Care Bill [HL]

Baroness Jolly Excerpts

Tuesday 16th July 2013 Lords Chamber

[Baroness Wilkins]

My Lords, I strongly support this amendment. If the Government do not agree with the intention behind the amendment, it is clear that they accept, no doubt at the Treasury’s insistence, that the social care crisis should continue for years to come. As we have already heard, the social care system is currently failing to support four out of every 10 disabled people of working age to do the basic things in life such as washing, dressing, eating and getting out of the house. The proposed national eligibility threshold will do nothing to change this. The cap on care costs for these people will be a fiction; unless their needs are assessed to be at the equivalent of “substantial” under the current FACS criteria, they could well spend a small fortune paying for care, none of which would count towards the overall cap.

The public would be shocked to learn that the level of needs spelled out in the amendment in the name of the noble Baroness, Lady Grey-Thompson, is not covered by the cap on care costs. The Government envisage that people whose needs are below the proposed national eligibility threshold will be helped by the universal preventive services covered in Clause 2. However, as the Care and Support Alliance points out, many of these services have already been axed in the cuts or are at risk of closure. The £2 billion funding is very welcome, but we need the Government to be clear with the public that they are endorsing the continuation of the social care crisis unless a major shift of resources takes place.

[Baroness Jolly]

My Lords, I, too, am delighted that these amendments have given us the opportunity to debate the eligibility criteria and I echo the comments of noble Lords who know better than I do how this will affect them. Eligibility is a critical issue, which affects both disabled people and older people with care needs—disabled people account for one-third of the people affected by the Bill and elderly people the other two-thirds.

The Joint Committee warmly recommended the introduction of a national minimum eligibility threshold as a key way of resolving the current postcode lottery in social care. The new eligibility framework and national threshold proposed in the Bill will go a huge way to alleviate the lottery of care and will be vital in ensuring that there is more clarity and consistency in the provision of care for disabled people and the elderly in England.

The focus on well-being in the Bill was hugely welcomed by the committee. This principle is the thread that runs through the Bill and will ensure that the care system not only delivers basic support but promotes older and disabled people’s independence, allowing them to realise their potential through participating more fully in their communities. This is a bold vision for the future and one that could truly revolutionise the care system. It is therefore key that these two elements of the Bill work seamlessly together so that the well-being principle is at the forefront of the Government’s mind when considering who will be eligible for care, something that the committee explicitly recommended in its report on the Bill.

However, as the Government have rightly recognised, social care is not merely about allowing people to “survive” but about enabling them to live full and independent lives. The Bill explicitly places a duty on local authorities to provide care that promotes the well-being of individuals. In a conversation yesterday with the Minister for Care and the noble Baroness, Lady Grey-Thompson, it was acknowledged that the draft regulations, which have already been referred to in this debate, were just that—draft. Much more can and needs to be done to make them asset or strength-based. Can my noble friend ensure that the work on the draft regulations proceeds at pace so that they are fit for purpose and meet the needs and requirements of all within the scope of the Bill? Can he also ensure that any work involves those from the sector and expert Members of this House?

[Lord Rix]

My Lords, the Minister knows perfectly well where I stand because I already talked about eligibility at Second Reading and in the debate last week on the future funding of health and social care, led by my noble friend Lord Patel. I was backed in that part of the debate on the question of someone having to reach a level of substantial disability before becoming eligible for care. It should be the right of all people with a disability at least to be assessed properly, from the lowest level of disability to the highest. A level may be set where tens of thousands of people are excluded, such as people with a learning disability. Many are already being excluded by local authorities and being denied the use of day centres, or whatever. I can only plead with the Minister to say something which would give a glow of optimism to all of us who are totally and utterly opposed to the level which the Government are likely to set.

NHS: Keogh Review

Baroness Jolly Excerpts

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

We will see the Chief Inspector of Hospitals picking up the baton, as it were, from Sir Bruce Keogh, whose way of working in this exercise has been very instructive. His judgments were based on talking, not just to a few people in the trust, but to patients, a wide range of staff and, in some instances, people outside the trust. I am sure that Sir Mike Richards, the new chief inspector, will want to learn from that. It will be up to the CQC to decide whether this will be institutionalised. Its methodology is evolving. The hospital aggregate rating system will have a role to play in systematising the evaluation of performance and in any future instances of very poor care we will no doubt see a level of transparency from the CQC which we have, perhaps, not had before. However, I would not want to commit the CQC to reporting annually to Parliament in a particular way. It will report annually to Parliament but it is largely up to it how it does it.

[Baroness Jolly]

My Lords, we welcome the drive to improve quality in these trusts and across the NHS, based on the eight ambitions for improvement held in the report. In the Statement read by the Minister, the Secretary of State said:

“In some cases, trust boards were shockingly unaware of problems discovered by the review teams”.

Surely the boards were in receipt of data on quality. If not, why not? If so, why was action not taken? What attention is being paid to issues of trust board governance and its support and development?

[Earl Howe]

We will now see follow-up action by the CQC, not least in the area of trust governance where the quality of that governance has been called into question by Sir Bruce. That will be done rapidly. It is by no means the case that governance is defective in every trust, but question marks have been placed on some and it is important that assessments are made, not just by the CQC, but by the Trust Development Authority and Monitor as the two bodies responsible for overseeing the provider section. It may be that the CQC will be asked to carry out further work, but we are looking, for the time being, to the TDA and Monitor to do that.

NHS: Foundation Trusts

Baroness Jolly Excerpts

Tuesday 16th July 2013 Lords Chamber

[Earl Howe]

My Lords, I am sure the noble Lord is aware that the provision for reviewing NHS mergers on competition grounds is not at all new. Responsibility for reviewing NHS mergers has moved from one independent body—the Co-operation and Competition Panel—to another, the OFT. This is a continuation of the approach that has been in place since 2009. In all these decisions what matters is what is in the interests of patients. The competition authorities will continue to review whether the potential benefits of a merger outweigh the potential costs to patients.

[Baroness Jolly]

My Lords, would my noble friend confirm whether any of those trusts yet to achieve foundation trust status were planning to merge with any on today’s Bruce Keogh list?

[Earl Howe]

I am not aware of any on Sir Bruce Keogh’s list which were planning to merge but, if I may, I will write to my noble friend with further details if that needs clarifying.

Health: Prescription Drugs

Baroness Jolly Excerpts

Thursday 11th July 2013 Lords Chamber

[Earl Howe]

My Lords, of course I will revisit that Answer, and I will come back to the noble Baroness if I find cause to correct what I have said. However, I agree with her that the risks associated with long-term use of tranquillisers have been well recognised for many years. There are several authoritative sources for guidance for prescribers on this issue. I believe that that guidance is having an effect because, as I said, the prescribing rate has considerably diminished of late. There is no shortage of guidance out there. There is the national formulary, which already describes the importance of gradual withdrawal from benzodiazepines, and there is a wide variety of other impartial and trustworthy information resources to support prescribing.

[Baroness Jolly]

My Lords, GP training is important but for a user the crucial thing is the availability of the services. Will my noble friend tell the House whether services for those addicted to prescription drugs are readily available within each CCG area and where one might find details of such services?

[Earl Howe]

My noble friend will be encouraged to know that Public Health England has published a commissioning guide for the NHS and local authorities which sets out its expectation that support should be available in every area for people with a dependency on prescription or over-the-counter medicines. Local authorities are now, as she is aware, responsible for commissioning services to support people to recover from dependence in line with local need. Most of the support available for people who are addicted to prescription drugs is with their GP and not in services treating those addicted to illegal drugs, but there is a range of services available.

Care Bill [HL]

Baroness Jolly Excerpts

Tuesday 9th July 2013 Lords Chamber

[Lord Rix]

My Lords, having heard the words about Mencap spoken by the noble Baroness, Lady Wilkins, I, as president, must of course support this amendment. I say “must”, but I am surprised that these amendments have to be tabled at all. I would have thought that any Bill dealing with care must deal absolutely explicitly with housing. After all, noble Lords will remember when the long-stay, sub-normality hospitals were closed in the late 1970s, the 1980s and the early 1990s, the very thing that was required was housing. Mencap did provide the housing in those days, as best it could, with the Mencap Homes Foundation. It has progressed now to Golden Lane Housing, which allows people with a learning disability actually to own their own housing with the appropriate support. These provisions are necessary, and I am amazed that these amendments were necessary in the first place.

[Baroness Jolly]

My Lords, I support this suite of amendments—this flight of amendments—on housing. As noble Lords have eloquently said, housing is the third side of the care triangle. Those of us who sat on the scrutiny committee were absolutely clear on that. We thought that it had been extended to our report, but clearly it has not been reflected totally in the Bill. There was mention of it in Clause 1, the well- being clause, in Clause 6 on co-operation, and also in Clause 8 on how to meet needs. The noble Lord, Lord Best, has filled in the gaps, with Clause 2 on prevention, Clause 3 on integration, Clause 4 on the provision of information and advice, Clause 5 on market shaping and Clause 9 on the assessment of needs. In each of these elements of the Bill, housing is imperative. The anxiety that many of us share is that if housing is not in these clauses, it will not be dealt with when an individual is assessed, or when there are issues around integration.

In the Select Committee, the most compelling witnesses were from the housing sector. They understood the impact that appropriate housing, and any adaptations to houses, would have on the lives of the people living there—on the health and well-being of the individual. The amendments in this group put housing where it should be. It is core to assessment and core to integration of care. It is a preventive measure, and it is also core to the provision of information. There is no point in having a conversation as a result of your assessment and as part of the information process if you are not aware of what your housing needs are, because without housing, the conversation makes no sense.

Local authorities need clear direction from the Government. The noble Lord, Lord Best, articulated this clearly when he introduced his amendments. Some health and well-being boards have got it and some have not. Those that have not should have it spelled out, so the amendments in this group are absolutely appropriate. I hope that my noble friend, when he sums up, will reassure the House in this regard.

Care Bill [HL]

Baroness Jolly Excerpts

Tuesday 9th July 2013 Lords Chamber

[Baroness Jolly]

My Lords, I will speak briefly to Amendment 86N, in the name of the noble Baroness, Lady Greengross. We have had an interesting debate, with quality at the heart of it. That is absolutely right because the whole principle of shaping markets has to be around providing quality and safe services for vulnerable people.

I was interested in the response to this that the noble Lord, Lord Hunt, had from ADASS. Certainly, I do not recollect from when it came to give evidence that that was its reaction, but I will look that up.

The other thing that I want to reflect on is this business of changing people for domiciliary care. That is not what people want. What people want is to be cared for by people they know; they do not want different people coming in day after day. My mother has a team of eight or nine people who call on her but she knows them all. That gives flexibility to the agency that sends them her way. It is not impossible. People need to know their care staff. My mother knows a week in advance who is coming, on what day and at what time, which is hugely reassuring.

I also have huge sympathy with those who have pointed to the scandal of zero-hours contracts. Whatever can be done to try to stop that practice must be looked at with some urgency. This is all about quality.

The amendment would ensure that services commissioned from providers are of high quality and provide a high level of safety for patients or those being cared for. The scrutiny committee recommended linking quality and safety with the NICE quality standards. That is really very straightforward: the NICE care quality standards exist, so why should services not be commissioned based on them?

Will my noble friend explain how quality will be assured and what the rationale is behind abandoning, or not taking up, the NICE link? Is he able to offer assurance by putting into regulations the link with those NICE standards?

Public Health England Advisory Board Membership

Baroness Jolly Excerpts

Thursday 4th July 2013 Lords Chamber

[Earl Howe]

My Lords, absolutely not. The noble Baroness to whom the noble Baroness refers is, in everybody’s eyes, a highly qualified person. It would be inappropriate in any case for me to comment on individual candidates, successful or unsuccessful. However, I can confirm, and I emphasise this strongly, that the recruitment campaign was managed in a way that completely complied with the principles of the Commissioner for Public Appointments’ code of practice. It was open and transparent, and appointments were made on merit against published criteria for the role.

[Baroness Jolly]

My Lords, will my noble friend explain what action is being taken to grow tomorrow’s female and minority leaders in health?

[Earl Howe]

My Lords, across the field of health it is difficult for me to give a generic answer, but the NHS Leadership Academy, which is now starting its work, will ensure that women with promise for leadership will be encouraged to come forward in a variety of roles, not just clinical but managerial. I hope that we will see the fruits of that work over the coming months.

Health: Diabetes

Baroness Jolly Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Baroness Jolly]

My Lords, the House has heard that eye screening is critical for those with diabetes. As the national screening programmes are now commissioned by NHS England on behalf of Public Health England, and while diagnostic and treatment services are commissioned by clinical commissioning groups, will my noble friend tell the House what challenges these arrangements pose to the patient when trying to assess quality?

[Earl Howe]

The key thing here is for NHS England, Public Health England and local commissioners to work closely together, which is indeed what they are doing, so that the patient experiences a seamless service. Essentially, the new commissioning arrangements for national screening programmes enable effective commissioning and oversight of the whole screening pathway, alongside integrating those with the diagnostic and treatment services. To ensure a quality service, local programmes are assured by NHS screening programmes’ quality assurance teams and services are measured against 19 standards.

Care Bill [HL]

Baroness Jolly Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Baroness Barker]

My Lords, I shall speak to Amendments 78A and 78B, which stand in my name and that of the noble Lord, Lord Hunt of Kings Heath. These and other amendments which will crop up throughout our discussions have been inspired by the Christian Science movement. I wish to say that I am not a Christian Scientist, but Christian Scientists hold to some very firm beliefs which are of great importance to them. Part of their belief system is that they do not wish to receive medical treatment in circumstances where other people would make a different decision. Therefore, in health Bills such as this, where we are setting out the principles that underlie what we define to be good care, it is not uncommon for me and the noble Lord, Lord Hunt, to put on record again that there is a spiritual dimension to health and well-being and that the way in which that spiritual belief is manifested can be different for minority groups.

One great strength of the Bill is that it takes a principled approach to what we define as well-being rather than attempting to define well-being in a descriptive sense. One reason why I think that that is increasingly important is that we have an increasingly diverse population. Therefore, the meaning of well-being for individuals is becoming distinct and diverse throughout society. The amendments place a duty on local authorities and relevant health bodies to respect the increasing diversity of our population.

There are two other reasons why I am very pleased to support the amendments. Like everyone else in the House, I am greatly in favour of the integration of health and social care. I see the undoubted benefits of that, but as someone who has worked in the field of social care, as opposed to health, all my life, I still carry with me the fear of the medicalisation of disability or of old age. When push comes to shove, when budgets are tight, some of the certainties which surround physical health, in particular, can overtake social goods which are less easy to define. Therefore, it is important that we ensure that we do not allow that to happen. One way to prevent that is by taking the approach of the amendments.

The final reason why I raise the amendments now is that I think that setting that out as they do right at the top of the Bill is a strong reminder to everyone who will refer to the Bill in years to come that the autonomy of individuals is an important part of health and well-being. You cannot have good health and be a fully functioning member of society if you do not have that autonomy, an autonomy which means that, in some cases, you have the right to make decisions which other people would regard to be unwise. It is a point of principle, but one which I think has a great deal of practical application not just for those who are receiving care but for those who are in charge of making decisions about it.

[Baroness Jolly]

My Lords, I am very sorry that the noble Lord, Lord Warner, is not in his seat. He tabled Amendment 79 to express the strength of feeling of Members of this House who were sitting on the scrutiny committee about the Secretary of State’s the duty to have regard to well-being. Were there room for more than four names to the amendment, there would have been more Members of your Lordships’ House on that list.

To put this in context—and the noble Lord, Lord Hunt, has taken us through quite a lot of this—this Bill was widely consulted. It was probably the coalition’s most widely consulted Bill; somebody might be able to tell me to the contrary. At each stage, people welcomed the well-being principle. Perhaps I may remind the House that in the majority report on the Bill, one of the recommendations was that the Secretary of State should have due regard. When the final Bill was produced, many in the sector approached me, and I suspect many others, to express their disappointment that that was not included in it. When the Secretary of State came to give evidence with the Minister for Care and Support, the right honourable Norman Lamb, he was very positive about it. According to the transcript of the session, Norman Lamb said:

“We absolutely want the wellbeing principle to apply comprehensively”.

The well-being principle is around the change of culture and it puts the person at the centre. It is absolutely critical that that happens, and next week we will debate the whole business of assessment and how we are undertaking it. However, unless the Secretary of State has to have regard to the same principle as local authorities, there is an opportunity for future Secretaries of State when making regulation to disregard well-being and just make regulation in the old way. One thing that sets this Bill aside from many others is that it is written in plain English and throughout its intention is pretty clear.

I ask the Minister if he is able to offer any assurance to the House, to the sector and to those for whom the Bill is written—the service users and the carers—that the Government will think again about the decision not to include in the Bill a duty on the Secretary of State to take well-being into consideration.

[Baroness Pitkeathley]

My Lords—

Care Bill [HL]

Baroness Jolly Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Noble Lords]

Order!

[Baroness Jolly]

I will be brief. I support the amendment in the name of the noble Lord, Lord Rix, on preventing needs for care and support for those with learning disability. We need to remember that those for whom the Bill is written are all vulnerable adults: whether they are vulnerable by virtue of their age; their learning disability; mental state; physical condition, whether that is disability or frailty; whether they are living at home or in other accommodation. A local authority should take all steps it considers will contribute towards adults experiencing, or being put at risk of, abuse or neglect. We have just heard about preventive measures: these are preventive measures linking in with needs. The outcome of the amendment would be a reduction in incidents of neglect or abuse. It might mean local authority employees raising concerns about individuals or organisations providing care; making it a regular agenda item at a team meeting and not turning a blind eye; whistle-blowing where appropriate and making it part of the well-being culture.

Before I saw the regroupings, I had also intended to speak to the amendments of the noble Lord, Lord Best, which were, at one time, grouped together. Amendment 88 seems to have become an orphan amendment within this group. I support it but I will speak to it when the rest of the amendments are dealt with.