Care Bill [HL]

Baroness Meacher Excerpts

Wednesday 9th October 2013 Lords Chamber

Moved by

[Baroness Meacher (CB)]

22: Clause 5, page 5, line 19, at end insert—
“( ) the need to adhere to specific minimum quality standards and requirements in the commissioning and provision of services to adults, as regulations may prescribe;”

[Baroness Meacher (CB)]

My Lords, I will also speak to Amendments 25 and 26 in this group and acknowledge the Government’s Amendments 24 and 27, which I will mention later. I start with Amendments 22 and 25. As many noble Lords have said, the Care Bill has the potential very significantly to improve the care of elderly and disabled people. However, there is also the possibility that only a part of that potential will be realised, particularly in the face of significant cuts to local authority budgets. Amendment 22 therefore places in the Bill a requirement for there to be regulations about how services are commissioned to ensure that they offer at least a sufficient level of quality to the individual. Amendment 25 ensures that home visits are not normally commissioned for less than 30 minutes. The amendments provide for a service of at least minimum quality, as I said, which will ensure the dignity of each elderly or disabled person. They also allow flexibility—which is important—for short visits, for example for the delivery of a meal or for giving an injection, and also for longer visits.

This became very clear to me when I met the director of the Bikur Cholim social care organisation, which has been in operation for many years looking after people in the Jewish community. The director told me that for a disabled, doubly-incontinent client, a morning visit cannot be completed in less than one hour. Dealing with the incontinence—and one does not want to go into too much detail about that—can be time consuming. A bath or shower is essential for a doubly-incontinent person; they need a change of clothes, possibly a change of sheets, to have food provided and help to get dressed.

When you think about all that, it is fairly obvious that you could not possibly do it in half an hour. However, in our financial context there is an increasing tendency to commission ever-shorter home visits, many lasting only 15 minutes, as has been well publicised on the “Today” programme twice this week. Indeed, a survey by the UK Homecare Association found that one in 10 visits already last only 15 minutes and the proportion of 15-minute visits has increased by 17% over the past five years.

Leonard Cheshire Disability has seen tenders for visits of only 10 minutes and, according to the person on the “Today” programme, these carers tend to take 10 minutes to take off what they describe as “their hat and coat”. I am quite curious about carers arriving in a hat and coat, but there we go. It means they would then have to shoot out of the door without their hat and coat. The mind boggles. This is a very serious issue and a tragic quote from a disabled client makes the point better than I can: “By the time they have got me to the commode and helped me to change, the time is up. I end up choosing between getting my meal prepared or having my commode emptied. Do I get a drink or do I go to the toilet?”.

Imagine having to make those kinds of choices. The public do not support depriving elderly and disabled people of a dignified service. Some 96% are critical of these very short visits for personal care; people understand about an injection, I think. Will the Minister clarify on the Floor of the House that a visit to deliver personal care, including, as it will inevitably, dressing, taking the client to the toilet or bathing, within a timeframe of 15 minutes is simply impossible and always will be. Therefore, one can say something pretty firm about it.

From the point of view of the carers too, workers complain that they have had to stay longer than 15 minutes in almost every visit, even though they are paid only for 15 minutes and they are not paid for their travel time either. As one said, “You just cannot possibly do this job in that length of time”. The question is whether we are giving sufficient priority to elderly and disabled people living at home. I think we have to answer, “Surely not”. The Minister, Norman Lamb, has very publicly criticised 15-minute personal care visits, but there is nothing in the Bill to prevent this practice from continuing and, indeed, from spreading further. The government amendments do not really tackle the problem, although I know that the Minister always tries very hard to do what he can. He will be aware of the 2,000 plus e-mails that have landed—not necessarily on his desk but in the office—within the past few days expressing concerns about this issue. It has concerned people very deeply.

I hope that the Minister can assure the House today that the Government will guarantee that our most vulnerable people can rest assured that their needs will be met and their dignity will be protected. This means, I fear, carers having enough time. I know, of course, that this means resources, so we are here coming down to priorities and where they really lie.

Amendment 26 is supported by the Care & Support Alliance of 70 organisations representing old and disabled persons, those with long-term conditions and their families. Clause 5 acknowledges the benefits of quality services but only requires local authorities to,

“have regard to … the need to ensure”,

that sufficient services are available. I am not quite sure how one has regard to those matters and then disregards them, so I am genuinely not sure what that means. The amendment would “require” local authorities to ensure that sufficient services are available to meet the needs for care and support of adults and their carers in their area. We are talking here about good planning of services over time, and also the planning of a comprehensive range of services for people with very different disabilities and needs being undertaken.

We take the view that the social care system is in crisis, too often leaving older and disabled people and their families without essential care and support; certainly, I take that view. Indeed, I emphasise that I fear that abuse of elderly and disabled people is very likely to be the next national scandal. We have had physical abuse of children; we have had sexual abuse of children. One has only to think about the love of parents for children to wonder, if parents are doing that to their children, how many elderly and disabled people may face abuse? I say this with the greatest possible sympathy and understanding for carers. How many of us can honestly say that we could live with, say, a dementing parent—I have had a dementing parent, so I have an understanding of this—year after year, without sufficient support, and always find the emotional, physical and every other kind of energy to provide that care, and often to give up your life to do so, without being reduced to behaviours of which one would be profoundly ashamed? If abuse occurs, we cannot blame the overburdened carers. It is up to us.

Meeting short-term needs is essential. This is not straightforward for people with fluctuating disorders. Somebody with multiple sclerosis, for example, can from time to time need full-time, 24-hour care. If that is not available, that person will have no option but to be moved into a residential home. Very often, the only space is in a residential home for the elderly. For, say, a 25 or 30 year-old, that is a deeply distressing experience, apart from being very expensive.

On the range of quality services, a tragic story about a deafblind man says it all. Some unqualified person delivered his breakfast but never told him where it was, so he went without breakfast for days. It was sitting on the fridge, but you have to have the training to tell you that you need to be very good on your communication. You could say that it is all very basic stuff, but this poor chap went hungry.

I very much welcome the Government’s amendments in response to these concerns but, unless I have missed something important—I confess that I may have—they do not seem to ensure that sufficient appropriate services are made available for vulnerable people. I am confident, nevertheless, that the Minister well understands the importance of this issue and very much hope that he can assure the House this evening. I beg to move.

[Baroness Masham of Ilton (CB)]

My Lords, I support Amendment 22 but am concerned about Amendment 25. Is it wise to mention 30 minutes? I declare an interest as president of a spinal injuries association. Some of our members have broken their necks and are paralysed from their neck down. To get a paralysed person up, to do an evacuation of their bowels and to wash and dress them, using a hoist, might take at least three hours. Surely it is better to stress the individual’s needs rather than to set in stone half an hour. Providers of care may use that as a marker.

A visit taking 15 minutes, as has recently been in the headlines, is totally ridiculous. Having the choice of whether a carer takes someone to the lavatory or gives them a drink is unacceptable. If stress is put on the carer who cannot do the job in that time, they will leave and not do the job at all. The person needing care is left in a dangerous position if adequate care is not given. The amendments need to be flexible and aimed at an individual’s personal needs. I hope very much that the Minister will look at this and will do something to make it acceptable.

--- Later in debate ---

[Earl Howe]

My Lords, we certainly know that the reduction in resources has had some effect. However, it is interesting that the feedback from local authority chief executives and directors of adult social services suggests clearly that the detrimental effect on the provision of adult social care is not as dramatic as one might suppose from the drop in local authority budgets. This is partly because of the funding provided by my department to local authorities to make up some of the gap. I would not wish to say that there has been zero effect. We think, from the feedback, that the volume of services has diminished by about 5%. This is 5% too much, in most people’s eyes, but may not be as significant as some have feared.

My second point is that central prescription risks prohibiting practices that may, in some circumstances, be consistent with high-quality care. For example, 15-minute homecare visits could well be appropriate in some situations, for instance for helping people to take medication, which is not a process that takes very long at all. Further, using legislation to ban specific processes may result in perverse incentives arising, without addressing the actual problem. A number of noble Lords made that point.

Thirdly, legislating for a specific period of time for which homecare visits must last risks reinforcing one of the key problems here: inappropriate use of time and task commissioning. Instead, we need to move away from overly prescriptive commissioning practices which focus on—

[Baroness Meacher]

My Lords, I apologise for intervening, but I want to make clear that there is absolutely no prescription: there is flexibility. It is simply saying that you cannot do a personal care visit of less than 30 minutes.

--- Later in debate ---

[Earl Howe]

My Lords, I was distinguishing between providers and commissioners. The CQC can do thematic reviews under, I believe, Section 48 of the Act, but we are talking there about providers. As regards commissioners, we are proposing in a later amendment to give the CQC powers to conduct special reviews where concerns have been raised about a particular local authority or NHS commissioner; there would not be periodic, regular reviews. However, the CQC will be looking at every provider over a period of time. The amendment from the noble Lord, Lord Hunt, specifically addresses the ability of the CQC to examine providers. I was saying earlier that it already has the necessary powers to do detailed work in whatever area it chooses.

I return to the issue of local authority commissioning practices. As I argued, the underlying causes of poor commissioning are cultural, and we need to work with local authorities to tackle these issues. We are therefore undertaking a number of non-legislative activities, including the development in co-operation with ADASS of a set of commissioning standards. These standards will enable individual authorities to gauge their own effectiveness, and will support the LGA and ADASS to drive sector-led improvement.

In addition, we are working with the Towards Excellence in Adult Social Care initiative to support local authorities to seek continuous improvement in their adult social care functions, and in the outcomes achieved. This programme brings together local, regional and national stakeholders, and is focused on providing peer support and interventions by local government to share learning, find new ways of engaging local people, and use knowledge of what works, data and innovation to drive improvement in the quality of services.

I hope that these arguments, and the amendments we have tabled, are sufficient to demonstrate to the House that we understand and agree with the strength of feeling around these issues. For the reasons I have set out, I cannot support the amendments tabled by noble Lords, but I hope that the arguments I have made today will be sufficient for those noble Lords to feel able not to press their amendments. I do not yet know what the noble Baroness, Lady Meacher, intends to do with her amendment, but it may be helpful for noble Lords to know that the Government do not consider that a decision on Amendment 25 is consequential on Amendment 22.

[Baroness Meacher]

My Lords, I thank the noble Earl for his thoughtful response and also all noble Lords who contributed to this debate. It has been very considered, and the points raised have been very important. These visits can require three hours of work, or one and a half hours—all sorts of different lengths of time. Whatever is decided ultimately must enable those visits needing that length of time to be undertaken in that way. I welcome the amendment of the noble Lord, Lord Hunt, and I am sure that the CQC has an enormously important role to play in this. I wonder whether the Minister would think it appropriate to require a thematic review of this issue to be undertaken by the CQC, bearing in mind the level of concern across the country about what is happening at the moment, which clearly is not acceptable in terms of these very short visits for personal care.

The noble Earl mentioned the 5% reduction in the budget for adult social care. It sounds small, but we all know that the adult social care budget has always been incredibly low—way below what it should be. Priority has never been given to this area of work, so a 5% reduction is pretty serious. There is a lot to be done. The noble Earl referred to guidance, regulations, and so on. I personally would welcome an opportunity to have a discussion with him about how, in the guidance and regulations, it might be possible to ensure that adequate priority is given to this area of work. This is really what we are talking about here.

My amendments are aimed at stimulating the debate. They are also an effort to draw out some commitments from the noble Earl, and to some degree I think we have achieved that objective. I do not know whether the Minister would be willing to have a conversation about what might be included in the guidance and regulations.

[Earl Howe]

My Lords, if it will assist the noble Baroness, I will be very happy to have a conversation with her at a mutually convenient time.

[Baroness Meacher]

With that assurance, I am happy to withdraw the amendment.

Amendment 22 withdrawn.