Care Bill [HL]

Baroness Pitkeathley Excerpts

Wednesday 3rd July 2013 Lords Chamber

Moved by

[Baroness Pitkeathley]

74: Clause 80, page 67, line 19, at end insert “including their integration with other relevant services”

[Baroness Pitkeathley]

My Lords, in the unavoidable absence of my noble friend Lord Warner, I shall move Amendment 74 and speak also to Amendment 75.

These two amendments give an opportunity to put into the Bill further emphasis on the importance of integration. Amendment 74 requires reviews by CQC of regulated health providers to cover the integration of those services with other relevant services. Amendment 75 does the same for reviews of local authority adult social care services. They are a clear reminder in the Bill that when CQC carries out such reviews it will have to pay attention to the issue of integration of services for the benefit of patients and service users.

I shall not detain the Committee today with yet another speech of a kind that I have made many times before on the importance of integration of health and social care services from the point of view of patients, service users and their carers. We all know how important that is. The Committee is familiar with the arguments and, more importantly, so is the Minister. Indeed, the Chancellor of the Exchequer, no less, acknowledged this in his announcement in the comprehensive spending review in regard to joint budgets. The announcement has been widely welcomed, although caution has been expressed about how these budgets will operate in practice.

The amendments are a modest attempt to give some practical effect to the aspiration for integration which we all share. I hope the Minister will say that it is a good idea, “Let’s do it”, and get us off to a cracking start this afternoon. I beg to move.

[Lord Hunt of Kings Heath]

My Lords, I declare an interest as a chair of a NHS foundation trust and as a consultant and trainer with Cumberlege Connections. I am happy to support my noble friend Lady Pitkeathley’s Amendments 74 and 75, which rightfully push the CQC into the direction of integration of services. I also sympathise with the amendments of the noble Baroness, Lady Greengross, Amendments 76ZZA and 76ZAA, to which she will speak later.

My Amendments 74A, 76ZA and 76ZB and my opposition to Clause 80 stand part go to the core of the purpose of CQC and its approach to performance assessment in health and social care. Inevitably, recent events at that regulator in relation to Morecambe Bay and before that at Mid Staffordshire will readily come to mind. There can be no doubt that the current leadership of CQC faces a major challenge in changing the culture of the organisation and its approach to inspections. It has much to do to restore both public confidence and confidence within the NHS about the way in which it operates. That is why this clause is so important.

Clause 80 substitutes Section 46 of the 2008 Act and provides that the CQC’s duty to conduct periodic reviews, assess performance and publish reports of such assessments, which are henceforth to be known as “ratings”, is to apply in respect of any regulated activities and any registered service providers as may be prescribed in regulations. In addition, where regulations so provide, the CQC must also review and assess the performance of the provision and commissioning of adult social services by English local authorities. CQC is to be given responsibility for determining the quality indicators against which services and providers will be assessed. This may include measures of financial performance and governance if the CQC deems this appropriate. Different quality indicators, methods and frequency in periods may be used for different types of cases. The CQC may also review the indicators of quality and method statement from time to time as it sees fit.

Let me say at once that I support the broad intention of these clauses to make the CQC responsible for rating providers and local authorities. I say again that one should not underestimate the task. It is important that the CQC is not put under undue pressure to rush to change the way that it operates and to introduce new ratings without proper pilots being done and without having enough time to do it.

I refer the noble Earl to the Nuffield Trust’s work. As he knows, the Nuffield Trust was commissioned to carry out a review for the Secretary of State into the possibility of rating providers of health and social care. It argued that the new ratings must be given adequate time to work together with a range of stakeholders in developing a system which enables both patient choice and professional leadership to drive up standards of quality. That is vital. Yet I am concerned by the document issued by the CQC recently that indicates that it is to start inspecting and regulating NHS acute hospitals, in the ways that it set out in that document, from October 2013. Indeed, from December 2013, it will begin to rate NHS acute trusts and NHS foundation acute trusts, aiming to complete them before the end of 2015.

Have Ministers put pressure on the CQC around the timing of those ratings? Secondly, does the noble Earl not think that there is a risk that the CQC will be forced to rush into a new system without proper consideration? I remind him that the chairman of the CQC has recently made a number of statements. First, he has said that the approach to inspections by the previous leadership was wrong; it was wrong to go for generalist inspections. He also says that the culture of the organisation was wrong. Given that there are about 1,000 people employed by the CQC, although I am not absolutely certain, how on earth is the culture going to change in a short period of three or four months? I just do not think it is going to happen.

I have great admiration for the current leadership of CQC, but the risk is that it is going to be forced into a new system too quickly and it could fall over. As a result, its credibility will be very much damaged. Let us face it; it is almost starting from a negative position. I must confess that I am surprised that such an ambitious timetable has been set.

Who will be assessed? As I have already intimated, the clause provides for the Secretary of State to draw up regulations laying out exactly which services the CQC will rate. They are likely to be hospitals, GP practices, care homes, domiciliary care services across both the public and privates sectors and local authorities. Will the noble Earl confirm that? Will he say why this is not specified in the Bill? Does he not consider it important enough for Parliament to decide which bodies should be assessed, and to do so in primary legislation rather than through regulations?

I asked at Second Reading whether clinical commissioning groups are to be assessed. If not, why not? The Bill allows for local authorities to be assessed for their performance in the commissioning of adult social services, so I cannot really see why NHS commissioners—the CCGs—should not be similarly covered. The same logic then applies to NHS England which, after all, has been given a massive commissioning budget in relation to specialist services. If it is appropriate for local authorities to be assessed for their commissioning responsibility, surely all health commissioners should be similarly assessed. That must apply to NHS England because otherwise I do not see who will hold it to account for the mammoth amount of resources it will spend on commissioning specialist services.

I am particularly interested in local authority assessment, particularly in the way that services are commissioned. Can the noble Earl tell me whether this is intended to be a priority for the CQC? He will know that there is real concern about the practices of many private sector providers in social care in using zero-hour contracts and allocating only 15 minutes with each client. It is vital for the CQC to be able to investigate the way in which local authorities commission those services. We will come to this in Clause 5 but it would be very useful if the noble Earl could confirm that the commissioning responsibilities of local authorities will be a priority for the CQC.

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[Earl Howe]

I completely understand the noble Lord’s point. He will remember that in the registration requirements for providers of health or social care, the existence of a complaints system is one factor on which the CQC will need to satisfy itself. On the quality of the complaints-handling system within that provider, my answer is that it is a powerful point and an important area, but in the end it is one on which we should let the CQC decide as it develops its methodology. I do not in any way dismiss the noble Lord’s suggestion, but it is one for the CQC to take forward.

[Baroness Pitkeathley]

My Lords, this has been a wide-ranging and well informed debate. It has focused on anxieties about the role and competence of the CQC. The anxieties seem to focus on questions about whether the job of the CQC is doable at all, doable in the very short timescale, or doable with current resources. Suggestions about how to address the anxieties and concerns have included piloting new structures, but there has been much support for the CQC being given time to improve its strategy and performance—although with strong reservations from my noble friend Lord Campbell-Savours. I am grateful for the support for my amendments on integration, and sorry that the Minister was unable to accept them. Given the concern and strength of feeling about the CQC, I am sure that we shall return to this matter on Report. For the present, I beg leave to withdraw the amendment.

Amendment 74 withdrawn.

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[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—

[Baroness Campbell of Surbiton]

My Lords, I apologise for not being able to bound in as soon as the noble Lord, Lord Hunt, sat down. At that moment my papers cascaded to the floor. I rise to support Amendment 78D. For logistical and physical reasons, as my noble Lords can probably hear, I was unable to put this amendment down myself and the noble Lord, Lord Hunt, has done miracles to articulate our conversations in such a lucid manner.

I feel, however, that I must give your Lordships a very clear example of why I believe this amendment is so necessary. Why do health and social care practitioners need this further direction in this amendment?

It is true that health and social care consumers enjoy greater personal control now, which affords a small percentage support to live independently in the community. I am an example of the few who live with complex health and social care requirements and live a life just like any other: pursuing a career, tending the family, or in my case revising legislation.

We remain, however, an exception, rather than the rule. Let me give your Lordships a couple of examples. Just over a year ago, I led a JCHR inquiry into Article 13 of the UNCRDP, a right to independent living. When we launched the findings, I dedicated the report to a disabled young man who had secured optimum control over his own life using social care direct payments. He lost everything within a couple of months, after his support needs changed, due to requiring a tracheostomy. He had graduated from university and was about to start his first job .

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I am not a fan of a health model of disability, but so many disabled people are living with considerable health issues. That is why we have to have a clear structure and direction in both health and social care so that they work together equally to produce outcomes for disabled people that enable them to go on living the life that they so long for: a life lived independently in the community.

[Baroness Pitkeathley]

My Lords, I apologise to the noble Baroness, Lady Campbell. I was so eager to follow the noble Baroness, Lady Jolly, on Amendment 79, and I did not know that she was wishing to speak.

I particularly wanted to follow the noble Baroness, Lady Jolly, in speaking in support of Amendment 79, on which my name appears as well as hers and the noble Lord, Lord Warner, who was unavoidably absent today, and indeed the noble and learned Lord, Lord Mackay.

It will not have escaped the notice of the Committee that we are all members of the Joint Select Committee which scrutinised this Bill. We were very keen to have in Clause 1 the recommendation that when making regulations or issuing guidance, the Secretary of State must have regard to these principles, as must as local authorities.

We put this issue to the Secretary of State and the Minister as the noble Baroness, Lady Jolly, has mentioned, when they appeared before the Joint Committee. They appeared to be very favourably inclined towards it. We were very hopeful that this would be in the Bill. The civil servants were clearly less eager about this, so perhaps it was no surprise that it did not appear. However, we took away from the evidence session the understanding that Ministers were sympathetic to the idea. That is one of the reasons this amendment has been tabled.

Sadly, the official line now seems to be that used by the Minister at Second Reading on 21 May, when he said that,

“the well-being principle in Clause 1 is intended to apply at an individual level, when a local authority makes a decision. This individual focus on the specific well-being and outcomes for that person is at the heart of the way that the Bill has been drafted. It is not intended to apply in a more general way. Given that we do not think it would be appropriate for the Secretary of State to be subject to the same duty, the Secretary of State does not make decisions at the individual level”.—[Official Report, 21/5/13; col. 829.]

Nobody could disagree with the first part of that statement but the second part simply does not follow on, because the Secretary of State’s actions in regulations and guidance determine to a great extent whether local authorities can discharge their duties under Clause 1.

If the Secretary of State asks so much of local authorities without adequate funding being available, they will simply be unable to discharge their duty. Only if the Secretary of State is bound by the same duty as the local authorities can there be any realistic chance that, over time, he will avoid making unreasonable demands of local authorities in the instructions that he gives them. The way that the Bill is drafted, the Secretary of State can simply pass the buck back to the local authorities, which differs from his position in relation to the NHS, where he is required to act in accordance with the NHS Constitution. If it was the Secretary of State’s intention, as he seemed to be saying in his oral evidence to the Joint Committee, to support the well-being principle in practical terms, this amendment should be acceptable, and I hope it will be.

[Lord Black of Brentwood]

My Lords, I shall speak to Amendments 78E, 87K and 88J, which are in my name. They raise the issue of companion animals—mostly cats, but dogs as well—and the positive role that they can play in the care of elderly, vulnerable and sick people, whose welfare is at the heart of the Bill. I should declare an interest as president of the Printing Charity, as it runs two homes providing sheltered accommodation and financial support and care for people from the printing industry.

Amendment 78E includes the positive contribution of a companion animal to an individual’s well-being in the list of factors to which a local authority must have particular regard in exercising its functions under Part 1. Amendment 87K includes identifying the role of companion animals in the care and support of an individual when a local authority is assessing their needs and those outcomes that an individual wishes to achieve in day-to-day life. Finally, Amendment 88J deals with the issue of companion animals in regulations under Clauses 9 and 10. Taken together, their purpose is to ensure that the benefit which companion animals can provide to well-being, a subject not currently covered in the Bill, is not overlooked by those implementing and interpreting it.

It is estimated that 25% of people over retirement age own one or more pets. For the elderly and vulnerable, the companionship that cats and dogs can bring cannot be overstated. Academic research over many years has documented this. One study by Brooks, Rogers and others, published just last year, highlighted the emotional and practical impact that companion animals offer. Noting that they provide unconditional support and love, as we all know, the study concluded that,

“the policy implications of this study suggest that pets might usefully feature alongside consideration of the usual support systems associated with the management of long-term conditions and in planning how needs might be ... creatively met”.

That, of course, is precisely what this Bill is designed for and what these amendments are crafted to deliver.

Cats in particular can help those who are vulnerable, through age or health, in three ways. First, there is a powerful body of evidence about the contribution of cats to physical health. According to one study published recently in the Journal of Vascular & Interventional Neurology—not a magazine I look at frequently, but it is there—they contribute to a reduction of fatal cardiovascular disease by around 30%.

Secondly, the ownership of a cat brings positive benefits to an individual’s mental health. Research conducted in 2011 for Cats Protection and the Mental Health Foundation among people with a mental health problem found that 76% of people who owned a cat felt they could cope with everyday life much better as a result, and that 87% said it had a positive impact on their well-being. Cats can be especially helpful for depression during the winter period—a particularly important point since, as we now know, this goes on for about nine months of the year. As the Cinnamon Trust, which works tirelessly to support the elderly and their pets, summarises it:

“Pets have the ability to bring happiness and laughter and lift depression. Communication with other people is often easier when a pet is present for reassurance”.

Thirdly, cats make particularly suitable companion animals for those with chronic health problems, including those who are immobile or disabled. I know that this is a charge always made against cat lovers, so I am not forgetting our canine friends. I highlight, for instance, the excellent work of the innovative Dementia Dog Project, which helps to keep people in the early stages of dementia active and engaged with their local community, as well as providing a constant companion to reassure those suffering from dementia in new or unusual situations. This project in particular shows that a dog may aid a sufferer to stay on longer in his or her home—an important ambition that many noble Lords have highlighted in this debate—and may even slow the onset of this terrible disease.

Real-life examples of how cats promote well-being and play a vital role in an individual’s care appear regularly in the excellent magazine, The Cat, which is a publication I do look at regularly and is published by Cats Protection. In recent months, there have been stories about how their cats helped an owner to cope with epileptic seizures, helped a seven year-old boy to deal with the debilitating problem of selective mutism, and comforted a 17 year-old girl confined to bed with the life-long incurable condition of Behçet’s syndrome. One particularly moving story related to how a visit from a cat to an elderly lady who was in a hospital ward and suffering from severe dementia got her to speak for the first time in three months.

There are many other examples. Indeed, I think of the experience of my own mother. In the last year of her life, she was widowed, immobile and more or less housebound. Her faithful cat, Toby, was her constant companion. She talked to him, laughed with him and moaned and shouted at him; he cared for her in return. Indeed, he lay on her bed as she died. That companionship is a priceless gift, which this legislation should protect. Let me explain briefly how these amendments might help, as I ask my noble friend the Minister to consider these three issues.

First, one of the many problems that those who are elderly with a pet can face is how to care for it when they go into a care home. There are some amazing care and retirement homes which welcome pets but others do not have a policy on them, which can cause anxiety and distress to those who need to enter one. For a person to have to give up what might be their sole companion is a tragedy for an owner and for the pet. It also adds to the growing burden on many animal charities, which are having to take increasing numbers of abandoned pets as economic problems have bitten hard in so many families.

Secondly, it would encourage those at the front line of care—GPs, in other words—to become aware of the role of a pet in an individual’s life. Many GP surgeries include in their information about the over-75s whether a companion animal forms part of the client’s household. The signal sent from amending the Bill would encourage many more GPs and clinical commissioning groups to ensure that this important information is routinely collected for all age groups, including the elderly.

Finally, the Bill needs to be drafted widely enough in its definitions of well-being and needs assessments to allow for money, whether budgets or direct payments, to be used where necessary to support an individual who perhaps wishes to retain a pet but is having problems due to health. Professional pet-sitting or feeding may be needed when an individual is hospitalised and where there are no friends or family to help. Knowing that a pet is being cared for can help encourage otherwise reluctant individuals to go into hospital for treatment and relieve anxiety. Equally, in cases where a care assessment shows that a companion animal would bring individual health benefits, money may be needed to help an individual obtain a companion animal. There are many examples of such budget programmes in other countries—most notably, I think, in Australia—where health and local authority budgets are pooled to provide companion animal support programmes. This principle should be embedded in regulation and statutory guidance for all relevant implementing bodies.

Most importantly of all, these amendments would ensure that the role of companion animals is given proper recognition and protection through an individual’s care journey. Some may be too vulnerable or frail to request that their beloved pet is taken into account when their care is planned. Others may need help or assistance in retaining their companion. Others still may not be aware of how a cat or a dog could improve their quality of life, ease their loneliness or help tackle a chronic disease. The amendments I have tabled would ensure that this happens as a matter of routine and is not left to chance in the way that, tragically, too often happens now.