Care Bill [HL]

Baroness Greengross Excerpts

Tuesday 9th July 2013 Lords Chamber

In conclusion, we come back to the importance of underlining integration at every opportunity, and I look forward to the debate.

[Baroness Greengross]

My Lords, I rise to speak to my Amendments 87ZA and 104A. I thank the noble Baroness, Lady Wheeler, for what she said and I heartily agree with her.

We read far too often about frail older people blocking beds in hospital wards and, apparently unintentionally, making the health service very difficult to function properly. However, they are there due to inadequate planning. These two amendments are intended to try to ensure that the discharge process is started when somebody goes into hospital—that is, right at the beginning of their stay in hospital.

We all have experience of very poor practice. My personal experience is of a 94 year-old who was admitted to a London hospital as an emergency and therefore arrived in pyjamas and with bare feet. He was returned home in pyjamas and with bare feet in the late evening in winter. He had to cross a grassy patch, go into his block of flats and up a flight of stairs in that condition in order to reach his home. There was no planned process to look after him. That sort of thing is totally unacceptable. The aim of this Bill is to stop that sort of practice and to make sure that it does not happen in the future. I think that all your Lordships feel the same about this: we have to get it right. As I said, I feel that the discharge plan should be initiated when someone is admitted to hospital and it should be used as the template for the discharge, when it occurs.

I declare an interest as chairing the All-Party Parliamentary Group on Dementia. We know from one of the inquiries that we have carried out that most frail older people who go into hospital have comorbidity—that is, they have more than one condition. If they have gone into hospital for a fractured femur to be fixed or for some other physical condition to be dealt with, they will stay in hospital for much longer if they also have, for example, dementia. They stay in hospital longer partly for the same reason: that no plan has emerged to look after them when they come out. It is very bad for them to be in hospital and it is bad for all the other patients as well, for obvious reasons. We need to ensure that the local authority and relevant partners know about the special conditions of a patient to get the planning right. We need to ensure that special care and support needs are taken into account long before they leave hospital. That is the reason for those two amendments, which I very much hope that the noble Earl will accept as part of good practice.

[Lord Rix]

My Lords, I wish to speak to Amendment 87ZB, so wholeheartedly supported by the noble Baroness, Lady Wheeler. It would add providers of relevant services to the list of relevant partners of the local authority. The amendment lays the foundation for a number of amendments which I have tabled in the safeguarding section of the Bill, which will be taken later. There has been widespread concern that the mechanisms and procedures in place to safeguard adults at risk of abuse or neglect are totally inadequate.

Time after time, we have witnessed how processes have failed or safeguarding has not been taken seriously, which has led to serious consequences for people with a learning disability. For example, there is the death of Francesca Hardwick and her mother Fiona Pilkington, the murder of Steven Hoskin, and more recently, the abuse scandal at Winterbourne View. There have been a number of prominent cases where the provider has failed to co-operate in providing information on adults at risk or where cases have occurred such as that reported in the aftermath of Winterbourne, where the provider declined to share information for the serious case review and there was no requirement on it to do so.

The amendment is therefore intended to add providers as relevant partners, so that they are in the frame for further amendments to the safeguarding part of the Bill in Clauses 41 to 46. When we talk about providers, I am referring to those who are providing a service which has been commissioned from a person's care plan, such as care and support or education services. Although I appreciate that regulations will set out other relevant partners, we feel that providers should be named explicitly in the Bill. This will emphasise the importance of the provider of services being subject to the duty to co-operate and will bolster the safeguarding process accordingly. I look forward to hearing the Minister’s thoughts on the matter.

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[Baroness Meacher]

My Lords, Amendment 82B has the effect of requiring local authorities not only to provide information about the system of care and support, how to access it and so forth, but also to take action to facilitate access to that information; that is, to try to make sure that people know it is available. My remarks also apply to Amendment 86C, to which I have added my name, which requires that the local authority must produce or arrange for the production of packs of information relevant to the needs of individuals with specific medical conditions and ensure that these packs are provided to individuals following the diagnosis of a specific condition—not waiting until much later on, when they probably need social care or other intervention.

First, I apologise to the Minister and to your Lordships that I was unable to be here for earlier sittings of the Committee. I have been out of the country a lot on other Lords’ business and just have not been able to participate. I also must thank the Alzheimer’s Society for its help with these amendments.

I join other noble Lords who have welcomed the Bill, which has an emphasis on the provision of care and support for people who need it. I was impressed by the quote at the top of the Department of Health Factsheet No. 1, which states:

“Information, information, information; without it, how can people be truly at the heart of decisions? Information should be available to all regardless of how their care is paid for. There are some things that should be universal; information is one”.

That is from a Department of Health document; perhaps other noble Lords have quoted it before me, in which case I apologise. The point is that if people are unaware that information and advice are available, they are unlikely to look for them. We can assume that if these amendments are not accepted by the Government, there will be considerable underuse of information services and, of course, that the people who will lose out will, as always, be the most vulnerable—those who most need that information.

The Alzheimer’s Society tells me that it frequently hears of the difficulties people face when struggling through the complexities of the health and social care system for the very first time. Too often, people with dementia and their carers report that they did not have access to the information and advice they needed because they simply did not know it was available. We all know that feeling: if only we had known that it was available, we would have looked for it, whatever it was. Sadly, people often come across services by chance and far too late.

If a person in the early stages of Alzheimer’s is aware of a memory clinic, for example, which can either provide help itself or refer the client on to organisations such as the Alzheimer’s Society well before they need social care, the client can make adjustments to help them continue living as normally as possible and for as long as possible in their own homes. These are simple things like putting a note on the front door that says, “Are your keys in your pocket?”, and suchlike. With guidance, carers can gradually increase the home adjustments as they notice the need for them and thus defer the need for the involvement of social services and ultimately residential care.

Noble Lords will know the point that I am coming to. We all know that resources are incredibly tight. The point is that timely information and making people aware that it exists is very cost-effective. If you manage to keep people in their homes much longer, and if you manage to help them avoid social services intervention, all this will save taxpayers’ money. We can expect that a small spend on a proactive approach to information provision will save the taxpayers a great deal of money over time. I beg to move.

[Baroness Greengross]

My Lords, I support Amendment 82B in the name of the noble Baroness, Lady Meacher, to which my name is also listed. At the same time I speak to Amendments 83, 83A, 84, and 85. I think that Amendment 86C is in the next grouping; I hope that I am right.

On Amendment 82B, we know that many people, as well as their carers, say that they did not have access to the necessary information and advice—and that they did not even know that it was available. They have had to seek out the information themselves. We are talking about people who are vulnerable and often at crisis point. It is the worst time for either frail people or their carers to have to find out where to go and how to find the advice they need. I would add that, in my long time working in this field with older people, I once had a telephone call from a Minister in the department whose mother needed care and who was asking me to help because this Minister had no idea where to go to get the information and advice. It is not just people who do not know their way round the right office—it is all of us at certain times. We just do not have the knowledge of where to go.

If we require local authorities to adopt a proactive approach to information provision, perhaps it will ensure not only that people have the right information at the right time but that the information is in a format that is accessible. This will help people to get the right care and support in place and give them the confidence they need in very difficult situations.

On Amendments 83, 83A, 84 and 85, I was very pleased to see that, in Clause 4, the Government have incorporated a key element of the Joint Committee’s report into the Bill, namely that it is part of a local authority’s duty to establish and maintain the service for providing people in its area with information and advice. We must make sure that advice relating to care and support includes information about access to regulated independent financial advice.

The Bill will also oblige local authorities to offer deferred payment agreements which will involve local authorities in taking an interest-bearing charge on the property of an individual against the cost of care fees which, as we know, will be repaid after the individual’s death. As has been said, however, individuals offered these products may be highly vulnerable. They expect the same authority to assess fairly both their eligibility for care and their ability to fund it, as well as providing appropriate advice and information about a financial product which the local authority itself is offering to pay for that care.

In a way this is in competition to FCA-regulated financial products, so, obviously, there is a potential conflict of interest here. This conflict is exacerbated if the care for which the loan is made is directly provided by the local authority and if the level of charges and interest are also determined by the local authority. It is therefore very important that people are directed towards regulated financial advice as part of the decision-making process. This amendment seeks to do that through regulated, accredited financial advisers such as the people who are members of SOLLA, the Society of Later Life Advisers. Only in that way can the development of safe and secure financial products be facilitated.

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[Lord Mackay of Clashfern]

My Lords, I have spent most of my life as an advocate, so I have to say how important advocacy is. I want to say a few words in relation to the point made by the noble Baroness, Lady Gale, about continuing NHS care. The point is important in that Clause 22, as the boundary between health and social care, is vital.

I would have thought—I may be wrong and obviously the noble Baroness will correct me—that it ought to be the general practitioner who advises a patient as to whether they need continuing NHS care. During our deliberations in the Joint Committee there was quite a lot of discussion about the question of continuing NHS care, and it is obvious that there is some conflict of interest. The local authority providing the care may wish to have it provided by the NHS since that would be free and not its responsibility, so the boundary between the NHS and local authorities is particularly relevant in this connection.

At the moment, I do not see how it can be for the patient to claim continuing NHS care. The GP should be able to say to the patient that they need it and that should be sufficient for it to be provided. The likelihood is that a patient would have great difficulty in assessing for himself or herself whether continuing healthcare was needed, so it must be a matter for professional advice. I think that the advice that we are talking about in this context is advice about local authority services, not about the services that the NHS can provide. However, as I say, the boundary between the two is vitally important. I hope that the point made so eloquently by the noble Baroness, Lady Gale, arising from her own inquiry, will be looked at with a considerable degree of care.

[Baroness Greengross]

My Lords, I hope that noble Lords will forgive me, but I forgot to speak to one of the amendments that is relevant to this group; that is, Amendment 86C. It is about people with dementia who have had a diagnosis. I know that the noble Earl will share the Prime Minister’s view and those of all of us who have looked at the number of people who receive a diagnosis of dementia. We now want to ensure that many more are diagnosed, and diagnosed early.

However, there are many reports that people diagnosed with dementia and their carers feel terribly abandoned after they have had the diagnosis. The Bill’s emphasis on access to prevention services and information and advice for people, particularly if their needs have not yet reached the threshold of eligibility for social care, is welcome. But there are no specific prompts to ensure that people receive the information they need at the time when it is most useful. The risk is that, although local authorities have set up information and advice services, the information does not reach people at the right time. A post-diagnosis information pack tailored to specific long-term conditions should be given to every individual who is diagnosed with one of those conditions. It would provide access to tailored information about the support that is available to them, and it would enable them to cope with the challenges of living with a long-term condition. The pack would provide information on the likely impacts of dementia and contain core information on national and local services. I think that this would be an important aspect of providing the right information and advice at the right time.

[Lord Beecham]

My Lords, this Bill has the potential to do for social care what Beveridge did for the welfare state and Bevan did for the health service. It is potentially the most significant development in, for example, residential care since the workhouses were replaced by a more civilised form of residential accommodation.

The noble Baroness, Lady Barker, anticipated precisely the point I was going to make, which is that this is not just a matter for local authorities. My principal reservation about these amendments, if I have one, is that it looks as though the entire burden of information and advice is to be placed on local authorities whereas of course, as the noble Baroness rightly said, there are other potential partners who clearly need to be involved. I scribbled on the grid that is helpfully provided by those who support the Front Bench on this side the words “in collaboration with”, and then I thought of a number of potential partners. Of course the health service is one of them, but in addition I would suggest that the Court of Protection needs to be involved. It has a supervisory and supportive responsibility for a particular group of people and, with the development of lasting powers of attorney and so on, their deputies as well. I have to say—I have said it before and I will say it again—that I am not convinced that the Court of Protection is doing a terrific job in this area, but that is another reason why it should be looked at as a potential partner.

There may be other partners. For example, in the case of younger people perhaps with a learning or other disability, there are roles for those involved in further education, the Department for Work and Pensions and the Department for Business, Innovation and Skills. Those bodies might look at their role in terms of what is available by way of education, training and so on. It seems to me that a range of organisations should be involved, certainly as a whole, but more particularly in the provision of information and advice.

On these Benches we support most of the amendments that have been moved and spoken to this afternoon, with the qualification that, where relevant and necessary, a reference to collaboration should be included. For example, in Amendment 82B, the first amendment moved by the noble Baroness, Lady Greengross, one would want to see “in collaboration with” appropriate partners.

We support the amendments, notably moved by my noble friend Lord Lipsey, around the provision of independent financial advice. That seems very important. I have a slight reservation about Amendment 86D, which is about payment of,

“the reasonable costs of a first consultation with an independent financial adviser”,

to be paid for “by the local authority”. If I am ever in need of this kind of advice, I would be able to afford that relatively easily. Given the pressure on budgets, is a universal application of that principle necessary or desirable? That, however, is a detail, that might be looked at later. Given the scale of the potential involvement and the potential conflict of interest referred to by several noble Lords, the independence and proper status of such financial advice are important considerations.

With regard to the amendment in the name of the noble Lord, Lord Sharkey, I will perhaps anticipate the Minister by quibbling over the word “demonstrably”. Frankly, I am not sure that that takes us very far. As the noble Lord admitted, what is demonstrable to some is not necessarily demonstrable to others. I do not think that that part of his amendment is particularly cogent, although I agree with the rest of it.

I have more serious doubt about the amendment of the noble Baroness, Lady Browning. Amendment 86H requires that the information and advice be provided by “social work-qualified staff”. It could be, but I am not sure that it should be a requirement that it should be, given the pressure on the service in dealing with casework as it is. I do not think that the skills of social workers are always consistent with the role of giving information and advice in the sense that is intended by the amendment.