placed in a queue was a clear indication of the dysfunctional nature of the system. Their prescription for eliminating queues was to establish a market mechanism which would ration medical services by pricing them.

A minimum list of the measures proposed that should be taken in reforming the NHS may be enumerated as follows: first, the establishment of the NHS as an independent trust; secondly, increased use of joint ventures between the NHS and the private sector; thirdly, extending the principle of charging; fourthly, a system of health credits to be supplemented, if so desired, by the patients; and, fifthly, a national health insurance scheme.

In a telling admission, the authors acknowledged that these reforms could not be achieved in a single step, for the reason that the public would find them unacceptable. Therefore, they accepted that the agenda would have to be fulfilled gradually and in stages. True to this agenda, the current Health Secretary, Jeremy Hunt, is on record as having called for the direct funding of the NHS to be replaced by an insurance system. I would like to suggest that this agenda has been firmly in the minds of the Conservative policymakers from that day to the present. It is on account of its cunning concealment as much as its gradual realisation that many of us have failed to recognise what has been afoot.

The story goes back further in time. The process of reform—that is, the process of turning the NHS into a business—began in a modest way in 1983 under Margaret Thatcher, when she commissioned the so-called Griffiths report, which led to the introduction of a body of managers into a system previously run by clinical professionals. It was not until January 1989 that Thatcher announced a major review of the NHS, which aimed, so she said, to extend patient choice and to delegate responsibility to where the services were provided. These have continued to be the misleading mantras of most of the Conservative reorganisations.

The resulting National Health Service and Community Care Act 1990 created GP fundholding in order to promote a quasi-market within the National Health Service. The subsequent Health Authorities Act 1995 abolished the 14 regional health authorities, which were replaced by eight regional offices of a newly established NHS Executive. Here, we see another theme of the Conservative reorganisations, which claim to promote decentralisation but which actually accomplish the reverse.

There were indications that the incoming Labour Administration of 1997 would reverse some of these reforms. Thus, in 1997-98, GP fundholding was abolished by the Labour Government. However, Labour soon took over from where the Conservatives had left off. In 2001, primary care trusts were established. In 2002, NHS foundation trusts were announced by the Health Secretary, Alan Milburn, and they were established via the health and social care Act of 2003. These trusts were centred on large hospitals, which were to be given a degree of independence from the Department of Health and from the strategic health authorities, and which were to have a degree of financial autonomy. At the same time, an extensive outsourcing of ancillary services was encouraged.

That autonomy enabled the trusts to pursue private finance initiatives, or PFIs, whereby a massive investment in the NHS was achieved under the Labour Administration. The PFIs have bequeathed a crippling legacy of debt to the NHS. Many hospital trusts have been bled dry by contracts that are demanding exorbitant rates of return for periods of as much as 30 years. A typical hospital refurbishment costing perhaps £9 million will eventually yield the private contactor as much as £80 million, and it is estimated that the NHS is currently paying £2 billion a year in PFI-related costs. Much of this income is going offshore in avoidance of taxes. Of course, one of the purposes of PFI was to shift the cost of big projects out of government borrowing figures. The fallacy of that approach to social investment should now be clear to anyone.

In the campaign that led to the election of 2010 and to the formation of a coalition Government, David Cameron asserted that the NHS would be safe in the hands of the Conservatives and that there would be no further top-down reorganisations. These were flagrant deceptions. Within a short period, the Secretary of State for Health embarked on the preparation of a major piece of legislation, which was to become the Health and Social Care Act 2012.

Perhaps that was par for the course. As Professor Turnberg—my noble friend Lord Turnberg—remarked in a speech in February this year, there have been eight reorganisations of the NHS in the 16 years that he has been in the Lords; that is, one every two years. However, as the NHS England chief executive, David Nicholson, famously said in a speech to the NHS Alliance conference, the reforms demanded such a big reorganisation that “you could probably see it from space”.

The Bill was a huge document, but we may remind ourselves of its salient points. To begin with, the leading clause has been widely interpreted as relieving the Secretary of State of the duty to provide a universal and comprehensive health service in England. That duty has devolved on to the newly created NHS England health executive. This interpretation of the clause is debatable. Nevertheless, it has allowed the current Secretary of State to criticise the NHS when things have gone wrong, instead of taking the blame himself.

Under the 2012 Act, NHS hospitals are allowed to make up to 49% of their money from private patients. Presumably, this allowance was intended as a means of alleviating the financial problems of the hospitals. The Act abolished the primary care trusts and the regional health authorities, and replaced them with clinical commissioning groups, or CCGs, which now control a large proportion of the NHS budget and commission local services.

The Act proposed that general practitioners and other health professionals should be given the responsibility for commissioning the majority of health services. However, that is not what has happened; nor does it seem to have been what was truly intended. The CCGs are told what they can and cannot do by the bureaucrats of NHS England, which is the newly styled NHS Executive, and by its secretive local area teams. They have imposed stringent controls on what can be provided, and those controls have become increasingly restrictive in consequence of the financial exigencies of the NHS. Notwithstanding the centralised and hierarchical control that it has imposed, this reorganisation has created a so-called postcode lottery in the provision of services, of which the availability now varies widely across the regions.

The clinicians are typically represented on the CCGs by a small handful of GPs from the largest and most prosperous practices. Smaller practices working under increased pressure cannot afford the necessary time to be involved. In 2013, the British Medical Journal used the Freedom of Information Act to discover that more than a third of the GPs on CCGs have conflicts of interest due to directorships or shares held in private companies. Much of the work of the CCGs is already being undertaken by commissioning support units, which were due to be outsourced to commercial companies in 2016.

Perhaps one of the most significant provisions of the Health and Social Care Act is to be found in Section 75, which has established the requirement for competitive tendering for the provision of services. It is extraordinary that commercial interests, represented by commissioning support units, should have become, in some instances, both providers of health services and the providers of advice on commissioning.

The requirement for tendering has imposed a huge administrative burden on the NHS, which is entailed in the commissioning, invoicing and billing of these services. This is wasting money and it is wasting the time of already overburdened clinicians. It is also seriously undermining the provision of services. The introduction of commercial profit-seeking providers means that services may be pared to the bone.

Private clinics are now competing with hospitals to conduct routine surgery on the understanding that, if complications arise, NHS hospitals will be obliged to provide the remedy. Hospitals can be financially unsettled when cheap and easy functions are subtracted in this manner. Also, if they are teaching hospitals, the experience of routine operations is denied to trainee doctors.

There have also been significant commercial inroads into general practice, where there is now a serious shortfall in the number of GPs. The response of NHS England to the resignations and retirements of the members of a group practice has been to put the services out to tender under a so-called APMS contract, with a limited five-year term. Such contracts are liable to be taken by commercial enterprises motivated by profit and intent on saving costs. The short-term nature of the contracts discourages investment, and the cost-saving motive results in inadequate levels of staffing, with peripatetic locum doctors in place of resident GPs. The costs and risks of tendering mean that independent GPs will struggle to compete with larger healthcare corporations.

Why are politicians of all parties and senior civil servants so attracted to the prospect of the commercial provision of health services? In answer to this, I should observe that many of them have strong affiliations to private health that often entail pecuniary interests. Simon Stevens, the current chief executive officer of NHS England, spent 10 years as a senior executive in UnitedHealthcare, which is the biggest multinational healthcare corporation in the United States. I should also observe that, with Andy Burnham as a notable exception, the majority of former Secretaries of State for Health have financial interests in commercial healthcare.

The conditions are now in place for a wholescale takeover of the NHS by commercial enterprises. In spite of numerous withdrawals of the private sector due to unprofitability attributed to the exigencies of the NHS finances, and in spite of some outstanding cases of fraud and malfeasance among private providers, it appears that the proportion of the NHS budget devoted to purchasing from private providers is increasing apace. Some commercial enterprises, such as Serco and UnitedHealthcare, have pulled out of providing medical services to patients, leaving behind them a wake of disorganisation. The overstretched NHS has had to pick up the pieces. Nevertheless, the accounts provided by the Department of Health in July of this year have shown that 7.3% of total NHS expenditure in 2014-15 went to private providers, which represents an increase of 1.2% over the previous year. This is the biggest annual rise in both absolute and percentage terms since 2006.

Meanwhile, so-called sustainability and transformation plans are being demanded from local NHS areas by NHS England. These are aimed at saving large sums of money, while improving the quality of healthcare. It has become abundantly clear that such plans amount to dangerous fallacies. They have already been widely discredited. They would lead to widespread closures and amalgamations of hospitals, and they would strip the NHS bare. I beg to move.

--- Later in debate ---

[Viscount Hanworth]

This has been an interesting and disturbing debate. We have had a diversity of opinions regarding the state of the NHS and its likely future, not many of which have been favourable. I am heartened by what I understand to be the reaffirmation of the founding principles of the NHS by the noble Lord, Lord Prior; however, I am very doubtful of his optimism.

Be that as it may, I draw attention to the National Health Service Bill, a Private Member’s Bill that had its Second Reading in the Commons on 11 March. The Bill, which was known in a previous version as the NHS Reinstatement Bill, proposes to reverse the 25 years of privatisation in the NHS by abolishing the essential purchaser-provider split, by re-establishing public bodies and by enshrining that the NHS reverts to an accountable public service. The Bill, which has been presented again for the 2016-17 Session, had another First Reading in the Commons on 13 July. It received the support of numerous Labour MPs and even from some Conservative MPs. This Bill merits our attention, as do the speeches that accompanied its introduction.

I reiterate that I am very grateful for all contributions to what has been a very fruitful debate—at least I hope it has been.

Motion agreed.

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Viscount Hanworth Excerpts

Wednesday 5th November 2014 Lords Chamber

[Baroness Barker (LD)]

My Lords, the Minister, the noble Baroness, Lady Greengross, and I have a fair degree of form on this subject, going back over a number of years. Indeed, as I listened to the Minister introducing this matter to the House tonight, my mind wandered back to the dreaded days of the NHS Redress Bill, when the noble Lord, Lord Warner, sought to assure those of us who, in those days, sat on the other side of the Chamber that all would be well in the NHS and there was no need for a duty of candour because a new culture of openness was going to work its way through the NHS.

I have to say that things have changed because back then the professional bodies representing the staff of the NHS fought that duty of candour tooth and nail, so it is rather pleasing to have the news this week that they now have changed their minds and are willing to accept that they should uphold the duty of candour. They are moving to a point of discussing with their members not whether, but how, they do that.

I agree with the Minister that the CQC in its present form is a long way from CSCI and its predecessors in their various guises. It is properly constituted, far better resourced and has a focus to its work. Albeit that it works across a far bigger canvas than it ever did in the past, it is already performing to a much higher degree than before.

However, I return to the point the noble Baroness, Lady Greengross, and I made during the passage of the Care Bill. In that legislation, in relation to care homes and incidents where vulnerable adults may be thought to be at risk of abuse, this House fell short in its legislative function in that it did not give a power of entry to people or bodies who suspected that there might be abuse taking place. It is with that deficiency in the law sitting in place that we have to judge all the regulations and guidance such as this that come before us and ask ourselves whether, if a person was being abused or maltreated in a care home, it would be detected.

Therefore, the noble Lord, Lord Hunt, is right to focus, as he has done, on the issues of complaints procedures and emergency planning. I accept that within the overall framework service providers are now required not only to provide their services but to report on outcomes for individuals and standard of care, but nonetheless, there is something slightly amiss. For me, it goes back to the issue of power of entry. It goes back to the point at which a concerned relative has the power to override things.

I would also like to ask the Minister for a point of clarification. It seems that Ministers are quite clear that the introduction of new basic standards rectifies what was clearly an unsatisfactory position whereby one could not prosecute a provider unless and until an improvement notice had been issued. That was clearly wrong, and a number of providers got off the hook on that technicality. Will the Minister clarify, if he can, that under these regulations a breach of fundamental standards is still not in and of itself a reason to trigger a prosecution and that a reason to trigger a prosecution is a breach of the regulations? I would like to know how the department sees that working in practice to cover the deficiency to which I alluded a moment ago.

Finally, I welcome the fit and proper person test. It is long overdue. It is a good job that it is coming to the statute book as quickly as it is.

[Viscount Hanworth (Lab)]

My Lords, the quality of the provision in old people’s care homes varies widely. In the best of them, the residents are treated with respect and solicitude. In the worst of them, as we have witnessed recently, they are treated callously and brutally by underpaid and badly trained staff.

The increasing longevity of our population is leading to a rising demand for the provision of care for the elderly. Until recently, the implications of these developments have been ignored by all but a few concerned parties. The matter was brought forcefully to the attention of the public at large by the financial collapse of the Southern Cross enterprise, which was responsible for at least 20% of the national provision of residential places in care homes. It was running 752 homes when it collapsed in 2011 with losses of £300 million.

Southern Cross had been acquired by the private equity firm Blackstone Capital Partners for £162 million in 2004. Thereafter, it expanded rapidly. Through acquisitions, it tripled the number of homes that it was managing. The directors became multimillionaires. Inspections that were conducted during the period of its expansion raised grave concerns over the provision of care by homes within the Southern Cross portfolio. Indeed, the enterprise was warned about failing standards in its homes as it prepared to float on the stock market.

A more dramatic instance of the failure of care was provided by the scandal of Winterbourne View, a public-funded private hospital. A “Panorama” investigation broadcast in 2011 exposed the physical and psychological abuse suffered at the hospital by people with learning disabilities and with challenging behaviour.

The problems besetting care homes have been due, in part, to the inadequacy of their regulatory oversight. They have also been due, in large measure, to the increasing financial stringency under which they are operating. The income received by the homes from fees has been falling. Those fees have been paid on behalf of the great majority of residents by local authorities. Their income has been driven down by the Government’s austerity measures. At the same time, their costs have increased through factors outside their control, such as rising energy prices.

Another adverse condition is that the borrowing of the care home sector averages 75% of its net assets. This abnormally high level of indebtedness has been a result of the borrowings that were linked to the spate of acquisitions that preceded the general financial crisis of the sector. It has been pushed even higher by trading losses. This will expose the sector greatly to the widely anticipated rise in interest rates in the not too distant future.

The Government have reacted to these problems in a manner that many people regard as inadequate. They have not sought to improve the financial circumstances of the care homes. Instead, they have sought to improve the regulatory framework affecting the care homes via amendments to the secondary legislation associated with the Health and Social Care Act 2008, which will come into force in April 2015.

According to the testimony of the Minister of State for the Department of Health in the Commons on 16 October, the new regulations will,

“bolster the power of the regulator to take enforcement action, including bringing prosecutions against providers of poor care”,

and issuing penalty notices.

He remarked that, under the existing regulations,

“a notice had to be served first before moving to prosecution. If the provider complied with the notice, nothing could be done”.—[Official Report, Commons, Sixth Delegated Legislation Committee, 16/10/14; col. 4.]

The essential purpose of the new regulations is, therefore, to encourage improvements in the quality of care by strengthening the sanctions for failures.